Vertigo

1. December 1, 2009 1
Definition of Vertigo
The word "vertigo" comes from the
Latin "vertere", to turn + the suffix "-
igo", a condition = a condition of turni
ng about
VERTIGO IS A HALLUCINATION OF
SELF- OR ENVIRONMENTAL
MOVEMENT,
MOST COMMONLY A FEELING OF
SPINNING, USUALLY DUE TO A DISTUR
BANCE IN THE VESTIBULAR SYSTEM
Dizziness is a common description for
many different feelings. The feeling of
dizziness may be very familiar to you,
yet difficult to describe.

2. December 1, 2009 2
Anatomy and Physiology
The Inner ear => semicircular cancel

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The Inner ear => Utricle saccule

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The Vestibular Nerve

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The Inner ear => Vestibular nerve

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The Brainstem and Temporal lope

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Sensory and motor inputs in balance

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Central Nervous System
Spinal cord
Brain
cerebrum
cerebral cortex
cerebral medulla
basal ganglia
brain stem
midbrain
pons
medulla oblongata
cerebellum

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Peripheral Nervous System
Sensory Nervous System -
sends information to the CNS fr
om internal organs or from exte
rnal stimuli.
Motor Nervous System - carries
information from the CNS to org
ans, muscles, and glands.
Sympathetic - controls
activities that increase ener
gy expenditures.
Parasympathetic - controls
activities that conserve ene
rgy expenditures

10. December 1, 2009 10
Causes of vertigo
1Vestibular system
Peripheral vertigo (Inner ear) ได้แก่ Semicircular canal
,Otolithic organ และ Vestibular nerve
Central Vertigo พยาธิสภาพเกิดที่ Brainstem , Cerebellum
หรือTemporal lobe
2Non-Vestibular system
Proprioreceptor System เช่น Cervical vertigo , sensory
polyneuropathy , MS
Visual system
Physiological เช่น Motion sickness
Pathological เช่น ลานสายตาสั้นหรือเอียง อัมพาตของกล้าม
เนื้อตา หรือต้อหิน
Cardiovascular (postural hypotension, aortic stenosis,
arrhythmias , DM , Dyslipidemia , Anemia , Orthostatic
Hypotension )
Psychogenic vertigo เช่น Hyperventilation syndrome , Manic-
depressive disorder

11. December 1, 2009 11
Causes of vertigo from medicine
ยากันชัก เช่น Carbamazepine ,Phenytion ,Primidone
ยาลดอาการซึมเศร้า เช่น Nortriphyline ,tricyclic , anti-
depressant
ยาลดความดันกลุ่ม ACE Inhibitor Enaril และ
Diuretic
ยาแก้โรคกระเพาะ เช่น Ranitidine , Cimetidine
ยาแก้ปวด เช่น Naproxen , Indomethacin
Antibiotic เช่น Streptomycin , tobramycin , Gentamycin
, Aminoglycoside
ยากลุ่ม neuroleptics เช่น Phenothiazine
กลุ่มยา Tranquilizers เช่น Diazepam ,
Chlordiazepoxide , Meprobamate

12. December 1, 2009 12
Vestibular caused of vertigo
Peripheral Vertigo Central Vertigo
Infection Infection
Perilabyrinthitis Meningitis
Labyrinthitis Encephalitis
Truma Truma
Post traumatic otolith Head Trauma
Labyrinthine contusion Vestibular Epilepsy
Acoustic trauma
Tumor Tumor
Glomus tumor Brain tumor , metastasis CA
Inflammatory Vascular
Meniere’s disease Vertebro-basilar stroke
Autoimmune disease Vertebro-basilar Insuffiency
Degenerative Degenerative
BPPV Cerebella atrophy
Toxic Demyelinated disease
Otoxicity Multiple sclerosis
Positional alcohol vertigo
Idiopathic
Acute vestibular Failure

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Lesion Associated symptom
LESION Associated symptom
Inner ear Hearing loss ,Tinnitus , otalgia , Fullness in the ear ,
Facial weakness
Brainstem Dipopia , dysarthria , Perioral ,numbness ,Extremity
weakness or numbness ,drop attack
Cerebellum Imbalance, In coordination, Ataxia
Temporal lobeAbsence spells, Gustatory Hallucination

