Vertigo sushmita

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Vertigo sushmita

  1. 1. DIZZINESS $ VERTIGO DR.SUSHMITA PAL Sunday, May 09, 2010
  2. 2. ORIGIN : from Latin word “vertÖ” “A spinning or whirling sensation” Sunday, May 09, 2010
  3. 3. DEFINITIONS : • A sensation of swaying or tilting • A sense of spinning or motion of the environment • A type of dizziness • A symptom of illusory movement Sunday, May 09, 2010
  4. 4. Sunday, May 09, 2010
  5. 5. Sunday, May 09, 2010
  6. 6. Causes Vestibular  Peripheral  Central Sunday, May 09, 2010  Medical causes(BP/ Arrhythmia / angina/ hypoglycemia / anemia/drugs , etc.)  Psychiatric (phobic disorders/ hyperventilation) Non Vestibular
  7. 7. • Peripheral  BPPV  Vestibular neuritis  Meniere’s disease  Ototoxic drugs  Perilymph fistula  SCD Syndrome  Acute labyrinthitis  Post concussion  Motion sickness  Acoustic neuroma • Central  Stroke(vertebro basilar insufficiency, Wallenberg syndrome)  Cerebellar disorders(tumors/ haemorrage)  Multiple sclerosis  Basilar artery migraine  Vestibular migraine  Cervical vertigo Sunday, May 09, 2010
  8. 8. APPROACH TO A DIZZY PATIENT  Appropriate history ( type of vertigo , its duration , triggering factors, certain associated symptoms, its frequency) Sunday, May 09, 2010 Forms/types of vertigo: Rotatory Postural Duration: Attacks/episodes Persistent Triggers: viz . Change in position Yes No Assosiated symptoms: viz. hypoacusis, double vision, ataxia Yes Yes/No Site of origin PERIPHERAL (labyrinth/ vestibular nerve) CENTRAL (Brain stem/cerebellum/ cortex)
  9. 9. General medical examination: BP (for hypo and hypertension) Cardiac examination : for arrhythmia , murmurs and bruit. Neurological examination : for cerebellar integrity and CN examination. Ophthalmological examination: for papilloedema , nystagmus saccades/smooth pursuit. Audio vestibular examination : inspection of TM , TFT with or without Pure tone audiometry. And an array of vestibular tests. Sunday, May 09, 2010
  10. 10. VEsTIbulAR AssEssmE NT CliniCal tests  Spontaneous nystagmus  Halmygi’s head thrust test  Fistula tests  Past pointing/Gait  Romberg’s test  Positional test (Dix- Hallpike maneuver) laboratory tests  Caloric tests  Cold caloric/modified Kobrak  Fitzgerald Hallpike bithermal caloric test  Cold air caloric test  Electronystagmography  Rotation test  Posturography  Optokinetic test Sunday, May 09, 2010
  11. 11. MANAGEMENT OF VESTIBULAR DISORDERS  Physiotherapy : certain vestibular exercises eg. Semont’s/Epley’s maneuver  Medical management using vestibular suppressants ( cinnarizine , promethazine) , vestibular vasodilators ( betahistine ) , anabolic steroids , antibiotics , etc.  Psychological/psychiatric and behavioral therapy  Surgical management ( eg. Endolymphatic decompression, Resection of neuroma , etc.) Sunday, May 09, 2010
  12. 12. Patient with h/o momentory( about 10 sec) rotatory vertigo , as soon as he gets up from the bed or goes to bed Sunday, May 09, 2010 BENIGN POSITIONAL PAROXYSMAL VERTIGO  Occurs with head movts or head roll  No numbness/headache/ear symptoms  Nausea/vomiting/oscillopsia may be +nt.  Positional test is diagnostic. Turn the head to Lt (45 degree) while sitting, then make him lie down towards Rt, shake the head, and w/f nystagmus. The nystagmus is rotatory / vertical, beating towards the forehead.
  13. 13. Treatment: • Liberatory movements : 3 times TID turn the head to R side(nonaffected) 45 degrees , move the patient to lie towards opposite side (L) again move him 180 degree away to lie on the opposite side (R) These movements accentuates the postural imbalance momentarily, But it is actually beneficial within a span of 3 -4 days. These movts are done to teach the otoconias in the ear. Sunday, May 09, 2010
