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