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VERTIGO

Vertigo and Dizziness : Multisensory syndrome

Vertigo Dizziness Vertigo

Dizziness
( Neuhauser and Lampert 2004)
( visual stimuli ) height vertigo
central vestibular otolith disorders
Vertigo Dizziness
( multisensory and sensorimotor syndromes )

vestibular system
Vertigo ( illusion
hallucination of movement )

( tilt) ( linear displacement )
Vertigo vestibular system

3
1. vestibular apparatus semicircular canal, utricle,
saccule
2. ( visual system)
3. ( proprioceptive system)
3 vestibular nuclei
6
1. Vestibulocerebellum
2. Spinal motorneurons
3. Reticular formation
4. Oculomotor nuclei extraocular muscles neck motorneurons neck muscles
( vestibulo-ocular reflexs)
5. Sensory cortex vestibulo-thalamo-cortical pathway
6. Brainstem center ocular motorneurons Spinal motorneurons

1. Disorders of perception : vertigo/ dizziness
2. Disorders of gaze stabilization : nystagmus
3. Disorders of postural control : falling tendency, ataxia
4. Disorders of vegetative system : nausea

1. VESTIBULAR (VESTIBULAR CAUSE ) 2

1.1PERIPHERAL CAUSE 6080
TRUE VERTIGO ALONE
Benign paroxysmal positional vertigo
Vestibular neuronitis
Positional alcohol nystagmus

VERTIGO, TINNITUS & HEARING LOSS

Menieres disease
Perilymphatic fistula
Acoustic Neuroma
Temporal bone fracture
Sudden SNHL
Ototoxicity
Labyrinthitis

1.2 CENTRAL CAUSE vestibular nuclei

Infection : Meningitis, encephalitis
Trauma : Head trauma, epilepsy
Tumor : Brain tumor
Vascular : Stroke, VBI
Demyelinated disease : Multiple sclerosis
Degenerative : Cerebellar atrophy

2. VESTIBULAR (NON-VESTIBULAR CAUSE )

2.1 OCULAR 2
2.1.1 Physiological vertigo

Static : Height vertigo

Moving : Motion sickness
2.1.2 Pathological vertigo

Visual performance disorders
Oculomotor disorders
2.2 Somatosensory vertigo
Sensory polyneuropathy , Cervical vertigo
2.3 MEDICAL DISEASE or MULTISENSORY DIZZINESS
DM , (presbyastasis)
2.4 PSYCHOGENIC phobic postural vertigo,
hyperventilation syndrome, manic depressive disorder

vestibular system peripheral central vestibular lesions

peripheral BPPV, Menieres disease, Vestibular neuritis
central

1.

1.1 ( type of vertigo )
1.2 ( onset & duration)
compensation
acute peripheral vestibular lesion vestibular
neuritis, labyrinthitis vestibular disorder
BPPV ,orthostatic
hypotension vertebrobasilar insufficiency

Menieres disease

Vestibular neuritis , ototoxicity, infarction of labyrinth, brainstem infarction, tumor

1.3 ( precipitating factors)

positional vertigo
BPPV perilymphatic
fistula Menieres disease otosyphilis
( Tullio phenomenon ) dilatation labyrinthine membrane
1.4 ( associated auditory symptoms)
( tinnitus) ( aural fullness)
peripheral vestibular lesion
Menieres disease

labyrinthitis

neuroma cerebellopontine angle tumor

acoustic

1.5 ( associated neurological symptoms)

( diplopia)
( dysphagia) ( dysarthria ) ( ataxia)
drop attack occipital
vertebrobasilar insufficiency
multiple sclerosis
temporal
lobe seizure incoordination cerebellar
lesion

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1.6 Predisposing factors

viral labyrinthitis vestibular neuritis 1-2

bacterial
labyrinthitis

temporal

otosclerosis, neurofibromatosis, spinocerebellar
degeneration
rubella, mumps

delayed endolymphatic hydrop

ototoxic drugs aminoglycosides
( oscillopsia)

postural hypotension ,
phenytoin cerebellar function
disequilibrium , Alcohol positional vertigo
cupula specific gravity

