vertigo and tests for evaluation seminar..pptx

Detailed explanation about vertigo and the major tests to evaluate clinically in the patients

1. 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

2. CAUSES V - Vascular E - Endocrine/Epilepsy R - received Treatment T - trauma I - infection/ inflammation G - growth(tumour) O - opthalmologic

3. Types of vertigo

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

5. NATURE OF VERTIGO ROTATIONAL BPPV LABIRYNTHINE FISTULA MENIERE’S DISEASE VESTIBULAR NEURONITIS VERTEBROBASILAR INSUFFICIENCY TRAUMA LABYRINTHITIS METASTATIC DEPOSITS IN CP ANGLE

6. UNSTEADINESS DRUGS TRAVEL SICKNESS PERILYMPH FISTULA HYPERVENTILATION VESTIBULAR INSUFFICIENCY CNS LESIONS

7. VERTIGO IN CHILDREN

8. TESTS FOR BALANCE PHYSICAL EXAMINATION Aural examination Assessment of hearing Assessment of stance and gait OTONEUROLOGICAL EXAMINATION Clinical assessments of eye movements Ocular control systems Vestibular ocular reflex and nystagmus Halmagyi head thrust Caloric testing Electronystagmography and videonystagmography

9. AURAL EXAMINATION Pneumatic Otoscopy- Hennebert's Sign nystagmus and vertigo with +/- pressure Normally: No nystagmus May be positive in: Perilymph fistula, Semicircular canal dehiscence syndrome, and Meniere's disease

10. OCULAR CONTROL SYSTEM

11. 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, and a 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

12. Types of Nystagmus

13. ALEXANDERS LAW It states that the amplitude of jerk nystagmus is largest in the gaze of direction of fast component 1 degree : Nystagmus only in the direction of the fast component 2 degree : Nystagmus in the primary gaze position 3 degree: Nystagmus in addition to above gazes , also present in the direction of slow component.

14. DIFFERENTIAL DIAGNOSIS

15. 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

16. HEAD THRUST TEST/ HEAD-IMPULSE TEST

17. 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 dela y. In case of hypofunctional horizontal canal fails to drive eyes to opposite. A catch up saccade brings them into position after a delay

18. 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- Modified Kobrak Test Fitzgerald-Hallpike Test Cold Air Caloric Test

19. MODIFIED KOBRAK TEST 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. Normally, nystagmus towards opposite ear will be seen in 5ml of ice water. If response is seen in between 5ml to 40ml, labyrinth is considered hypoactive. No response to 40ml, indicates dead labyrinth.

20. FITZGERALD-HALLPIKE TEST/ BITHERMAL CALORIC TEST: Caloric testing is the mainstay of vestibular laboratory testing and produces nystagmus by thermal stimulation of vestibular system. 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 semicircular canals induced by 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 semicircular canal, which causes a cupular deflection and a change in activity of the vestibular nerve. Cold irrigation produces a utriculofugal deflection – fast nystagmus component away from the ear; warm irrigation produces a utriculopedal displacement – fast nystagmus component towards the ear.

21. Steps of caloric test Patient lies supine with head tilted 30% 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.

22. 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. It is only a rough qualitative test

23. 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).

24. TEST FOR GAIT ROMBERG 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.

25. UNTERBERGER’S TEST / 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 go times in 1 sec. Rotation to one side indicates vestibular hypofunction of that side or hyperfunction of the opposite

26. 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

27. ELECTRONYSTAGMOGRAPHY Electronystagmography is an important test done to evaluate patients with vertigo, dizziness and balance problems. The study of eye movements provides a lot of information about the functioning of the brain and the balance system. ENG is used to second eye movements in different conditions and with different tests. By analyzing these movements, we are able to understand the area affected by the disorder

28. 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

29. 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.

30. 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.

31. 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.

