Transcript Introduction
Guidelines on vertigo
1. Introduction
In 1985, the Royal Belgian Ear Nose and Throat, Head and Neck Surgery Society and the Belgian Professional Union of Ear Nose and Throat, Head and Neck Surgery founded the Otoneurological and Expertie’s Commission. Since this time, the Professor R. Bonivrer is the president. Actual members of this commission are :
Professors Christian DESLOOVERE, Naïma DEGGOUJ , Floris WUYTS,
Physicians Sarah CASTELEYN, Stéphane DEJARDIN, Chantal GILAIN, Catherine HENNAUX, Christian VAN NECHEL. In 1986, the publication, in the Acta O.R.L. Belgica of expertise’s recommendations for ear nose and throat specialists already talk about vestibular exploration. Anne ENGLEBERT, In lack of evidence based medicine for this specific subject and under Doctor ROBILLARD’s impulse, the commission, since December 2003, wrote guidelines on exploration and treatment of vertigo. Those recommendations are established both on the commission’s members experience and the daily scientific advances on vertigo. Specials articles wil be joined in the publication in B-ENT, the journal of the Royal Belgian ENT Society : they explain tests and explorations. An (*) sign rises to annexes. Guidelines are based on more recent otoneurological’s findings and will be actualised in the future. Annexed references give lector’s possibility to go deeper on this subject.
2. Patient history
2.1. Vertigo or dizziness
Description (rotatory vertigo, horizontal or vertical linear sensations , postural imbalance) Start, duration, frequency Provocative event (e.g. position, orthostatism, spontaneous, Valsalva, Tullio (*)) Initial manifestations Autonomic symptoms Gait : quality and perturbating factors Direction of body tilt or imbalance (lateral, posterior ) Falls : circumstances (curent occupations, situation)
2. Patient history
2.1. Vertigo or dizziness
2.1.1. Visual influence (*)
Mobile environment intolerance Acrophobia (*) 2.1.2. 2.1.3. Agoraphobia (*), Anxiety (HAD and PHQ scale annexed) (*) Effect on life quality evaluation (DHI scale annexed) (*)
2.2.1. 2.2.2. 2.2.3. 2.2.4. 2.2.5.
2. Patient history
2.2. Otologics symptoms (for each complain, look for the laterality and the temporality with vertigo)
Hypoacousia of hyperacousia, fluctuating hearing, diplacousia, distorsion Tinnitus continuous, pulsating, positional Hearing fulness or pressure Otalgia Otorrhea
2. Patient history
2.3. Visual manifestations (*)
2.3.1. 2.3.2. 2.3.3. 2.3.4. 2.3.5. Amaurosis Horizontal or vertical diplopia Oscillosia Visual field inversion Refraction correction related
2. Patient history
2.4. Neurological manifestations (precise temporality with vertigo)
2.4.1. 2.4.2. 2.4.3. 2.4.4. Migraines, headache and facial pain Sensitive and motors manifestations (e.g. Precision movement of superior members) Symptoms related to other cranial nerves disorders Symptoms related with cervical spine disorders (e.g. cervicalgia)
2.5.1. 2.5.2. 2.5.3. 2.5.4. 2.5.5. 2.5.6. 2.5.7. 2.5.8. 2.5.9. 2.5.10. 2.5.11. 2.5.12. 2.5.13.
2. Patient history
2.5. Prior history
Hereditary (according to curent pathology study) E.N.T. Neurologicals Traumatics Cardio-vascular and vascular risk factors (hypertension, diabete, cholesterol, smoking Metabolic and hormonal Infectious Immunological Locomotricity (rheumatologic, orthopedic) Strabismus, amblyopia, multifocal refracted lenses (*) Gait habits (lack of activity, long time lying position …), Sport (diving …) Occupation Toxic (drugs, professional, alcohol, smoking)
2. Patient history
2.6. Treatment
Curent, recent modification Prior (ototoxic) Physiotherapy, cervical manipulation, vestibular training or repositioning maneuvers (to be precised)
3. Clinical examination
3.1. Otorhinologic
3.1.1. 3.1.2. Otomicroscopic examination Rhinologic exam depending on symptoms
3.2. Oculomotor and nystagmus
3.2.1. Visual control test 3.2.1.1. Gaze holding hability 3.2.1.2. Vertical or horizontal ocular misalignment (*) 3.2.1.3. Restriction in ocular amplitud movements 3.2.1.4. Smooth pursuit and saccade testing 3.2.1.5. Inibitory testing of vestibulo-ocular reflex (VOR) (*) 3.2.2. Halmagyi test(*)
3. Clinical examination
3.2. Oculomotor and nystagmus
