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As the World Turns Andrew K. Chang, MD, FACEP

As the World Turns: Vertigo in the Emergency Department

Andrew K. Chang, MD, FACEP Department of Emergency Medicine Albert Einstein College of Medicine Montefiore Medical Center

Teaching points to be addressed

Case Presentation

• What differentiates peripheral from central vertigo? • What differentiates benign paroxysmal positional vertigo (BPPV) from other causes of peripheral vertigo, such as labyrinthitis and vestibular neuritis? • What is the treatment of choice for BPPV?

• 67 year-old man • Rolled over in bed • After a few seconds delay, he developed nausea and felt as if the room was spinning • Symptoms resolved within 30 seconds • Room spun in the opposite direction when he rolled back to his original position

Andrew K. Chang, MD

Andrew K. Chang, MD

Past Medical History & Social History • Hypertension, on atenolol • No surgeries • Nonsmoker, occasional alcohol

Physical Exam • • • • •

VS: 37.2, 145/85, 90, 18, sat 98% Alert, anxious Head, eyes, ears, neck exam: normal Cardiac exam: normal Rest of exam: normal

• Neurologic exam (detailed): normal

Andrew K. Chang, MD

Andrew K. Chang, MD

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As the World Turns Andrew K. Chang, MD, FACEP Differential Diagnosis • Peripheral Vertigo

Your Differential Diagnosis?

• • • •

Benign paroxysmal positional vertigo (BPPV) Vestibular neuritis Labyrinthitis Meniere’s disease

• Central Vertigo • Stroke/Vertebrobasilar insufficiency

Andrew K. Chang, MD

ED Course

Hallpike Test

• A diagnostic Hallpike test was performed • Torsional nystagmus and reproduction of symptoms in the right head-hanging position • Asymptomatic in the left head-hanging position

Andrew K. Chang, MD

Hallpike Video Clip

Andrew K. Chang, MD

Nystagmus video clip

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As the World Turns Andrew K. Chang, MD, FACEP ED course

BPPV

• The Epley maneuver was performed at the patient’s bedside with complete resolution of symptoms • No imaging or lab tests done • No intravenous line placed • Length of stay 20 minutes • Patient very grateful

• Benign Paroxysmal Positional Vertigo • Age • Head trauma

Andrew K. Chang, MD

Characteristic story

Andrew K. Chang, MD

Dissecting the acronym “BPPV” • “B” = Benign

• • • •

Turn head After a few seconds delay, vertigo occurs Resolves within 1 minute if you don’t move If you turn your head back, vertigo recurs in the opposite direction

• Not a brain tumor • Can be severe and disabling

Andrew K. Chang, MD

Dissecting the acronym “BPPV” • “P” = Paroxysmal

Andrew K. Chang, MD

Dissecting the acronym “BPPV” • “P” = Positional

• Episodic, not persistent • Helpful feature in the differential diagnosis

Andrew K. Chang, MD

• Occurs with position of head • Turning over in bed • Looking up • Bending over

Andrew K. Chang, MD

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As the World Turns Andrew K. Chang, MD, FACEP Dissecting the acronym “BPPV” • Peripheral

• “V” = Vertigo

• CN VIII • Vestibular apparatus

• An illusion of motion • “The room is spinning” • Other descriptions • • • •

Vertigo • Central • Brain stem • Vestibular nuclei in medulla and pons

• Cerebellum

Rocking Tilting Somersaulting Descending in an elevator

Andrew K. Chang, MD

Vertigo PERIPHERAL Onset

Tinnitus/hearing loss

Sudden Severe Paroxysmal Frequent Absent Can be present

Nystagmus

Torsional/horizontal

Nystagmus

Fatigable

Intensity Duration Nausea/Diaphoresis CNS signs

Andrew K. Chang, MD

Anatomy: Membranous labyrinth CENTRAL Slow, gradual Ill defined Constant Infrequent Usually present Absent Vertical Non-fatigable

• Semicircular canals • Utricle • Endolymph

Andrew K. Chang, MD

Andrew K. Chang, MD

Anatomy: Semicircular canals • Semicircular Canals (SCC)

Anatomy: Utricle • Utricle

• Horizontal • Anterior • Posterior

• Connected to SCC • Contains endolymph • Otoliths (otoconia) • Calcium carbonate • Attached to hair cells • Macule (end organ)

• Cupula • End organ receptors

• Endolymph

Andrew K. Chang, MD

Andrew K. Chang, MD

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As the World Turns Andrew K. Chang, MD, FACEP Vestibular system • Tells brain which way the head moves without looking • SCC: angular acceleration • Utricle: linear acceleration

Andrew K. Chang, MD

Physiology

• Otoliths become detached from hair cells in utricle • Inappropriately enter the posterior semicircular canal1

