Vertigo: ENT Perspective on Diagnosis and Management

Gerard Kelly 
MD MEd FRCS(Ed) FRCS(ORL-HNS)
ENT surgeon 
17
th
 April 2018
Vertigo with an ENT spin
The Leeds Teaching
Hospitals NHS Trust
The Spire Hospital
Leeds
aims
to discuss the management of the patient with
vertigo from an ENT perspective
objectives
give a differential diagnosis for a patient presenting
with dizziness
list the typical symptoms BPPV, vestibular neuritis,
Meniere's syndrome, vestibular migraine, orthostatic
hypotension, proprioceptive failure, brain stem CVA,
MS
note the key questions in the history of the dizzy
patient
design a management plan for these conditions
undefined
 vertigo definition
 
 
vertigo is the hallucination of movement
undefined
diagnosis?
 balance physiology
brain – central processor
 
input
   
  
inner ear (vestibular,
auditory)
eyes
proprioception - stretch
receptors /
somatosensory
output
eyes
posture muscles
 balance
inner ear balance system
 
3 balance canals
 balance
inner ear balance system
 
3 balance canals
stabilize gaze
 balance
inner ear balance system
 
3 balance canals
stabilize gaze
the ‘vestibulocular reflex’
 balance
inner ear balance system
 
3 balance canals
stabilize gaze
the eyes are hard wired to
work together – the clinical
sign of vestibular problems is
nystagmus – they eyes do the
same movement 
 balance
when the vestibular system goes wrong
 
 balance
symptoms and signs
 
 balance
symptoms and 
signs
 
 nystagmus
 
nystagmus is named in the
direction of the fast
movement
R                                                                L
 balance
symptoms and signs
 
 balance
symptoms 
and signs
 
 dizziness
 
if the balance system
fails the inner ears are
not in equilibrium
sensory conflict
(somatosensory
receptors and eyes tell
the brain that we are not
moving, but the vestibular
system says that we are)
undefined
 balance physiology
brain – central processor
 
input
   
  
inner ear (vestibular,
auditory)
eyes
proprioception - stretch
receptors /
somatosensory
output
eyes
posture muscles
undefined
Neurology
ENT
BPPV
Menieres
Labyrinthitis
Vestibular
Migraine
Multiple
sclerosis
CVA
Acoustic
neuroma
Persistent
Postural
Perceptual
Dizziness
Dr Oliver Lily’s slide
undefined
treatment?
undefined
diagnosis?
undefined
history
how long does it last
associated symptoms
when did it start
relation to movement
sensitivity to lights and sounds
aggravating and relieving factors
undefined
history
how long does it last?
seconds BPPV
minutes migraine, Meniere's, TIA
hours vestibular neuronitis, migraine, Meniere’s,
CVA
undefined
history
associated symptoms
hearing loss
fullness
tinnitus
Meniere’s
undefined
history
associated symptoms
dysphasia, dysarthria, paralysis
brain stem stoke
undefined
history
relation to movement
when you have a damaged labyrinth you do not
want to move your head, when you are having a
stroke – probably makes no difference- your are
sick what ever happens
undefined
history
light / sound sensitive during attacks?
migraine
undefined
history
loud sound causes dizziness
fistula
now realise that this is a canal dehiscence
undefined
history
light headed when getting up off a bed or a chair?
postural hypotension
the brachial artery is a big artery at the level of the
heart– the change in BP is very transient – it will not be
picked up by BP measurement
older, medicated, diabetic, dys-autonomic, obese
unfit
undefined
history
go back to the first attack
this will give you the diagnosis in a lot of cases
undefined
history
blackouts with dizziness?
undefined
history
blackouts with dizziness?
not vestibular
syncopal patient belongs where?
undefined
history
blackouts with dizziness?
not vestibular
syncopal patient belongs where?
cardiology
undefined
examination
cranial nerve examination
look at the ears
hall pikes
unterberger’s
romberg’s
examination
take off the patients shoes and socks
test joint proprioception and vibrotactile sensation
128Hz tuning fork
undefined
investigation
 
undefined
vertigo investigation
 
vertigo
in isolation is rare sign of acoustic neuroma
in a series of 1,358 patients none had acoustic
neuromas
Gandolfi MM, Reilly KR, Galatioto J, Judson RB, Kim AH. Cost-effective analysis of unilateral vestibular weakness investigation.
Otol Neurotol
 (2015);36(2):277-81.
undefined
treatment
BPPV, migraine, Meniere's, TIA, vestibular
neuronitis, CVA, superior canal dehiscence
undefined
BPPV
Epley manoeuvre
undefined
triggers for vestibular migraine
barometric pressure weather changes
hormonal fluctuations
sleep variation
stressors
anxiety / depression
undefined
epidemiology
lifetime prevalence of migraine:
 
-
 
5.7-20% of males
 
-
 
17.6-29% of females
among migraine patients:
 