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Causes of vertigo
A VERTIGO
1~90% are vestibular
Peripheral Vertigo (40%)
a. Benign positional vertigo (~75%)
b. Labyrinthitis (vestibular
neuronitis)
c. Menier's Disease
Central Vertigo
a. Acoustic Neuroma
b. Intracranial pressure
abnormalities
c. Idiopathic
Audiometry is helpful to distinguish
Nystagmus
a. This is the major sign of true
vertigo
b. Vertical nystagmus is always
abnormal
B. Presyncope / Syncope
C. Dysequilibrium
Peripheral neuropathy
Previous Stroke
Arthritis
Parkinson's Disease
D. Mental Status Changes

E. Psychiatric Disease (~20%)

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Criteria for Admission
Diplopia , Dysarthria , Ataxia , Facial numbness ,
Facial weakness , Hemiparesis , Loss of consciousne
ss , Loss of Vision , Loss of Consciousness , Speech
difficulties
Sudden or Persistent headache
Prominent neck pain
Tingling in the face
Weakness or numbness in an arm or leg
History of recent head Trauma
Discharge from the ear
History of Ear Infection
History of Post traumatic Dizziness
Post – surgery
Singular neuronectomy
Labyrinthectomy

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Investigation
Important points in the history:The history is all important and may
give a quite good indication of the cause of vertigo. Remember that g
eneral medical causes such as anaemia, hypotension and hypoglycae
mia may present with dizziness.
onset – ask Spontaneous , Position Induce , Acute , Paroxysmal
,Incidious
duration (common causes):
seconds benign paroxysmal positional vertigo
hours Menieres disease
weeks ,labyrinthitis ,post-head trauma ,vestibular neuronitis
years ,may be psychogenic
associated auditory symptoms – otorrhea , tinnitus , hearing loss
neurologic symptoms such as visual disturbance, dysarthria in a
central lesion
examination of ear drums for infection
special auditory tests
other associated symptoms nausea and vomiting in a vestibular cause

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Investigation
Neurological Examination
cranial nerve
Examination , motor Power , sensation ,(Proprioception)
Cerebellar system gait Function tests:
Romberg's sign ยืนตรงเท้าชิดมือกอดอกแล้วหลับตาถ้าผิดปกติตัวจะ
เอียงไปข้างที่ผิดปกติ , Unterberger test ยืนกำามือประสารกันเหยียดไป
ข้างหน้าแล้วเดินซอยเท้าอยู่กับที่เป็นเวลา30วินาทีดูว่ามีการเซหรือ
เอียงมากกว่า45องศา
Nystagmus( Hallpike manoeuvre )
Spontaneous nystagmus อาการกระตุกของลูกตาขณะมองตรงไปข้าง
หน้า
Gaze-evoked nystagmus อาการกระตุกของลูกตาขณะตามองไป
ทิศทางใดทางหนึ่ง
Positional nystagmus อาการกระตุกของลูกตาขณะหันหรือหมุนศรีษะ
เช่น Hallpike manoeuvre ผป.นั่งบนเตียงให้ผป.หันศรีษะไปข้าง
ใดข้างหนึ่งประมาณ 45องศา แล้วล้มตัวลงนอนอย่างรวดเร็ว
โดย ศรีษะจะห้อยจากขอบเตียงประมาณ 30 องศา
caloric tests ดู Nystagmus ใช้นำ้าอุ่นอุณหภูมิ44และ30องศา กระตุ้นแต่ละ
ข้างประมาณ 30องศาสังเกตุทิศทางการ กระตุกของลูกตา

18. December 1, 2009 18
Investigate : Dix-Hallpike maneuver 1

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Investigate : Caloric tests

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Special Investigation
1. LAB: CBC , UA , FBS , E’lyte , CHOL , TG , Thyroid
function test , VDRL , FTA-ABS , Anti-HIV
2. EKG , Echocardiogram
3. Audiogram
4. Auditory brainstem response (ABR)เพื่อแยกสาเหตุจาก
Cochlear หรือ Retro-cochlear
5. Electronystagmogarphy (ENG) ตรวจ Nystagmus แยก
Vestibular ระหว่าง Central
6. Radiological spine
Film C-SPINE
Film Mastoid
CT-Brain , MRI

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Auditory brainstem response (ABR) Test

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Why use ENG? Electronystagmogarphy
(ENG)
Peripheral vs Central
Lateralize lesion
Support a diagnosis &
documented PE
BPPV, Meniere’s,
labyrinthitis, ototoxicity, AIED

