Vertigo

By Dr Piyush Ojha , DM Resident, GMC Kota
under guidance of Prof. Dr Vijay Sardana (HOD,Neurology)

1. VERTIGO : Approach to Patient DR. PIYUSH OJHA DM RESIDENT DEPARTMENT OF NEUROLOGY GOVT MEDICAL COLLEGE, KOTA

2. EPIDEMIOLOGY Approximately 30% people - experience moderate to severe dizziness at some point in their life ( Neuhauser et al. 2005 ). 80% - seek medical care at some point. Though most people report nonspecific forms of dizziness, nearly 25% of these people report true vertigo. Dizziness - Females > Males and older people In the United States, 7.5 million annual ambulatory visits to physician offices, hospital OPDs, and emergency departments for dizziness, making it one of the most common principal complaints. ( Burt and Schappert 2004 ).

3. HISTORICAL BACKGROUND Prosper Meniere (1861) - first to recognize the association of vertigo with hearing loss and to localize the symptom to the inner ear. Robert Barany (1906) First clinical description of BPPV in 1921. introduced Caloric testing - most widely used test of the Vestibulo -ocular reflex (VOR). Nobel Prize for mechanism of caloric stimulation.

4. Neuroimaging in 1970s greatly expanded understanding of causes of dizziness/vertigo - prior to which, stroke was considered an exceedingly rare cause of vertigo( Fisher 1967 ). Over the past 25 years - understanding of the mechanisms for the common neuro- otological disorders has increased.  BPPV – now readily identified and cured bedside. The Head-Thrust test – bedside test to identify a vestibular nerve lesion, and has particular utility in helping distinguish vestibular neuritis from a posterior circulation stroke ( Halmagyi and Curthoys 1988;  Kattah et al. 2009; Newman- Toker et al. 2008;  Nuti et al. 2005 )

5. “ Dizziness ” refers to various abnormal sensations relating to perception of the body’s relationship to space. Dizziness - may represent variety of symptoms including : Spinning or movement of the environment (True vertigo) Light-headedness or Presyncope , or Imbalance while walking Patients may also use the term for other sensations such as visual distortion, nonspecific disorientation and anxiety. DIZZINESS / VERTIGO

6. In a classic paper, Drachman and Hart (1972) described four subtypes of dizziness: Vertigo, Presyncopal lightheadedness , Disequilibrium and other dizziness.

7. NORMAL ANATOMY & PHYSIOLOGY The Peripheral vestibular system consists of: - Three semicircular canals Otoloithic apparatus (Utricle and saccule ) and The vestibular component of the eighth cranial nerve. The Semicircular canals sense angular movements. Utricle and saccule sense linear movements.

8. ANATOMY OF THE INTERNAL EAR

9. The plane in which the eyes deviate as a result of vestibular stimulation depends on the combination of canals that are stimulated . Once vestibular signals leave the vestibular nuclei - divide into vertical, horizontal, and torsional components. So a lesion of central vestibular pathways can cause a pure vertical, pure torsional , or pure horizontal nystagmus .

10. HISTORY OF PRESENTING ILLNESS History and physical examination - the most important information Often, patients have difficulty describing the exact symptom experienced. The first step is to define the symptom.

11. Following questions should also be enquired: Symptom constant or episodic Accompanying symptoms How did it begin (gradual / sudden) Aggravating or alleviating factors? If episodic, what was the duration and frequency of attacks, and what were the triggers?  One key point is that any type of dizziness may worsen with position changes, but some disorders such as BPPV only occur after position change.

12. CAUSES OF VERTIGO

13. CAUSES OF VERTIGO

14. “ Red flags ” suggestive of a Central vestibular lesion :- Other central signs or symptoms Direction-changing nystagmus Vertical nystagmus A negative head-thrust test A skew deviation or S ubstantial stroke risk factors ( Kattah et al. 2009 )

15. RECURRENT POSITIONAL VERTIGO Positional vertigo - symptom being triggered , not simply worsened, by certain positional changes. Most likely BPPV - but this is not the only possibility. Strong suspicion of BPPV when the positional vertigo is brief (<1 minute), has typical triggers, and is unaccompanied by other neurological symptoms. A burst of vertical torsional nystagmus - specific for BPPV of the posterior canal ( Aw et al. 2005 ).

