Patient with vertigo if comes to opd how to diagnose

Vertigo is the topic

1. MANAGEMENT AND TYPES OF VERTIGO
MODERATOR –Dr SathishKumar K N
PRESENTOR –Dr SpurthiKabber

2. DEFINITIONS
DIZZINESS -Sensation of altered orientation in space -less than half have true vertigo.
SYNCOPE-Progressive light headedness, fainting or dimness of vision a central vascular
phenomenon.
VERTIGO–Illusion of either oneself or the environment rotating.
OSCILLOPSIA–Described as jumpy , jerky , bobbing , wobbly or blurred vision

3. CAUSES
V -Vascular
E -Endocrine/Epilepsy
R-Received treatment
T -Trauma(labyrinthine injury)
I -Infection/ Inflammation
G -Growth(tumour)
O -Opthalmologic

4. Types of Vertigo

6. CAUSES OF VERTIGO
Peripheral Vertigo
•Benign paroxysmal positional vertigo (BPPV)
•Meniere disease
•Vestibular neuritis
•Labyrinthitis
•Herpes zoster
•Acoustic neuroma
•Complications of Otitis media
•Perilymphaticfistula
•Aminoglycoside toxicity
•Viral infections
•Cogan syndrome
Central Vertigo
•Brainstem ischemia/infarction
•Vertebrobasilar insufficiency
•Space-occupying lesions
•Demyelination syndromes
•Vestibular migraine
•Chiari malformation

7. NATURE OF VERTIGO
ROTATIONAL
1.BPPV
2.LABIRYNTHINE FISTULA
3.MENIERE’S DISEASE
4.VESTIBULAR NEURONITIS
5.VERTEBROBASILAR INSUFFICIENCY
6.TRAUMA
7.LABYRINTHITIS
8.METASTATIC DEPOSITS IN CP ANGLE

8. UNSTEADINESS
1.DRUGS
2.TRAVEL SICKNESS
3.PERILYMPH FISTULA
4.HYPERVENTILATION
5.VESTIBULAR INSUFFICIENCY
6.CNS LESIONS

13. TESTS FOR BALANCE
PHYSICAL EXAMINATION
1.Aural examination
2.Assessment of hearing
3.Assessment of stance and gait
OTONEUROLOGICAL EXAMINATION
1.Clinical assessments of eye movements
2.Ocular control systems
3.Vestibular ocular reflex and nystagmus
4.Halmagyihead thrust
5.Caloric testing
6.Electronystagmography and videonystagmography

14. AURAL EXAMINATION
Pneumatic Otoscopydone using seigalpneumatic speculum.
Fistula test
1.Hennebert'sSign–false positive fistula test seen in meneire’sdisease.
2.Positive in: Perilymph fistula, Semicircular canal dehiscence syndrome, and Meniere's
disease.

15. NYSTAGMUS
❑The eye response to a head rotation
consists of a combination of a slow phase
or drift until the eye reaches the edge of
the outer canthus.
❑Fast phase to reset the eye in its initial
position.
❑This pattern repeats itself as long as the
head rotation lasts. This saw-tooth pattern
is called nystagmus

16. Types of Nystagmus

17. DIFFERENTIAL DIAGNOSIS

18. VESTIBULO –OCULAR REFLEX / DOLL’S
EYE REFLEX
Most commonly used as a test of brainstem
function.
The patient's eyelids are held open while the
head is briskly rotated from side to side.
The eyes will normally move as if the patient is
fixating on a stationary object.
If there is a negative doll's eyes reflex then the
eyes remain stationary with respect to the head.

19. HEAD THRUST TEST/ HEAD-
IMPULSE TEST

20. A brief, high acceleration rotation of head in the horizontal plane are applied while instructing
the patient to look carefully at the examiner's nose.
In normal individual there is no delay.
In case of hypofunctional horizontal canal fails to drive eyes to opposite. A catch up saccade
brings them into position after a delay.

21. TYPES OF CALORIC TEST
The basis of this test is to induce nystagmus by thermal
stimulation.
The advantage of this test is that each labyrinth can be
tested separately.
3 TYPES-
1.Modified KobrakTest
2.Fitzgerald-Hallpike Test
3.Cold Air Caloric Test

22. MODIFIED KOBRAK TEST
1.It is quick office procedure. Ear is irrigated with ice water for 60sec, first with 5ml
and if there is no response, 10, 20, 40ml.
2.Normally, nystagmus towards opposite ear will be seen in 5ml of ice water.
3.If response is seen in between 5ml to 40ml, labyrinth is considered hypoactive.
4.No response to 40ml, indicates dead labyrinth.