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Other DDx(Differential diagnosis) to consider
การวินิจฉัยแยกโรคจากภาวะต่าง
Ramsay Hunt Syndrome (Vertigo component)
Otosclerosis (Vertigo)
Middle Ear Effusions (Vertigo)
Motion Sickness (Vertigo)
Seizure Disorder (Syncopal appearing)
Vasovagal episode (Syncope and can get short tonic -clonic jerks
few beats of low intensity without a real post-ictal phase, alert and
responsive after waking up)
Autonomic Dysfunction (Near Syncope, Syncope)
Hypoglycemia (Near syncope or syncope)
Dysrythmias (Near syncope or syncope)
Psychiatric Causes (emotional)

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Consultations
Because many differential diagnoses
exist, consultations with the following s
pecialists are recommended:
Neurologist
Cardiologist
Endocrinologist
Internal medicine specialist

25. December 1, 2009 25
Treatment of vertigo
1. การรักษาจำาเพาะสำาหรับแต่ละโรค เช่น
Cerebral Thrombosis รับไว้ในโรงพยาบาล ให้ Antiplatelet
Brain Tumor Surgery
BPPV รักษาโดยวิธีกายภาพบำาบัด Modified Epley
Meniere’s Disease Diuretic drug
2.Medication
Anti Vertigo Drug : Antihistamines เช่น
Dramamine , Bonamine , Phenergan
Side effect Asthma , Glaucoma , Prostate
Enlargement
Beta histamine เช่น Merislon , Serc
Side effect Asthma ,Peptic ulcer
,Pheochromocytoma
Peripheral vasodilators & Cerebral
activators เช่น Sturgeon , Sibelium
Side effect Parkinsonism
Anti Vomiting Drug : Plasil , Stemetil ,
Droperidol ,Motilium
Side effect GI Bleeding
,Pheochromocytoma ,Epilepsy ,Hypotension ,Glaucoma ,
(Liver & Kidney disease)
Minor Tranquillizers Diazepam
Side effect Glaucoma , Drug Addict
3. Surgery Labryrinthectomy

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When Is Surgery Recommended?
If vertigo attacks are not controlled by
conservative measures and are disabling, one of the following surgical procedures might be
recommended:
Intratympanic treatment, also known as chemical labyrinthotomy, is an office procedure in
which a medicine, such as gentamicin, is injected into the middle ear. Other medicines may
be used. Gentamicin is an antibiotic that causes a partial loss of balance function in the tre
ated ear, controlling vertigo in about three fourths of cases and usually preserving hearing.
Apart from a period of disequilibrium that can occur as the patient adjusts to the new level
of balance function, this treatment is usually very well tolerated.
It is also significantly simpler and less invasive than other surgical treatments.
The endolymphatic shunt or decompression procedure is an ear operation that is usually
preserves hearing. Attacks of vertigo are controlled in one-half to two-thirds of cases, but c
ontrol is not permanent in all cases. Recovery time after this procedure is short compared to
the other procedures.
Selective vestibular neurectomy is a procedure in which the balance nerve is cut as it
leaves the inner ear and goes to the brain. Vertigo attacks are permanently cured in a high
percentage of cases, and hearing is preserved in most cases.
Labryrinthectomy and eighth nerve section
are procedures in which the balance and
hearing mechanism in the inner ear are destroyed on one side. This is considered when the
patient with Ménière’s disease has poor hearing in the affected ear. Labryrinthectomy and
eighth nerve section result in the highest rates for control of vertigo attacks.

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BENIGN PAROXYSMAL POSITIONAL VERTIGO
(BPPV)


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Causes
The organ of balance, located in your inner
ear, is the vestibular labyrinth. It includes
loop-shaped structures (semicircular canals) t
hat contain fluid and fine, hair-like sensors th
at monitor the rotation of your head. These c
anals all attach to the utricle, which contains t
iny granules or crystals of calcium carbonate (
otoconia). These particles are attached to sen
sors that help detect gravity and back-and-for
th motion.

