Dizzy Quiz Fall 2013

Welcome to BalanceMD's Quarterly ONLINE Dizzy Quiz!  

Congratulations to the latest winner of the iPod Shuffle, a physician from IU Health, who wishes to remain anonymous!

We have been hosting a "Dizzy Quiz" several times a year for the past five years in order to bring awareness to physicians and other healthcare providers regarding the great advances in knowledge and technology that have been made over the past two decades in the field of vestibular medicine.  We are now able to diagnose and treat conditions causing dizziness and vertigo FAR better than we could just 20 years ago. 

Below are the questions and answers for our Fall 2013 "Dizzy Quiz".  This exercise is meant to emphasize that "vertigo" is a symptom, not a diagnosis, and that we need to establish a diagnosis, ie, what is causing the "vertigo", to know how best to treat the patient's symptoms.  These two scenarios are based on two patients with similar symptoms but completely different diagnoses that I saw in the office for the first time in August 2013.  The correct answer is highlighted in yellow, with commentary in green text below.

Should you know of patients who might benefit from our services, please go to the "Referring Physicians" tab, print a copy of the "Consultation Request Form", fill it out and fax it to us!

Patient 1

John is a 49 year old man who has been experiencing intermittent vertigo for the past 10 years, noting the spells have been increasing in frequency and severity for the past several months and he is "going downhill".  He describes that his vertigo spells may last up to a few minutes at a time, and are notably worse when driving.  He often has to pull off the road and he avoids highways.  He describes the sensation as "uneasy and rocky" and shopping in large department stores makes this sensation worse.  He has a history of severe headaches in the past and currently has a mild headache 1-2 times per week.  He was born deaf in his left ear and partially deaf in his right and this has not changed.  He was seen by an otolaryngology (ENT) specialist in Indianapolis years ago for this, was told there was nothing that could be done, and was eventually prescribed Zoloft because he was an anxious person.  Examination reveals decreased hearing, left > right.  Otherwise, no pathologic nystagmus is present.  No focal neurologic findings are noted.

Question 1.  What is the most appropriate next step?

A.  Tell John you concur with what he has been told in the past and nothing can be done to help
B.  Prescribe meclizine 25 mg tid because meclizine helps all types of dizziness
C.  Order an MRI of the brain for John because it is likely that he has a brain tumor
D.  Refer John to physical therapy (PT) because PT is effective for most patients with dizziness
E.  Order Vestibular Function Testing to determine if he may have an easily identifiable vestibular system disorder causing his symptoms so that you know how best to treat him

Commentary:  These days, we now know that the most common cause of dizziness, perhaps 60-70% of all dizziness, is migraine.  Unfortunately, many patients with "migraine-associated dizziness" or "vestibular migraine" are not having concomitant headaches, so this condition often goes unrecognized.  This patient, in fact, was suffering from migraine-associated dizziness and his symptoms resolved after being on Elavil 10 mg qhs for 3 weeks (after 10 years of symptoms).  His vestibular function evaluation, other than the pre-existing hearing loss on the left, was normal, consistent with this diagnosis.  So (A) is not correct because we are now better able to recognize migraine as a common cause of dizziness.  These patients represent most patients who have had recurrent dizziness over time without hearing loss and typically have been prescribed meclizine or told to go on a low salt diet (with the thought of "vestibular Meniere's", ie, Meniere's without hearing loss, which we now know is a diagnosis that does not exist).  (B) is incorrect because most patients prescribed meclizine report no benefit, in fact, most become drowsy in addition to remaining dizzy.  Meclizine has very limited use, but is helpful in treating an acute vestibulopathy, such as an attack of Meniere's, Vestibular Neuritis or Labyrinthitis.  Of course, meclizine is also helpful in reducing motion sickness.  Otherwise, meclizine has limited usefulness and should NEVER be prescribed chronically.  In patients with neuropathy or vision loss, meclizine may actually make patients more likely to fall.  (C) is not correct because brain tumors are an exceedingly rare cause of dizziness.  In fact, the likelihood of finding anything on an MRI to explain dizzy symptoms in a patient without hearing loss and with a normal neurologic examination has been calculated to be about 1/10,000.  (D) is incorrect because PT, while helpful for many patients suffering with specific causes for dizziness, is typically not helpful for the most common cause of dizziness, migraine-associated dizziness.  Only about 15% of 'dizzy' patients benefit from PT/vestibular rehabilitation.

