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Lakshan's vertigo presentation rcs

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  • 1. Vertigo Dr. MTD lakshanMBBS, MS(ORL), DOHNS(Eng), FEB ORL HNS, FRCS ORL-HNS(Edin) Consultant ENT and Head and Neck Surgeon DGH Hambantota Ruhunu Clinical Society Annual Sessions 2012 1
  • 2. Objectives1.Define Vertigo2.Essential Clinical Evaluation of patients3.Common Vertiginous Syndromes4.Common Management strategies
  • 3. Definition• Illusion of Movement (Rotatory & Postural)• Differentiate from • Light headedness, • Imbalance, • Visual phenomenon, • faintish-ness
  • 4. Basic Sciences• Systems involved : • Vestibular • Ocular • Proprioception • Central Nervous System
  • 5. Basic Sciences
  • 6. Anatomy
  • 7. Schematic drawing of the vestibular epithelium showingthe two cell types and the nerve connections made on each.
  • 8. The position of the crista ampularis and cupula within a cross sectionof the ampulla of one semicircular canal. Also shown is the movement of the cupula and its embedded cilia during rotation first in one direction and then in the opposite direction.
  • 9. Shearing force in vestibular organs. Upper diagram shows arrangement of cilia on a hair cell as seen from above; position of kinocilium indicated by larger dot. Dashed line indicates direction of effective shearing forces; forces at right angles are ineffective. Lower diagram shows section through hair cell along dashed line (upper diagram) with cilia at rest (center) and tilted right and left. Tilt toward kinocilium excites, tilt away deceases excitation.
  • 10. Brainstem pathways forcontrol of eyemovements by the left horizontal semicircular canal.
  • 11. Clinical Evaluation
  • 12. Aetiology• BPPV• Phobic Postural Vertigo• Central Vertigo• Vestibular Migraine• Meniere’s disease• Vestibular Neuronitis• B/L Vestibulopathy• PLF• Superior Semicircular Canal Dehiscence
  • 13. History• Key Question: True Vertigo or Not
  • 14. Type• Rotatory : “Merry go round’• Postural : “Boat ride” - B/L vetibulopathy• Lightheaded ness
  • 15. Episode Duration• Episodic / Continuous• Episode duration - Seconds, Minutes/Hours, Days
  • 16. Precipitations• At rest without any precipitation• Walking• Coughing, loud sounds• Turning in the bed• Turning head to a side• Certain social / environmental conditions
  • 17. Accompanying• Inner Ear Symptoms• Diplopia Sensory symptoms, dysphagia, dysarthria• Headache - Migraine
  • 18. Other-History• Recent Respiratory Infection• RTA• PMHx• Disability• Previous treatments and success
  • 19. Examination Neuro-otological• Complete Ear Examination• Nystagmus• VII• Other Cranial Nerves• Romberg’s
  • 20. Examination Neuro-otological Neuro-otological• Tandem gait• Stepping test• Head thrust test
  • 21. VOR• Video
  • 22. Investigations• Directed• Inner Ear Test Battery : FBC, ESR, TSH, VDRL, Lipids, FBS• Calorics ENG - video• Electrocochleography, ABR,VEMP• MRI
  • 23. Four CD of Vertigo Management• Correct Diagnosis• Correct Drugs• Correct Dosage• Correct Duration
  • 24. Pharmacotherapy 7 A’s• Anti Emetics - Dimenhydronate• Anti Inflammatory - Steroids• Anti - Migraine - Beta-blockers, topiramate• Anti Menieres - Betaserc• Anti Depressants - SSRI• Anti Convulsants - Carbamezepine• Amino Pyridines - for cerebellar gait disorders
  • 25. BPPV• canalolithiasis theory• Dix Hallpike test +• Epley Manoeuvre
  • 26. Dix Hallpike Test
  • 27. Epley Manoeuvre
  • 28. Meniere’s Disease• Saccin Theory / Dark Cell theory• Aural fullness vertigo tinnitus hearing loss fluctuating• Diagnosis of exclusion• treatment : salt restriction, diuretics, betahistine, Intratympanic gentamicin, Grommet, Meniett, ELS Surgery, Vestibular nerve section, labirynthectomy
  • 29. Vestibular Neuronitis• Medical Management• self improving
  • 30. Summary• True Vertigo or Not• Central vs Peripheral• Clinical Evaluation and Judicious Investigations• Medications and Physical treatment modalities• Satisfying to properly assess and treat a vertigo patient
  • 31. Questions?• Thank You!• email questions to:• lakshent@gmail.com