vestibular assessment
DESCRIPTION
Vestibujlar assessmentTRANSCRIPT
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Assessing the vertiginous patient in ED
Jim Fleet
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Vestibular assessment - Objectives
1. The differential diagnosis of “dizziness”
2. Clinical anatomy and clinical physiology of the vestibular apparatus
3. Diagnostic strategy4. Clinical assessment techniques
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History
• 62 year old male shop worker• Brought into A&E via ambulance
06:00– Complaining of “room spinning around
him”
• Walked downstairs after waking normally and felt suddenly unwell– Sweaty, clammy, nauseated
• Collapsed to ground, unsure if LOC
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History
• Vomited 3 to 4 times • Difficulty hearing• Mild frontal headache• Oscillopsia• Some rhinorrhea in preceding days
previously, otherwise well• Nothing like this previously
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History
• No ongoing medical conditions and no regular medication
• Smokes 20-30/day since youth• No alcohol
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Examination
• G.C.S 15/15• BP - 141/94; P - 88, reg; T – 35 0C• Sats 99% air, BM 5.4• No meningism• Cardio-respiratory and abdominal
systems normal
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Examination
• Truncal instability with ongoing vertigo
• Gait not assessed• Pupils equal and responsive• No ophthalmoplegia• Loss of hearing right ear
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Examination
• Other cranial nerves normal• Tone, power, sensation all normal• Reflexes
– 2+ and symmetrical– Plantars down-going
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Nystagmus
• http://stroke.ahajournals.org/content/40/11/3504/suppl/DC1
• 1a
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Investigations
• ECG – sinus rhythm, normal axis• Blood – normal haematology and
biochemistry
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Summary
• 62 year old smoker• Collapse and acute vertigo
– Symptoms setting
• Vomiting• Nystagmus and hearing loss• Investigations normal
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How to Proceed?
• Differential diagnosis?• Additional information
– Further history?– Further investigation?– Further investigation?
• Inpatient or outpatient?
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Dizziness
• Non-specific term used by patients• Summation of symptoms and pathology
– Vertigo– Disequilibrium
• Any pathology of balance homeostasis
– Pre-syncope– Nonspecific “dizziness”
• Vestibular pathology important in the dizzy patient– 40% peripheral– 10% central (higher in older age)
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How common is it?
• Common!– 3rd most common medical symptom
reported in general medical clinics (Kroenke,
1989)
– Most common complaint in over 75s (Sloane,
1989)
– 22-30% annual prevalence (Neuhauser, 2009)
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Aetiology
• Broad spectrum of causes
• Surprisingly similar in varying settings– A&E– Primary care– Medical clinics– Dizziness clinics
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Anatomy
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Inner ear anatomy
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Inner ear anatomy
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The Hair Cell
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Central integration
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Vestibulo- ocular reflex
Neural firing rate
Lateral rectus
Medial rectus
Abducens nucleus
Oculomotor nucleus
Vestibular nucleus
Head turning
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Diagnostic strategy
• Stepwise approach • First identify possible vestibular
pathology– Does my
dizzy/falling/unsteady/vertiginous patient have vestibular deficit?
• Acute/intermittent vs chronic– Based on history
• Peripheral vs central– History and examination
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Acute causes
• Peripheral– Often common and self limiting– Often outpatient management and
follow up
• Central– Rare but more serious– Often inpatient investigations
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Differential diagnosis
Acute/intermittent Chronic
Peripheral Vestibular neuritisBPPVMeniere’s disease
Tumour/nerve compressionBilateral vestibular disorderCholesteatomaAge related changes?
Central StrokeVertiginous migraine
StrokeTumourDemyelination
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Peripheral vs Central Disorder: Symptoms
PVD Symptoms CVD
Severe Vertigo Not always
Severe at onset Nausea/Vomiting Rare
Mild Imbalance Severe
Common Hearing loss Rare
Mild (except bilateral PVD)
Oscillopsia Severe
Rare Neurological symptoms Common
Fast Compensation Slow
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Identifying the vestibular patient - History• What do you mean by dizzy?