3.2.3. 3.2.3.1. Under videoscopic or Frenzel glasses (without fixation) Spontaneous and other gaze holding abnormalities 3.2.3.1.1. 3.2.3.1.2. Vestibular nystagmus (*) Non vestibular nystagmus (*) 3.2.3.2. Positioning nystagmus (to be done at the end of the clinical evaluation)(*) 3.2.3.2.1. 3.2.3.2.2. 3.2.3.3. Méthodology (patient sitting, head to knees, supine, 90°lateal rotating of the whole body and head to the right and after to the left, supine + head rotating, Hallpike or Brandt and Daroff, Rose ) sequences not necessary in this order (*) Clinical signification (diagnostic criterias) Horizontal and vertical Head shaking test (*) 3.2.3.3. Dynamic visual hability (*)
3. Clinical examination
3.3. Other cranial nerves
Face sensitivity defect (If neurinoma is suspected, complete facial sensitivity exploration, front pain sensitivity and corneal reflex included) Claude Bernard Horner’s sign Face and oropharyngolaryngal sensitivity
3.4. Members
3.4.1. Superior’s members cerebellars signs (dysmétria, adiadocokinesia) 3.4.2. Sensitive or motor inferior members defect
3. Clinical examination
3.5. Stato-kinetic tests
3.5.1. 3.5.2. 3.5.3. 3.5.4. 3.5.5. 3.5.6. Index’s test, finger pointing test Romberg’s test (standard or sensitivated) Unterberger or Fukuda (*) Standard gait and star’s gait tests Gait exploration Dynamic Gait Index*
4. Diagnostic Progression
4.1. Isolated Vertigo 4.1.1. Isolated positioning vertigo (*) 4.1.1.1. Positioning vertigo : 1° episod 4.1.1.1.1. If history evocative of benign paroxysmal positioning vertigo (BPPV.) Otomicroscopy and hearing test Searching for the pathological canal Execute the Repositioning maneuver After one week see : If asymptomatic : end of investigation If residuals symptoms still after 2 or 3 repositioning maneuvers : see 4.1.1.1.2. 4.1.1.1.2. If history and clinical presentation “atypic” Baseline explorations : Complete clinical examination(see chapter 3), Hearing test, Brainstem Evoked Response Audiometry (BERA), Videonystagmography (VNG) Electronystagmography (ENG) + oculomotricity, Subjective visual vertical perception test (SVV.), Vestibular Evoked Myogenic Potentials (VEMP) 4.1.1.2. Positioning vertigo : relapse Baseline exploration (seen in 4.1.1.1.2) + Temporal bone scanner if conductive hearing loss
4. Diagnostic Progression
4.1. Isolated Vertigo
4.1.2. Non positioning isolated vertigo 4.1.2.1. If baseline exploration (see 4.1.1.1.2.) non contributive: review patient history and test: Metabolic exploration (glycemia and thyroïd) Cardio-vascular exploration Psychological exploration (anxiety, phobia …) Migraines event 4.1.2.2. If baseline exploration suggesting labyrinthic pathology (see VNG or ENG criterias) Study of peripheral vestibular aetiologic pathology : If no result : VEMP to exclude inferior vestibular neuritis. If cardio-vascular risk : exploration 4.1.2.3. If baseline exploration finding nonlabyrintic pathology (see VNG or ENG, BERA, Oculomotricity criterias) Neurological exploration Specific neurological imaging
4. Diagnostic Progression
4.2. Vertigo and hearing signs
4.2.1. 4.2.2. In any case, baseline exploration : hearing test, fistula test, BERA, VNG or ENG + oculomotricity, VVS, VEMP Conductive hearing loss Tympanometry + acoustic reflex Temporal bone’s TDM if otosclerosis suspected, acqueduc dilatation, superior canal dehiscence syndrome … Perceptive hearing loss Tympanometry +acoustic reflex (level of reflex,"reflex Decay” test-R.D.T.) Supraliminar tests Otoacoustic-emissions Temporal bones and pontocerebellar angle MRI if retro-cochlear lesions suspected (EcoG if Meniere’s desease suspected) Genetic research if familial history (DFNA9)
4. Diagnostic Progression
4.3. Vertigo and neurological symptoms
4.3.1. Vertigo and headache or facialgy 4.3.1.1. Patient with unusual vertigo and brutal headache = Emergency (unusual intensity and localisation) Exploration have to be done within hours. 4.3.1.1.1. Latero-cervical pain: Look for vertebral dissection (MRI) 4.3.1.1.2. Occipital pain: Look for :
Expansive lesion of posterior fossa (infratentorial tumor, blood collection …) (TDM)
Arnold-Chiari decompensation (MRI)
Basilar aneuvrism (TDM)
4. Diagnostic Progression
4.3. Vertigo and neurological symptoms
4.3.1.2. Vertigo and usual known headache 4.3.1.2.1. vestibular migraine (*) Personal and familial history Usuals starting events like migraines 4.3.1.2.2. Anxious tension headache and vertigo Cervicalgia, whiplash Imbalance without vertigo
4. Diagnostic Progression
4.3. Vertigo and neurological symptoms
4.3.2.Vertigo, imbalance and visuals symptoms 4.3.2.1. Ocular desalignement or diplopia (*) 4.3.2.1.1. horizontal 4.3.2.1.1.1. convergent
Nuclear or post nuclear VI nerve lesion