1. Parnes LS, McClure JA. Laryngoscope 1992;102:988-92.

Andrew K. Chang, MD

Pathophysiology of BPPV

• Normal situation

• BPPV

• As one turns head to the right • Endolymph moves ÆSCC receptors fire Æ “head turning right” • Stop turning headÆ endolymph stops moving Æ SCC receptors stop firing Æ “head has stopped moving”

Andrew K. Chang, MD

The Epley Maneuver • • • •

Pathophysiology of BPPV

• Stop turning head Æ otoliths keep moving Æ drag endolymph Æ receptors continue to fire inappropriately Æ “head is still moving” • Eyes Æ “head is NOT moving” • Brain Æ room must be spinning in the opposite direction Andrew K. Chang, MD

Epley maneuver • Canalith repositioning maneuver • 5 step head hanging maneuver

First described in 19922 Bedside > 80% cure rate 2,3 Immediate relief

• Moves otoliths out of the posterior semicircular canal and back into utricle where they belong 2. 3.

Epley J. Otolaryngol Head Neck Surg 1992;107:399-404 Lynn S, et al. Otolaryngol Head Neck Surg 1995;113:712-20. Andrew K. Chang, MD

Andrew K. Chang, MD

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As the World Turns Andrew K. Chang, MD, FACEP Epley maneuver

Epley maneuver

• 1. Repeat Hallpike • Previously performed diagnostic Hallpike test tells you the starting position (right or left)

• Turn head 90 degrees in the other direction

Andrew K. Chang, MD

Epley maneuver • 3. Patient rolls onto shoulder, rotates head and looks down towards floor

Andrew K. Chang, MD

Epley maneuver • 4. Patient sits back up • 5. Head forward

Andrew K. Chang, MD

Epley maneuver

Andrew K. Chang, MD

Andrew K. Chang, MD

Epley maneuver (video clip)

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As the World Turns Andrew K. Chang, MD, FACEP Epley maneuver

The Epley Maneuver • Contraindications4

• Repeating the Epley maneuver • Post procedure • Remain upright for 8-24 hours

• • • • •

Unstable heart disease High grade carotid stenosis Severe neck disease Ongoing CNS disease (TIA/stroke) Pregnancy beyond 24th week gestation (relative)

4. Furman JM, Cass SP. N Engl J Med 1999;341:1590-96 Andrew K. Chang, MD

Complications • Vomiting

Andrew K. Chang, MD

Lab studies • In a straightforward case, no lab studies are needed!

• IV promethazine

• Converting to horizontal canal BPPV • Bar-b-que maneuver

• Hemoglobin • Fingerstick glucose • Electrolytes if prolonged vomiting

Andrew K. Chang, MD

Medications

Andrew K. Chang, MD

Consultations

• Sensory Conflict Theory

• Will depend upon institution (neurology vs. otolaryngology)

• Class A: benzodiazepines • Prevents process of vestibular rehabilitation

• Class B: anticholinergic • Scopolamine: takes 4-6 hrs; not effective in ED

• If not better with Epley maneuver • If focal neurologic exam

• Class C: antihistaminic • IV promethazine (Phenergan) • PO meclizine (Antivert)

Andrew K. Chang, MD

Andrew K. Chang, MD

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As the World Turns Andrew K. Chang, MD, FACEP Summary

Teaching points

• BPPV may be a severe and incapacitating disease • Diagnosis via history, nonfocal neurological exam, and a positive Hallpike test • Treatment is with the Epley maneuver • IV promethazine (Phenergan) is probably the best ED medication if one is needed

• What differentiates peripheral from central vertigo? • What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? • What is the treatment of choice for BPPV?

Andrew K. Chang, MD

Teaching points • What differentiates peripheral from central vertigo? • Peripheral vertigo is more intense, has a sudden onset, is paroxysmal, has fatigable and rotatory nystagmus, and has a nonfocal neurological examination

Andrew K. Chang, MD

What differentiates BPPV from labyrinthitis and vestibular neuritis (VN)? • BPPV • Requires head movement • Duration of seconds • Usually in elderly • No relation to viral syndrome • Responds to Epley maneuver

• Labyrinthitis/VN • No head movement needed • Duration of hours/days • Any age • Viral syndrome usually precedes • Epley maneuver is ineffective

Andrew K. Chang, MD

Andrew K. Chang, MD

Teaching points • What differentiates peripheral from central vertigo? • What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? • What is the treatment of choice for BPPV?

Andrew K. Chang, MD

Teaching points • What differentiates peripheral from central vertigo? • What differentiates benign paroxysmal position vertigo (BPPV) from other cause of peripheral vertigo, such as labyrinthitis and vestibular neuritis? • What is the treatment of choice for BPPV?

Andrew K. Chang, MD

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As the World Turns Andrew K. Chang, MD, FACEP Teaching points • What is the treatment of choice for BPPV? • The Epley maneuver (canalith repositioning maneuver)

Questions??? FERNE

www.ferne.org

[email protected] Andrew K. Chang, MD