Evaluation of a dizzy adult

Dr. R. Srinivasa Raghavan Royal National Nose Throat and Ear Hospital London

dizziness vertigo balance problem light headed travel sickness panic attack disequilibrium dont like turning right quickly dont like supermarkets any more ?!?!?

Wanted:
A system that reacts promptly and accurately to head movements

Proprioception

Labyrinth

Visual input

Graviceptors

Gaze stabilisation Vestibuloocular reflex

3D movement balance

Autonomic regulation Circadian rythm

Mechanism of rotation detection

semicircular canal

Utricle and Saccule

Transducers

Push-Pull Principle

Ambiguity of the otolith system

6 ways to move

3 Rotations

SCC 3 Translations Utriculus sacculus

Vestibular system
1) provide general orientation of the body with respect to gravity 2) enable balanced locomotion and body position 3) readjust autonomic functions after body reorientation and 4) ensure gaze stabilisation

Ocular stabilising systems

VOR
maintenance of gaze during head movements

saccades

(3500 - 6000/s) maintenance of visual target on fovea by either voluntary effort or involuntary reflex (i.e. fast phase of nystagmus) smooth pursuit (<600/s) maintains gaze on moving target

OKN
primitive smooth pursuit involving whole retina corrective saccades relocate gaze onto new targets coming into visual field

Vestibulo-ocular Reflex
VOR: Stabilises images on the retina during head movements, by moving the eyes in a direction opposite to that of head movement

Includes the semicircular canal ocular reflexes and otolith-ocular reflexes.

Working principle of the VOR for gaze stabilization

Anatomical basis of the VOR

Three Neuron arc 1st order neurons from vestibular sensory apparatus 2nd order neurons from vestibular nuclei 3rd order neurons from external ocular motor nerve nuclei to the external ocular muscles

Impairment of VOR
Unilateral vestibular damage results in two types of abnormality within VOR Static imbalance -difference in tonic discharge rate between vestibular nuclei on two sides spontaneous nystagmus

Loss of dynamic sensitivity - during rotation decreased gain of VOR Oscillopsia

Smith and Curthoys,1988

Tests for VOR

Head thrust (Halmagyi and Curthoys,1988) Head shaking nystagmus test

Vestibular Dynamic Visual acuity test Calorics

Head Thrust test

Patient fixates on a target (examiners nose). Eye position observed after rapid thrust of head to right and left. During head thrust toward side of lesion, there is catch up saccade.

Head shaking nystagmus test

Patient closes eyes and flexes head down to 30, then head oscillated 20 times in the horizontal plane. At the end if VOR impaired, nystagmus to opposite side of lesion.

Saccades
check saccades i.e fast eye movements look back and forth between 2 targets and observe: reaction time (latency) accuracy velocity

Saccadic abnormalities: CNS pathology or ocular myopathy

Cerebellar dysmetria
under or over-shooting (hypo- or hypermetria)

Internuclear ophthalmoplegia (INO)

(failure of adduction, nystagmus in abductimg eye)

Lesion of parapontine reticular formation (PPRF)

(contralateral gaze palsy)

Lesion of frontal cortex (ipsilateral gaze palsy) One and a half syndrome
Failure of conjugate gaze in one direction in INO and other

Supranuclear degeneration (Steele-RichardsonOlszewski) Latency with vertical EM affected before horizontal

Smooth pursuit i.e tracking eye movements

check in both horizontal and vertical planes
if pursuit is broken, in which direction?

