Evaluation of vertigo

Evaluation of vertigo with special focus for MBBS undergraduate students

1. Evaluation of
vertigo
Dr Krishna Koirala
2020-06-22

2. Questions
•Define vertigo. Classify vertigo according to its
duration.
•Write down the characteristics of peripheral vertigo.
•How will you investigate peripheral vertigo?
•How do you differentiate BPPV from central vertigo?

3. Introduction
•Illusion of motion of self or the surrounding
•Mostly a symptom of vestibular lesion
•Vertigo
–Rotatory : Vestibular lesion
–Tilt / Drop : Otolith dysfunction
–Unsteadiness : Miscellaneous

4. •Typesofvertigo
–Objective:thepatienthasthesensation
thatobjectsintheenvironmentaremoving
–Subjective:thepatientfeelsasifheorshe
ismoving
–Pseudovertigo:anintensivesensationof
rotationinsidethepatient'shead

5. •Vertigo must not be confused with
–Dizziness
–Light Headedness
–Blackouts
–Fainting xzcvbn,m
–BGiddiness
–Disequilibrium
•Dizziness occurs due to CNS, CVS , ANS, GIT ,
Psychiatric disorders etc.

6. Main Categories of Dizziness
Category Description %ofpatients
Vertigo Falsesenseofmotion,
possiblyspinningsensation
45to54
DisequilibriumOff-balance Upto16
Presyncope Feeling of losing
consciousnessorblackout
Upto14
LightheadednessVaguesymptoms,possibly
feelingdisconnectedwiththe
environment
~10

7. Etiology of vertigo
Vest. end organVest . NerveCentral
Peripheral(Account for 85% of cases) Accounts for 15%cases
Erosion InflammationInflammation
Irritation DegenerationDegeneration
Vascular Vascular Vascular
Degeneration Trauma
Trauma Neoplasm
Inflammation
Neoplasm
Metabolic
Autoimmune

8. Evaluation
•History
•Physical examination
•Investigations

9. History
•The most important clue to diagnosis
•Most important points
–Duration : seconds, minutes, hours
–Associated hearing loss
–Episodic/ continuous
–Association to head movement

10. Rotatoryvertigo
Seconds Hours Days/weeks
Deafness
•Labyrinthine
fistula
No deafness
•BPPV
•Cervical Vertigo
•Vertebrobasilar
Insufficiency
Deafness
•Endolymphatic
hydrops
•Syphilis
•Meniere’s disease
No deafness
•Rec. vestibulopathy
•Decompensation
Deafness
•Labyrinthitis
No deafness
•Vestibular
neuronitis
•Head injury
•Infarction

11. Unsteadiness
Seconds Hours Days/weeks
•Visual
•Vestibular
•Proprioception
•Perilymph Fistula
•Drugs
•Functional
•Age Related
•Drugs
•Trauma
•Infarction
•Tumors
•Psychogenic

12. •Episodic
–Labyrinthine fistula
–BPPV
–Cervical vertigo
–Vertebrobasilar artery
insufficiency
–Endolymphatic hydrops
–Rec. Vestibulopathy
–Caloric stimulation
–Decompensation
•Non -episodic
–Labyrinthitis
–Vestibular neuronitis
–Central lesions
–Psychogenic

13. Peripheral vertigo
Duration of
episodes
Auditory Symptoms
Present
Auditory Symptoms
Absent
Seconds Perilymph Fistula BPPV
Hours Meniere’s syndrome
Syphilis
Recurrent
vestibulopathy
Vestibular migraine
Days Labyrinthitis
Labyrinthine concussion
Vestibular neuronitis
Months Vesti. Schwannoma
Ototoxicity
Head trauma,
Psychogenic

14. •Postural / movements
•BPPV
•Cervical vertigo
•Vertebrobasilar artery insufficiency
•Loud sound /straining
•SSCC dehiscence syndrome
•Perilymph fistula
•Hyperventilation
•Anxiety, panic disorder, multiple sclerosis

