Dr. Hoskin - Vestibular Neurology

Vestibular Disorders
Barrow Outpatient Neurology

Advanced Practice 2-Day Bootcamp
Justin Hoskin
January 11, 2022
Barrow Outpatient Neurology Advanced Practice 2-Day Bootcamp
Disclosures
None
Outline
• Vestibular Disorders
• History and Physical
• Common Vestibular Disorders: (BPPV, MD, vestibulopathy,
vestibular migraine, presyncope)
• When to test, treat, and refer
Common Clinic Presentation
Patient presents to your clinic and states, “I just feel so dizzy”.
How do we approach this common complaint?
Can anything be done?
When should I be worried?

Strupp 2020
History
Important clues to the diagnosis are found in:

• Temporal Course
• Accompanying Symptoms
• Precipitating and Modulating Factors
Temporal Course
• When and how did the dizziness start?
• Is the dizziness occurring in distinct episodes?
• How long does the dizziness last?
• How has the dizziness changed with time?
Temporal Course
• Onset
• Acute with severe symptoms
• Acute unilateral vestibulopathy, brainstem or cerebellar stroke
• Slow with less debilitating Symptoms: > 3 months
• Bilateral vestibulopathy, functional dizziness, neuro-degenerative disease
• Duration of Attack
• Seconds to minutes
• BPPV, vestibular paroxysmia, third window syndrome
• Minutes to hours
• Vestibular migraine, Meniere’s Disease, Episodic Ataxia Type 2
• Chronic or constant
• Bilateral vestibulopathy, functional dizziness, neuro-degenerative disease
Accompanying Symptoms
• Do you have symptoms that occur during a dizziness attack?

• Hearing loss? Nausea? Aural fullness? Tinnitus?
• Outside of the attacks, do you have other signs and symptoms
present?
• Headache? Hearing loss? Nausea? Photophobia?
• Weakness? Double vision? Dysarthria?
• Do symptoms occur while at rest or with movement only?
Accompanying Symptoms
• Hyperacusis, tinnitus, aural fullness

• Meniere’s Disease
• Double vision, ataxia, dysarthria, hemiparesis, hemihypesthesia
• Cerebellar stroke
• Headache attacks, migraine history, photophobia, phonophobia,
aura
• Vestibular Migraine
• Oscillopsia at rest
• Acute unilateral vestibulopathy, Meniere’s Disease (attack), vestibular
migraine
• Oscillopsia with movement
• Bilateral vestibulopathy
Precipitating and Modulating Factors
• Are there any triggers that the patient has identified?

• Moving to supine position? Rolling in Bed? Loud noises? Walking and
running?
• Attacks occurring in any body position including while holding still?
• Attacks triggered by situations and environment? (crowds, open
spaces, grocery stores)
• Anything that can lead to improvement of symptoms?
Precipitating and Modulating Factors
• Symptoms present even at rest

• Meniere’s attack, vestibular migraine, acute unilateral vestibulopathy,
vestibular paroxysmia, cerebellar stroke
• Evoked by changes in body position
• BPPV, central positional vertigo, orthostatic dizziness
• Evoked by changes in pressure or loud noises
• Third window syndrome
• Walking and running
• Bilateral vestibulopathy
• Situations (crowds, open spaces, grocery stores)
• Functional Dizziness
• Improvement with distraction, sporting activities, alcohol
• Functional Dizziness
Vertigo vs Dizziness
• Dizziness - Non-specific term encompassing feelings of imbalance,

spinning and lightheadedness.
• Vertigo - the sensation of self-movement or the movement of your
surroundings
• Lightheadedness - Feeling of faintness
Outline
• Vestibular Disorders
• History and Physical
• Common Vestibular Disorders
• When to test, treat, and refer
Clinical Case
53 year old man who presented to clinic with episodes of dizziness.

