Evaluation of Dizziness Best Practices David R Friedland, MD, PhD

Professor and Vice-Chairman Chief, Division of Otology and Neuro-otologic Skull Base Surgery Chief, Division of Research Department of Otolaryngology and Communication Sciences Medical College of Wisconsin, Milwaukee, WI

Financial Disclosures • No conflicts of interest or disclosures relevant to this topic • Some work presented herein was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant Number 8UL1TR000055. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Vestibular Disorders Program • To efficiently, effectively and appropriately care for patients with vestibular chief complaints

Otologic Dizziness • • • • • • •

Presbystasis Benign Paroxysmal Positional Vertigo Meniere’s Disease Vestibular Neuronitis / labyrinthitis Ototoxicity Superior canal dehiscence / fistula Acoustic neuroma

Non-Otologic Dizziness • • • • • • • •

Vestibular migraine Depression Anxiety Neuropathy Multiple sclerosis Chiari malformation Arrhythmia / Cardiac Sleep apnea

• • • • • • • •

Respiratory Orthostatic Musculoskeletal Stress Cervicogenic Neurosurgical Pharmaceutical Visual

Vestibular Disorders Program - MCW • 10-page intake questionnaire sent to every new vestibular patient • Responses are analyzed to derive a likely diagnosis and scheduling protocol • A small subset of responses are helpful in predicting the most common disorders

Frequency of Diagnoses Final Diagnosis

Final Ear-Related Diagnosis

Almost all were migraine related

212 consecutive questionnaires

Most Common Disorders • BPPV • Meniere’s Disease • Vestibular Migraine

BPPV Benign Paroxysmal Positional Vertigo

Clinical practice guideline: benign paroxysmal positional vertigo Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RW, Whitney SL, Haidari J; American Academy of Otolaryngology-Head and Neck Surgery Foundation.

Otolaryngol Head Neck Surg. 2008;139:S47-81.

Strong Recommendation • Diagnose posterior canal BPPV if positive DixHallpike

Recommendation • Treat posterior canal BPPV with CRP/Epley maneuver • Differentiate BPPV from other causes of dizziness • Perform supine roll test if Dix-Hallpike negative • Factors that may modify treatment for BPPV • Reassessment within 1 month of treatment • Reevaluate initial treatment failures for persistent BPPV or other causes

Option • Offer vestibular rehabilitation • Offer observation

Clinical Practice Guideline: No recommendation for/against audiometric testing in patients diagnosed with BPPV

Clinical Practice Guideline: Strong recommendation to diagnosis posterior canal BPPV when vertigo associated with nystagmus provoked by Dix-Hallpike maneuver

Dix-Hallpike Testing

Clinical Practice Guideline: Recommendation to perform supine roll test if history compatible with BPPV and Dix-Hallpike negative (sensitivity/specificity/PPV/NPV have not been determined)

Supine Roll Test • Assess for horizontal canal BPPV • Represents 5-15% of cases of BPPV • Two types (both direction-changing):

1. Geotropic: nystagmus beats toward undermost ear 2. Apogetropic: nystagmus beats away from undermost ear

• Shorter latency, longer duration, poor fatigability, greater vertigo intensity, emesis

OHNS, CPG 2008

Clinical Practice Guideline: Recommendation to treat patients with posterior canal BPPV with a repositioning maneuver (no comment regarding lateral/superior canal variant)

Clinical Practice Guideline: Option to offer vestibular rehabilitation as initial treatment

Meniere’s Disease

Diagnostic Criteria - 2015 • Lopez-Escamez et al. (2015) Diagnostic Criteria for Meniere’s Disease. J Vest Res 25(1):1-7 • Consensus statement of the Equilibrium Committee of the AAO-HNS, Classification Committee of the Barany Society, Japan Society for Equilibrium Research, European Academy of Otology and Neurotology, and Korean Balance Society

Diagnostic Criteria - 2015 • Definite Meniere’s Disease – Episodic vertigo • 20 minutes to 12 hours

– Low-to-medium frequency sensorineural hearing loss – Fluctuating aural symptoms • Hearing, tinnitus, and/or fullness in affected ear

Diagnostic Criteria - 2015 • Probable Meniere’s Disease – Episodic vestibular symptoms • Vertigo or dizziness • 20 minutes to 24 hours

– Fluctuating aural symptoms • Hearing, tinnitus, and/or fullness in affected ear

Meniere’s Disease Episodic Vertigo

• Recurrent and episodic • Vertigo • Last 30 minutes to ~4 hours (0.20 is likely BPPV – Sensitivity of 79% – Specificity of 65%

• If LP(Meniere’s)>0.15 is likely Meniere’s – Sensitivity is 81% – Specificity is 85%.

• If LP(Migraine)>0.25 is likely migraine-related – Sensitivity is 76% – Specificity is 59%

Vestibular Patient Algorithm New Vestibular Patient: Give Intake Questionnaire Analyze Intake Questionnaire Using Predictors

Likely BPPV

Likely Meniere’s

Likely Migraine

Consider Audiogram or other testing (VNG; ECoG) with Appointment

Vestibular Therapy

MD Evaluation

Recommend Neurology

Vestibular Disorders Conclusions

• Complex and complicated chief complaint • History is a significant part of diagnosis • Appropriate triage reduces lag time, reduces redundancy, reduces multiple provider visits, reduces tests, and can improve patient and provider satisfaction • Mathematical predictors may be a useful tool for triage