Somewhere near vestibular nuclei Orbital trauma Convergent spasmus (post-traumatic) 4.3.2.1.1.2. divergent
Mesenceplalic lesion or nerve III
Orbital lesion 4.3.2.1.2. vertical 4.3.2.1.2.1. Skew, Ocular Tilt Reaction (*) Vertical saccades palsy in under- thalamic lesions near otolitics’s pathway 4.3.2.1.2.2 Nerve IV lesion (post-traumatic in 30%)
4. Diagnostic Progression
4.3. Vertigo and neurological symptoms
4.3.2.2. Non vestibular nystagmus and oscillopsia (*)
Gaze evoked nystagmus
Acquired pendular nystagmus
Flutter, opsoclonus Congenital nystagmus (idiopathic, latent uncompensed) Oculomotricity palsy (loss of vestibulo-ocular gain) 4.3.2.3. Excessive visual dependance (*) (generally after vestibular deficiency) 4.3.2.4. Post refraction change
Multifocal lenses
Important and recent refraction correction
4. Diagnostic Progression
4.4. Other vertigo
4.4.1. Child’s vertigos Like adult specifications but special attention to:
Serous otitis Familial history of migraines Tumor are more frequent Food Familial stress BPPV less frequent before 10 years of age
4. Diagnostic Progression
4.5. Imbalance without vertigo
4.5.1 Imbalance with hearing loss or not, without any neurological sign 4.5.1.1. Drug side effect or interference (local or general), ototoxicity 4.5.1.2 4.5.1.3 4.5.1.4. 4.5.1.5 Hemodynamic troubles
blood pressure
arythmia Metabolic troubles
diabete
dysthyroïdia
surrenal dysfunction Genetic (DFNA9 – COCH gene …) Anxiety, agoraphobia (*) 4.5.2. Combine with neurological defect Neurological exploration must be done
5. Laboratory examination
(Following §4 Diagnostic criteria indications) 5.1. 5.2. 5.3. 5.4.
5.5. 5.6. Hearing test Tonal, vocal, supraliminar depending on pathology Tympanometry/Stapedial (acoustic) reflex Auditory brainstem response Electrocochleography (If Meniere desease or perilymph fistula suspected) Otoacoustic-emissions Vestibular-evoked myogenic potentials (VEMP) (*)
5. Laboratory examination
(Following §4 Diagnostic criteria indications) 5.7. VNG or ENG (*norminative data)
5.7.1. Gaze holding in primar and lateral positions under fixation (20 to 30° maximum ) 5.7.2. Exploration for spontaneous and positional nystagmus without fixation 5.7.3. Ocular poursuit 5.7.4. Saccade analysis 5.7.5. Optokinetic poursuit 5.7.6. Rotatory/pendular tests 5.7.7. Caloric test (see “CRITERES ATTEINTE CENTRALE” in Acta ORL belgica 1986,40,907-915)
5. Laboratory examination
(Following §4 Diagnostic criteria indications) 5.8. Vertical or horizontal visual perception test (*) 5.9.
Posturography
5.9.1. Static 5.9.2. Dynamic
5.10. Vibratory nystagmus (*) 5.11. Otolith linear and rotatory test (*)
5.11.1. Excentric rotative test 5.11.2. OVAR
6. Treatment Strategy
6.1. Medical treatment (*) 6.2. Vestibular rehabilitation : soon in BE-ENT (Symposium in november 2005) 6.3. Psychologic approach (*)
6.3.1. Anxiolytic 6.3.2. Relaxation 6.3.3. Comportemental 6.3.4. Psychotherapia
6.4. Surgical Treatment (*)
• Norminative data in ENG and VNG • Benign paroxysmal nystagmus:diagnosis and treatment • Neuro-ophtalmological symptoms in vertigo and dizziness • Head shaking nystagmus • Vibration induced nystagmus • Tullio’s phenomenom • Vestibular evoked myogenic potentials • Unilateral centrifugation • Static and dynamic balance clinical investigation • Vertigo and psychological troubles • Medical treatment of vertigo • Surgical treatment of vertigo • Index
References
Brandt Th.
Vertigo. Its Multisensory Syndroms Springer Verlag Edit., 2th edition, 2000, ISBN, 3-540-19934-9 Leigh R.J., Zee D.S.
The Neurology of Eye Movement.
Oxford University Press, 1999, 3th edition Balow R.W., Honrubia V.
Clinical Neurophysiology of the Vestibular System.
Oxford University Press, 2001, 3th edition Luxon L.
Text book of Audiological Medicine.
Clinical Aspects of Hearing and Balance.
Martin Dunitz edit. London : 2003.
References
Brandt Th., Strupp M.
General Vestibular Testing.
Clinical Neurophysiology 2005, 116, 406-426 Fife T.D., Tusa R.J., Furman J.M., Zee D.S., Frohman E., Baloh R.W., Hain T., Goebel J., Demer J., Eviatar L.
Assessment: Vestibular testing techniques in adults and children.
Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.
Neurology 2000; 55: 1431-1441 Expertise Médicale en Oto-Rhino-Laryngologie. Recommandations.
Acta O.R.L. Belgica, 1986, 40, 907-915.
Vertiges chez l’Adulte : Stratégies diagnostiques.
Place de la rééducation vestibulaire.
On te Website www.anaes.fr
in Publications:Neurologie:Septembre 1997 ISBN 2 910653-33-1