Episode 32 - Vertigo

Episode 32: Vertigo

The sun rises over the San Joaquin Valley, California, today is October 20, 2020.It’s time to talk about vaccines again. The ACIP (Advisory Committee on Immunization Practices) posted new recommendations for meningococcal vaccinations on September 25, 2020. 

There are two kinds of meningococcal vaccines in the US: 
1. Meningococcal conjugate or MenACWY vaccines (Menactra®, Menveo®, and MenQuadfi®)
2. Serogroup B meningococcal or MenB vaccines (Bexsero® and Trumenba®). 
Let’s discuss how they are given.

MenACWY: Menactra (MenACWY-D), Menveo (MenACWY-CRW), and MenQuadfi (MenACWY-TT) 

MenACWY routine: The meningococcal conjugate vaccine should be given to ALL PATIENTS at 11 to 12 years old, with a booster dose at age 16. Remember, it’s a two-dose series, the booster dose at age 16 is important to provide protection during the ages of highest risk of infection. So, that was easy. The hardest part is for patients younger than 10 years old because only patients who are at risk receive routine meningococcal conjugate vaccines before age 11. 

MenACWY in special groups: This vaccine is given to patients older than 2 months old only if they are at increased risk for meningitis (i.e., persistent complement component deficiencies; persons receiving a complement inhibitor such as eculizumab [Soliris] or ravulizumab [Ultomiris]); persons who have anatomic or functional asplenia; persons with HIV infection; microbiologists routinely exposed to Neisseria meningitidis; persons at increased risk in an outbreak; persons who travel to or live in hyperendemic or epidemic areas; unvaccinated or incompletely vaccinated first-year college students living in residence halls; and military recruits.) I invite you to consult ACIP recommendations regarding vaccination in special groups. 

MenB: Trumenba (MenB-FHbp), Bexsero (MenB-4C)  

MenB shared decision: MenB vaccination is not routinely recommended for all adolescents. It may be given to adolescents and young adults (16 through 23 years old, preferred age is 16-18 years old) on the basis of shared clinical decision. Those who decide to receive MenB vaccine, receive two doses 1-6 months apart depending on the brand name you use. MenB vaccines are not recommended before age 10 in any case. Adults older than 24 and older don’t need MenB unless they are at increased risk.

MenB in special groups:Patients with certain medical conditions (persons with persistent complement component deficiencies; receiving a complement inhibitor; with anatomic or functional asplenia; microbiologists exposed to isolates of N. meningitidis; and persons at risk in outbreaks) should receive MenB vaccine. 

These recommendations will be included in the updated 2021 immunization schedules, and the AAFP will review changes to the schedules once they are available (1).

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.

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“A man is who he thinks about all day long” –Waldo Emerson.

If you think you are not good enough, you may not reach your goals. So, think positive about yourself all day long, and you will become that person you think you are and will reach your goals.

Hi, this is Dr Carranza, I’m a PGY3, and today I will interview a special guest.

Question Number 1: Who are you? 

Hello, I’m Jagdeep Sandhu. I’m a 4th year medical student from Ross University, currently doing a sub-internship in family medicine. I’m originally from Seattle, Washington. I have an Indian ancestry, so I enjoy meditating and cooking Indian dishes.

Question number 2: What did you learn this week? 

Lightheadedness vs Vertigo

This week we learned about dizziness and its differentials. It is important to differentiate dizziness vs lightheaded because a lot of patients will say they are dizzy when they are truly lightheaded. To be honest dizziness (at least for me) is one of the toughest complaints to get from a patient as it is hard to pinpoint its etiology.

Important questions to ask the patient are:

Do you feel like you’re going to pass out? Do you experience a sense of darkness in front of your eyes? (points to syncope)Is the room spinning? Are you having nausea or vomiting? Ringing in your ears? (points to vertigo) 

 

Peripheral Vertigo

Peripheral refers to vertigo originated from the ear structures, whereas central from the brainstem. 