23. FITZGERALD-HALLPIKE TEST/
BITHERMAL CALORIC TEST:
Advantage of caloric stimulation is that each labyrinth can be tested separately and also be performed in
infants and children.
Caloric stimulation is thought to be based on convection current in the horizontal semicircularcanals.
Inducedby a thermal stimulus colder or warmer than body temperature in the external auditory canal.
The gradient of temperature produces a change in the specific gravity of the endolymph in the horizontal
semicircularcanal.
This causes a cupulardeflection and a change in activity of the vestibular nerve.
Cold irrigation produces a utriculofugaldeflection –fast nystagmus component away from the ear; warm
irrigation produces a utriculopedaldisplacement –fast nystagmus component towards the ear.

24. Steps of caloric test
Patient lies supine with head tilted 30degree forward so that horizontal canal is
vertical.
Ear is irrigated for 40 sec alternately with water at 30 degree C and 44 degree C.
Eyes are observed for nystagmus.
Time taken from the starting point of irrigation to the end point of nystagmus is
recorded and charted on a calorigram.
If no nystagmus in any ear, test is repeated with water at 20 degree C for 4min before
labelling the labyrinth dead.
A gap of 5 min should be allowed between two ears.(cold-opposite, Warm -same.)
Depending upon the response CANAL PARESIS and DIRECTIONAL
PREPONDERANCE can be understood.

25. DUNDAS GRANT COLD –AIR
CALORIC TEST
It is done when there is perforation of Tympanic
membrane.
Dundas grant tube is a coiled copper tube wrapped in
cloth.
The air in the tube is cooled by pouring ethyl chloride
and then blown into the ear.

26. FISTULA TEST
Basis of this test is to induce nystagmus by producing pressure changes in the external canal
which is then transmitted to the labyrinth.
Stimulation of labyrinth results in nystagmus and patient complains of vertigo.
Normally test is NEGATIVE.
POSITIVE in erosion of horizontal canal by cholesteatoma, fenestration operation (surgically
created), abnormal opening in oval window (post stapedectomy) or the round window (rupture of
round window membrane).
FALSE NEGATIVE TEST seen in cholesteatoma covering the fistula site.
FALSE POSITIVE TEST seen in congenital syphilis, and in about 25% cases of Meniere's
disease (HENNEBERT'S sign).

27. TEST FOR GAIT
ROMBERG’S TEST
Patient is asked to stand with feet together and arm by the side with eyes first open and then
close.
In peripheral vestibular lesion with eyes open patient can compensate but with eyes closed
patient can't, and sways to the sit of lesion.
In central lesion, patient shows instability.

28. Unterberger’sTest/Fukuda Stepping Test
Patient is asked to close his eyes with out-
stretched hands in front and asked to step
up and step down his feet alternately 1time
in 1 sec.
Rotation to one side indicates vestibular
hypofunction of that side or hyperfunction
of the opposite

29. TANDEM GAIT TEST
Patients are asked to walk heel to toe in a straight line or in
a circle
Complex function evaluates many aspects of balance
Poor performance seen in cerebellar lesions, but can be
seen in many disorders
It has Poor sensitivity and specificity

30. ELECTRONYSTAGMOGRAPHY
The study of eye movements provides a lot of information about the functioning of the brain and
the balance system.
ENG is used to studyeye movements in different conditions and with different tests. By
analyzing these movements, we are able to understand the area affected by the disorder.

31. ENG detects eye movements by virtue of a
change in the cornea retinal potential during
these movements.
The changes in potential are picked up by
surface electrodes placed near the eyes of the
patient.
Findings of ENG must be correlated with the
history given by the patient and other neuro
ontological tests to identify the cause of
vertigo or dizziness.

32. TEST CONDUCTED DURING ENG
Test for spontaneous nystagmus-Nystagmus is the jerky oscillatory movement of the eyes
caused by disturbances in the balance system. In many cases, this nystagmus cannot be accurately
diagnosed by naked eye examination.
Test for gaze -This test checks the ability to hold gaze at a point. Patients with balance disorders
may have problems in holding their eyes steady on a fixed point.
Saccades-This test checks the ability to move the eyes and appropriately focus on another object
of interest. 3 parameters are measured.
Smooth pursuit -A light moving like a pendulum is presented to be followed by the patient with
eye movements without moving the head. The ability to track it with the required velocity and
precision is measured.

