Vestibular Rehab Blog Series: 3 of 12
Hello, everyone, and welcome to video 2 of lesson 2. I will be talking about utilizing clues from the intake to create a working diagnosis. This video will be based on the characteristics of dizziness that we just talked about. Now, this one will be quite a bit longer than the previous video, so let's go ahead and get started. But don't forget to use your quick guide as a reference if this is a newer topic for you.
So, let's think about a patient that describes their dizziness as a spinning sensation or vertigo. And they further describe their vertigo as the world spinning around them. In my head, when I'm listening to someone, I'm thinking about the most likely and the most serious, one of the additional clues that we're focusing on here, you'll note at the top of the slide, which is seconds to minutes. So, the patient describes their vertigo as the world's spinning around them and it lasts seconds to minutes. Now, one of the most common causes of brief spells of vertigo is BPPV or benign paroxysmal positional vertigo. It is a brief episodic vertigo related to position changes such as rolling over, looking up, looking down, bending over. As I said, it is the most common and fortunately it is the most treatable. The duration of this from seconds to minutes is typically less than 60 seconds. Now, certainly some patients will say it lasts two minutes or initially they'll say, oh, it lasts...it just went on and on. And you'll further ask: now the room's spinning around you kept going on and on and on? And they're like, no, that just lasted maybe a minute, maybe two minutes but then I felt bad for a long time. You really want to hone in on: how long did it last? Seconds to minutes?
So one of the red flags I would look for is more towards the minutes, because the most serious to me would potentially be a TIA or a transient ischemic attack, which may be difficult to actually confirm because it's so transient, especially if this is something new or happening. Now, if there's a spinning vertigo, that may be 10 to 15 minutes, I might even be worried about 5 to 15 minutes. We certainly never want to put people in a box, but 5 to 15 minute vertigo of the room spinning really isn't classic for BPPV, and it's not classic for some of the other types of vestibular disorders we're going talk about.
So, let's take a very similar scenario. Patient describes of dizziness as a spinning sensation and it's the world spinning around them. But the difference here is in the duration. Here we're going talk about minutes to hours. We just talked about seconds to minutes. So, any type of spinning vertigo that last minutes to hours in my head, I would begin to think about Meniere's disease. It is recurrent, spontaneous spells of intense vertigo lasting 20 to 30 minutes, up to several hours, maybe all day, and can oftentimes take days to recover.
There's usually hearing loss ringing in the ears and aural fullness, which is a pressure. Sometimes people even get the pressure or the ringing as a warning sign before the spell hits. Now, this is a very similar description of migraine associated vertigo (MAV). As you can see, this can also result in recurrent spontaneous spells of intense vertigo, 20 to 30 minutes, lasting several hours. It does not require a headache to be present, but typically with MAV we don't see the hearing loss associated with it or the aural fullness and pressure.
So how would we know the difference in Meniere's and MAV? There's certainly some key characteristics. Migraine associated vertigo does typically not have such notable otologic symptoms as Meniere's and otologic, again referring to the ear. So, in the previous video I talked about where we look for red flags or key indicators that might give us clues. So with MAV, they have a history of migraines. We typically don't associate the onset of migraine associated as the first type of migraine someone has. It often develops later in life.
A hearing test is super helpful because with Meniere's you're going to see a low frequency hearing loss and we wouldn't expect that with migraine associated vertigo. So a comprehensive hearing test is a key differential. But again, we can start to gather a working diagnosis just in the intake itself.
So, this is just looking at the difference of endolymphatic hydrop's versus Meniere's versus migraine associated vertigo. Endolymphatic hydrops, in the literature, you'll oftentimes see that used synonymously with Meniere’s. In the clinic, we look at endolymphatic hydrops as a less severe form. So endolymphatic is referring to the endolymph inside the inner ear. So the fluid stabilization of the inner ear, which likes higher potassium and lower sodium, is fluctuating. Also, in the clinic with endolymphatic hydrops, we typically don't see that low frequency dip. If we did, we would suspect Meniere’s disease. So, spells are less severe with endolymphatic hydrops. But with Meniere's and migraine associated vertigo, the intensity can be quite disabling for both of those. Once again, the low frequency hearing loss is a key differential for Meniere's.