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The symptoms of BPPV
The symptoms of BPPV include dizziness or vertigo, lightheadedness,
imbalance, and nausea. Activities which bring on symptoms will vary a
mong persons, but symptoms are almost always precipitated by a chan
ge of position of the head with respect to gravity. Getting out of bed or
rolling over in bed are common "problem" motions . Because people wi
th BPPV often feel dizzy and unsteady when they tip their heads back t
o look up, sometimes BPPV is called "top shelf vertigo." Women with B
PPV may find that the use of shampoo bowls in beauty parlors brings o
n symptoms. An intermittent pattern is common. BPPV may be present
for a few weeks, then stop, then come back again.
Dizziness
A sense that you or your surroundings are spinning or moving (vertigo)
Lightheadedness
Unsteadiness
A loss of balance
Blurred vision associated with quick head movements
Nausea
Vomiting

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Investigation
Electronystagmography (ENG)
laboratory tests
MRI) scan will be performed if a stroke
or brain tumor is suspected

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The Dix-Hallpike test, also called the
"Hallpike"
is the definitive diagnostictest for Benign Paroxysmal Positional Vertigo (BPPV).

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Treatment of vertigo
A The manuever starts sitting upright . This maneuver should be done by your doctor or
physical therapist both for safety (you may be dizzy) and to observe the eye movements.
B First, your doctor will have you briskly lie on your back with your head turned to the
symptomatic side at a 45 degree angle. This picture illustrates a treatment of the right side. Your
head will be kept in this position for 30 to 60 seconds, based on the duration of the vertigo as
measured by observation of your eye
D Next your doctor will turn your head to the other side, and keep it in that position for
another 30 to 60 seconds. You may be dizzy again.
The Epley maneuver

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The Semont Maneuvers

34. December 1, 2009 34
Home Exercise Therapy (Brandt-Daroff exercises).

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Meniere’s disease
Figure 1a: Normal membranous
labyrinth
1b. Dilated membranous labyrinth in
Meniere's disease (Endolymphatic Hydrops)

36. December 1, 2009 36
The Normal Inner Ear
The hearing and
balance nerve
Carries information to
the brain from both
parts of the inner ear.
D
The hearing canal
Collects sound
information.
C
The balance canals
Collect balance
information.
B
The endolymphatic
sac
Keeps inner ear fluid at
a constant level.
A

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The Abnormal Inner Ear
The hearing and balance
nerve
Distorted information travels fro
m the inner ear to the brain.
D
The hearing canal
Swelling distorts or blocks
sound information.
C
The balance canals
Swelling in the balance canals
distorts balance information.
B
The endolymphatic sac
Backed-up fluid in the sac and
inner ear leads to swelling and
pressure.
A

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Clinical features (Symptoms )
fluctuating sensorineural hearing
loss
early stage reversible, later stage
residual
recruitment
tinnitus: roaring sound
episodic vertigo, min. to hrs.
fullness or pressure in ear
20%bilateral

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Investigate
A panel of blood tests is used to rule out obvious metabolic imbalances,
infections, and hormonal problems. Tests of the following should be performed:
Thyroid stimulating hormone (TSH), T4, and T3 to rule out hyperthyroidism
and hypothyroidism
Glucose to rule out diabetes
Sedimentation rate and antinuclear antibody to rule out autoimmune
disorders
Urine to rule out proteinuria and hematuria and indicators of otorenal
syndrome
CBC count to rule out anemia and leukemia
Electrolyte levels to rule out salt/water imbalance
Fluorescent treponemal antibody (FTA-ABS) to rule out neurosyphilis and
Lyme disease
Allergy testing is needed for allergy-mediated Méni่re disease.
Imaging Studies:
MRI of the brain is used to detect the following:
Abnormal masses or anatomy, specifically, acoustic neuromas or other
cerebellopontine angle lesions
Other lesions (eg, multiple sclerosis, Arnold-Chiari malformations)
Tumors (rarely found but should be ruled out)
CT scans are used to detect the following:

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Treatments for Ménière's disease
Dietary Manipulations
Low salt (low sodium) diet
Water intake
Caffeine restriction
Chocolate restriction
Alcohol restriction
General dietary considerations
Diuretics (Water pills)
Dyazide; Maxzide; Maxzide-25
HCTZ, Esidrix
Lasix
Diamox

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Recommended Adult Lifestyle Changes To Reduce The Frequency Of
Ménière’s Disease Episodes
Avoid alcohol, caffeine, excessive
fatigue, smoking, and streess
Eat properly
Get plenty of sleep
Remain physically active

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Intratympanic gentamicin injection (ITGM)