33. FEATURES
Uses electrodes to record corneo-retinal potential.
The sensitivity of recording is 2º (which is less than VNG) due to distantly placed electrodes.
Able to record horizontal eye movements. Vertical eye movement recording is not very accurate.
Cannot record torsion.
The detailed finding of oculomotor tests not possible.
Artefacts due to blinking electromagnetic and electrical disturbances and EEG activity of the
brain can interfere with the interpretation of results.
Detection of posterior canal BPPV not possible in many cases as a torsional element not detected.

34. OPTOKINETIC TEST
Patient is asked to follow a series of vertical stripes on
a drum moving first from right to left and then from
left to right.
Normally it produces nystagmus with slow component
in the direction of moving stripes and fast component
in the opposite direction.
Optokinetic abnormalities are seen in brainstem and
cerebral hemisphere lesions.
Thus this test is useful to diagnose a central lesion.

35. ROTATION TEST
Patient is seated in Barany's revolving chair with his head
tilted 30°forward and then rotated 10 turns in 20 s.
The chair is stopped abruptly and nystagmus observed.
Normally there is nystagmus for 25-40 s.
The test is useful as it can be performed in cases of
congenital abnormalities where ear canal has failed to
develop .
Disadvantage of the test is that both the labyrinths are
simultaneously stimulated during the rotation process and
cannot be tested individually.
The test has now been made more sophisticated by the use
of torsion swings, electronystagmography.

36. GALVANIC TEST
It is the only vestibular test which helps in differentiating an end organ lesion from that of
vestibular nerve.
Patient stands with his feet together, eyes closed and arms out-stretched .
Thena current of 1 mA is passed to one ear.
Normally, person sways towards the side of anodal current.

37. POSTUROGRAPHY
It is a method to evaluate vestibular function
by measuring postural stability
Maintenanceof posture depends on three
sensory inputs-visual, vestibular and
somatosensory.
It uses either a fixed or a moving platform.

38. BENIGN PAROXYSMAL
POSITIONAL VERTIGO
Most common peripheral cause of vertigo
Disorder of the semicircular canals with free floating particles in the endolymph or these particles fixed to the cupula of canal.
In BPPV otoconiafrom the utricle are thought to collect in semicircular canals.
First clinical description of positional vertigo is attributed to Barany in 1921 and in 1952 DIX and HALLPIKE were clearly describe the
provoking maneuvers.
Presents as vertigo precipitated by change in head position.
Brief episodes of vertigo that wake a patient up from sleep are nearly always BPPV
BBPV arises most commonly from Posterior Semicircular canal.
BPPV –DIAGNOSIS
DIX HALLPIKE MANOEUVRE
SIDE LYING TEST
ROLL TEST

39. DIX HALLPIKE MANOEUVRE
Points to be remembered before starting the procedure
-Explain the patient regarding the procedure
-Take CONSENTfrom the patient and patient attenders
-check for any stiffness neck or back
The direction of eye movement is in the plane of the canal or the canals that are stimulated.
In the Right Dix Hallpike -Left Anterior and Right posterior canals are stimulated(LARP)
In the Left Dix Hallpike -Right anterior and Left posterior canals are stimulated (RALP)

41. TREATMENT OF P -BPPV
REPOSITIONING MANOEUVRES
1) EPLEY’S MANOEUVRES
2) SEMONT’S LIBERATORY MANOEUVRES
3) BRANT-DAROFF POSITIONAL EXERCISES

43. SEMONT’S LIBERATORY MANOEUVRE

44. BRANDT –DAROFF POSITIONAL
EXERCISE
This exercise consist of a rapid sequence of lateral head /body tilts.
Starting from sitting position, patient rapidly moves to the
challenging position, i.e. lying on the affected side(nose 45 degree
up) and remains in this position for atleast30sec or until the vertigo
subsides.
The patient then sits up for 30sec and thereafter assumes the
opposite head lateral and nose up position for 30sec before sitting
up.
This is repeated for 15minutes three times daily.
Disadvantage of this test is self induced vertigo attack,henceit is not
the first line treatment.

45. INVESTIGATIONS REQUIRED IN
CONDITIONS LIKE:
Imaging of Posterior fossa is required in :
1) Nystagmus is atypical for any of the BPPV syndromes
2) Brainstem or cerebellar signs are present
3)positional vertigo does not resolve with repeated therapeutic
manoeuvres
Acute cases may require anti histaminics/ anti vertigo drugs
Fatiguing exercises -patient placed repeatedly in the vertigo-provoking position
Particle Positioning Manoeuvers –Epley’s Manouvre

46. COMPLICATIONS
1)Gait instability following canalolithrepositioning procedure
2)Conversion of P-BPPV to A-BPPV or H-BPPV
3)Both Epleysand semontsmanouveresinvolve some neck strain and may be uncomfortable
or impossible to perform in patients with severe cervical problems.
Best solution in this situation is to do an Epleysmanouvreon a couch where the upper half of
the body can be lowered by 20 -30 degree which obviates the need for head reclination.