So, we've talked about spinning vertigo. The patient describes the room spinning around them. We've talked about seconds to minutes, minutes to hours. Now we're going to talk about hours, two days. Here again, what's the most likely? What's the most serious? Now the most common cause of spinning vertigo that lasts hours to days is an inner ear infection and it's typically viral. And with a bacterial inner ear infection, the patient would also have fever. So, it's called a vestibular neuritis, where there's the sudden onset of vertigo, it last hours to days. Typically vomiting but there's no hearing loss. A labyrinthitis is the same as above with sensory neural hearing loss in one ear. Keep in mind that inner ear infections, greater than 95 percent of the time, they're single events, whereas BPPV has a high recurrence.
You just heard me talk about endolymphatic hydrops, Meniere's, migraine associated vertigo, they are recurring spells. Now what about the most serious? That would be a stroke if there's a compromise to posterior blood flow that effects the vertebral basilar artery, that can result in vertigo. Now, oftentimes when people come into the clinic, we're thinking about stroke being ruled out. However, there will be some instances where imaging is normal, but it is suspected that they actually may have suffered a stroke versus an inner ear infection.
So, let's look at some of these characteristics. Inner ear infection versus stroke. An inner ear infection typically follows an illness, a sinus infection, an upper respiratory infection, or another stressful event. So just stress alone can trigger an inner ear infection. There's typically some level of warning with an inner ear infection. People generally don't feel well or they may wake up feeling a little dizzy and then as time goes on, it gets worse. And before they know it, they have severe vertigo. It's not this: I'm walking across the room. I fell on the floor. No warning. And that's what a stroke would typically result in. We would oftentimes expect central signs as well. And as I said, in previous imaging that would have indicated a stroke. But if it affects those distal arteries away from the vertebral artery, closer to the inner ear, it may actually not show up in imaging due to the nature of the size of MRI slices. Depending on the location of those slices, it could actually miss where the stroke occurred. I'm always aware if someone has no previous history and it was a sudden onset of vertigo, zero warning.
So, what if the patient says, yes, I'm spinning, but it's not the room spinning. It's more of a sensation in their head and a feeling of being off. And again, we're always putting the pieces together. This is all about patterns. But this one is just a slightly different pattern than what we just talked about, because it's a feeling inside my head versus the world spinning around me. We always need to rely on other characteristics of dizziness, not just one. As you all know, the word vertigo really has little value. All you know is that they've probably reported dizziness to someone, but it doesn't give you any clues with the word alone as to what might be going on. So just as we talked about in the previous video, you want to talk about the onset of symptoms that trigger and or associated symptoms.
So, let's take a look at some other inner ear pathologies. Here's some clues from the onset and triggers. And we're to talk about superior canal dehiscence. This is certainly not one of the more common vestibular disorders but I do want to mention it. The onset is often associated with head trauma, but not always. It is thought that many people have superior canal dehiscence, which is a structural abnormality of the inner ear, but it's never a problem. And oftentimes when people hit their head, that's a trigger to make them start having symptoms. And here people will report dizziness and or unsteadiness with loud noises, one's own voice, especially when singing, or talking for long periods of time. A key characteristic here is asking another question when they say dizziness or unsteadiness with loud noises. And that question is, do the loud sounds irritate you? Or do they actually make you dizzy and unsteady? And if they say the latter, then it's possible that they have a dehiscence because a number of people will say, oh no, it doesn't make me dizzy or unsteady, but it really irritates me.
