The StR Vestibular Disease Study Day - May 21st 2021

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The day will be done via Zoom and starts at 10am. This is unfortunate, but we must make the most of what opportunities we can get.

 

The aims of the day are simple enough. I want to cover the parts of the ISCP Curriculum that usually cause difficulty for doctors of all degrees of seniority. We will discuss basic physiology and pathophysiology because this enhances our understanding of the system of balance, why the patient complains of the symptoms that they do, why we see physical signs, and what we can do for the patient.

 

Detailed descriptions of individual diseases is not really a part of the day but we will talk about some and I will direct you to good articles / books for learning factual knowledge for clinical life and examinations.

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Naturally, this won't be a skills training day which is a pity because how we examine a patient profoundly influences what we find. Skills training can be gained from your Consultants to some extent but I would recommend that you seek out your audio-vestibular teams as these will be able to show you how to examine and show the pitfalls of poor examination. Some of the bigger units in Wales use audio-vestibular services almost exclusively to see new patients with balance problems, and other units are looking to do this too. This means that those departments will become your best source of training in the future.

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Proposed Order of Service (subject to variation as the day needs).

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Introduction / Housekeeping

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Preliminary assessment of pre-reading knowledge - Forms based quiz

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Presentation on vestibular physiology

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Kahoot! study of vestibular compensation key facts

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Break 1.

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Group work on the vestibular histories presented below

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Break 2.

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Presentation on HINTS

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Depending on time...Disequilibrium of Ageing +/- pathophysiology of the fistula test

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Summary and close

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Here are the links to the various assessments during the day.

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1. Vestibular anatomy and physiology assessment.

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2. Nystagmus assessment.

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3. Kahoot! session on vestibular compensation.

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Cases for group discussions.

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Case 1.

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A 54 yr. old lady presents as a follow-up with continued attacks of severe dizziness. She says that they happen often and that she usually has a sensation of pressure in her left ear before they come. She gets tinnitus and deafness with the attacks but these wear off when her balance returns to normal.

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She is otherwise well apart from frequent migraine which she manages using relaxation techniques. She has severe neck pain and stiffness following a road traffic accident prior to her last review. These problems persist. She needs to drive for work.

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The last doctor she saw told her to take betahistine and prochlorperazine. She has been taking these three times daily since her last review six months earlier.

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At the last appointment she was sent off for tests, she says. Your review of the notes finds a letter from the audiology department and there is an MRI to review.

 

Physical examination of her ears and balance system is normal on the day of review but a head impulse was impossible due to neck pain.

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Her audiogram shows symmetric, cookie bite losses in sensory function.

 

Her audiovestibular work up is as follows:

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Left canal paresis of 19%

Left directional preponderance of 35%

VHIT not performed due to neck pain

HHIT not performed due to neck pain

Smooth pursuit normal

Saccades normal

Dix-Hallpike not possible due to limitations in neck mobility

CTSIB within normal limits for age

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Otoscopy normal

DHI: 73/100

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1. What is your differential diagnosis?

2. What further investigations would be appropriate to refine your diagnosis?

3. What is Jongkee's formula and what is it used for used for?

4. What is the DHI and what are the three domains within it?

5. What are the normal ranges for canal paresis and directional preponderance?

6. Why are video head impulse tests preferred to caloric stimulation these days?

7. What will your initial management be? ​

8. What other advice does the patient need?

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Case 2.

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A 67 yr. old lady attends with dizzy spells that are frequent. She cannot tell you exactly how it feels but she thinks that it happens every day and that it lasts for minutes. Most of the day she is fine but getting into bed causes problems with the dizziness. Once she is lying down she does not move much in case she feels dizzy again. When walking she feels unsteady especially at night. She is on hypertensive medication and a statin. Her hearing is declining and she gets tinnitus at night.

 

Physical examination is limited because she has a bad back on the day of her consultation and can’t lie down. Her ears look normal and she has normal saccades. Her smooth pursuit is a little jerky. Horizontal head impulse testing is normal. Pupils are symmetrical and respond both directly and consensually to light. Audiometry finds bilateral high-frequency sensory deafness of a moderate degree.

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At the end you are pretty sure she has BPPV but you can't easily confirm it, and there are possible alternatives to be ruled out.

 

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1. What is your differential diagnosis and how would you confirm from which differential she was suffering? 