15. Examination
•Ear examination
–Tuning fork tests
–Vestibular function tests
•Ophthalmic examination
–Optokinetic movements
–Smooth pursuit movements
–Saccades
•Neurological examination including cerebellar
function tests

16. Vestibular function tests
•Spontaneous nystagmus / Gaze nystagmus
•Head thrust test
•Head shake test
•Positional test /Positioning test-Dix Hallpike
•Fistula test
•Valsalva / hyperventilation / loud noise
•Romberg's test –normal / sharpened
•Tandem walk test

17. Features PeripheralCentral
1. Nystagmus character
a. Direction Fixed Changes
b. Duration Short (days)Long (weeks)
c. Effect of optic fixationInhibited Unchanged
d. Latency Present Absent
2. Imbalance Mild Severe
3. Nausea & vomiting Severe Variable
4. Deafness & tinnitus Common Rare
5. Neurological deficitRare Common

18. Provoking factor Causes
Change in head positionB.P.P.V., labyrinthitis, multiple
sclerosis
Sudden standing up from
sitting position
Orthostatic hypotension
Sudden neck movement Cervical spondylosis, VBI
Recent URTI Vestibular neuronitis
Stress Psychogenic, migraine
Change in ear pressurePerilymph fistula

19. Associated
symptoms
Causes
Deafness + tinnitus
+ aural fullness
Meniere’s disease
Imbalance Vestibular neuronitis, Acoustic neuroma
Headache Migraine, Acoustic neuroma
Focal neurological
findings
Acoustic neuroma, Central vascular
causes
Ear discharge Labyrinthitis, perilymph fistula

21. Investigations
1. Vestibular
–Caloric Test
•Fitzgerald Hallpike Bithermal Caloric Test
•Modified Kobrak’s Test
•Dundas Grant Test
–Electronystagmography
–Rotation Chair Testing
–Dynamic Posturography

22. Investigations
2. Audiological
–PTA, Glycerol Dehydration Test
–ECoG
–BERA
3. Radiological
–X Ray Cervical Spine
–Doppler USG Carotico -Vertebral System
–HRCT Temporal Bone
–MRI Brain
4. Serological : TPHA, Autoantibodies

23. Caloric test
•BasicVestibularfunctiontest
•Principle:
–OnirrigationofEACwithwarm/coldwater
temperaturechangesinlabyrinthwhichcauses
convectioncurrentformationininnerearfluids
–Endolymphmovesunderconvectioncurrent
influenceandstimulatesthelabyrinth
–Nystagmusisseen

25. Fitzgerald -Hallpike
•Bithermal Caloric Test
•Patient kept supine with head elevated 30
o
(Makes
HSCC vertical & more sensitive)
•Each ear is irrigated with both warm & cold water
(Warm water : 44
o
C, Cold water : 30
o
C)
•Rate of Irrigation : 500ml/ min
•Duration of Irrigation : 60-90 sec or when nystagmus
occurs whichever is early.
•Amount of Irrigation usually: 300-350 ml.

26. •Wait 10 minutes before changing ear or water to allow
temperature to get normal
•Note Nystagmus Direction & Duration

27. Procedure

28. •DirectionNystagmus“COWS”
–Cold:OppositeSide
–Warm:SameSide
•DurationofNystagmusiscalculatedfromstartof
irrigationtoendofNystagmus(Normal90-140Sec)
•Calculationofresults:Thenystagmuselicitedin2
earsusingwarm/coldstimulusiscompared
mathematicallyusingJonkee’sformula

29. •Calculating % Canal Paresis
CP% = ( RW + RC ) –( LW + LC ) X 100
( RW+ RC + LW + LC )
> 20 % is significant
•Calculating % Directional Preponderance
DP% = (RW + LC) –(RC + LW) X 100
RW+ RC + LW + LC
> 25 % is significant