Vertigo

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1. VERTIGO

2. Objectives Vertigo Defintion , Types, Causes Central & Peripheral Vertigo Clinical Tests Laboratory Tests BPPV Vestibular Neuronitis Dizziness and Vertigo Quiz What will I Learn Today ?

3. FAQ’s in RGUHS Examination Fistula Test Caloric Test BPPV Vestibular Neuronitis Aural causes of Vertigo Evaluation Of Vertigo

4. 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.

5. Types

6. Physiological Vertigo Balance between 3 stabilising sensory systems is lost. Non-adaptation of vestibular system to unfamiliar head movements. Unusual head & neck positions

7. Pathological Vertigo

8. Peripheral & Central Vertigo Peripheral : Lesions of vestibular end organs ( 8 5 % of all cases of vertigo) Intermediate: Lesions in vestibular nerve Central : Lesions of central nervous system(vestibular nuclei) ( 15% of all cases )

9. Peripheral & Central Vertigo

10. Central Vertigo V ascular causes: Hypertension, Basilar artery insufficiency E pilepsy: both disease & its treatment R oad Traffic Accident: Head trauma T umor: of brainstem, 4 th ventricle & cerebellum I nfection: Meningitis, Encephalitis G lial diseases: Multiple sclerosis O thers: Parkinsonism, Psychogenic

11. Peripheral Causes for Vertigo BPPV Vestibular Neuronitis Meniere’s disease Labrynthitis Vestibulotoxic Drugs Perilymph Fistula Head injuries & Surgical trauma Syphillis Acoustic Neuroma

12. Evaluation of Vertigo

13. Clinical Tests of Vestibular Function Spontaneous Nystagmus Fistula test Romberg Test Gait Past-Pointing & Falling Dix Hallpike Maneuver Test of Cerebellar Dysfunction

14. 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

15. Nystagmus

16. Nystagmus

17. Nystagmus- Types

18. Rt gaze Lt gaze Degrees of Nystagmus (Alexander’s Law) Grade I Grade III Grade II Primary position

19. 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 : Negative Fistula present Fistula sign + Cholesteatoma True Positive Fistula absent Fistula sign + Congenital syphillis False positive Fistula present Fistula sign - Dead ear False negative

20. Fistula Test

21. Laboratory Tests Caloric Test Electronystagmography Optokinetics Rotational Test Galvanic Test Posturography

22. Caloric test Principle: To induce nystagmus by thermal stimulation of the vestibular system Advantages: Each labryinth can be tested separately Also checks for labrynthine origin of vertigo

23. Caloric Test- Types Modified Kobrak Test: 60°, 60 s, Ice water 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 C old- S ame W arm- O pposite 3 . Cold air caloric test: Done in TM perforation

24. Caloric Test

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

26. Other tests Optokinetic Test Useful to diagnose a Central lesion Rotation Test Barany’s Revolving chair, 30° forward head tilt

27. Other tests Galvanic test Only test which helps in differentiating end organ lesion from that of nerve lesion. Posturography

28. Treatment of Vertigo Reassurance/Psychological Support Pharmacotherapy Adaptation exercises Intratympanic antibiotic injections Surgery Conservative Destructive

29. 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

30. 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

31. Benign Paroxysmal Positional Vertigo Sex: F>M Age: Old age (6 th decade) Predisposing factors: MAC Causes: TIM Associations: Cervical diseases, Ear diseases, Vertibrobasilar insufficiency , CNS Disease Differential Diagnosis:

32. Signs & Symptoms Symptoms 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

33. Investigations Electronystagmography(ENG) Caloric Test Audiometry Posturography

34. Treatment Medical WAIT & WATCH Vestibulo -suppressant medication Vestibular Rehabilitation: Cawthorne exercises Canalith repositioning (CRP): Epley Maneuver Semont maneuver Surgical (failure of CRP) Labyrinthectomy Posterior canal Occlusion Singular neurectomy Vestibular nerve section Transtympanic Aminoglycoside application

35. Vestibular Neuronitis Sudden onset of vertigo, nausea, vomiting w/o tinnitus and deafness. Etiology : Labrynthine Stimulation by: Virus, Idiopathic Age( > adolescents) Sex( M=F ) Pathophysiology: Inflammatory process in vestibular nerve, self-limiting

36. Vestibular Neuronitis Clinical Features: 1. Vertigo 2. Nausea and Vomiting 3. Normal Hearing 4. Nystagmus Investigations: PTA, Caloric Test, ENG Treatment: Bed Rest and Reassurance Drugs

37. Vertigo-like symptoms Faintness Light-headedness Unsteadiness Motion intolerance Imbalance Floating sensation

38. Vertigo & Dizziness

39. Quiz

40. Question 1 Nystagmus pattern in peripheral Vertigo

41. Question 2 Other name of Bithermal Caloric Test

42. Question 3 Treatment of Choice in BPPV?

43. Question 4 Vestibular disease in which patient presents with vertigo & normal hearing?

44. Question 5 Vestibulotoxic Drugs

45. Thank you