VERTIGO

Objectives

• Vertigo Defintion, Types, Causes• Central & Peripheral Vertigo• Clinical Tests • Laboratory Tests• BPPV• Vestibular Neuronitis• Dizziness and Vertigo• Quiz

What will I LearnToday ?

FAQ’s in RGUHS Examination

• Fistula Test• Caloric Test• BPPV• Vestibular Neuronitis• Aural causes of Vertigo• Evaluation Of Vertigo

Vertigo- Definition

• Not a disease, But a symptom.

A feeling in which the external world seems to revolve around the individual or in which the individual itself seems to revolve in space.

Types

Rotation

Rotatory

Non-rotatory

Patient’s perception

Subjective

Objective

Stimulus involved

Spontaneous

Induced

Physiological Vertigo

• Balance between 3 stabilising sensory systems is lost.

• Non-adaptation of vestibular system to unfamiliar head movements.

• Unusual head & neck positions

Pathological Vertigo

Pathological

Vestibular

Peripheral Intermediate Central

Non-vestibular

Occular Other

Peripheral & Central VertigoPeripheral: Lesions of vestibular end organs ( 85% of all cases of vertigo)

Intermediate: Lesions in vestibular nerve

Central: Lesions of central nervous system(vestibular nuclei) ( 15% of all cases)

Peripheral & Central Vertigo

Central Vertigo

Vascular causes: Hypertension, Basilar artery insufficiency

Epilepsy: both disease & its treatment

Road Traffic Accident: Head trauma

Tumor: of brainstem, 4th ventricle & cerebellum

Infection: Meningitis, Encephalitis

Glial diseases: Multiple sclerosis

Others: Parkinsonism, Psychogenic

Peripheral Causes for Vertigo

• BPPV• Vestibular Neuronitis• Meniere’s disease• Labrynthitis• Vestibulotoxic Drugs• Perilymph Fistula• Head injuries & Surgical trauma• Syphillis• Acoustic Neuroma

Evaluation of Vertigo

Tests for assessment of

Vestibular functions

Clinical tests Laboratory tests

Clinical Tests of Vestibular Function

1. Spontaneous Nystagmus2. Fistula test3. Romberg Test4. Gait5. Past-Pointing & Falling6. Dix Hallpike Maneuver7. Test of Cerebellar Dysfunction

Nystagmus• Involuntary rhythmical oscillatory movement of the eyes.• Triggered by inner ear stimulation.• Slow pursuit movement initially, fast rapid resetting phase .• Nystagmus is always named after direction of the fast phase

Nystagmus Based on Direction

Rotatory/Tortional

Horizontal

Vertical

Nystagmus

Nystagmus

Peripheral

Lesion of Labyrinth/8Th nerve

Supressed by Optic fixation

Enhanced in darkness

CentralLesion in Vestibular nuclei, Brainstem,

Cerebellum

Nystagmus

Nystagmus- Types

Nystagmus

Spontaneous

Looking straight ahead, sides &

focusing

Not induced by any stimulus

Presence always indicates an

ORGANIC LESION

Induced

Caloric

Positional(Head)

Rotational

Optokinetic

Rt gaze Lt gaze

Degrees of Nystagmus(Alexander’s Law)

Grade I

Grade III

Grade II

Primary position

Fistula Test• Principle: To induce nystagmus by producing pressure

changes in the EAC which are transmitted to the labyrinth. Stimulation of Labyrinth causes nystagmus & vertigo.

• E.A.C. pressure is increased by intermittent tragal pressure or Siegelization

• Normally : NegativeFistula present Fistula sign + Cholesteatoma True PositiveFistula absent Fistula sign + Congenital

syphillisFalse positive

Fistula present Fistula sign - Dead ear False negative

Fistula Test

Laboratory Tests

1. Caloric Test2. Electronystagmography3. Optokinetics4. Rotational Test5. Galvanic Test6. Posturography

Caloric test

• Principle: To induce nystagmus by thermal stimulation of the vestibular system

• Advantages:o Each labryinth can be tested separatelyo Also checks for labrynthine origin of vertigo