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2. ( physical examination)
2.1

orthostatic hypotension systolic 20

cardiovascular system, respiratory system, endocrinology system

systemic
2. 2 ENT
cholesteatoma fistula test
pneumatic otoscope (nystagmus) (vertigo)
fistula semicircular canal lateral semicircular canal
fistula test (Hennerberts sign)
Menieres disease perilymphatic fistula
tunning fork 512 Hz screening test
conductive hearing loss sensorineural hearing loss
2.3
Mental status over
medication , metabolic encephalopathy
cranial nerve
o CN 2, 3, 4, 6 fundoscopy visual field
visual field defect, papilledema CNS
o CN 5 sensation corneal reflex
lesion cerebellopontine angle tumor acoustic neuroma

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o CN 7 facial palsy hearing loss tinnitus

temporal Ramsay Hunt
syndrome, fracture temporal bone lesion IAC
o CN 9-12 (skull
base)
motor sensory system proprioception
cerebellar function coordination function
finger-to-nose, alternate hand movement, heel-to knee test
2.4 vestibular system
- Romberg test

acute vestibular lesion

cerebellar
chronic vestibular lesion compensation
functional or psychogenic cause

-Sharpened Romberg test

Romberg test
(sensitivity)
-Tandem gait test

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cerebellar function
vestibular function ( propioceptive
cerebellar )
-Unterberger or stepping test
50
vestibular loss
45
-Vestibulo-ocular reflexes
o Head shaking nystagmus

30 Frenzel glasses
optic fixation
horizontal semicircular canal
input end organ velocity-storage center CNS
vestibular system input velocity storage center
slow phase input
nystagmus fast component lesion ( lesion )
o Head trust test

vestibular loss
defect VOR fix
compensatory refixation saccades

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o Caloric test
horizontal semicircular canal
30 30 44
nystagmus 2
-. (visual ocular control)
fundoscope oculomotor pathways involve
CNS oculomotor function

1. saccade eye movement

2. pursuit
smooth ( 40 / sec)
3. ( nystagmus)
3.1 spontaneous nystagmus nystagmus vestibular
system peripheral type central type
spontaneous nystagmus Frenzel
glasses peripheral type spontaneous nystagmus optic
fixation central type spontaneous nystagmus
3.2 gazed evoked nystagmus nystagmus 30

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3.3 positional nystagmus nystagmus 2

3.3.1 static positional nystagmus
-> Barrel roll test
Benign paroxysmal positional vertigo(Horizontal canal)

Supine roll test (Barrell roll)

3.3.2 paroxysmal positional nystagmus 45

positioning Dix-Hallpike maneuver
Benign paroxysmal positional vertigo(Anterior & Posterior canal)

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Dix-Hall pike test

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3.
3.1 impedance audiometry
audiogram pure tone audiometry
speech audiometry
Impedance compliance
3.2 Auditory brainstem response (ABR) 8

cochlear retrocochlear
ABR acoustic neuroma
3.3 Vestibular function test electronystagmography ( ENG)
vestibular
caloric test
3.4 (laboratory test)
systemic disease , ,
hypothyroidism, syphilis

-CBC, ESR ESR inflammation autoimmune inner ear
disease
-FBS, BUN, Cr, Cholesterol, triglyceride, thyroid function test
-VDRL, FTA-ABS TPHA

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3.5 (imaging)
- (film cervical spine) , film IAC

- thin-section temporal bone CT scan lesion

temporal bone fracture MRI
acoustic neuroma
multiple sclerosis, hemorrhage, infarction, tumor CT MRI
central cause, CP angle lesion acoustic neuroma

3
1. ( Medical therapy)
2. ( Surgical therapy)
3. ( Rehabilitation therapy)
( physical therapy)

80 %
2
-( specific treatment )
Menieres disease ,
Autoimmune inner ear
-( symptomatic treatment )