47. TREATMENT OF H-BPPV
1)FORCED PROLONGED POSITION
2)270 DEGREE BARBECUE MANOEUVRE
3)360-DEGREE YAW ROTATION
4)LIBERATORY MANOEUVRE

48. COMPLICATIONS AFTER H-BPPV
MANOEUVRES
H-SCC canalolithiasismay convert into cupulolithiasisafter rotaionmanouevres, which may
convert to horizontal canal-plugging, which causes Unidirectional nystagmus.
In such situations Vigorous head shaking or gentle head percussionmay unplug the canal.

49. TREATMENT OF A -BBPV
MODIFIED EPLEY’s MANOUEUVRE
The modified Epley starts using the Dix-Hallpike with the head turned 45 degrees away from
the affected ear .
Then brought to 30 degrees below the horizontal.
It is kept in this position for 30 seconds.
then elevatedwhile maintaining a supine position with the head at 45 degrees for 1 minute.
A seated position is then assumed with the chin bent forwards at 30 degrees

50. SURGICAL TREATMENT OF BPPV
Posterior semicircular canal occlusion surgery.
Singular neurectomy via Transcanalapproach.

51. VESTIBULAR NEURITIS
It occurs after a viral infection, and occurs more common in children than adults.
It presents with Acute severe vertigo, Nystagmus, nausea and vomiting
Vertigo is worsened by head movements and patient often prefers to lie down usually with the
affected ear up.
Bithermalcaloric testing shows unilateral reduced vestibularresponse.
Vertigo is prolonged and subsides gradually over days and weeks.
Associated with URTI, may occur in epidemics.

52. MANAGEMENT OF VESTIBULAR
NEURITIS
Sedation given IV if necessary
Antiemetic
Vestibular suppressants cinnarizine, Promethazine etc
Prednisolone may be used
Antiviral drugs acyclovir, Valacyclovir, where cause is Herpes Simplex or Zoster

53. MENIERE’S DISEASE
Presents as a triad of episodic Vertigo, fluctuant hearing loss and tinnitus. This is associated with
nausea and vomiting and a sensation of aural fullness.
Vertigo -sudden, usually severe, few minutes to 2 hours or so, feeling of rotation either of patient
or objects around him.
Deafness -Sensory in type, low frequency, gradually progressive, reversible initially, marked
distortion sometimes.
Tinnitus may be very troublesome, exaggerated during an attack, may precede attacks of
giddiness.
Additional Symptoms-Vagal disturbances nausea, vomiting Headaches,Anxiety

54. DIAGNOSIS
Vestibular tests
Audiometry
According to ASA-HNS criteria definite meniersdisease is:
Two or more definitive spontaneous episodes of vertigo lasting at least 20 mins.
Audiometricallydocumented hearing loss at least one occasion
Tinnitus or aural fullness in the suspected ear
Others causes excluded.

55. Management
Non ablative procedures
1.Intratympamicinjection of corticosteroids
Partially ablative procedures like
1.Intratympamicinjection of gentamicin
Surgical techniques like
1.Endolymphaticdecompression
2.Vestibular neurectomy
3.Labyrinthectomy

56. PERILYMPH FISTULA
An abnormal connection between the inner and middle ear due to a defect in the labyrinthine
bone or in the round or oval windows.
CLINICALLY-sudden or fluctuating hearing loss and dizziness along with tinnitus.
CAUSES-cholesteatoma, Syphilis, Neoplasm, latrogenic(after stapes surgery), Direct or indirect
trauma (Barotrauma, acoustic, physical exertion),
FISTULA TEST -classically demonstrates the fistula -Hennebert' s sign. Positive in some
patients, not all. False positive in patients with Meniere's Disease.
MANAGEMENT -Conservative to begin with bed rest, head elevation, avoidance of physical
straining, sedation for 10 days.
Explore under LA -close the defect. Very little hearing improvement but significant relief in
vertigo.