The dizziness most often occurs in the morning when first waking up
and lasts for about a minute. He further describes the dizziness as a
spinning sensation with associated nausea. He occasionally has
headache after the episodes. Episodes can also be triggered while in
the shower or when rolling over in bed. What is the most likely
diagnosis?
Benign Positional Vertigo

• History
• Recurrent attacks of spinning vertigo induced by changes in head
position
• Most often lying down supine or turning into supine position while lying
down (rolling in bed)
• Lasts for several seconds to a minute
• Associated with advanced age, prior falls, and reduced physical
activity

• Physical Exam
• Widely Normal
• Patient may be a little anxious about moving around
• Dix-hallpike maneuver
• Short latency
• Symptoms with nystagmus - vertical (upbeating) with
torsional (top pole of the eyes beat toward the lower ear)
• Approximately 95% are idiopathic

• Generally follow a specific pattern of nystagmus in
relationship to the semicircular canal affected.
• Posterior Semicircular Canal >> horizontal >> anterior
Dix-Hallpike
• Seated position
• Turn head 45 degrees toward the ear to
be tested
• The clinician then lies the patient down
quickly with their head past the end of
the bed and extends their neck 20
degrees below the horizontal
• Maintaining the initial rotation of the head.
• Watch patient's eyes for torsional and
up-beating nystagmus
• May start after a brief delay and persist for
no more than one minute. This would
indicate a positive test.
Bhattacharyya, et al
BPPV
• Treatment: Epley or Semont

• Success rate 95%
• Older patients struggle and may have persistent symptoms
• Vestibular Therapy
• Horizontal Canal - less common - horizontal nystagmus in horizontal
head turn
• Anterior Canal - least common - downbeat nystagmus with torsional
component
Epley Maneuver
Bhattacharyya, et al
Epley Maneuver
http://what-when-how.com/acp-medicine/the-dizzy-patient-part-3/
Clinical Case
53 year old man who presented to your epilepsy clinic 1 week after sudden
onset of severe spinning vertigo that started while at work. He has well
treated epilepsy without other medical comorbidities. During the vertigo
attack, he had associated nausea, vomiting, and a tension-type headache.
During the episode he went to SJHMC ED and had a negative MRI Brain for
stroke. He was admitted for observation and improved with anti-nausea
medications. His severe vertigo symptoms lasted for about 10 hours and
he is now left with a general sense of imbalance, dizziness, and foggy
thinking. Your basic neurologic examination is normal.
What is the most likely diagnosis? Any other history questions? What
additional examination steps can you take? What testing can be done?
Unilateral Vestibulopathy
• “Vestibular Neuritis”, “Vestibular neuronitis”, “Vestibular

neuropathy”
• History
• Acute onset spinning vertigo
• Lasts for ~ 24 hours
• Accompanied by oscillopsia, falls, and nausea
• Generally no hearing loss
• Examination
• Horizontal spontaneous nystagmus with fast phase toward the
unaffected side
• Head Impulse Test demonstrates unilateral peripheral
dysfunction
• No signs of CNS involvement
Head Impulse Test

• May be related to recent infection, possibly HSV-1.

• Testing
• Vestibular Nystagmography (VNG)
• Treatment
• Short steroid course
• Vestibular therapy
Clinical Case
53 year old man with history of migraine headache presented to clinic

with several episodes of severe spinning vertigo. During the vertigo
attack, he had associated nausea, vomiting, migraine headache, right
ear fullness, and right ear tinnitus. His severe vertigo symptoms
lasted for about 10 hours and he is now left with a general sense of
imbalance, dizziness, and foggy thinking. Your basic neurologic
examination is normal.
additional examination steps can you take? What testing can be
done?
Meniere’s Disease
• Diagnostic Criteria for “Definite MD”:

• Two or more spontaneous attacks of vertigo Lasting 20 min to 12 hours
• Audiometrically documented hearing loss at low frequency, associated with
attack
• If not documented - can diagnosis “probable Meniere’s”
• Fluctuating tinnitus or fullness in the affected ear
• No evidence of another cause
Meniere’s Disease
Pathogenesis: endolymphatic hydrops
Nakashima et al 2016
Meniere’s Disease
• Treatment:
• Lifestyle
• Low-salt diet
• Abstinence from coffee or alcohol
• Medication
• diuretic use
• Betahistine 48 -144mg/day
• Surgical
• Transtympanic gentamicin (ENT referral) - ablative, can lead to hearing loss
• Transtympanic corticosteroids
• Endolymphatic Sac Surgery
• Labyrinthectomy
Clinical Case
53 year old male with DM, HTN, CAD on aspirin 81 mg who presented
with spinning vertigo that started 3 hours ago without cessation. He
has associated nausea, vomiting, and double vision. Your exam finds
direction changing sustained end-gaze nystagmus, a disconjugate gaze,
dysmetria on finger to nose testing bilaterally, and significant
imbalance.
Central Vertigo, Stroke
• “Acute Vestibular Syndrome”

