Our errors in diagnosing dizziness slides


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Our errors in diagnosing dizziness slides

  1. 1. Best DoctorsPhysician WebinarsCase Studies in Diagnostic Errors:Our Errors in Diagnosing Dizziness
  2. 2. Hugh Calkins, MDNicholas J. Fortuin M.D. Professor of CardiologyProfessor of MedicineDirector, Cardiac Arrhythmia Services; Electrophysiology Laboratory; JohnsHopkins ARVD/C Program; Johns Hopkins AF CenterPresident, Heart Rhythm SocietyCliff A Megerian, MD, FACSProfessor and Chairman Otolaryngology-Head and Neck SurgeryCase Western Reserve University School of MedicineDirector Ear, Nose and Throat InstituteRichard and Patrica Pogue Endowed Chair in Auditory Surgery and Hearing SciencesUniversity Hospitals Case Medical Center, Cleveland, OhioJennifer Derebery, MDAssociate, House Ear Clinic, Inc.Clinical Professor, Department of OtolaryngologyUniversity of Southern California School of MedicineMartin Samuels, MD, MSc, FAAN, MACP, FRCPChairman, Department of Neurology, Brigham and Women’s HospitalProfessor of Neurology, Harvard Medical SchoolModerator and Panel
  3. 3. ACCME InformationOur Errors in Diagnosing DizzinessBest Doctors® is accredited by the AccreditationCouncil for Continuing Medical Education (ACCME)to provide Continuing Medical Education (CME) forphysicians.To view this CME activity (webinar), you will need aWindows or Mac operating system and todownload the WebEx conferencing software.To claim your CME credit, you will be provided witha brief CME questionnaire. Any information youprovide in this questionnaire is confidential thoughmay be used for reporting purposes to the ACCME.If you have questions about this webinar as anACCME activity, please emailphysicians@bestdoctors.com.
  4. 4. Disclosure InformationOur Errors in Diagnosing DizzinessThe panelists on today’s webinar have the following financial relationships to disclose:• Dr. Hugh Calkins has no relevant financial relationships to disclose• Dr. Jennifer Derebery has disclosed that she has the following financial relationships with:– Epic Hearing Healthcare• Board of Directors– Alcon Laboratories• Speakers Bureau– Sonitus Medical Inc.• Board of Directors; Member of Scientific Advisory Board– SRxA• Advisory board; Speakers Bureau– Sunovion Inc.• Advisory Board; Speakers Bureau– Teva• Advisory Board– Merck• Speakers Bureau– Janssen Pharmaceutical Companies• Research Support• Dr. Cliff Megerian has no relevant financial relationships to disclose• Dr. Martin A. Samuels has no relevant financial relationships to disclose• None of the Best Doctors staff who assisted in preparing the content of this webinar have relevant financialrelationships to disclose• No reference will be made to off label use and/or investigational use of pharmaceuticals/devices in this webinar
  5. 5. Dr. Samuels’ Case34 year old woman with dizziness, by which shemeans a sense of impending faint, only occurring inthe upright posture. The problem has been presentfor a couple of years but is clearly worsening in thepast few months. Meclizine yields no benefit. Shehas been told by an autonomic specialist that she haspostural orthostatic tachycardia syndrome (POTS).Midodrine causes hypertension but no benefit. Legcrossing with thigh clenching maneuvers havemodest benefit but less so in the past three months.