16. Central positional nystagmus - disorders affecting the posterior fossa , including tumors , cerebellar degeneration, Chiari malformation, or MS. Nystagmus typically downbeating and persistent, though a pure torsional nystagmus may occur as well.

17. PHYSICAL EXAMINATION A brief general medical examination is important. Postural Hypotension measurement. Orthostatic hypotension - probably the most common general medical cause of dizziness among patients referred to neurologists. Identifying an irregular cardiac rhythm may help. Other general examination measures to consider in individual patients include a Visual assessment (adequate vision is important for balance) and a musculoskeletal inspection (significant arthritis can impair gait).

18. GENERAL NEUROLOGICAL EXAMINATION Very important in patients complaining of Vertigo because vertigo can be the earliest symptom of a neurodegenerative disorder ( Lau et al. 2006 ) Can also be an important symptom of stroke, tumor , demyelination , or other pathologies of the nervous system. The cranial nerves should be thoroughly assessed.

19. OCULAR MOTOR ASSESSMENT :- 1 st step – Normal ocular movements & search for Nystagmus Nystagmus – objective accompaniment of vertigo and defined as “ rhythmic oscillation of the eyes, with a fast movement in one direction and a slow movement in the other .” Nystagmus - classified as spontaneous, gaze-evoked, or positional. The direction of nystagmus - conventionally described by the direction of the fast phase, which is the direction it appears to be “beating” toward . Fast component may be horizontal, vertical, rotatory , or any combination of these .

20. Spontaneous nystagmus can have either a peripheral or central pattern. Central lesions can rarely mimic a “peripheral” pattern of nystagmus ( Lee and Cho, 2004 ;  Newman- Toker et al., 2008 ). The peripheral pattern of spontaneous nystagmus is unidirectional. Other characteristics of peripheral spontaneous nystagmus are increase in velocity with gaze in the direction of the fast phase, and decrease with gaze in the direction opposite of the fast phase. ( Alexander’s Law )

21. VESTIBULAR NERVE EXAMINATION A unilateral or bilateral vestibulopathy can be identified using the Head-thrust test. In patients with normal vestibular function, the VOR results in movement of the eyes in the direction opposite the head movement. Therefore the patient’s eyes remain on the examiner’s nose after the sudden movement. The test is repeated in the opposite direction. If a corrective saccade is observed bringing the patient’s eyes back to the examiner’s nose after the head thrust, impairment of the VOR in the direction of the head movement is identified.

22. POSITIVE HEAD THRUST TEST

23. POSITIONAL TESTING Can help identify peripheral or central causes of vertigo. The most common positional vertigo – BPPV – due to free-floating calcium carbonate debris - usually in the posterior semicircular canal – occasionally horizontal canal and rarely anterior canal. The characteristic burst of upbeat torsional nystagmus is triggered in patients with BPPV by a rapid change from the sitting-up position to supine head-hanging left or head-hanging right ( Dix– Hallpike test ). A burst of nystagmus in the opposite direction (downbeat torsional ) occurs when the patient resumes the sitting position.

24. DIX-HALLPIKE MANEUVRE

25. AUDITORY EXAMINATION Bedside Otoscopy examination. Finger rubs at different intensities and distances from the ear are a rapid, reliable, and valid screening test for hearing loss in the frequency range of speech ( Torres- Russotto et al. 2009 ). If a patient can hear a faint finger rub stimulus at a distance of 70 cm (approximately one arm’s length) from one ear, then a hearing loss on that side—defined by a gold-standard audiogram threshold of greater than 25 dB at 1000, 2000, and 4000 Hz—is highly unlikely. On the other hand, if a patient cannot hear a strong finger rub stimulus at 70 cm, a hearing loss on that side is highly likely.

