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Vertigo 1
1. Dr Zuraida Zainun
MSc (Medical Audiology), MDMSc (Medical Audiology), MD
Senior lecturerSenior lecturer
Audiology PrgrammeAudiology Prgramme
School of Helth SciencesSchool of Helth Sciences
Universiti Sains MalaysiaUniversiti Sains Malaysia
drzuraida@yahoo.com
http://bal-exercise.blogspot.com/
2. Elicit history and evaluate dizziness
Understand vestibular testing
Knows differential diagnosis in dizziness
Understand management concepts
3. 3
‘’a disturbance that causes an individual to
feel unsteady, giddy, woozy, or have a
sensation of movement, spinning, or
floating’’. http://www.nidcd.nih.gov/health/balance/balance_disorders.asp
4.
5. Philip D. Sloane, MD, MPH; Remy R. Coeytaux, MD; Rainer S. Beck, MD; and John Dallara, MD Dizziness: State of the Science Ann Intern Med. 2001;134:823-832.
Dizziness
subtype
Type of sensation Temporal
Characteristics
Other Specification
Vertigo A feeling one that one or
One’s surroundings are
Moving (spinning)
Episodic vertigo
(seconds to days)
Continuous
vertigo (most of
the time for at
least a week)
Characteristics, duration, and date of the
first episode, length of episodes; and
exacerbating factors.
Presyncope A lightheaded, faint feeling, as
though one were about to pass
out.
Typically occurs
in episodes
lasting seconds
to hours.
1) Has syncope ever occurred during an
episode
2) Do episodes occur only when the
patient is upright, or do they occur in
other positions?
3) Are episodes associated with
palpitations, medication meals, bathing,
dyspnea, or chest discomfort?
Disequilibriu
m
Unsteadiness:
- felt in lower limb
- prominent when standing or
walking
- relieved by sitting or lying
down
Usually present.
Although it may
fluctuate in
intensity
Identify whether symptom occurs in
isolation or accompanies another
dizziness subtype; describe exacerbating
factors.
Other
dizziness;
anxiety-
related,
ocular, tilting
environment
, other
A feeling not covered by the
above definitions, may include
swimming or floating
sensations, vague
lightheadedness, or feeling of
dissociation.
Present all the
time ~
days/weeks/year
s
-Is dizziness a/w anxiety or
hyperventilation?
- Was change in vision connected with
dizziness onset? -
Environment is tilting sideways (suggests
an otolith problem?
8. *Chief complaints
*Dizzy !! Lightheadacheness!! Headache!! Floating!! Presyncope!!
*Whirling !! Swaying!! Unsteadiness!!
*True vertigo or not ?
A) Nature
*B) Duration of attack:
BPPV-seconds
TIA-minutes
Meniere’s-hours
Vestibular Neuronitis-Days
Ototoxins-years (See Hain, 1997)
*C) Associated symptom
positional related, hearing disturbance, headache,
stress
D) Precipitating/ provoking factors
Spinning Vestibular
Unsteadiness Central lesion
Presyncopal/
feeling faint Orthostatic
Unspecific
(dissociation) Psychology
9. •Otoconia exist within a part of the inner ear
• crystals of calcium carbonate derived from a structure in the ear called the "utricle“
10. Duration of episode
Suggested diagnosis
Seconds Peripheral: unilateral loss of vestibular fx, late
stage of acute vestibular neuronitis & MD
Seconds - minutes BPPV. perilymphatic fistula
Minutes – one hour Posterior transient ischemic attack;
perilymphatic fistula
Hours MD; perilymphatic; migraine. Acoustic neuroma
Days Early acute vestibular neuronitis*’stroke;
migraine; Multiple sclerosis
Weeks Psychogenic (constant ~weeks w/o
Improvement)
*-Early acute vestibular neuritis can be two days or as long as one week or more .
12. Provoking Factor Suggested diagnosis
Changes in head
position
Acute labyrinthitis;BPPV; CPA
Tumour ;multiple sclerosis (MS);
PLF
Spontaneous
episodes
AVN; CVA (stroke or TIA; MD ;
migraine; MS
Recent URTI Acute vestibular neuronitis (AVN)
Stress Psychiatric or psychological
causes; migraine
Changes in ear
press., trauma,
excess. straining,
loud noises
Perilymphatic fistula (PLF)
13. Past medical history
-vascular risk factors
-ear surgery
Family History
-Similar disorder ?
-Migraine
Drug History
-present and past exposures to ototoxins,
antihypertensives.