2. Examination is incomplete due to her back pain. What clinical test do you most want to do on this lady?

3. How can you get around the limitations on examination imposed by her back pain?

4. If you confirm BPPV using alternative examination methods, how are you going to treat it?

5. What is the relevance of her hearing difficulty and tinnitus to the diagnosis? 

6. Does she require an MRI scan of her internal acoustic meatus? 

7. What medication might you prescribe? 

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When you are eventually able to examine this patient, with the help of a colleague to stabilise her, you find that she has a geotropic torsional nystagmus with her left ear to the ground. It has a latent period and is fatiguable, but shows no reversibility. You perform a left-sided Epley manoeuvre and offer suitable post-Epley advice.

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She returns to clinic after two weeks feeling no better. The only examination finding that has changed is that she now has a persisting geotropic, non-torsional nystagmus with the left ear downwards. Her right sided examination is normal.

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1. What is the diagnosis?

2. How will you cure her?

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Case 3.

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A 75 yr. old man attends the Accident Department where you work. Your CT1 sees him first and calls you with their findings.

 

The patient complains of intense vertigo and has had it for a few hours. He is nauseated and has vomited. He is pale and sweaty and resents any movement as it makes him feel worse. He complains of hearing loss in the right ear and wears a hearing aid. The loss is not new and neither is his tinnitus, which is only present in the right ear.

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The PMH includes: well-controlled Type 1 diabetes, hypertension (on a calcium channel blocker), age related macular degeneration.

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His BP is 180/110 on admission and his pulse is 95. His GCS is 15 and MEWS 0. He is not slurring his words but cannot stand up unaided. The CT1 says that he has nystagmus but that his cranial nerves are normal. The patient looks a little dehydrated.

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1. What eye signs must you look for that confirm that the patient has an ear related disease and not a stroke? 

2. What is the name of these tests?

3. If you think that he has had a stroke, what symptoms should you elicit by questioning? 

4. Your examination supports a diagnosis of a vestibular disease and not a neurological one. What is the most likely diagnosis? You may offer a differential here if you wish.

5. What will your initial treatment approach be?

6. What things will stop the patient from making a full recovery?

7. What learning points will you discuss with your CT1 during a debrief later?

8. Which nerve does vestibular neuritis preferentially affect and why?

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Case 4.

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A 54 yr. old lady presents to ENT OPD from Audiology with dizziness.  She has had dizziness most of the time for the last six months or so and it is causing her great difficulty with her work as a wine sales-person. Her job requires her to drive and to be around people in a busy wine shop. She finds that her dizziness makes her anxious at work because she fear stumbling into a display and also being judged for being drunk by others.

 

At work she has taken to sitting down and doing telesales work instead because she doesn't feel dizzy while sitting, only when she is up and moving around. She says that she has good days and bad days and, on bad days, she fears turning her head as it makes her feel much worse. She had hoped that working from home during lock-down would help her recover but she has found it very distressing using a computer as her symptoms worsen. Now she is back in the sales room, things are worse and she fears for her job security.

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She has had no change in her hearing, no tinnitus, and no otorrhoea. Her eyesight is good and she has no serious ongoing medical problems. She recalls an attack of vertigo about a year ago. It lasted several days and she was stuck in bed with vomiting at the time. Following that event she experienced brief vertigo while rolling in bed and her doctor 'spun me around on a couch and it has been gone ever since'. He current dizziness does not feel the same, she says.

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'What with the bad vertigo a year ago, the dizzy spells that I had afterwards, and now this, I'm at my wits end', she says.

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Your clinical examination is normal. She is not on any medicines.

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The Audiology department supply vestibular function tests in their referral. They show:

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Normal saccades and smooth pursuit

Equally reactive pupils

Impulse testing for all six canals found them normal

No calorics were done

Gait appeared a little stiff and cautious

Romberg's was normal

Tandem gait was normal as was quiet stance on a compliant surface with eyes open and closed

Audiometry was normal

PHQ-9 is 10

DHI 80

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Audiology have tried a course of vestibular rehabilitation but this has failed, hence their referral to you.

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After some head scratching, you think that the patient has PPPD.

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1. What does PPPD stand for?

2. What are the Bárány Society diagnostic criteria for PPPD?

3. Why have balance exercises failed?

4. How will you describe the problem to the patient?

5. What medications may help?

6. Are there other therapies that may assist?

7. Would you request an MRI scan, and why?

8. Is life time adversity (eg bullying at work, relationship problems) more common in PPPD sufferers?