Dizziness and Acoustic Neuroma - Providence Health …/media/Files/Providence OR...Dizziness and...

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Dizziness and Acoustic Neuroma Harold Kim, M.D. NW Ear Institute Portland, OR

Transcript of Dizziness and Acoustic Neuroma - Providence Health …/media/Files/Providence OR...Dizziness and...

Page 1: Dizziness and Acoustic Neuroma - Providence Health …/media/Files/Providence OR...Dizziness and Acoustic Neuroma Harold Kim, M.D. NW Ear Institute Portland, OR What is a Neurotologist?

Dizziness and Acoustic

NeuromaHarold Kim, M.D.

NW Ear Institute

Portland, OR

Page 2: Dizziness and Acoustic Neuroma - Providence Health …/media/Files/Providence OR...Dizziness and Acoustic Neuroma Harold Kim, M.D. NW Ear Institute Portland, OR What is a Neurotologist?

What is a Neurotologist? Otolaryngologist (ENT) by residency training.

2 year fellowship in Neurotology/Skull Base Surgery

In sum: the E in ENT

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Agenda Definitions

Primer on dizziness

Acoustic Neuroma

Primer on management

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Dizziness 5-10% of population suffer from it

40% of individuals over age 40 years have it

3.9 million visits to emergency rooms in U.S. for dizziness (2011)

5.4% of visits to ER are due to “serious diagnoses.”

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When Should You Image?

When Should You Refer?

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Predictors of Serious Diagnoses

Focal examination findings

Age over 60 years

Imbalance as symptom

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What Do You Need To Be

Right? Knowledge

Time

Attention

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Definition Dizziness

Imbalance

Vertigo

Lightheadedness

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Initial Work Up Characterize “dizziness”

Gradual or sudden

Intermittent or constant

Associated symptoms

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Associated Symptoms Tinnitus

Hearing loss

Ear fullness

Visual Symptoms

Ear drainage

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Physical Examination How does the patient look when they walk into the

room?

Look in their ears

Look at their eyes

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Old Stand By

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Office Maneuvers To Help Dx

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Relevance of Nystagmus Fast component points toward stronger side

Vertical nystagmus confirms central etiology

Not possible to fake

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Common Causes of Dizziness Benign Paroxysmal Positional Vertigo (BPPV)

Vestibular Migraines

Meniere’s Disease

Vestibular Neuritis

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Epley Maneuver

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Vestibular Migraines 5 vestibular episodes of moderate to severe severity

lasting 5 minutes to 72 hours

Current or previous history of migraine

One or more of the following accompanying 50% of

episodes

Headache

Phonophobia or photophobia

Visual aura

Not better accounted for by another vestibular or ICHD

diagnosis

Cephalagia 33 (9): 629-808

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Meniere’s Disease 2 or more episodes of spontaneous vertigo lasting 20

minutes to 12 hours

Hearing loss

Tinnitus

Aural Fullness

Monsell EM, Otolaryngol Head Neck Surg 1995

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Vestibular Neuritis Acute peripheral vestibular loss from vestibular nerve

hypofunction

Acute rotary vertigo that transitions to imbalance

Hallmark:

Horizontal nystagmus

Suggestive history

No auditory symptoms

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Vestibular Neuritis Treatment is regular ambulation and mobilization

Possible role for corticosteroids of detected early.

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Predictors of Serious Diagnoses

Focal examination findings

Age over 60 years

Imbalance as symptom

Page 24: Dizziness and Acoustic Neuroma - Providence Health …/media/Files/Providence OR...Dizziness and Acoustic Neuroma Harold Kim, M.D. NW Ear Institute Portland, OR What is a Neurotologist?

Acoustic Neuroma Comprises 80% of all cerebellopontine angle tumors.

Incidence is 1-2 per 100,000

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Clues to Acoustic Neuroma

Diagnosis

Symptoms refer to one side

Hearing

Tinnitus

Imbalance

Vertigo rare

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How To Diagnose?

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How to Diagnose? MRI of Internal Auditory Canal and Brain with and

without Gadolinium

What about a CT?

Only show large tumors

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Do They Need Contrast?

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Now What? Refer

Neurotologist

Neurosurgeon

But . . .

How do we address this?

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It’s Complicated

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Ways to Treat Acoustic

Neuroma Do Nothing

Surgery

Radiation

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What Goes In Determining

Treatment

Tumor Size

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Hearing Status

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Speech Discrimination Poor speech discrimination is indicative of

retrocochlear pathology

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What About Dizziness? None of the Treatment Modalities Alter Balance

Vestibular Rehabilitation

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Watchful Waiting Repeat MRI in 6 months

If no change, repeat yearly

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Pratnaik et al., 2015 54.5% showed no growth.

7.8% showed slow growth.

1.3% showed fast growth.

87% showed favorable patterns for watchful waiting.

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Outcomes Serial Imaging:

22.3% needed change in treatment approach in 12 years.

24.3% had decline in hearing to non-serviceable levels.

Imbalance and Dysequilibrium at presentation presented

almost 3 fold increase in likelihood of tumor growth.

Jethanamest D, Rivera AM, Ji H, et all, Laryngoscope 2015

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Watchful Waiting Facial nerve sequela very rare.

Progressive imbalance that responds to vestibular

rehabilitation.

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Surgery Hearing Preservation

Hearing Sacrificing

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Outcomes Surgery

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Hearing Dependent on preoperative levels

Up to 80% retain useful hearing if hearing preservation

approach used.

Dependent on surgical approach

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Balance Mild increase in dizziness when measured using the

dizziness handicap index (DHI) at 6 months after

surgery.

Thomeer et al., Otol Neurotol 2015

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Priorities of Surgery Safe delivery from surgery

Complete or near complete excision of tumor

Facial nerve function

Hearing improvement

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Radiosurgery

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Radiosurgery Objective of this treatment

Prevent further growth

Success is defined as not needing further management

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Gamma Knife Radiosurgery

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Radiosurgery Outcomes

Over 90% tumor control

Hearing preservation-

89.7% at 1 year

84.7% at 3 years

76.5% at 5 years,

68.6% at 10 years.

Combs SE et al., Radiother Oncol 2013

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Radiosurgery Outcomes

Facial nerve control-96.2% (Yang et al., Neurooncol

2009).

Dizziness

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What’s The Right Answer For

Me?

It’s Complicated

Treatment modality does determine QoL.

Diagnosis biggest detriment to QoL.

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Biggest Detriments to

Diagnosis/Treatment

Dizziness

Headache

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Questions?