Differentials of peripheral vertigo include:

Benign paroxysmal positional vertigo: Transient episodes of vertigo caused by stimulation of vestibular sense organs, this is most commonly due to calcium debris within the posterior semicircular canal, known as canalithiasis. It affects middle-age and older patients; and twice as many women than men. Classically, patients describe a brief spinning sensation brought on when turning in bed or tilting the head backward to look up. The dizziness is quite brief, usually seconds, rarely minutes.

The way to Evaluate/diagnose BPPV is with Dix-Hallpike maneuver (turn the patient’s head 45 degrees to one side, then you help you lie back quickly so their head hangs slightly over the edge of the table. If horizontal or rotation nystagmus is noted, the patient has BPPV) and can be cured with Epley’s maneuver.

Vestibular neuritis: This is inflammation of the vestibular nerve, which is usually caused by a viral infection. It’s characterized by rapid onset of severe, persistent vertigo, nausea, vomiting, and gait instability. Hearing is preserved but if there is hearing loss(unilateral), then it is diagnosed as labrynthitis.  

You can Evaluate/diagnose with a positive head impulse (or head thrust) test and gait instability but know that the patient is still able to ambulate. (lasts a few days and resolves spontaneously) 

Herpes zoster oticus: It is also known as Ramsay Hunt syndrome when it causes facial paralysis; it occurs due to latent VZV virus in the geniculate ganglion.  The patient will complain of ear pain and vertigo. On exam, you will find vesicles in the auditory canal and auricle along with ipsilateral facial palsy. You can treat with Acyclovir or Corticosteroids. 

Meniere disease: Itoccursdue to excess endolymphatic fluid pressure, which causes episodic inner ear dysfunctionresulting in the classic triad of vertigo lasting for minutes to hours, usually associated with unilateral tinnitus and hearing loss. Unfortunately, the hearing loss can sometimes be permanent. It usually affects one ear and although it can occur at any age, most cases start between young adults and middle age adults. Evaluate and diagnose clinical features, get an audiogram for hearing loss. Patients go into remission spontaneously but it can reoccur. 

Other causes of peripheral vertigo: 

Labyrinthine concussion (traumatic peripheral vestibular injury)

Perilymphatic fistula (complication of head injury, barotrauma, or heavy lifting in which a fistula develops at the otic capsule)

Aminoglycoside toxicity

Vestibular schwannoma (unilateral hearing loss associated with neurofibromatosis type 2)

 

Central Vertigo

Vestibular migraine: The mechanism is unknown, so you have to rely on the patient's history of vertigo associated with migraine headache and classic migraine symptoms such as visual aura, photophobia, or phonophobia.

Brainstem ischemia: which is due to embolic, atherosclerotic occlusions of the vertebra-basilar arterial system. A few things fall under this category such as TIA, Wallenberg syndrome (lateral medullary infarction), Labyrinthine infarction (Anterior Inferior cerebellar artery) etc. Evaluate and diagnose with Imaging of the head and treat according to diagnosis. 

 

Question number 3: Why is that knowledge important for you and your patients? 

It is important for when we are working at both the clinic and at the hospital as recognizing serious vertigo can help us plan for intervention. 

For example, if a patient presents with vertigo and on exam you find vesicles on their ear and facial paralysis then you can immediately begin therapy with a combination of Valacyclovir and Prednisone but if it is a severe case then the patient might need IV treatment.

Also, if the patient has vascular risk factors then it is important to keep ischemia as part of your differential when your patient presents with acute sustained vertigo. Remember that for any stroke time of onset is KEY! CT should be done if MRI is not available but MRI is more sensitive for cerebellar infarctions.

Question number 4: How did you get that knowledge? (learning habits)

I did an ENT rotation in my 3rd yeard of medical school and learned from Dr Trang. I recommend that rotation to all medical students. I also searched in UpToDate, FP notebook app, AAFP and my attendings. See details below.