26. The whisper test can also be used to assess hearing at the bedside ( Bagai et al. 2006 ). For this test, the examiner stands behind the patient to prevent lip reading and occludes and masks the nontest ear, using a finger to rub and close the external auditory canal. The examiner then whispers a set of three to six random numbers and letters. Overall, the patient is considered to have passed the screening test if they repeat at least 50% of the letters and numbers correctly. Tunic Fork tests – Weber and Rinne test

27. IMAGING To rule out central causes of vertigo. CT scan can rule out a large mass with exception of smaller lesions due to artifact and poor resolution in the posterior fossa ( Chalela et al., 2007 ). MRI - imaging modality of choice, expensive BPPV, vestibular neuritis, or Meniere disease - do not require an imaging. Patient having focal neurological symptoms or having unexplained neurological deficits or an otherwise rapid, unexplained progression of symptoms - MRI should be strongly considered.

28. COMMON DISORDERS CAUSING VERTIGO

29. VESTIBULAR NEURITIS Rapid onset of severe vertigo, nausea, vomiting, and imbalance. Symptoms gradually resolve over several days, but some symptoms can persist for months. Etiology - probably viral. Benign and self-limited Diagnosis - Peripheral vestibular pattern of nystagmus and a positive head-thrust test in the setting of a rapid onset of vertigo without other neurological symptoms.

30. The mainstay of treatment is symptomatic. A course of corticosteroids has been shown to improve recovery of the caloric response but has not been shown to improve the functional or symptom outcome ( Fishman et al. 2011 ). Vestibular physical therapy can help patients compensate for the vestibular lesion VESTIBULAR NEURITIS

31. BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) Most common cause of vertigo in the general population. Patients typically experience brief episodes of vertigo when getting in and out of bed, turning in bed, bending down and straightening up, or extending the head back to look up. Repositioning maneuvers are highly effective in removing the debris from the canal, though recurrence is common. Once the debris is out of the canal, patients are instructed to avoid extreme head positions to prevent the debris from re-entering the canal. Patients can also be taught to perform a repositioning maneuver if they have a recurrence of the positional vertigo . Medication not indicated , as it is a mechanical problem .

32. MENIERE DISEASE Characterized by recurrent attacks of vertigo associated with auditory symptoms (hearing loss, tinnitus, aural fullness) during attacks. Gradually followed by progressive hearing loss. Attacks variable in duration, mostly lasting > 20 minutes, and associated with severe nausea and vomiting. Course of disease highly variable. For some patients, the attacks are infrequent and decrease over time, but for others they can become debilitating.

33. Occasionally auditory symptoms are not appreciated by the patients or identified by interictal audiograms early in the disorder. But eventually patients develop these features, usually within the first year. Usually unilateral, Bilateral in about 1/3 patients. Endolymphatic hydrops or expansion of the endolymph relative to the perilymph regarded as the etiology , though exact cause unclear.

34. Some patients with confirmed disease experience abrupt episodes of falling to the ground, without loss of consciousness or associated neurological symptoms ( Otolithic catastrophes of Tumarkin ). Patients report the sensation of being pushed or thrown to the ground often resulting in fractures or other injuries. Bedside interictal examination - may identify asymmetrical hearing Head-thrust test is usually normal.

35. Treatment – includes aggressive low-salt diet and diuretics ( Poor evidence ). Long-term administration of B etahistine-dihydrochloride (3 X 48 mg/d for 12 mo) have been reported to have positive effects on the frequency of attacks. The goal of therapy is freedom from attacks for at least 6 months; then the dosage can be slowly reduced every 3 months, depending on the course. Long-term treatment, often for many years. Intratympanic gentamicin injections can be effective and are minimally invasive. Sectioning of the vestibular nerve and destruction of the labyrinth are other procedures ( Minor et al. 2004 ).