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1. VESTIBULAR SUPPRESSANTS

- ANTIHISTAMINES promethazine, Dimenhydrinate
-ANTICHOLINERGIC scopolamine
-ANTIDOPAMINERGICS metoclopramide
-GABA - AGONISTS diazepam
-CALCIUM ANTAGONISTS cinnarizine , flunarizine

central compensation

physical exercise

2. VASODILATORS
- HISTAMINE DERIVATIVES
-BETAHISTINE DIHYDROCHLORIDE (SERC)
-BETAHISTINE MESYLATE (MERISLON)
cerebral blood
flow central compensation Menieres
disease
3. Nootropic drugs Ergoline derivatives (NICERGOLINE ), Decrease blood viscosity
(PENTOXIFYLLINE , PIRACETAM), Increase cerebral oxygenation (ALMITRINE /
RAUBASINE ), Free radical scavenger (GINGO BILOBA)

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( physical therapy)

compensation

vestibular

Cawthrone-Cooksey exercise
Brant-Daroff exercise

cupula semicircular canal
utricle cupulolithiasis canalolithiasis BPPV
canal canalith repositioning
maneuver ( CRP ) Epley Semont technique posterior canal BPPV
DixHallpike maneuver
Contraindication in Dix-Hallpike maneuver
-patients with significant vascular disease
-cervical stenosis
-severe kyphoscoliosis
-Limited cervical range of motion
-Down syndrome
-severe rheumatoid arthritis
-cervical radiculopathies
-Pagets disease

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-ankylosing spondylitis
-low back dysfunction
-spinal cord injuries
-morbid obesity

Canalith Repositioning Maneuver

Semont maneuver

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Vestibular Rehabilitation
Brandt-Daroff exercises

Patient instructed to sit and then to move rapidly into the challenging position, to remain in position for at least 30 s, and
then up for 30 s before assuming the opposite head-down position 30 s.

Peripheral vestibular vertigo

Peripheral vestibular
1.Benign Paroxysmal Positional Vertigo (BPPV)
Pathophysiology : cupulolithiasis & canalolithiasis
History : Patient reports repeated episodes of vertigo with changes in head position.
Nystagmus : by Dix-Hallpike test :Rotational & geotropic nystagmus , Latency : 2-20 sec,
Duration : < 60 sec, Reversibility,Fatigability
Treatment : Reassure ( spontaneous recovery, Recurrent) , CRP

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Complication of CRP : Nausea and vomiting, Hypotension, pallor, sweating, Anxiety, panic
attack, Continuous vertigo due to canalith jam, Moving otolith to other canals.
2.Menieres disease: Endolymphatic hydrops
-discrete episodic attacks, with each attack exhibiting a characteristic triad of sustained vertigo,
fluctuating hearing loss, and tinnitus
-Protracted nausea and vomiting
-Duration lasts longer (usually : hours)
-Decline in sensorineural hearing
Treatment
Diet : low salt diet (< 2 g/day)
Diuretics
Vascular agent : Betahistine, almitrine/raubasine
Other : aminoglycosides
Surgical therapy
3.Vestibular neuritis
-Vertigo is of gradual onset, developing over several hours, followed by a sustained level of vertigo
lasting days to weeks
-Vertigo is present at rest (not requiring positional change for its onset)
-Preceded by a viral prodrome
-Severe levels of nausea, vomiting, sweating, and pallor, which are also typically sustained along with
the vertigo.

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Treatment : Symptomatic
4.Labyrinthitis
-peripheral vestibular dysfunction ~ vestibular neuritis
-auditory portion of the inner ear is affected : hearing loss and tinnitus
-Vestibular symptoms precede cochlear symptoms by hours to days
PE : spontaneous nystagmus, SNHL
Rx : as etiologies , ATB
5.Perilymphatic Fistula
-Result from disruption of membranes of labyrinths, usually oval or round window asso. trauma,
surgery, defect in stapes footplate
-Vertigo brought on by loud sounds ,or pressure changes of the external auditory canals
6.Acoustic Neuroma
-Nerve sheath tumor
S/S -Unilateral SNHL**** (progressive or sudden HL), tinnitus, vertigo or disequilibrium, facial
nerve dysfunction
-Late stage: brainstem & cerebellar compressive symptoms