VERTIGO

Guided by:
DR.JYOTHI RAVINDRA,
Assistant professor,
Dept of shalakya tantra.
 Content

1 Definition 2 Etiology

3 Pathophysiology 4 Types and treatment

DEFINITION

A feeling " in which the external world

seems to revolve around the individual
or in which the individual seems to
revolve in space".
Incidence
 Approximately 30% people- moderate to severe dizziness
 80% seek medical help
 Most ppl reportnon specific form of dizziness, nearly25%
of these report true vertigo.
 Females>males and older people

Prosper meniere (1861) first to recognise vertigo with

hearingloss and to localize the symptom to inner ear.
What causes
vertigo?
1.vestibular system
2.visual system
3.proprioceptive
system
Pathophysiology
Sudden pathological dimunition of function in one side

Information reaching the cortex is mismatched

Relative hyperfunction of intact side

Uncontrolled and prolonged vestibular reflexes

VERTIGO
Causes of vertigo
VERTIGO

Pathological. Physiological

Non vestibular vestibular

Peripheral. intermediate central

Physiological causes Non vestibular
Intermediate causes causes
1. Mismatch- motion sickness, 1. Ocular vertigo
1. Vestibular
height vertigo,visual vertigo 2. Orthostatic hypotension
neuronitis
2. Vestibular system subjected 3. Anemia
2. Acoustic neuroma 4. Epilepsy
to never adapted head 3. Drugs 5. Migraine
movements 6. Psychogenic
3. Unusual head and neck Vestibular causes
1 2 3 4
5
movements
Peripheral causes Central causes
1. BPPV 1. Vertibrobasilar insu ciency
2. Menier's disease 2. Cervical spondylosis
3. Labyrinthitis 3. Whiplash injury
4. Head injuries and surgical 4. Arterio sclerosis
trauma 5. Brainstem ischaemia
 Peripheral Central
VERTIGO VERTIGO
Nystagmus Unidirectional,
horizontal,fast phase Bidirectional, vertical,
opposite lesion may last to months

Imbalance Moderate; able to walk Diffe Severe; unable to

Tinnitus& Common rence stand
Rare
deafness
Visual No inhibition;none,
Inhibits ;lasts 3-40sec immediate vertigo and
fixation and nystagmus
latency
Approach to a case of VERTIGO

 Nausea, vomiting and imbalance

 H/o recurrent episodes in the past- BPPV
 Tinnitus and hearing loss- inner ear
pathology
 Triggers and relieving factors
 Nystagmus
 Examination
• General examination
• Neurological examination: cerebellar dysfunction,corneal
reflex and special test
• ENT Examination: eardrum,EAC, tuning fork test,fistula test
• Hearing test
• Balance test: Romberg test,unterberger test,babinski Weill
test,barany pointing test
• Eye movement tests- nystagmus test,caloric Test,
electronystagmography,optokinetic test.
• Positional tests-hallpike maneuver
• CT scan, MRI (when required)
Benign paroxysmal Vestibular Labyrinthitis
positional vertigo neuritis
• Vertigo • Vertigo
• Vertigo • Disequilibrium
• Lightheaded • Disequilibrium
• N/V
• Nausea/
• Nausea • Oscillopsia
vomiting • Hearingloss and
• Oscillopsia tinnitus
TREATMENT

Reassurance/psychological
1
support
Vasodilators: Betahistine
2 Labyrinthine sedative: cinnarizine
Antiemetics: domperidone
3 Intratympanic inj of
Gentamycin
4 Surgery
Meniere's disease (Endolymphatic
hydrops)
• Inner ear disease
• Peak incidence- 40-60yrs ofage,seen equallyin both
sexes
• Commonly unilateral,47% cases- bilateral involvement
1)vertigo 3) tinnitus
2)sensorineural hearing loss 4)aural fullness
Etiologic factors and symptomatology
 Pattern of attack

Vertigo Deafness Tinnitus

Classic triad of symptoms
 Pathophysiology
Gradual distension of endolymphatic system

Thinning and atrophy of Reissners membrane and saccular wall

Rupture and release of endolymph in small perilymph space

Sensory and neural structure exposed to K+ rich endolymph

Sudden hearing loss and vertigo

When perilymphatic compartment is restored to normal, symptoms subside

Rupture heals and the process is repeated

 Vertigo(96%)
• Episodic,sudden onset
• Asso.. with N/V and diarrhea Add your title

• Tullio phenomenon: loud sounds

or noise produce vertigo Hearing loss(88%)

• Improves after the attack

• Normal during periods of remission
• Slow and progressive deterioration
of hearing
Tinnitus
• Low pitched
• Aggravated during acute
attacks
• Change in intensity and pitch
maybe the warning symptom
Sense of fullness

Accompany or precede an
attack Of vertigo
Examination
1
Acute attack-severe vertigo

5 1
2 Diaphoretic and pale

3
Raised BP,PR &RR
4 2
4
Rinnes test AC>BC
3

5 Weber's test lateralized to

affected ear
Investigations
Otoscopy- normal
1 1. Recruitment test
2 Audiometry 2. SISI
Menier's 3. Tone decay test
disease

3 Electrocochleography
4
Caloric test and
glycerol test
OTOSCOPY Add your words here,according
to your need to draw the text
box size
TITLE2

Add your words here,

according to your need to TITLE1 TITLE3
Add your words here,according
draw the text box size to your need to draw the text
box size

Add your words here,

according to your need to
draw the text box size
TITLE5 TITLE4 Add your words here,according
to your need to draw the text
box size
OTOSCOPY