Caloric Test- Types1. Modified Kobrak Test: 60°, 60 s, Ice water2. Fitzgerald-Hallpike Test/Bithermal Caloric Test:• Supine position• Water at 30° & 44°• Head tilt: 30° forward• 5 mins gap b/w 2 ears• Direction of Nystagmus:COWS

Cold- SameWarm- Opposite

3. Cold air caloric test: Done in TM perforation

Caloric Test

Electronystagmography

• Detects both Spontaneous and Induced nystagmus.• Depends on presence of Corneo-retinal potentials

Other tests

Optokinetic TestUseful to diagnose a Central lesion

Rotation TestBarany’s Revolving chair, 30° forward head tilt

Other tests

Galvanic test

• Only test which helps in differentiating end organ lesion from that of nerve lesion.

Posturography

Treatment of Vertigo

1. Reassurance/Psychological Support2. Pharmacotherapy3. Adaptation exercises4. Intratympanic antibiotic injections5. Surgery• Conservative• Destructive

Benign Paroxysmal Positional Vertigo

• Most common cause.• Described by Barany• Definition: Abnormal sensation of motion that is

elicited by certain provocative positions.• These provocative positions usually trigger specific

eye movements i.e. Nystagmus

Rotational Geotropic Latency: 1-5 s

Duration: 20-30 s Fatiguable

Associated with Vertigo

Reversible

BPPV

Canalithiasis:(Canal stones)• Otoconial debris are

floating freely in the canal portion of the SCC

• Free floating• Most common• Posterior SCC m/c

involved.

Cupulolithiasis: (cupula stones)• Otoconial debris are

adhered to the cupula of the crista ampullaris.

• Not free floating• Not common

Benign Paroxysmal Positional Vertigo

• Sex: F>M• Age: Old age (6th decade)• Predisposing factors: MAC• Causes: TIM• Associations: Cervical diseases, Ear diseases,

Vertibrobasilar insufficiency , CNS Disease• Differential Diagnosis:

Signs & SymptomsSymptoms• Sudden Onset• Have few asymptomatic

periods in between• Dizziness triggered by head

movements• Classic BPPV: erect to

supine, 45° • During attacks, Rolling spin• Symptoms dissipate within

20-30 s after a violent start.

Signs• Neurological

examination: Normal• Dix-Hallpike maneuver:• Caloric Test: Normal or

Hypofunctional

Investigations

• Electronystagmography(ENG)• Caloric Test• Audiometry• Posturography

TreatmentMedical1. WAIT & WATCH2. Vestibulo-suppressant

medication3. Vestibular Rehabilitation:

Cawthorne exercises4. Canalith repositioning

(CRP):• Epley Maneuver• Semont maneuver

Surgical(failure of CRP)1. Labyrinthectomy2. Posterior canal Occlusion3. Singular neurectomy4. Vestibular nerve section5. Transtympanic

Aminoglycoside application

Vestibular Neuronitis• Sudden onset of vertigo, nausea, vomiting w/o tinnitus and

deafness.

• Etiology: Labrynthine Stimulation by:Virus, IdiopathicAge(>adolescents)Sex(M=F)

• Pathophysiology: Inflammatory process in vestibular nerve, self-limiting

Vestibular Neuronitis• Clinical Features:1. Vertigo2. Nausea and Vomiting3. Normal Hearing4. Nystagmus

• Investigations: PTA, Caloric Test, ENG

Treatment: 1. Bed Rest and Reassurance2. Drugs

Vertigo-like symptoms

Faintness Light-headedness Unsteadiness Motion intolerance Imbalance Floating sensation

Vertigo & Dizziness

Vertigo

Specific term

Includes only Vertigo

More common in elderly

Dizziness

Broad term

Includes vertigo, syncope,

unsteadiness

All age groups

Quiz

Question 1

• Nystagmus pattern in peripheral Vertigo

Question 2

• Other name of Bithermal Caloric Test

Question 3

• Treatment of Choice in BPPV?

Question 4

• Vestibular disease in which patient presents with vertigo & normal hearing?

Question 5

• Vestibulotoxic Drugs

Thank you