  6. 6. Examination• Blood pressure– Lying: 130/75– Sitting: 150/90– Standing: 110/65 with symptoms• Heart Rate– Lying: 72– Sitting: 84– Standing: 110 with symptoms• Cardiac examination is normal• Mental state is normal• Neurological examination is normal
  7. 7. Diagnosis?• Pheochromocytoma of the adrenal• Postural Orthostatic Tachycardia Syndrome(POTS)• Asymmetric septal hypertrophy• Takotsubo-like cardiomyopathy• Anxiety• Paraganglioma of the carotid bulb
  8. 8. Diagnosis?• Pheochromocytoma of the adrenal• Postural Orthostatic Tachycardia Syndrome(POTS)• Asymmetric septal hypertrophy• Takotsubo-like cardiomyopathy• Anxiety• Paraganglioma of the carotid bulb
  9. 9. Principles from Case:Adrenal Pheochromocytoma• POTS is a syndrome; not a diagnosis• Long term exposure to catecholamines leads todown-regulation of receptors in resistancevasculature (splanchnic and muscle)• Highest blood pressure in sitting position suggests acatecholamine secreting tumor in the abdomen• Paragangliomas are chromaffin cell tumors outside ofthe adrenal
  10. 10. Dizziness PanelJennifer Derebery MD FACSHouse ClinicLos Angeles, CA
  11. 11. “The Balance System”BrainVestibularsystemVisual systemProprioceptivesystem
  12. 12. Dizziness - Differential DiagnosisPeripheral Central SystemicMeniere’s Disease Acoustic neuroma Cardiac arrhythmiaAcute otitis media Brainstem CVA Cardiac valvular dz.Perilymphatic fistula CNS trauma Carotid stenosisCholesteatoma CNS neoplasm Orthostatic hypoten.Viral labyrinthitis Multiple sclerosis Alcohol intoxicationBacterial labyrinthitis Vertebrobasilar insuff. Sleep deprivationVestibular neuronitisMotion sickness Med. overdoseOtotoxicity Presbystasis Toxin exposureOtologic surgery Psychogenic disorders HypoglycemiaOtologic injury/trauma Arnold-Chiari malform. Autonomic dysf.Otosyphilis CNS infection HyperventilationBPPV Seizure disorder PanicMigraine
  13. 13. Differential Diagnosis of Dizziness in the Elderly• Presbystasis• Vestibular loss• Polypharmacy• CVA/TIA• Cardiac• Multifactorial• Labile BP/Orthostasis• BPPV• Meniere’s Disease• Vertebrobasilar insufficiency– Duplex Ultrasound studyBrainVestibularsystemVisual systemProprioceptivesystem
  14. 14. Urgent Cases• CNS (brainstem/cerebellar) infarct• CNS (brainstem/cerebellar) hemorrhage• CNS infection• Complicated otitis media– Acute purulent otitis media– Chronic otitis media withcholesteatoma
  15. 15. Diagnosis Based on the TemporalPattern of SymptomsSeconds BPPV, postural, centralMinutes TIA’s, centralHours Meniere’sDays Viral labyrinthitisConstant Metabolic, psychogenic,toxic, central
  16. 16. VertigoEpisodic ContinuousHearing + Meniere’s Labyrinthitisloss- BPPV VestibularneuritisThe Vertigo matrix
  17. 17. Recurrent BPPV?Migraine-associated Vertigo• Spontaneous or positionalvertigo• Head motion intolerance• Visual vertigo• Episodic – secs (10%) tominutes (30%) to hours(30%) to several days(30%)• Headache• Photo, phonophobia
  18. 18. The diagnosis of vestibular migraine is based on recurrentvestibular symptoms, a history of migraine, a temporalassociation between vestibular symptoms and migrainesymptoms and exclusion of other causes of vestibularsymptoms. Symptoms that qualify for a diagnosis ofvestibular migraine include various types of vertigo as wellas head motion-induced dizziness with nausea. Symptomsmust be of moderate or severe intensity. Duration of acuteepisodes is limited to a window of between 5 minutes and72 hours.Lempert T, et al. Vestibular migraine: diagnostic criteria. J Vestib Research.2012;22(4):167-72.Migraine-associated vertigo
  19. 19. Migraine-associated Vertigo• Any age• F > M• Family history common• Migraine HA’s often replaced by vertigo spellsin women around menopause
  20. 20. Migraine Associated VertigoTreatment• Beta-blocker – Propranolol 10mg po bid• TCA’s – Amitriptyline 25mg po qhs• Topiramate – 25mg po qhs• Acetazolamide• Triptans – acute Rx• Vestibular suppressants• Referral to Neurology
  21. 21. My Mistake in DiagnosisJennifer Derebery MD FACS
  22. 22. Patient 1• 89 yo active male is seen in consultationat the request of his primary care MDfor evaluation of dizziness and hearingloss.
  23. 23. History• Poor daily balance• Walks unassisted Has not fallen• Some hearing loss (no fluctuation)• Family complains• No aural symptoms with dizziness• C/o fatigue, increase sleepiness last 4 months
  24. 24. PMHx• HTN• No cardiac history• Non smoker• No history migraine• Parents had hearing loss with age• Some occupational noise exposure in distantpast
  25. 25. Physical exam• Healthy appearing man; arrives with cane and family• Falls asleep during exam• Weber mid; AC > BC, AU• No spont. or gaze-evoked nystagmus• Ears normal• CN intact• Head tilt test negative• Romberg/tandem Romberg –unable to do tandem gait, widebased stance• Orthostatics negative• Audiologist had to awaken repeatedly to obtain audiogram
  26. 26. Audiogram
  27. 27. What Next?
