A simplified but organized structure for determining the important parameters for decision making in patients with dvertigo

1. Sasan Dabiri, MD, Associate Professor
Department of Otorhinolaryngology – Head & Neck Surgery
Amir Alam Hospital – Tehran University of Medical Sciences
I ra n i a n E N T S o c i e t y Pa n e l D i s c u s s i o n
J u l y 2 0 1 9

2. Iranian ENT Society Panel Discussion : Vestibular Migraine
Vertigo
Presyncope
Disequilibrium
Psychiatric
Not
specific
Dizziness - Etiology
Vertigo: Diagnostic Approach

3. Iranian ENT Society Panel Discussion : Vestibular Migraine
Vertigo
Presyncope
Disequilibrium
Psychiatric
Not
specific
Dizziness - Etiology
Peripheral
Central
Dizziness - Etiology
Vertigo: Diagnostic Approach

4. Iranian ENT Society Panel Discussion : Vestibular Migraine
Vertigo
Presyncope
Disequilibrium
Psychiatric
Not
specific
Dizziness - Etiology
Peripheral
Central
Dizziness - Etiology
Vertigo: Diagnostic Approach

5. Iranian ENT Society Panel Discussion : Vestibular Migraine
Vertigo: Diagnostic Approach
T h e accurate diagnosis of th e u n d erlyin g etiology
is th e crucial step in th e man agement of vertigo

6. Iranian ENT Society Panel Discussion : Vestibular Migraine
Imaging
Audio-
Vestibular
Tests
Physical
Exam.
History
Vertigo: Diagnostic Approach
T h e accurate diagnosis of th e u n d erlyin g etiology
is th e crucial step in th e man agement of vertigo

7. Iranian ENT Society Panel Discussion : Vestibular Migraine
Imaging
Audio-
Vestibular
Tests
Physical
Exam.
History
Vertigo: Diagnostic Approach
T h e accurate diagnosis of th e u n d erlyin g etiology
is th e crucial step in th e man agement of vertigo

8. Iranian ENT Society Panel Discussion : Vestibular Migraine
Imaging
Audio-
Vestibular
Tests
Physical
Exam.
History
Vertigo: Diagnostic Approach
T h e accurate diagnosis of th e u n d erlyin g etiology
is th e crucial step in th e man agement of vertigo

9. Iranian ENT Society Panel Discussion : Vestibular Migraine
Imaging
Audio-
Vestibular
Tests
Physical
Exam.
History
T h e accurate diagnosis of th e u n d erlyin g etiology
is th e crucial step in th e man agement of vertigo
Vertigo: Diagnostic Approach

10. Iranian ENT Society Panel Discussion : Vestibular Migraine
History
 True or pseudo-vertigo
 One attack or more
 Episodic or continuous
 Duration of each episode
 Chronology of symptoms
 How does start at first time
(straining, trauma)
 Associated symptoms (oto, neuro, ocular)
 Associated histories
(medico-surgical, family, drug, psychologic)
 Effect of life style
 environment
 Effect of head movement
ear pressure changes
Vertigo: Diagnostic Approach

11. Iranian ENT Society Panel Discussion : Vestibular Migraine
 Ear Exam (inspection)
 Eye Exam (position & Nystagmus)
 Neurologic Exam (R/O ataxia)
 Sound or Pressure (3rd window)
 Vibration (SSCD, MD, VS)
 Hyperventilation (phobia, central)
demyelination: MS, VS, Vascular
 Positional testing (Hallpike , roll test)
 H I T test (canal dysfunction)
 Head shaking test
Physical
Exam.
History
Vertigo: Diagnostic Approach

12. Iranian ENT Society Panel Discussion : Vestibular Migraine
Audio-
Vestibular
Tests
Physical
Exam.
History
 VNG (saccade , pursuit , nystagmus )
 Evoked evaluation
• Caloric Test ( lower freq. )
• Head Shaking ( 1-2 Hz )
• V-HIT ( 3-5 Hz )
 Rotatory chair test
 Posturography ( C D P )
 PTA-SRT-WRS, AR
 ECoG
 VEMP (cervical, ocular)
Vertigo: Diagnostic Approach

13. Iranian ENT Society Panel Discussion : Vestibular Migraine
Imaging
Audio-
Vestibular
Tests
Physical
Exam.
History
 C T :
• Otic capsule involvement
• SSCD Sx. / any other 3rd window
• Large vestibular aqueduct Sx.
 M R :
• Meniere’s Disease
• CP Angle lesions
• Other central disorders
Vertigo: Diagnostic Approach

14. Iranian ENT Society Panel Discussion : Vestibular Migraine
Imaging
Audio-
Vestibular
Tests
Physical
Exam.
History
Concurrent disorders might b e p res ent in th e s ame time
Patients with vertigo h ave s ome d egree of pseudo-vertigo
T h e etiology might change d u rin g time
Vertigo: Diagnostic Approach

15. Iranian ENT Society Panel Discussion : Vestibular Migraine
References
• Rose BD et al. UpToDate. http://www.uptodate.com/contents/search (last seen: Oct. 2016)
• Approach to the patient with dizziness
• Evaluation of the patient with vertigo
• Pathophysiology, etiology, and differential diagnosis of vertigo
• Overview of nystagmus
• Pharmacologic use of glucocorticoids
• Flint PW et al. Cummings Otolaryngology - Head & Neck Surgery, 6th ed. (2015)
• Principles of applied vestibular physiology
• Evaluation of the patient with dizziness
• Peripheral vestibular disorders
• Surgery for vestibular disorders
• Bronstein AM et al. Oxford Textbook of Vertigo and Imbalance. 1st ed. (2013)
• Hain TC. MRI Imaging of Meniere's Disease/Syndrome. http://www.dizziness-and-balance.com/disorders/
menieres/mri-hydrops.html (last modified: Jul. 2016)
• Baráth K et al. Detection and Grading of Endolymphatic Hydrops in Meniere Disease Using MR
Imaging. Am J Neuroradiol 2014; 35: 1-6
• Curthoys IS. The Interpretation of Clinical Tests of Peripheral Vestibular Function. Laryngoscope 2012;
122: 1342–52
• … and some web sources for photos