– “…do you just feel lightheaded or do you see the world spin around you as if you had just got off a play-ground roundabout?” (Evans, 1990)
• Notoriously unreliable E.g. movement descriptions in syncope (Newman-Toker, 2007)
– Timing• ?Acute onset• ?Recurrent
– Trigger• ?Spontaneous
– Triage• ?Red flags
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Red flags in acute vertigo (adapted from
Barraclough, 2009)
• Any central neurological symptoms or signs– General neurological– HINTS testing
• New type of headache (esp. occipital)– Suggests possible vascular event
• Acute deafness– Suggests acute ischaemia/damage of the
labyrinth or brainstem
• Altered conscious– Needs syncope risk stratification if T-LOC– Encephalopathic process
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Neurological examination – eyes
• Eye movements – Assessment for nystagmus
• Is it up/down beating?• Is it uni-directional?
• Skew– Cover test
• VOR assessment - Head thrust test • Dix-Hallpike to Epley manoeuvre if
considering BPPV
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Head Thrust Test
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Videos
• Head thrust test – 1a +/- 1b
• Gaze evolved nystagmus - utah
• Cover test/skew deviation - 3
• Dix-Hallpike - bmj
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HINTS testing
• Abnormal head trust test less helpful• Can we improve bedside analysis• HINTS study (Kattah, 2009)
– Head Impulse test– Nystagmus – direction changing, vertical– Test of Skew
• 100% sensitive and 96% specific• Better than DW MRI up to 48 hours• Junior neurology residents similar ability
(Chen, 2010)
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Examination – ears and face
• Tympanic membranes• New onset deafness • Pupils
– ? Horners’
• Ataxia/cerebellar signs• Sensory loss• General neurological examination
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Vertigo – what then?
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Benign paroxysmal positional vertigo
• Free floating otoconia in canals– Usually posterior
• Most common cause of vertigo• Short lived intense rotatory vertigo related
to reproducible head position• Vomiting unusual, hearing normal• Rotatory upbeating, non-sustained
nystagmus (beware down beating)– Dix-Hallpike 79% sensitivity and 75% specificity
(Halker, 2008)
• Epley manoeuvre rapidly fix problem– 92% at 6 months and falls reduction (Richard, 2005)
(Gananca, 2010)
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Video – Epley manoeuvre
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Summary
• 62 year old smoker• Collapse and acute vertigo
– Symptoms setting
• Vomiting and ataxia• Nystagmus and hearing loss
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Other points - examination
• External ear normal• Nystagmus
– Spontaneous bi-ocular leftwards horizontal jerk nystagmus accentuated by left gaze, suppressed by fixation
• Hearing– Weber’s test to left
• Thrust test positive to right
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MRI
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Progress
• Remained ataxic• Stayed for further inpatient
investigation• Neurology and ENT review
– CVA?– Acute labyrinth failure ? cause
• Sent to tertiary centre
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Progress• Images r/v
– ? Maturing frontal and cerebellar contusions and evolving subdural haematoma
• CT head– R transverse petrous fracture involving
labyrinth and petrous potion of semi-circular canals
• Gradual compensation• For local follow up with ENT and
falls service
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Summary
1. Vestibular anatomy/physiology explains vertigo
2. Careful history can exclude mimics3. Care examination can differential
peripheral and central causes
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Mechanisms of Vertigo/dizziness
• Baloh & Honrubia, 2001
Type Mechanism
Physiological Sensory conflict due to unusual combination of sensory inputs e.g. motion
Vertigo Imbalance in tonic vestibular signals
Visual Mismatch of visual and vestibular signals e.g. Ocular and vestibular pathology
Multi-sensory Impairment of 2 or more sensory inputs of balance
Psychological Impairment of central integration of sensory inputs
Disequilibrium/ataxia Loss of neurological function: proprioception, motor, cerebellar
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Vestibular pathology - is it important?
• Increasingly recognised– Associated with reduced quality of life– Symptoms often impairing
• 80% in vestibular dizziness
– Greatly increased risk of falls (Agrawal, 2009)
• x12
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Vestibular pathology - is it important?
• Asymptomatic prevalence exceptionally common• Also increased risk of falls• 35.4% of US adults aged 40 years• 84.8% in over 80s (Agrawal, 2009)
– Accumulation of damage with poor compensation
– Depletion of vestibular hair cells and otoliths
– Dysfunction of the remaining hair cells– Loss of vestibular ganglion cells
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Relevance to elderly care?
• Age groups concerned• Non-specific presentation
– Often referred to elderly care
• Multi-factorial– Non speciality specific condition– Patient preference
• Important sequelae– Falls/fractures/function
• Treatable
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Blood Supply
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• http://www.asha.org/aud/articles/CentralVestib/