Abnormalities of smooth pursuit

Horizontal
Cerebellum Pons Parieto-occipital lobe

Vertical
Downward: low brainstem Upward: pre-tectal, basal ganglia Note: age, alcohol, psychotropic medication, anticonvulsants

Adaptation in vestibular hair cells

It avoids saturation of hair cell responsiveness by large or sustained stimuli It allows a cell to detect small stimuli in the presence of an enormous background input It places the hair cell bundle in a sensitive region of its operating domain

BPPV Vestibular neuritis Herpes zoster oticus Meniere's disease Labyrinthine concussion Perilymphatic fistula Semicircular canal dehiscence syndrome Cogan's syndrome Recurrent vestibulopathy Vestibular schwannoma (acoustic neuroma) Aminoglycoside toxicity Otitis media CENTRAL ETIOLOGIES Migrainous vertigo Brainstem ischemia TIA Wallenberg's syndrome Cerebellar infarction and hemorrhage Chiari malformation

BPPV
The dizziness is brief usually seconds, rarely minutes when turning in bed or tilting the head nausea but rarely vomit predictably provoked and continue for weeks or months Episodes may recur. Diagnosis History Dix-Hallpike positive in only 50 to 80%

Vestibular Neuritis
Rapid onset severe, persistent vertigo (one or two days) Nausea, vomiting and gait instability

spontaneous vestibular nystagmus, a positive head thrust test, and gait instability without a loss of the ability to ambulate
Cerebellar haemorrhage or infarction may be similar

Meniere's disease
Peripheral vestibular disorder Excess endolymphatic fluid pressure episodic inner ear dysfunction spontaneous episodic vertigo minutes to hours unilateral tinnitus, hearing loss, and ear fullness the vertigo is often severe nausea and vomiting and disabling imbalance The disequilibrium may last for several days Horizontal-torsional nystagmus is typically seen on examination during an attack

Compensation upon unilateral lesion

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Left Vest Nucl

Right Vest Nucl

Prevalence of unexplained symptoms in medical clinics at UK Teaching Hospital

Clinic Chest Cardiology Gastroenterology Rheumatology Neurology Dental Gynaecology Total Prevalence (95% CI) 59% (46-72) 56% (46-67) 60% (45-73) 58% (47-69) 55% (45-65) 49% (37-61) 57% (50-68) 56% (52-60)
Prof. S. Wessely, BMJ. 2001 March 31; 322(7289): 767

One study showed 20% of consecutive patients evaluated in a dizziness clinic had panic disorder (Clark et al 1994)

Anxiety / panic attacks secondary to vestibular dysfunction

The reported incidence is 15-28%

15% Stein et al 1994 16% Sullivan et al 1993 17.2% Persoona et al 2003 20% Yardley and Beech 2001 20.4% Clark and Leslie 1992 26% Honrubia et al 1996 27.8% Yardly and Masson 1992

The reported incidence of Depression secondary to vestibular dysfunction 5-38%

5% Sullivan et al 1993 7.1% Yardly and Masson 1992 11% Kroenke et al 1993 11.2% Persoona et al 2003 37.4 % Honrubia et al 1996 38 % Eagger at al 1991

Vestibular Anxiety and Panic - two types

Primary (early/somatic)
hard wired component Immediate somatopsychic response to disorientation Instinctive

Secondary (late/cognitive)
Fear (cognition) regarding future attacks of dizziness Its social consequences and disability Worries about illnesses such as tumours/ mental illness Begins when pt begins to worry about significance of symptoms

Jacob RG et al 2003

Rehab is the Key to the management of vestibular imbalance

Balance-Anxiety Link
Parabrachial nucleus (PBN) network mediate visceral, vestibular and extra-vestibular information PBN network generate emotional, affective and physiological manifestations of fear and anxiety

(Balaban and Thayer, 2001)

1.

Prof. Floris Wuyts, Head of the Vestibular Function Lab & Research, University Antwerp (Research co- operation with NASA) Baloh and Honrubia, Clinical Neurophysiology of the Vestibular System, Oxford publication, third edition

2.

3.

Clark, D. B., Hirsch, B. E., Smith, M., Furman, J. M. R., & Jacob, R. G. (1994). Panic in otolaryngology patients presenting with dizziness or hearing loss. American Journal of Psychiatry, 151(8), 1223-1225.
Prof. S. Wessely, BMJ. 2001 March 31; 322(7289): 767

4.