16. *Gait
*Cranial nerves
*Motor power and
reflexes (e.g. Babinski)
*Sensory
(proprioception)
Cerebellar sign ;
a) Finger to nose
b) Dysdiadokinesia
c) Tandem gait (hell to
toe) with eye open
and closed
17. *Romberg’s test
Fall to one side:
- Posterior column lesion
- Acute ipsilateral vestibular lesion
*Fukuda @ Unterberger test
-Walk on the spot for 2 minutes with eye
closed
-Positive when patient turn > 45°
-Ipsilateral peripheral lesion
18. l) Spontaneous nystagmus
MD, Vestibular Neuronitis, central disorders, to
rule out Psychiatric (used Frenzel's goggles)
ii) Range of eye movements
Gaze paresis
Ocular paresis
iii) Cover test for strabismus : a
deviation or misalignment eyes.
strabism– eye muscle position ~ one or both
eyes may turn in (esotropia), out (exotropia), up
(hypertropia) or down (hypotropia).
http://dewa-dony.blogspot.com/2008/10/strabismus.html
19. - to detect vestibular neuritis, acoustics,
and to rule out psychiatric disturbance
Head-shake test - (Hain et al, 1987)
75% sensitive but wrong side in 1/4 of
the time.
Head Thrust test
21. - to detect ototoxicity and other
bilateral vestibulopathies
Dynamic illegible 'E' test or DIE
(Longridge, 87).
22. 1. DIX-HALLPIKE TEST
-Rotatory upbeating; Post SCC
-Rotatory downbeating; Ant. SCC
video 1
video 2
video 3 cupulo
Treatment for Post. SCC- Epley’s
menourve
2. ROLL TEST
- horizontal nystagmus
video 1
Treatment- Barbeque menourve
24. 3) Fistula Test or Valsalva test- Occasionally helpful
4) Hyperventilation test – 30 seconds, look for
nystagmus. Helpful when nystagmus changes
direction compared to vibration or head-shaking
nystagmus.
5) Carotid Sinus Compression - for syncope patients.
6) Vertebral artery test - for persons with neck-
position induced vertigo (cervical vertigo).
25. Feature Peripheral Vertigo Central Vertigo
Nystagmus Mix horizontal & tensional;
inhib. by fixation of eyes;
Fades after a few days; not
change direction with gaze
to either side
Purely vertical , horizontal, or
torsional; not inhibited by
fixation of eyes ; last weeks
to months; change direction
With gaze towards fast phase
Of Nystagmus
Imbalance Mild to moderate; able to
walk
Severe; unable to stand or
walk
Nausea,
vomiting
May be severe Varies
Hearing loss,
tinnitus
Common Rare
Neurologic
Sx
Rare Common
Latency
(follow. pro-
vocative)
Longer (up to 20 seconds) Shorter (up to 5 seconds)
26. Indication;
Assess vestibular function
Locate the lesion organ/part
Causative factor/etiology
Vestibular rehabilitation assessment
39. 1. Investigation and diagnosis
2. Explanation
3. Rehabilitation plan
- correction of remediable problems
-General medical condition
- general fitness programmed
- physical exercise regimens (i.e. Vestibular rehabilitation by
physiotherapist/ homebased)
Cawthorne cookseey exercise (CCE)
Customised CCE
Epley’s Menourve
Brandt Daroff exercise
- psychological assessment
-Psychological intervention i.e. CBT, Relaxation Rx.
- medication- realistic family/social/occupational goals
- surgery
4. Monitoring/feedback/follow up
5. Discharge
Reproduced with permission from Luxon LM, Davies RA, eds.
Handbook of vestibular medicine. London: Whurr Publishers, 1997.
40. 40
Cawthorne cookseey exercise (CCE)
Customised CCE
Bal Ex : Homebased video module for
balance exercises = customised CCE +Prayer
movement
41. 1. Kroenke K, Lucas CA, Rosenberg ML, et al. Causes of persistent dizziness: a
prospective study of 100 patients in ambulatory care. Ann Intern Med.
1992;117:898-904.
2. LM Nashner, FO Black, and C Wall, 3d Adaptation to altered support and visual
conditions during stance: patients with vestibular deficits J. Neurosci. 1982 2: 536-
544.
3. Shupert CL, Black FO, Horak FB & Nashner LM (1988) Coordination of head and body
in response to support surface translations in normals and patients with bilaterally
reduced vestibular function. In Amblard B, Berthoz A, Clarac F (eds) Posture and
gait: Development, Adaptation and Modulation. New York: Elsevier Science
Publishers.
4. Allum, J.H.J., Honegger, F. and Pfaltz, C.R. (1989) The role of stretch and
vestibulo-spinal reflexes in the generation of human equilibriating reactions.
Progress in Brain Research 80, 399-409
42. 5. Bles W, de Jong JMBV. Uni- and bilateral loss of vestibular function. In: Disorders
of posture and gait.—Bles W, Brandt T, eds. (1986) Amsterdam: Elsevier, 1986, PP
127-139
6.Fregly AR (1974) Vestibular ataxia and its measurement in man. In: Kornhuber HH
(ed) Handbook of Sensory Physiology,. vol VI. Springer, New York, pp 321–360
7.Handbook of Balance Function Testing by Gary P. Jacobson (Author), Craig W.
Newman (Author), Jack M. Kartush Singular; 1 edition (October 1, 1997)
8.http://www.neuroanatomy.wisc.edu/virtualbrain/BrainStem/13VNAN.html
9.http://www.utmb.edu/otoref/Grnds/Vestibular-2004-0414/Vestibular-2004-
0414.htm
10. http://www.bcdecker.com/SampleOfChapter/1550092634.pdf