32. 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 and it is not possible to perform the caloric test. 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 and computer analysis of the results

33. 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 and then a current of 1 mA is passed to one ear. Normally, person sways towards the side of anodal current. Body sway can be studied by a special platform

34. POSTUROGRAPHY It is a method to evaluate vestibular function by measuring postural stability and is based on the fact that maintenance of posture depends on three sensory inputs-visual, vestibular and somatosensory. It uses either a fixed or a moving platform. Visual cues can also be varied. The clinical application of posturography is still under investigation

35. BENIGN PAROXYSMAL POSITIONAL VERTIGO Most common peripheral cause of verigo Disorder of the semicircular canals with free floating particles in the endolymph or these particles fixed to the cupula of canal. In BPPV otoconia from 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

36. DIX HALLPIKE MANOEUVRE Points to be remembered before starting the procedure - Explain the patient regarding the procedure - Take CONSENT from 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)

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

38. SEMONT’S LIBERATORY MANOEUVRE

39. 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 atleast 30sec 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,hence it is not the first line treatment.

40. 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

41. COMPLICATIONS Gait instability following canalith repositioning procedure Conversion of P-BPPV to A-BPPV or H- BPPV Both Epleys and semonts manouveres involve 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 Epleys manouvre on a couch where the upper half of the body can be lowered by 20 -30 degree which obviates the need for head reclination.

42. TREATMENT OF H-BPPV FORCED PROLONGED POSITION 270 DEGREE BARBECUE MANOEUVRE 360- DEGREE YAW ROTATION LIBERATORY MANOEUVRE

43. COMPLICATIONS AFTER H-BPPV MANOEUVRES H-SCC canalolithiasis may convert into cupulolithiasis after rotaion manouevres , which may convert to horizontal canal-plugging, which causes Unidirectional nystagmus. In such situations Vigorous head shaking or gentle head percussion may unplug the canal.

44. 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 and brought to 30 degrees below the horizontal. It is kept in this position for 30 seconds then elevated while 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

45. SURGICAL TREATMENT OF BPPV Posterior semicircular canal occlusion surgery. Singular neurectomy via Transcanal approach.

46. 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. Bithermal caloric testing shows unilateral reduced vestibular response Vertigo is prolonged and subsides gradually over days and weeks Associated with URTI, may occur in epidemics.

47. 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

48. 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

49. DIAGNOSIS DIAGNOSIS- Vestibular tests Audiometry. Including the glycerol test According to ASA-HNS criteria definite meniers disease is: Two or more definitive spontaneous episodes of vertigo lasting at least 20 mins . Audiometrically documented hearing loss at least one occasion Tinnitus or aural fullness in the suspected ear Others causes excluded.

50. Management Non ablative procedures Intratympamic injection of corticosteroids Partially ablative procedures like Intratympamic injection of gentamicin Surgical techniques like Endolymphatic decompression Vestibular neurectomy Labyrinthectomy

51. 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.

52. LABYR INTHITIS 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

53. 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 ( ampullopetal displace- ment of cupula).

54. 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.

55. 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.

56. 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

57. 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

58. ABLATIVE PROCEDURES FOR C on TROL OF VERTIGO LABYRINTHECTOMY VESTIBULAR NEURECTOMY

59. Labyrinthectomy Most destructive procedure for treatment of meneires disease. Both hearing and vestibular function is uniformly destructed person with no functional hearing and have failed intratympamic gentamicin injection are Ideal candidates. Higher rate of vertigo control than vestibular neurectomy . 2 approaches – transcanal and transmastoid Most commonly performed through transmastoid approach.

60. Transmastoid approach Procedure begins with cortical mastoidectomy with postauricular approach This approach allows complete visualization and removal of all three semicircular canal ampullae , utricle , saccule . Advantages: Considered gold standard due to complete vestibular tissue removal Allows concomitant cochlear implantation

61. Transcanal labyrinthectomy Also known as oval window labyrinthectomy . Performed by approaching inner ear through external auditory canal Advantages : Less invasive Short operative time Lower rish complications like CSF leak , facial nerve injury.

62. Vestibular neurectomy Two approaches mainly : Translabyrinthine vestibular neurectomy Transcochlear vestibular neurectomy Translabyrinthine vestibular neurectomy extends the transmastoid labyrinthectomy Transcochlear vestibular neurectomy extends the transcanal labyrinthectomy .

63. 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

64. THANK YOU