  14. 14. TREATING MANEUVERS EPLEY’S Turn the head 45 degree hrztally towards affected side Tilt him backwards to horizontal position, with yet the same head tilt. Vertigo ppts. Maintain the same position until vertigo stops.( debris moves towards the apex). Head is turned 90 degree towards unaffected side,also pt is rolled towards unaffected side so that face is towards the floor. (debris moves back in the canal, vertigo ppts). Pt is seated with head down tilt of 30 degree, brings the otoconia back in the utricle SEMONT Turn the head 45 degree hrztally same towards unaffected side Tilt 105 degree to make him lie on affected side , head hanging & nose pointed upwards(3 min).Debris moves to the apex of the canal. Now, moving him 180 degree from aff to unaff side with nose pointing downwards.Debris moves towards the exit of the canal. He is slowly seated. Debris gets back in the vestibule. Sunday, May 09, 2010
  15. 15. Sunday, May 09, 2010
  16. 16. Patient with h/o rotatory vertigo , lasts for an hr to 7 hrs, usually once or twice a week, associated with heaviness of ear/head & diminished hearing. MENIERE’S DISEASE • Tinnitus + aural fullness • Vertigo lasts minimum for about 20 min. • Best way to prevent the vertigo is to prevent the hydrops • Prophylactic Rx: Betahistine 48 mg TID : 9- 10 mths Intratympanic injection of gentamycin Sunday, May 09, 2010
  17. 17. H/o rotatory vertigo , since 2 or 3 days , continous , with imbalance, nausea /vomiting + VESTIBULAR NEURITIS • High grade fever+ nt ; invariably with raised counts • Lasts for 5 days to 2 or 3 wks • Spontaneous oscillopsia +nt • Hrztal nystagmus +nt towards healthy side suppressed by visual fixation • Pathological head thrust test • +ve Romberg’s test (sway towards affected side) • Viral etiology(HSV/HZV) • While walking , surroundings are hazy/unable to read, & while stable , everything is clear. Sunday, May 09, 2010
  18. 18. Management:  Symptomatic treatment  Vestibular suppresants for 3 – 5 days eg. Dimenhydrinate, Clonazepam, Cinnarizine  Increasing the inner ear circulation eg. Betahistine  Treating the pathology using MPA( 100 mg /day) +/- antivirals  Vestibular exercises for 30 min TID : to improve the central vestibular compensation Sunday, May 09, 2010
  19. 19. H/o recurrent attacks of rotatory vertigo , nausea+/- vomiting,headache , lasting for min to hrs VESTIBULAR MIGRAINE • Other migrainous symptoms +nt • During the attack : pathological head thrust test + postural imbalance • During the attack free period : peripheral vestibular deficit signs are +nt but not postural imbalance • o in the line of migraine (prophylaxis & treatment) o And vestibular suppressants. Sunday, May 09, 2010
  20. 20. H/o postural vertigo , episodic, lasting for few minutes PHOBIC POSTURAL VERTIGO • Normal neurological signs • Subjective instability of gait ( fear of falling) • Vegetative disturbances • Triggering factors: eg. Crowd of people , entering a car/lift/store/room • Management : i. Improves with alcohol ii. SSRI eg. Fluvoxamine iii. Psychoeducational + Behavioral therapy STROKE • Neurological signs +nt • Impaired Tandem walking • Ataxia & other cerebellar signs +nt • H/o fall with injury +nt • Spontaneous nystagmus +nt • Principle of treatment is to augment the circulation Sunday, May 09, 2010
  21. 21. • CERVICAL VERTIGO Postural vertigo , associated with certain neck movements and it lasts for few minutes , no neurological signs , X ray is diagnostic in spondylosis. Management : avoid chiropractic maneuvers and Betahistine to improve vestibular circulation. • MOTION SICKNESS Physiological vertigo Rotatory vertigo , triggered by motion due to mismatch of two different stimulus (eye & vestibule) viz. car sickness, space sickness , sea sickness etc. • OTOTOXICITY Due to the vestibulotoxic drugs eg. Streptomycin , gentamycin , tobramycin etc. • BASILAR MIGRAINE : postural vertigo + dysarthria + diplopia + tinnitus Sunday, May 09, 2010
  22. 22. Sunday, May 09, 2010 THANK YOU

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