• “Clinical syndrome of acute-onset, continuous vertigo, dizziness, or unsteadiness lasting
days to weeks”
• CT sensitivity 7-16%
• DWI misses 15-20% of acute posterior fossa infarctions
Acute Vestibular Syndrome
Pearls
• Urgent ED evaluation
• Be mindful of the patient’s medical comorbidities
• Careful evaluation and documentation of eye movements, other
cranial nerve findings, and ataxia symptoms
Clinical Case
53 year old man with history of migraine headache presented to clinic

with several episodes of spinning vertigo. During the vertigo attack,
he had associated nausea, vomiting, migraine-type headache. His
symptoms lasted from a few hours to a few days. Outside of the
attacks he describes moments of dizziness (imbalance), foggy
thinking, and nausea. Your thorough vestibular examination is
normal.
done?
Vestibular Migraine
• The most common causes of recurrent, spontaneous attacks of

vertigo.
• Average age 40.9
• Women 64.1%
• Diagnostic Criteria
• At least 5 episodes of vestibular symptoms last 5 min to 72 hour
• History of migraine
• At least 50% of episodes are preceded by migraine symptoms
Vestibular Migraine
• Evaluation
• MR Brain with MRA H&N
• VNG and audiogram, especially if timing or hearing symptoms present
• Many patients with MD also have migraine
• Treatment tends to focus on migraine related medications

• Perhaps earlier use of verapamil, SSRI, SNRI
Clinical Case
53 year old man with history of migraine, anxiety, depression,

headache presented to clinic with dizziness. He had benign positional
vertigo 2 years ago that went untreated for several months before
finally receiving treatment with the Epley maneuver. More recently,
he describes a daily dizziness (floating sensation) without associated
headache or nausea. Symptoms are worsened by any movement,
visual commotion, going to the grocery store, etc. Your thorough
vestibular examination is normal.
done?
Functional Dizziness
• “Persistent postural perceptual dizziness”

• Chronic dizziness
• Often described as a sensation of floating
PPPD
1. One or more symptoms of dizziness, unsteadiness, or non-spinning

vertigo present on most days for 3 months or more
2. Persistent symptoms occur without specific provocation, but are
exacerbated by:
a. Upright posture
b. Active or passive motion
c. Exposure to moving visual stimuli or complex visual patterns
3. Precipitated by acute condition
a. May be vestibular or not
PPPD
• Evaluation
• Patient’s often have already undergone a battery of tests
• MRI, vestibular testing, etc
• Treatment
• No controlled trials
• SNRI, SSRI
• Topamax, gabapentin, TCAs
• Reassurance
• ?Vestibular therapy
Clinical Case
78 year old woman with history of Parkinson’s Disease and mild cognitive
impairment presented to clinic with several episodes of dizziness. She
further clarifies this as a sense of imbalance. Episodes often occur early in
the morning when getting up to go to the restroom. She has no episodes
while supine or seated. Sometimes she feels the urge to sit down after
standing for a time. During the dizziness she denies nausea, vomiting, or
headache. Her symptoms seem to come and go without clear rhyme or
reason. Her exam is consistent with prior (right sided resting tremor,
bradykinesia, and increased tone).
Orthostatic Hypotension
• Likely a drop in blood pressure when standing is contributing to

symptoms
• Common phenomenon in the elderly, particularly those with
neurodegenerative conditions
Orthostatic Hypotension
• Evaluation:
• Clinical orthostatic vital signs
• Prolonged Tilt Table examination
• Treatment
• Lifestyle
• Standing slowly, staying hydrated, increase salt intake, abdominal binder, compression
stockings
• Medication
• Midodrine, etc
Orthostatic Intolerance
• Variety of symptoms that occur in the upright posture:

• “dizziness”, “vertigo”, imbalance, headache, nausea, palpitations, fatigue,
etc
• Broader differential
• Postural orthostatic tachycardia syndrome
• Orthostatic hypotension
• Vasovagal Syncope
• Dysautonomia
• Aging
• Medication Side Effect
Orthostatic Intolerance
• May require:
• cardiac evaluation
• discussion with PCP on medication cessation
• initiation of new medications
Workup
• History and Exam

• MR brain imaging
• Vestibular testing
• VNG
• Tilt Table Testing
• VEMP, vHIT, audiogram, rotational chair, electrocochleography
Treatment
• Condition dependant
• Meclizine is fine for PRN severe vertigo. It is not a schedule
medicine
• Anti-nausea PRN medications
• Scopolamine and dramamine for motion sensitivity
• Vestibular Therapy
Referral
Additional Citations
1. Bhattacharyya, N. & Baugh, Reginald & Orvidas, L. & Barrs, David & Bronston, L.J. & Cass, S. & Chalian, Ara & Desmond, Alan & Earll, J.M. & Fife, Terry & Fuller,
D.C. & Judge, James & Mann, N.R. & Rosenfeld, Richard & Schuring, L.T. & Steiner, R.W. & Whitney, Susan & Haidari, J.. (2008). American Academy of
Otolaryngology-Head and Neck Surgery Foundation Clinical Practice Guideline benign paroxysmal positional vertigo. Otolarygol Head Neck Surg. 139.
2. Nakashima, T., Pyykkö, I., Arroll, M. et al. Meniere's disease. Nat Rev Dis Primers 2, 16028 (2016). https://doi.org/10.1038/nrdp.2016.28
3. Hoskin JL. Ménière's disease: new guidelines, subtypes, imaging, and more. Curr Opin Neurol. 2021 Dec 3. doi: 10.1097/WCO.0000000000001021. Epub ahead
of print. PMID: 34864755.
4. Fife TD. Approach to the History and Evaluation of Vertigo and Dizziness. Continuum (Minneap Minn). 2021 Apr 1;27(2):306-329. doi:
10.1212/CON.0000000000000938. PMID: 34351108.
5. Strupp M, Dlugaiczyk J, Ertl-Wagner BB, Rujescu D, Westhofen M, Dieterich M. Vestibular Disorders. Dtsch Arztebl Int. 2020 Apr 24;117(17):300-310. doi:
10.3238/arztebl.2020.0300. PMID: 32530417; PMCID: PMC7297064.
6. Baron R, Steenerson KK, Alyono J. Acute Vestibular Syndrome and ER Presentations of Dizziness. Otolaryngol Clin North Am. 2021 Oct;54(5):925-938. doi:
10.1016/j.otc.2021.05.013. Epub 2021 Jul 20. PMID: 34294435.

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Vestibular Disorders

Barrow Outpatient Neurology

Common Clinic Presentation

Patient presents to your clinic and states, “I just feel so dizzy”.

How do we approach this common complaint?

Can anything be done?

When should I be worried?

Important clues to the diagnosis are found in:

• Do you have symptoms that occur during a dizziness attack?

• Hyperacusis, tinnitus, aural fullness

Precipitating and Modulating Factors

• Are there any triggers that the patient has identified?

Precipitating and Modulating Factors

• Symptoms present even at rest

• Dizziness - Non-specific term encompassing feelings of imbalance,

53 year old man who presented to clinic with episodes of dizziness.

Benign Positional Vertigo

Benign Positional Vertigo

Benign Positional Vertigo

• Approximately 95% are idiopathic

• Treatment: Epley or Semont

• “Vestibular Neuritis”, “Vestibular neuronitis”, “Vestibular

Head Impulse Test

• May be related to recent infection, possibly HSV-1.

53 year old man with history of migraine headache presented to clinic

• Diagnostic Criteria for “Definite MD”:

Central Vertigo, Stroke

• “Acute Vestibular Syndrome”

Acute Vestibular Syndrome

53 year old man with history of migraine headache presented to clinic

• The most common causes of recurrent, spontaneous attacks of

• Treatment tends to focus on migraine related medications

53 year old man with history of migraine, anxiety, depression,

• “Persistent postural perceptual dizziness”

1. One or more symptoms of dizziness, unsteadiness, or non-spinning

• Likely a drop in blood pressure when standing is contributing to

• Variety of symptoms that occur in the upright posture:

• History and Exam

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