  28. 28. My Diagnosis• Presbycusis• Presbystasis
  29. 29. My Treatment• Hearing aid evaluation• Niacin• Vestibular rehab/ use cane• No further evaluation
  30. 30. Patient Outcome• Fell 2 weeks later in home• Emergency Room MRI: 6 metastatic brainlesions; Primary found to be lung• Died in 2 weeks of disease
  31. 31. Note to Self• Even with age, unusual to fall asleep so muchin exam and audio.
  32. 32. Dr. Calkins’ Case• 25 yo woman• Complains of intermittent dizziness• She describes the episodes as a sense ofimbalance.• Occur while standing.• Denies syncope
  33. 33. Dr. Calkins’ CasePrior evaluation:• Physical examination – BP 110/70, pulse 60,no change on standing – no abnormalitiespresent• ECG – normal• Event monitor – no arrhythmias seen• Echocardiogram - normal
  34. 34. Dr. Calkins’ CaseTilt Table Test• Developed severe presyncope 20 minutes into tilt.• SBP fell from 110 to 70, HR fell from 86 to 40• Symptoms of lightheadedness and imbalancereproduced.Treatment• Increase salt and fluid• Education• Sleep with head higher than feetClinical course- symptoms resolved
  35. 35. Dr. Megerian’s Case• 37 year old female with VHL syndrome(history of renal cysts, retinal angiomas andpheochromocytoma).• 2 years history of fluctuating left sided hearingloss, recent onset of intractable vertigo andleft sided tinnitus.• Received diagnosis of Meniere’s disease.
  36. 36. Dr. Megerian’s Case• Audiogram– Left ear with 55dB SNHL in the low frequencies– SRT 50, Discrimination 72%– Right ear with normal hearing– SRT 5, Discrimination 100%• ENG– 33% left caloric weakness
  37. 37. Dr. Megerian’s Case
  38. 38. Intraductal In-Situ Papillary HyperplasiaMegerian et al., Laryngoscope, 1995, 105: 801-8
  39. 39. Mechanisms of Cochleo-VestibularSymptomsLonser et al., NEJM, 2004, 350:2481-6
  40. 40. Dr. Megerian’s CaseUnderwent post auricular mastoidectomy withexcision of endolymphatic sac tumor.
  41. 41. Retrolabyrinthine-TransduralMegerian, Haynes et al., Otol & Neurotol,2002,23:378-87
  42. 42. Transmastoid RetrolabyrinthineJeffrey et al., J.Neurosurg, 2005, 102:503-12
  43. 43. Transmastoid RetrolabyrinthineJeffrey et al., J.Neurosurg, 2005, 102:503-12
  44. 44. Transmastoid RetrolabyrinthineJeffrey et al., J.Neurosurg, 2005, 102:503-12
  45. 45. VHL• Autosomal dominant• Germline mutation of VHL gene (chromosome3)• Prevalence 1/39,000• Predisposition to benign/malignant visceraland CNS lesions
  46. 46. VHL• Visceral neoplasms– Renal cell carcinoma and cysts– Pheochromocytoma– Pancreatic neuroendocrine tumors– Reproductive adnexal cystadenoma• CNS neoplasms– Hemangioblastoma (cerebellum, brainstem, spine)– Retinal angioma– ELST
  47. 47. VHL and ELST• Incidence 11-16%• Bilateral 30%• ELST associated to Online MendelianInheritence in Man VHL disease (No. 193300)
  48. 48. Grade II• 40 yo male withataxia, vertigo, andhearing loss• Staged post-fossaand transmastoidresection
  49. 49. Grade IV• Presented 6 years laterwith multiple cranialnerve palsies• Tumor involved clivus,cavernous sinus, andsphenoid sinus
  50. 50. Future Issues• Early identification in VHL• Early excision• Role of Gamma Knife• Meniere’s remains diagnosis of exclusion• Sporadic cases outnumber syndromic cases
  51. 51. Thank you for joining us!• Have an idea about how we can improve our next BestDoctors webinar? Give us your feedback:bestdoctors.com/webinarfeedback.• Read more on clinical decision support and social media &medicine on our blog at ClinicalCurbside.com• Subscribe to our diagnostic accuracy newsletter, upcomingwebinars and other content at bestdoctors.com/Subscribe