Assessing the vertiginous patient in ED

Jim Fleet

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

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

History

• Vomited 3 to 4 times • Difficulty hearing• Mild frontal headache• Oscillopsia• Some rhinorrhea in preceding days

previously, otherwise well• Nothing like this previously

History

• No ongoing medical conditions and no regular medication

• Smokes 20-30/day since youth• No alcohol

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

Examination

• Truncal instability with ongoing vertigo

• Gait not assessed• Pupils equal and responsive• No ophthalmoplegia• Loss of hearing right ear

Examination

• Other cranial nerves normal• Tone, power, sensation all normal• Reflexes

– 2+ and symmetrical– Plantars down-going

Nystagmus

• http://stroke.ahajournals.org/content/40/11/3504/suppl/DC1

• 1a

Investigations

• ECG – sinus rhythm, normal axis• Blood – normal haematology and

biochemistry

Summary

• 62 year old smoker• Collapse and acute vertigo

– Symptoms setting

• Vomiting• Nystagmus and hearing loss• Investigations normal

How to Proceed?

• Differential diagnosis?• Additional information

– Further history?– Further investigation?– Further investigation?

• Inpatient or outpatient?

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)

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)

Aetiology

• Broad spectrum of causes

• Surprisingly similar in varying settings– A&E– Primary care– Medical clinics– Dizziness clinics

Anatomy

Inner ear anatomy

Inner ear anatomy

The Hair Cell

Central integration

Vestibulo- ocular reflex

Neural firing rate

Lateral rectus

Medial rectus

Abducens nucleus

Oculomotor nucleus

Vestibular nucleus

Head turning

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

Acute causes

• Peripheral– Often common and self limiting– Often outpatient management and

follow up

• Central– Rare but more serious– Often inpatient investigations

Differential diagnosis

Acute/intermittent Chronic

Peripheral Vestibular neuritisBPPVMeniere’s disease

Tumour/nerve compressionBilateral vestibular disorderCholesteatomaAge related changes?

Central StrokeVertiginous migraine

StrokeTumourDemyelination

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

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

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

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

Head Thrust Test

Videos

• Head thrust test – 1a +/- 1b

• Gaze evolved nystagmus - utah

• Cover test/skew deviation - 3

• Dix-Hallpike - bmj

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)

Examination – ears and face

• Tympanic membranes• New onset deafness • Pupils

– ? Horners’

• Ataxia/cerebellar signs• Sensory loss• General neurological examination

Vertigo – what then?

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)

Video – Epley manoeuvre

Summary

• 62 year old smoker• Collapse and acute vertigo

– Symptoms setting

• Vomiting and ataxia• Nystagmus and hearing loss

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

MRI

Progress

• Remained ataxic• Stayed for further inpatient

investigation• Neurology and ENT review

– CVA?– Acute labyrinth failure ? cause

• Sent to tertiary centre

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

Summary

1. Vestibular anatomy/physiology explains vertigo

2. Careful history can exclude mimics3. Care examination can differential

peripheral and central causes

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

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

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

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

Blood Supply

• http://www.asha.org/aud/articles/CentralVestib/