• To visualise condition of the

ear canal and eardrum
• Cause can be detected for
ear fullness, hearingloss,etc.,
• it is normal in
Menier'sdisease
AUDIOMETRY
1.Pure tone audiometry
In early stages,lower frequencies are affected and
involved curve becomes flat or a falling type.
speech audiometry
2.
• fundamental tool in hearing lostolorence assessment
along with PTA ,it can aid in determining the degree of
deafness and type of hearing loss.
• It provides information on word recognition and about
tolerence to speech stimuli
SPECIAL AUDIOMETRY TESTS
1.Recruitment test
• Phenomenon of abnormal growth of
loudness
• Ppl with cochlear disorders can't hear
low frequency sounds and say "to speak
louder" followed by the complaint of "
stop shouting"
2. SISI (SHORT INCREMENT SENSITIVITY
INDEX)
• It is designed to find out whether or not the
pt can hear very small changes in sound
intensity (i.e.,1db)
• It is important because if the disorder is in
the cochlea then the pt will be able to hear
changes smaller than the normal ear can hear
• better than 70% in 2/3rd of pts
• Normal (0-15%) cont.....
• Continuous tone given 20dB above hearing threshold and
sustained for 2min
• Every 5 sec tone intensity increased by 1dB and 20such
blips are given
3.Threshold tone decay test
• Used to detect retro cochlear lesions
• To measure nerve fatigue
• Normally,a person can hear a tone continuously for
60sec
• In nerve fatigue,stops hearing earlier
• It indicates vestibular hypofunction
ELECTROCOCHLEOGRAPHY
(ECochG)
• It is an ideal test for diagnosis of
Menier'sdisease
• It is done to determine if there is too
much of fluid in the inner ear
• Normal :SP/AP = 30%
• IN Menier'sdisease more than 30%
Sp - summating potential
Ap- action potential
 Caloric test
• Pt lies supine with head tilted 30° forward so that
horizontal canal is vertical
• Ears are irrigated for 40s alternatively with water at
30°C and at 44°C
• Eyes observed for nystagmus
• Cold water induces nystagmus to opposite side and
warm water to the same side(COWS -mnemonic)
• Depending on response to the caloric test,we can find
canal paresis or dead Labyrinth,directional
preponderance
DIAGNOSIS
Committee on hearing and equilibrium of AAOHNS

1.definite -2/more spontaneous episodesof

vertigo lasting 20min /longer
A) audiometry-hearing loss atleast in one
occasion
B) tinnitus/aural fullness in affected ear
2.Probable-
A)one definitive episode of vertigo
B) audiometry-hearingloss once
C) tinnitus or aural fullness in treated ear

3.possible-
A) episodic vertigo without documented
hearingloss(vestibular variant)
B) sensorineural hearing loss with disequilibrium but
without definitive episodes ( cochlear variant)
Management

General measures
1. Reassurance: psychological
support
2. Cessation of smoking
3. Low salt diet
4. life style modification
Management of acute attacks

• Reassurance
• Bed rest
• Vestibular sedative - diazepam,
prochlorperazine
• Vasodilators-Carbogen
Management of chronic attack

• Vestibular sedative-prochlorperazine
• Vasodilators- Betahistine TID
• Diuretics- furosemide (control recurrent
attacks)
• Avoid allergens
• Hormonal therapy if endocrinal origin
Intratympanic gentamycin
therapy
a. It is a vestibulotoxic
b. Daily/weekly injections into middle ear
c. Drug is absorbed through the round Window and
cause destruction of the Vestibular Labyrinth.
d. Priorly anaesthetize with phenol swab stick
e. Abt 0.5cc sol is injected into the middle ear with
25 gauge needle
f. Pt remains in this position for 30min
 Surgical
treatment
Conservative treatment

a. Endolymphatic sac decompression

b. Cochleostomy
c. Sacculotomy
d. Endolymphatic shunt operation
 Surgery reducing vestibular activity without
damaging cochlea
a. Ultrasonic destruction of
Vestibular labyrinth
b. Vestibular nerve section

Destructive surgery
a. Labyrinthectomy
b. Laser destruction of inner
ear
 म रोग
च वद् मतो गा ं भूमौ पत त सवदा।
मरोग इ त ेयो रजः प ा नला मकः।।
(मा. न.17/19)

Characterized by reeling of a body like a turning

wheel and person falls on the ground regularly.

It manifests due to predominance of raja,pitta and

vata
च क सा स ांत
1 नदानप रवजन 5 शरोधारा : गो धा/
दशमूला स ीर
2 शोधन: वरेचन, ब त

3 स ववजाय च क सा योग च क सा: शीषासन,

6
हलासन, सवागासन,
4 शमन च क सा ाणायाम
शमन च क सा
i. नारीके ला जल+ यव स ू+ म ी
ii. रालाभा वाथ+घृत+शकरा
iii. शतावरी+बलामूला+ ा ा ीरपाक
iv. रसायन औष ध+ ध+ म ी
रस योग अवलेहा योग
• वसंत मालती रस
• रस स र • चं ावलेह
• मू ा तका रस • आमाल यवालेह
• रासायन
अ र योग
घृत योग • अ गंधा र
• क याणक घृत
• महाक याणका घृत • दशमूला र
• बला र ा
 Reference:
Text book of ENT and

！
head &neck surgery -P.
Hazarika,D.R.Nayak,R.

THANKS
Balakrishnan
Diseases of ENT and
head and neck surgery-
PL Dingra,Sruti Dingra
मा. न.१७,
Kc TB-ajay kumar By-
sharma NAMANA K.T.
UG 4th professional,
GAMC, MYSORE.