36. FAMILIAL BILATERAL VESTIBULOPATHY Patients typically have brief attacks of vertigo (seconds) followed by progressive loss of peripheral vestibular function leading to imbalance and oscillopsia , usually by the fifth decade. Recurrent attacks of vertigo may cause damage to vestibular structures, leading to progressive vestibular loss. Bedside head-thrust test may show bilateral corrective saccades when vestibulopathy is severe. As the vestibulopathy becomes more severe, attacks of vertigo become less frequent and eventually cease. No gene mutations identified till date.

37. PHARMACOTHERAPY OF VERTIGO

38. VESTIBULAR SUPPRESSANTS

39. GINKGO BILOBA IN VERTIGO :- A multicenter clinical trial was performed to compare the efficacy and safety of Ginkgo biloba  extract EGb 761 and betahistine at recommended doses in patients with vertigo. 106 patients were randomly assigned to double-blind treatment with EGb 761 (240 mg per day) or betahistine (32 mg per day) for 12 weeks. Two drugs were similarly effective in the treatment of vertigo, but EGb 761 was better tolerated. Ginkgo biloba  extract EGb 761 enhances cerebral and vestibular blood flow by decreasing blood viscosity . It improves neuronal plasticity as well as mitochondrial function and energy metabolism and protects neurons from oxidative damage. Treatment of Vertigo: A Randomized, Double-Blind Trial Comparing Efficacy and Safety of Ginkgo biloba  Extract EGb 761 and Betahistine : International Journal of Otolaryngology Volume  2014 (2014)

40. PIRACETAM IN VERTIGO :- Piracetam has been shown to be effective in vertigo of both central and peripheral origin. T hought to act on vestibular and oculomotor nuclei in the brain stem and thus on the central control of balance enhancing mechanisms of compensation and habituation . P iracetam alleviates vertigo after head injury, vertigo of central origin as, for example, in vertebrobasilar insufficiency and in peripheral vestibular disorders, especially in middle-aged and elderly subjects. Piracetam decreases the frequency but probably not the severity of exacerbations in patients with chronic or recurrent vertigo. The usual dosage of piracetam in vertigo is 2.4-4.8 g daily.

41. CANAL REPOSITIONING THERAPIES (CRT)

42. EPLEY’S MANEUVRE FOR POSTERIOR CANAL BPPV

43. SEMONT MANEUVRE FOR TREATMENT OF POSTERIOR CANAL BPPV

44. LEMPERT (BBQ) MANEUVRE FOR HORIZONTAL CANAL BPPV

45. ROLL MANEUVRE FOR HORIZONTAL CANAL BPPV

46. GUFONI MANEUVRE FOR HORIZONTAL CANAL BPPV

47. DEEP HANGING MANEUVRE FOR ANTERIOR CANAL BPPV

48. VESTIBULAR REHABILITATION THERAPY

49. BRANDT-DAROFF EXERCISES

50. CAWTHORNE COOKSEY EXERCISES Were devised in 1940s. Mainly for unilateral vestibular lesions. Initially, the exercises performed are slow gradually increasing speed as patient tolerates the movement. The patient should experience an increase in symptoms with movement. Exercises performed for at least 1 minute several times each day for adaptation to occur. Advantage - low-cost and effective.

51. With object fixed & head moving With head fixed & object moving With both head and object moving in opposite direction With object fixed and subject asked to jump up and down slowly on a Trampoline ( Otolothic stimulation)

52. THANK YOU

53. REFERENCES Bradley’s Neurology in clinical practice 7 th edition Adams & Victor’s Principles of Neurology 10 th edition Localization in Clinical Neurology: Brazis :6 th edition DeJong’s The Neurologic examination : 7 th edition Vertigo – A clinical approach : Medicine Update 2010 Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review)

54. REFERENCES Vestibular Rehabilitation : An Overview : HS Writer Seminars in Neurology : Neuro-otology An update on pharmacotherapy of vertigo : J. Chem. Pharm. Res., 2010, 2(3):381-386