1
   Vertigo    › Perception of abnormal movement    › Peripheral or Central                                        2
   Vertigo - Prevalence    › 1 in 5 adults report dizziness    › More in elderly    › Worsened by decreased       visual...
   Syncope    › Transient loss of consciousness with loss of postural tone   Pre-syncope    › Lightheadedness - an impen...
   Pathophysiology    › Complex interaction of visual, vestibular and      proprioceptive inputs that the CNS integrates ...
6
   Labyrinth: Bony / membranous   Bony Labyrinth: Cavernous opening in petrous temporal bone   Memb Labyrith: Epithelia...
Contains four elements :1. Supporting cells:        1. Simple columnar epithelium ( lines Macule)        2. Simple cuboida...
   The hairs are micro villi   Each hair cell contain 40-80 hairs with single kinocalcium        Kinocilium araises fro...
   3 semicircular ducts   Detects angular    acceleration   Memb. labyrinthis is in direct    continuation with Utricle...
   One end of each duct enlarges at its    attachment to Utricle (Ampullae)   The Ampulae are functional counter    part...
   Hair cells are embedded including    gelatinous mass called cupula   Cupula are equivalent of otolithic    membrane, ...
First order Neurons   Scarpa ganglion /    Vestibular ganglion   Situated in base of internal    auditory canal Vestibu...
   2nd order Neuron    › Descending fibres  vestibulospinal tract  spinal cord    › Ascending fibres  a.Direct / b. ML...
Medial & lat vestibulo spinal tractsMedial VST   Medial vest. Nucleus (crossed & uncrossed fibre)  MLF     upto cervica...
› Normally there is  balanced input from  both vestibular systems› Vertigo develops from  asymmetrical vestibular  activit...
   Nystagmus    › Rhythmic slow and fast eye movement       Slow component usually ipsilateral to diseased structure    ...
   BPPV                         CNS infection (TB, Syphillis)   Labyrintitis                 Tumor (Benign or Neoplast...
   Is it true vertigo?         Abn eye movements?   Autonomic symptoms?         Past H/O trauma?   Onset and duration...
   Cerumen/FB in EAC          BP and pulse in both arms   Extauditory canal          Orthostatic vital signs    vesicl...
   Inner ear               Brain stem    ›   Hearing loss         › Loss of consciousness    ›   Tinnitus             › ...
With the pt sitting on the examination table, facingforward, eyes open, the physician turns the pts head 45degrees to the ...
Position-1             23
24
25
26
Peripheral        CentralOnset               Sudden            Usually slowSeverity of Vertigo Intense           Usually m...
 Glucose and ECG in the “dizzy” patient Cold caloric testing Electronystagmography and audiology CT- if cerebellar mas...
   Labyrinthine Disorders    › Most common cause of true vertigo    › Five entities       Benign paroxysmal positional v...
   Extremely common   Otoconia displacement   No hearing loss or tinnitus   Short-lived episodes   Pptd by rapid chan...
31
 Associated hearing loss and tinnitus Involves the cochlear and vestibular  systems Abrupt onset Usually continuous F...
   Serous    › Adjacent inflammation due to ENT or meningeal      infection    › Mild to severe vertigo with nausea and v...
   Toxic    ›   Due to toxic effects of medications    ›   Still relatively common    ›   Mild tinnitus and high frequenc...
   Chronic    › Localized inflammatory process of the inner     ear due to fistula formation from middle to     inner ear...
   Suspected viral etiology   Sudden onset vertigo that increases in    intensity over several hours and gradually    su...
   Usually virally mediated-most often VZV   Affects vestibular ganglion, but also may    affect multiple ganglions   M...
 First described in 1861 Triad of vertigo, tinnitus and hearing loss Due to cochlea-hydrops    › Unknown etiology    › ...
 Often patients have eaten a salty meal  prior to attacks May occur in clusters and have long  episode-free remissions ...
   Peripheral vertigo with central manifestations   Tumor of the Schwann cells around the 8th    CN   Vertigo with hear...
 Central   Vertigo  › Vertebrobasilar               › Head Trauma    Insufficiency                 › Neck Injury     Ath...
   Important causes of central vertigo   Related to decreased perfusion of vestibular    nuclei in brain stem   Vertigo...
   Most commonly will also have:       -Dysarthria         -Ataxia       -Facial numbness       -Hemiparesis        -Dipl...
   Abruptly falls without warning, but does not loose    consciousness   Believed to be caused by transient quadraparesi...
   Rare, but treatable   Arm exercise on side of stenotic subclavian artery    usually causes symptoms of intermittent  ...
   Occlusion of PICA   Relatively common cause of central vertigo   Associated Symptoms:    ›   nausea    ›   Vomiting ...
   Neurosurgical emergency   Suspected in any patient with sudden onset    headache, vertigo, vomiting and ataxia   May...
   Vertigo is presenting symptom in 7-10%   30% develop vertigo in the course of the    disease   May have any type of ...
   Due to damage to the inner ear and central vestibular    nuclei, most often labyrinthine concussion   Temporal skull ...
   Syndrome of vertigo, dysarthria, ataxia, visual    changes, paresthesias followed by headache   Distinguishing featur...
   Hypoglycemia    › Suspected in any patient with diabetes with      associated headache, tachycardia or anxiety   Hypo...
   Based on central / peripheral causes   VBI should be considered in any elderly    patient with new-onset vertigo with...
   Severe Ménière disease may require    chemical ablation with gentamicin   Attempt Epley maneuver for BPPV   Mainstay...
54
   Understand what the patient means by    “dizzy”   Differentiate central from peripheral    › Often there is significa...
56
a. Diminishes with fixationb. Unidirectional fast componentc. Can be horizontorotary or verticald. Nystagmus increases wit...
c. Can be horizontorotary or vertical  Peripheral nystagmus is typically  horozonto-rotary, not pure horizontal or  rotary...
a. Does not change with gaze fixationb. Can be unidirectional or bidirectionalc. Can be horizontal, rotary or verticald. N...
e. Can be dramatically accentuated    by head movement Vertigo and nystagmus produced by central causes does not significa...
a. Vestibular neuronitisb. Acute labrynthitisc. BPPVd. Acoustic neuromae. Ménière Disease                           61
c.   BPPV will not have associated hearing     loss or tinnitus     All of the other responses will have     hearing loss ...
4. The Dix-Halpike maneuver is useful in the    treatment of BPPV?True or False ?                                        63
False   The Dix-Halpike is used to precipitate   the nystagmus if the nystagmus and   vertigo have resolved so a correct  ...
5.   All of the following have been implicated     in causing vertigo : True or False ?     1. Loop diuretics     2. Antic...
TrueMany everyday medications can cause   vertigo which is easily reversible if   recognized.                             ...
67
68
69
70
71
72
73
74
75
Upcoming SlideShare
Loading in...5
×