There's also a structural abnormality of the inner ear referred to as perilymphatic fistula. It's most often associated with barometric trauma, which can be scuba diving, lifting, straining, but can also be head trauma. And with these triggers, dizziness is typically associated with changes in pressure: when I cough, when a sneeze, when I lift, and they may also report hearing loss with it, which is a slightly different than with superior canal dehiscence. Another type of vestibular disorder that's not as common is an acoustic neuroma. Now this is a benign tumor. It's most commonly associated with asymmetrical hearing loss and ringing in the ears that can progress to dizziness and unsteadiness. And certainly there can be neurological disorders that result in dizziness. But here we would be trying to pick up on other central signs such as double vision or dysarthria. And with central nervous system disorders, nausea is not as prevalent as with peripheral vestibular disorders. And there can also be just this general vestibular dysfunctions. They may deny any otologic symptoms, no neurological symptoms. They simply report movement related dizziness and/or unsteadiness. They deny true spinning, rocking sensations, lightheadedness, and sometimes it can occur after illness, stress, severe allergies, or even head trauma.
So, let's look at some key characteristics here. With acoustic neuroma, if someone comes into the clinic and reports asymmetrical hearing loss, or hearing loss in one ear, that is a red flag. So many people will say, well, it's because I listen to loud music when I was younger. Loud music does not affect one ear unless you're in a band sitting right next to someone all the time on one side. So asymmetrical hearing loss is a red flag. Certainly, with neurological, we're looking for other central signs. And with general vestibular dysfunction, movement related dizziness and or unsteadiness. The key word there is movement. When we're up, moving around, turning our head, we are highly relying on our inner ear for information about where we are in space.
So, it's the small clues and oftentimes patients are telling you this, giving you the clues, where you're not even having to ask all the questions. So, what about constant dizziness? What about 24/7? Well, here are some characteristics of a vestibular disorder that is now a diagnosis which is called persistent postural perceived dizziness. You'll often hear people refer to it as 3PD. And these vestibular related diagnoses that I'm talking about aren't near as common as BPPV, inner ear infections, or even Meniere's disease, or migraine associated vertigo. So, here are the characteristics for 3PD: dizziness non spinning greater than three months. It may wax and wane in severity, but it lasts for a long time, hours. It can occur without specific provocation. But there's three exacerbating factors: upright posture, active or passive motion without regard to direction or position, and exposure to busy places. It's oftentimes triggered by events such as the acute onset of vertigo, an illness, or psychological distress. And symptoms are not accounted for about any other disease or disorders such as the ones I've previously talked about. What if no dizziness? What if they don't describe their dizziness as lightheaded, spinning, or feeling unsteady? But it's a rocking and/or swaying sensation. If you have a patient that has these symptoms after being on a cruise or long travel by air car train, then consider Mal de DeBarquement Syndrome or MdDS. Symptoms are worse with being still and improve with movement. And remember, I just said with the inner ear, symptoms are usually worse with movement and better with being still. If not related to any activity, then rocking and swaying sensations can also be associated with anxiety as a possible cause.
Now here I have just unsteady. Of course, that may be all a little confusing because we do have unsteadiness as kind of a type of dizziness. You know, a lot of people when you interview them. You'll ask them, is the room spinning? And they're just like, oh, no, no, the room is not spinning. Everyone keeps asking me that. I'm really, really unsteady, especially walking on uneven surfaces, quick turns. Then consider maybe peripheral neuropathy. You can ask about burning, tingling, numbness in their feet. It could simply be multifactorial from sensory deficits like deficits in their visual system, somatosensory, and/or vestibular. We do see this more in the aging population, but what if it's kind of drastic? You know, there's a sudden change and it happened after receiving IV antibiotics or cancer treating drugs, then we have to think about ototoxicity. These folks don't have dizziness. They're super unsteady and they don't have dizziness because both ears have been damaged. So typically, movement related dizziness or acute vertigo comes from one ear not matching the other ear. And if it's severe enough, the room could actually spin.
All right, so what is this about? It's because video 2 of lesson 2 has just wrapped up. That was a lot to take in. So just breathe. Give yourself some time to digest it all.
Click here to progress to the next blog in this series: Symptoms to Clinical Tests