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Speaking Medical: Otolith 
by Gina Cha, MD

Stones are located in many unsuspected places in the body. Such is the case of otoliths. An otolith is a calcium carbonate structure in the saccule or utricle of the inner ear, specifically in the vestibular system of vertebrates. The saccule and utricle, in turn, together make the otolith organs. An otolith can cause great trouble if it’s out of its regular place. When otoliths are dislodged from their usual position within the utricle, and migrate into one of the semicircular canals (most commonly the posterior canal), moving the head causes movement of the heavier otolith debris in the affected canal causing abnormal endolymph fluid displacement and a resultant sensation of vertigo.

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Espanish Por Favor: Sereno
by Claudia Carranza, MD, and Hector Arreaza, MD

Hi! This is Dr Carranza with our section “Espanish Por Favor”. The word of the week is SERENO (maybe we can have beach waves crushing in the background). SERENO is a state of mind, a peaceful feeling. To be SERENO means to be calm, peaceful, untroubled, tranquil. 

Sometimes when people are frustrated or too excited you can say: “Sereno, no te preocupes,” which you can loosely translate as “chill, don’t worry.”

Sometimes you might ask someone how they are doing and they can say: “Sereno, sin preocupaciones,” which means “calm, without worries.” Nowadays not many people might actually feel that way but you can always remind them to lay back, relax, and take a deep breath “SERENO!”

Another meanings of the word sereno includes “humidity on the atmosphere at night.” In some Latin American countries, sereno can make you sick if you, for example, shower and go outside at night, or you can get worse if you are sick and go outside. The sereno can also be used in folk medicine to “macerate” some herbal teas or remedies giving it a special property to cure illnesses. This may not be used in all countries but at least I know it’s true in Mexico and Venezuela.

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For your Sanity: Superman
by Tana Parker, MD

 

Friend 1: Do you want to hear a really good Batman impression?

Friend 2: Sure, go on. 

Friend 1: NOT THE KRYPTONITE!

Friend 2: That’s Superman.

Friend 1: Thanks, man, I've been practicing.

 

“eBay is so useless. I tried to look up lighters and all they had was 13,749 matches.”

“I just saw my wife trip and fall while carrying a laundry basket full of ironed clothes. I watched it all unfold.”

I made a playlist for hiking. It has music from Peanuts , the Cranberries, and Eminem. I call it my trail mix.

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Conclusion: Now we conclude our episode number 32 “Vertigo.” Dr Carranza and Jagdeep had an entertaining conversation about the differential diagnosis of peripheral and central vertigo. Don’t forget to practice the Dix-Hallpike and Epley’s maneuvers for BPPV. Otolith is a tiny stone located in the inner ear that can cause vertigo when it gets stuck in the semicircular canals. The word sereno (pronounced (say-RAY-noe) as an adjective is pretty much the same as the English serene, however, Dr Arreaza explained that sereno as a noun refers to the humidity on the air thought to be the “cause” of many ailments in some Latin cultures. 

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Arianna Lundquist, Claudia Carranza, Jagdeep Sandhu, Gina Cha, and Tana Parker. Audio edition: Suraj Amrutia. See you next week! 

 

 

 

 

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References:

Meningococcal vaccine updates: https://www.aafp.org/news/health-of-the-public/20201007meningococcalvacc.html. Review full article at: https://www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm?s_cid=rr6909a1_w

 

Labuguen, Ronald H., M.D., University of Southern California, Los Angeles, California, Initial Evaluation of Vertigo, Am Fam Physician. 2006 Jan 15;73(2):244-251. https://www.aafp.org/afp/2006/0115/p244.html

 

Furman, Joseph M, MD, PhD, and Jason JS Barton, MD, PhD, FRCPC, Evaluation of the patient with vertigo, UptoDate, last updated: Feb 11, 2020. https://www.uptodate.com/contents/causes-of-vertigo?search=vertigo&sectionRank=1&usage_type=default&anchor=H5&source=machineLearning&selectedTitle=3~150&display_rank=3#H20