57. LABYRINTHITIS
There is thinning or erosion of bony capsule of labyrinth usually of the horizontal semicircular canal.
Causes –1) CSOM with cholesteatoma is most common cause
2) Neoplasm of middle ear
3) Trauma to labyrinth
Types: a) Suppurative labyrinthitis
b) Serous labyrinthitis
Clinical features: severe vertigo with Nausea and vomiting,
Spontaneous Nystagmus
Fast component is towards the affected side in Serous labyrinthitis
Fast component is towards the unaffected side in suppurative labyrinthitis

58. It is diagnosed by "fistula test" which can be performed in two ways.
1. Pressure on tragus-Sudden inward pressure is applied on the tragus. This
increases air pressure in the ear canal and stimulates the labyrinth. Patient
will complain of vertigo. Nystagmus may also be induced with quick
component towards the ear under test.
2. Siegel's speculum-When positive pressure is applied to ear canal, patient
complains of vertigo usually with nystagmus. The quick component of
nystagmus would be towards the affected ear (ampullopetaldisplacementof
cupula).

59. TREATMENT
Patient should be bed rest, head immobilised with affected ear above
Antibacterial therapy
Labyrinthine sedatives
Myringotomy is done is labyrinthitis has followed Acute otitis media and the drum is bulging.

61. OTOTOXICITY CAUSING VERTIGO
Tendency of certain drugs to cause functional impairment and cellular degeneration of tissues of
the inner ear
Common agents
Aminoglycosides -Streptomycin & gentamicin –vestibulotoxic
Loop Diuretics –Furosemide
Salicylates
Cytotoxic agents -Cis platinum
Other Agents commonly causing Vertigo-alcohol, barbiturates, tranquilizers and anticonvulsants.

62. MEDICATIONS FOR ACUTE VERTIGO
ORALLY ADMINISTERED AGENTS
ANTIHISTAMINICS ,FIRST GENERATION
DIMENHYDRINATE 50mg every 4 to 6hrs
DIPHENHYDRAMINE 25mg to 50mg every 4 to 6hours
(maximum daily dose 200 to 300mg)
MECLIZINE 12.5 to 50mg every 6 to 12hours
(maximum daily dose 100mg)
BENZODIAZEPINES
ALPRAZOLAM 0.5mg immediate release every 8 hours
CLONAZEPAM 0.25 to 0.5mg every 8 to 12 hours
DIAZEPAM 1 to 5mg every 12hours
LORAZEPAM 1 TO 2mg every 8 hours

63. ANTIEMETICS
METOCLOPRAMIDE 5 to 10mg every 6hours
ONDANSETRON 4mg every 8 to 12hours
PROCHLORPERAZINE 5 to 10
PROMETHAZINE
PARENTERALLY ADMINISTERED AGENTS FOR ACUTE EMERGENCY
ANTIHISTAMINES, FIRST GENERATION
DIPHENHYDRAMINE 10 to 50mg IV
DIMENHYDRINATE 50mg IV
ANTIEMETICS
METOCLOPRAMIDE 10mg IV
ONDANSETRON 4 to 8mg IV
PROCHLORPERAZINE 2.5 to 10mg IV

64. ABLATIVE PROCEDURES FOR
CONTROL OF VERTIGO
1)LABYRINTHECTOMY
2)VESTIBULAR NEURECTOMY

65. Labyrinthectomy
Most destructive procedure for treatment of meneiresdisease.
Both hearing and vestibular function is uniformly destructed
person with no functional hearing and have failed intratympamicgentamicin injection are Ideal
candidates.
Higher rate of vertigo control than vestibular neurectomy.
2 approaches –transcanaland transmastoid
Most commonly performed through transmastoidapproach.

66. Transmastoidapproach
Procedure begins with cortical mastoidectomywith postauricularapproach
This approach allows complete visualization and removal of all three semicircularcanal ampullae
, utricle , saccule .
Advantages:
1.Considered gold standard due to complete vestibular tissue removal
2.Allows concomitant cochlear implantation

67. Transcanallabyrinthectomy
Also known as oval window labyrinthectomy.
Performed by approaching inner ear through external auditory canal
Advantages :
1.Less invasive
2.Short operative time
3.Lower rishcomplications like CSF leak , facial nerve injury.

68. Vestibular neurectomy
Two approaches mainly :
1.Translabyrinthinevestibular neurectomy
2.Transcochlearvestibular neurectomy
Translabyrinthinevestibular neurectomyextends the transmastoidlabyrinthectomy
Transcochlearvestibular neurectomyextends the transcanallabyrinthectomy.

69. REFERENCES
SCOTT BROWN 8
TH
EDITION TEXT BOOK
CUMMINGS OTOLARYNGOLOGY 6
TH
EDITION TEXT BOOK
BALLENGERS 16
TH
EDITION TEXT BOOK
Shambaugh–surgery of the ear 6
th
edition

70. THANK YOU