Patient 2

Molly is a 42 year old woman who has been experiencing intermittent vertigo for the past 10 years, noting the spells have been increasing in frequency and severity over the past 6 months and occur several times per day.  Spells of vertigo are unprovoked, occur randomly and last seconds at a time.  She describes having motion sensitivity and being the passenger in a car makes her feel uneasy.  She has a history of migraine headaches, occurring about once every three months, triggered either by her menstrual cycle or changes in weather.  Her migraines have not changed appreciably in the past several years.  She has sensitivity to noise, in that loud noises briefly increase her dizziness and she notes that her eyes feel like they jump.  She sometimes has tinnitus, noted when she moves her eyes back and forth.  Over the years, she has been seen by two different neurologists and two different otolaryngology (ENT) physicians.  She has had an MRI and VNG (formerly known as ENG - vestibular function test), each performed on two occasions, with normal results.  She has been prescribed meclizine and diazepam without benefit.  Examination reveals normal hearing, no pathologic nystagmus, and no focal neurologic findings.

Question 2.  What is the most appropriate next step?

A.  Repeat the MRI for the third time because she is a young woman with multiple neurologic symptoms and she must have MS
B.  Be sure that her vestibular function testing was a complete evaluation and included a rotational chair and VEMP (Vestibular Evoked Myogenic Potential), not just a VNG; if not, proceed with ordering this for her
C.  Referral to physical therapy (PT) because PT is effective for most dizzy patients and she has not had PT yet
D.  Order a carotid doppler study because many patients with intermittent vertigo have carotid stenosis as an underlying cause
E.  Tell Molly that she has been seen by 4 specialist physicians over the years for the same symptoms and if she had something treatable, it would have been diagnosed by now.  So she will just have to "learn to live with it".

Commentary:  Although the patient described above has a history of migraine headaches and was said to have had 2 normal VNGs (vestibular function testing) performed elsewhere, she has an interesting sensitivity to noise, in that noise causes her to feel more dizzy and her eyes to 'jump'; even more interesting, she can hear her eyes moving back and forth in her head.  These symptoms are suspicious for a newly-recognized condition, superior canal dehiscence syndrome (SCD), which is simply the thinning or absence of temporal bone overlying the superior semicircular canal of the inner ear.  This condition is not picked up by the usual VNG (Videonystagmogram) testing, but is readily recognized by VEMP (Vestibular Evoked Myogenic Potential).  In fact, it was determined, first by abnormal VEMP, then by CT of the temporal bones, that she did indeed have SCD as the cause of the dizziness, and NOT migraine.  This case stresses the importance of first, recognizing her symptoms while taking her history, then having the availability of testing to confirm the diagnosis.  Unfortunately, the vast majority of facilities offering VNG do not offer VEMP or rotational chair evaluations, the VEMP in this case being what led to the correct diagnosis.  She will be undergoing surgery December 2013 to repair her SCD.  It is likely that her dizzy symptoms will resolve after this procedure is performed.  So, (A) repeating the MRI is not needed and (C) as noted in the prior question, while PT/vestibular rehabilitation is quite helpful to many patients, the majority of patients with dizziness do NOT benefit from PT; whether they might benefit or not simply depends on their underlying diagnosis.  (D) is incorrect because the carotid arteries do NOT supply blood to regions of the brain that cause dizziness/vertigo when blood flow is affected, such as in TIA.  This is a common misconception.  The vertebrobasilar arteries supply blood flow to the brainstem/cerebellum, which is the brain region where patients may experience vertigo as a result of a TIA.  Of course (E) is incorrect, as it is unfortunately quite typical for some 'dizzy' patients to see multiple physicians.  One study reported that 38% of 'dizzy' patients see four or more physicians attempting to find a correct diagnosis and appropriate treatment.

Thank you for participating.  I am hopeful that this exercise will be educational with regard to understanding what all we are now able to offer "dizzy" patients from both a diagnostic and treatment standpoint.

Should you know of patients who might benefit from our services, please print a copy of the "Consultation Request Form", fill it out, and fax it to us!

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