-
 
27-33% report episodic vertigo
 
-
 
28-72% report non-specific dizziness
vestibular migraine approximately 1% of general population
(5-10 times Meniere's disease)
undefined
dietary Changes
food triggers
sugar content
timing of meals
magnesium 200 mg BID
B-2 supplementation 200 mg BID
butterbur root 10 mg QD
undefined
 
 
DIET
 
F
O
R
 
THE
 
M
IGRA
I
NE
 
PATIENT
A
v
o
i
d
Ripened Cheeses  (Cheddar, Em
m
entaler, Gruyere, Stilton, Brie, and Came
m
bert) Cheeses th
a
t
 
are
p
e
r
m
itted:  (A
m
erican, Cottage, Cream
 
and Velveet
a
)
Licorice
Herring
Chocolate
Vinegar (except white vinegar)
Anything fer
m
ented, pickled or 
m
arinated
Sour crea
m
, yogurt
Nuts, peanut butter, seeds (sunflower, sesa
m
e, pumpkin, etc.) Hot fresh breads
raised coffeecakes and raised d
o
ughnuts.
(These 
a
re 
p
er
m
itted, if
 
they are 
a
ll
o
wed to cool.
 
Toast is 
pe
r
m
itted) Pods of broad
beans (lima, navy, pinto, garbanzo and pea pods)
Any foods 
c
ontaining large a
m
ounts of
 
m
onosod
i
um
 
gluta
m
ate (Chinese 
f
oods) Onions
Canned figs
Citrus foods (no 
m
ore than one serving per day:
 
one orange, one grapefruit,
 
one glass of orange juic
e
)
Bananas (no 
m
ore than one-half banana per day) Raisins
Papayas
Pizza
Excessive tea, coffee and cola beverages (no 
m
o
re than 2 cups total per day) Avocado
Fer
m
ented sausage (
p
rocessed 
m
eats such as bologna, sala
m
i
, pepperoni, sum
m
er sausage, hot dogs and ha
m
)
Chicken li
ve
rs
Avoid all alcoholic beverages, if
 
possible.
 
undefined
lifestyle Changes
regular sleep
stress management
exercise
oral contraceptive use
undefined
stepwise treatment of vestibular
migraine
step 1: institute a migraine diet
step 2: tricyclic antidepressant (nortriptyline)
  
-dose titration 10 – 50mg
step 3: beta-blockers (atenolol)
  
-dose titration 12.5 – 50mg
step 4: neurologic consultation/other medical regimens
Reploeg MD, Goebel JA Otol Neurotol 23:364-371, 2002
undefined
Meniere’s syndrome
betahistine
bendroflumethiazide
intratympanic steroids, intratympanic gentamicin
grommet
endolymphatic sac decompression
labyrinthectomy
vestibular nerve section
undefined
vestibular neuritis
vestibular sedatives used in the short term
vestibular rehab
undefined
vestibular neuritis
vestibular sedatives used in the short term
vestibular rehab
undefined
examination
ears
cranial nerves
proprioception, vibrotactile
hall pikes (not just for BPPV)
undefined
www.LeedsENT.com
 for vestibular rehab exercises, main
page
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Explore the comprehensive approach to diagnosing and managing vertigo from an ENT perspective, covering differential diagnoses, typical symptoms, key questions in patient history, and management plans for various conditions. Gain insights into the physiology of balance, inner ear functions, and clinical signs of vestibular problems.

  • Vertigo
  • ENT
  • Diagnosis
  • Management
  • Balance

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  1. The Spire Hospital Leeds Vertigo with an ENT spin Hospitals NHS Trust The Leeds Teaching Gerard Kelly MD MEd FRCS(Ed) FRCS(ORL-HNS) ENT surgeon 17th April 2018

  2. aims to discuss the management of the patient with vertigo from an ENT perspective

  3. objectives give a differential diagnosis for a patient presenting with dizziness list the typical symptoms BPPV, vestibular neuritis, Meniere's syndrome, vestibular migraine, orthostatic hypotension, proprioceptive failure, brain stem CVA, MS note the key questions in the history of the dizzy patient design a management plan for these conditions

  4. vertigo definition vertigo is the hallucination of movement

  5. diagnosis?

  6. balance physiology brain central processor output input inner ear (vestibular, auditory) eyes proprioception - stretch receptors / somatosensory eyes posture muscles

  7. balance inner ear balance system 3 balance canals

  8. balance inner ear balance system 3 balance canals stabilize gaze

  9. balance inner ear balance system 3 balance canals stabilize gaze the vestibulocular reflex

  10. balance inner ear balance system 3 balance canals stabilize gaze the eyes are hard wired to work together the clinical sign of vestibular problems is nystagmus they eyes do the same movement

  11. balance when the vestibular system goes wrong

  12. balance symptoms and signs

  13. balance symptoms and signs

  14. nystagmus nystagmus is named in the direction of the fast movement R L

  15. balance symptoms and signs

  16. balance symptoms and signs

  17. dizziness if the balance system fails the inner ears are not in equilibrium sensory conflict (somatosensory receptors and eyes tell the brain that we are not moving, but the vestibular system says that we are)

  18. balance physiology brain central processor output input inner ear (vestibular, auditory) eyes proprioception - stretch receptors / somatosensory eyes posture muscles

  19. Dr Oliver Lilys slide Persistent Postural Perceptual Dizziness Neurology ENT BPPV Vestibular Migraine Acoustic neuroma Labyrinthitis Multiple sclerosis Menieres CVA

  20. treatment?

