10 Minute H & P of the Dizzy Patient Hamid R. Djalilian

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10 Minute H P of the Dizzy Patient

• Hamid R. Djalilian, M.D.
• Director of Otology and Neurotology
• hdjalili_at_uci.edu
• ent.uci.edu

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Balance

• Visual, vestibular, proprioception
• Ankles
• Knees
• Hips
• Paraspinal
• Vestibular
• Utricle, Saccule, SCC
• Vestibulo-ocular reflex
• CNS
• Cerebellum, Brainstem, PPRF
• CV, metabolic, cerebrovascular

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DIZZINESS

• Vertigo
• Light-headedness
• Dysequilibrium
• Imbalance
• Near Syncope

• Floating
• Whooziness
• Visual distortion
• Ataxia
• Anxiety

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Vertigo

• Vertigo Sensation of motion that does not exist
• Nystagmus causes sensation of motion
• No true vertigo without nystagmus

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Vertigo DDx

• Peripheral
• BPPV
• Menieres
• Labyrinthitis
• Vestibular neuritis
• Perilymph fistula
• Post-traumatic vertigo
• Superior Canal Dehiscence
• Acoustic Neuroma

• Central
• Migraine and epilepsy
• Multiple sclerosis
• Cerebro-vascular Disease
• Cervical Vertigo
• Multisensory deficit

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Vertigo/Dizziness History

• What does it exactly feel like?
• Movement around you (spinning)? Lightheadedness?
  Feel like passing out? Imbalance?
• How long does it last?
• Associated with hearing loss, pressure, vomiting?
• What makes it start?
• What makes it stop?

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Physical Exam

• Ear exam
• EOMI (nystagmus at 15o)
• Complete neuro exam
• CN exam
• Romberg
• FNF
• Tandem gait
• Proprioception
• Dix Hallpike
• ENG/Audio/VEMP

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Benign Paroxysmal Positional Vertigo (Posterior
Canal)

• Recurrent episodes of vertigo
• Characteristics Geotropic
• Lasts lt 1 min
• Delayed onset (few secs)
• Brought on by one ear down position
• Treatment Epley

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Horizontal Canal BPV

• Positive Dix-Hallpike in both directions
• Geotropic direction-changing nystagmus
• Affected side is worse with that ear down
• Tx Barbeque roll
• 360o roll 90o at a time away from affected ear
  starting with affected ear down

HSC BPV Log/BBQ-roll for Left HSC BPV
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Menieres Dz
X
X
O
O
O
O
lt gt
lt
gt
gt
gt
O
X
O
X
lt
X
lt
X

• Vertigo gt20 min, lt24hrs (typically 2-3hrs)
• Low-freq HL
• Ear fullness (plugging, pressure)
• Tinnitus (buzzing/humming sound) low freq

Low Frequency SNHL
X
X
X


X
X



?


?
?
?
?

?
Peak-shaped
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Labyrinthitis

• Most common misdiagnosis
• Prolonged sustained vertigo gt 1 wk
• Must have associated hearing loss
• No vomiting No labyrinthitis
• Cause viral
• Treatment Steroids, Benzodiazipines
• Residual vestibular dysfxn/hearing loss
• Vestibular neuronitis Labyrinthitis w/o HL

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Perilymph Fistula

• Cause
• Spontaneous?
• Physical trauma
• Barotrauma (Divers)/plane landing/hard hit on
  surfing
• Symptoms
• Episodic vertigo
• Hearing loss (fluctuating SNHL)
• Assocd w cough, valsalva, sneeze, elevator
• Treatment
• Surgical

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Superior Canal Dehiscence

• Conductive HL supra-threshold bone conduction
• Fullness of ear(s)
• Autophony
• Hearing loss
• Dizziness Dizziness w tragal pumpling, Tullio
  phenomenon
• Lower threshold on VEMP

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Superior Canal Dehiscence

• Ultra-thin CT (0.5mm cuts)
• Negative PLF or Stapedectomy explorations
• Hear Eyes moving

DJ Lee
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Superior Canal Dehiscence

• Not all SCD patients are dizzy
• VEMP thresholds lt70dB (normal 80-95)
• Treatment Surgical

DJ Lee, UMASS
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Acoustic Neuroma

• The great masquerader
• Can present as BPV, Menieres, Labyrinthitis, or
  does not fit any d/o
• MRI in unilateral tinnitus, asymmetric HL,
  Menieres, sudden HL, labyrinthitis, atypical
  vertigo

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Post-traumatic vertigo Labyrinthine Concussion

• Cause hemorrhage, neural injury, cellular
  injury, fracture, PLF
• BPV
• Menieres
• Cervical vertigo
• Perilymph fistula
• Factitious (psychological) vertigo
• Treatment
• Pin down dx if possible
• Antihistamines, vestibular rehab, soft cervical
  collar

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Mal de Debarquement

• Persistence of perception of motion after a
  cruise/boat ride
• Most commonly in middle aged women
• Vestibular rehabilitation

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Migraine-Associated Vertigo

• Migraine
• True vertigo with or without nausea and vomiting
• Motion intolerance
• Headache not required
• Sensitivity to sound (Hyperacusis) light
  (photophobia)
• Timing few minutes to 2 hours and 49 having
  spells that lasted longer than 24 hours
• Headache is not required to make the dx of MAV

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Cervical Vertigo

• Vascular vs. proprioception
• Dizziness (non-specific) and neck pain
• Exam tenderness/stiffness of neck mm
• W/U MRI/A r/o vascular abnormality
• Eval for disk disease
• Tx NSAIDS, mus relaxants, massage, rarely Botox

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Vestibular Implant

• Implant a micro-gyroscope
• Send the information to the vestibular nerve

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Summary

• BPV
• Menieres
• Labyrinthitis/Vest neuritis
• Superior Canal Dehiscence

• Seconds, Tx c Epley
• Mins to hrs, HL, Tinnitus, pressure
• Days, vomiting
• Unexplained aural fullness or autophony,
  sensitivity to loud sounds or straining,
  Conductive HL and NORMAL reflexes/tymps