  21. diagnosis?

  22. history how long does it last associated symptoms when did it start relation to movement sensitivity to lights and sounds aggravating and relieving factors

  23. history how long does it last? seconds BPPV minutes migraine, Meniere's, TIA hours vestibular neuronitis, migraine, Meniere s, CVA

  24. history associated symptoms hearing loss fullness tinnitus Meniere s

  25. history associated symptoms dysphasia, dysarthria, paralysis brain stem stoke

  26. history relation to movement when you have a damaged labyrinth you do not want to move your head, when you are having a stroke probably makes no difference- your are sick what ever happens

  27. history light / sound sensitive during attacks? migraine

  28. history loud sound causes dizziness fistula now realise that this is a canal dehiscence

  29. history light headed when getting up off a bed or a chair? postural hypotension the brachial artery is a big artery at the level of the heart the change in BP is very transient it will not be picked up by BP measurement older, medicated, diabetic, dys-autonomic, obese unfit

  30. history go back to the first attack this will give you the diagnosis in a lot of cases

  31. history blackouts with dizziness?

  32. history blackouts with dizziness? not vestibular syncopal patient belongs where?

  33. history blackouts with dizziness? not vestibular syncopal patient belongs where? cardiology

  34. examination cranial nerve examination look at the ears hall pikes unterberger s romberg s

  35. examination take off the patients shoes and socks test joint proprioception and vibrotactile sensation 128Hz tuning fork

  36. investigation

  37. vertigo investigation vertigo in isolation is rare sign of acoustic neuroma in a series of 1,358 patients none had acoustic neuromas Gandolfi MM, Reilly KR, Galatioto J, Judson RB, Kim AH. Cost-effective analysis of unilateral vestibular weakness investigation. Otol Neurotol (2015);36(2):277-81.

  38. treatment BPPV, migraine, Meniere's, TIA, vestibular neuronitis, CVA, superior canal dehiscence

  39. BPPV Epley manoeuvre

  40. triggers for vestibular migraine barometric pressure weather changes hormonal fluctuations sleep variation stressors anxiety / depression

  41. epidemiology lifetime prevalence of migraine: - 5.7-20% of males - 17.6-29% of females among migraine patients: - 27-33% report episodic vertigo - 28-72% report non-specific dizziness vestibular migraine approximately 1% of general population (5-10 times Meniere's disease)

  42. dietary Changes food triggers sugar content timing of meals magnesium 200 mg BID B-2 supplementation 200 mg BID butterbur root 10 mg QD

  43. DIET FOR THE MIGRAINE PATIENT Avoid Ripened Cheeses (Cheddar, Emmentaler, Gruyere, Stilton, Brie, and Camembert) Cheeses that are permitted: (American, Cottage, Cream and Velveeta) Licorice Herring Chocolate Vinegar (except white vinegar) Anything fermented, pickled or marinated Sour cream, yogurt Nuts, peanut butter, seeds (sunflower, sesame, pumpkin, etc.) Hot fresh breads raised coffeecakes and raised doughnuts. (These are permitted, if they are allowed to cool. Toast is permitted) Pods of broad beans (lima, navy, pinto, garbanzo and pea pods) Any foods containing large amounts of monosodium glutamate (Chinese foods) Onions Canned figs Citrus foods (no more than one serving per day: one orange, one grapefruit, one glass of orange juice) Bananas (no more than one-half banana per day) Raisins Papayas Pizza Excessive tea, coffee and cola beverages (no more than 2 cups total per day) Avocado Fermented sausage (processed meats such as bologna, salami, pepperoni, summer sausage, hot dogs and ham) Chicken livers Avoid all alcoholic beverages, if possible.

  44. lifestyle Changes regular sleep stress management exercise oral contraceptive use

  45. stepwise treatment of vestibular migraine step 1: institute a migraine diet step 2: tricyclic antidepressant (nortriptyline) -dose titration 10 50mg step 3: beta-blockers (atenolol) -dose titration 12.5 50mg step 4: neurologic consultation/other medical regimens Reploeg MD, Goebel JA Otol Neurotol 23:364-371, 2002

  46. Menieres syndrome betahistine bendroflumethiazide intratympanic steroids, intratympanic gentamicin grommet endolymphatic sac decompression labyrinthectomy vestibular nerve section

  47. vestibular neuritis vestibular sedatives used in the short term vestibular rehab

  48. vestibular neuritis vestibular sedatives used in the short term vestibular rehab

  49. examination ears cranial nerves proprioception, vibrotactile hall pikes (not just for BPPV)

  50. www.LeedsENT.com for vestibular rehab exercises, main page

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