Vertigo and Dizziness

2,292

Published on

Published in: Education
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
2,292
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
119
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Transcript of "Vertigo and Dizziness"

  1. 1. 1
  2. 2.  Vertigo › Perception of abnormal movement › Peripheral or Central 2
  3. 3.  Vertigo - Prevalence › 1 in 5 adults report dizziness › More in elderly › Worsened by decreased  visual acuity / proprioception or vestibular input Dizziness › Non-specific term › Different meaning to different people  Could mean - Vertigo - Syncope - Presyncope - Weak - Giddiness - Anxiety - Anemia - Depression - Unsteady 3
  4. 4.  Syncope › Transient loss of consciousness with loss of postural tone Pre-syncope › Lightheadedness - an impending loss of consciousness Psychiatric dizziness › Dizziness not related to vestibular dysfunction Disequilibrium › Feeling of unsteadiness, imbalance or sensation of “floating” while walking 4
  5. 5.  Pathophysiology › Complex interaction of visual, vestibular and proprioceptive inputs that the CNS integrates as motion and spatial orientation 3 Semicircular Canals › Rotational Movement › Cupula 2 Otolithic Organs › Utricle & Saccule › Linear Acceleration › Macula 5
  6. 6. 6
  7. 7.  Labyrinth: Bony / membranous Bony Labyrinth: Cavernous opening in petrous temporal bone Memb Labyrith: Epithelial membranous lining of bony Labyrinth Endolymph: Fills membranous labyrinth Perilymph: Between bony and membranous labyrinth 7
  8. 8. Contains four elements :1. Supporting cells: 1. Simple columnar epithelium ( lines Macule) 2. Simple cuboidal epithelium ( lines U & S)2. Hair cells : Specialized receptor cells3. Otolithic membrane : Gelatinous mass embedded with ca. carbonate crystals (otolith)4. Dendrites of vestibular neurons : Carries afferent impulses to brainstem 8
  9. 9.  The hairs are micro villi Each hair cell contain 40-80 hairs with single kinocalcium  Kinocilium araises from centriole  Kinocilium is located in periphery of each hair cell  Polarizes hair cell in its direction Kinocilium polarizes in relation to striola Striola is an imaginary curved line 9
  10. 10.  3 semicircular ducts Detects angular acceleration Memb. labyrinthis is in direct continuation with Utricle Ducts lie in right angle planes to each other  any angular direction of head could be identified 10
  11. 11.  One end of each duct enlarges at its attachment to Utricle (Ampullae) The Ampulae are functional counter part of macule Ampullae contain thickened sensory epithelium – ampullary crest Ampullary crest contain columnar epithelial supporting cells with interspersed kinocilia containing hair cells 11
  12. 12.  Hair cells are embedded including gelatinous mass called cupula Cupula are equivalent of otolithic membrane, but lack calcium carbonate crystals The right & left pair of any particualr SC canals are mirror image of each other If defelction excites one, it inhibits the other  brain appreciates head movements 12
  13. 13. First order Neurons Scarpa ganglion / Vestibular ganglion Situated in base of internal auditory canal Vestibular Labyrinth  Vestibular nuclei Sup, Inf, med, lat 13
  14. 14.  2nd order Neuron › Descending fibres  vestibulospinal tract  spinal cord › Ascending fibres  a.Direct / b. MLF  Oculomotor nuclei › Cerebellum recieves fibres also through 2nd order neuron 14
  15. 15. Medial & lat vestibulo spinal tractsMedial VST Medial vest. Nucleus (crossed & uncrossed fibre)  MLF  upto cervical spinal segmentLateral VST Lateral vest.Nucleus (Deiter’s N) uncrossed fibres to the entire spinal cord 15
  16. 16. › Normally there is balanced input from both vestibular systems› Vertigo develops from asymmetrical vestibular activity› Abnormal bilateral vestibular activation results in truncal ataxia 16
  17. 17.  Nystagmus › Rhythmic slow and fast eye movement  Slow component usually ipsilateral to diseased structure  due to vestibular or brainstem activity  Fast component due to cortical correction  Direction named by fast component Physiologic Vertigo › “motion sickness” › A mismatch between visual, proprioceptive and vestibular inputs › Not a diseased cochleovestibular system or CNS 17
  18. 18.  BPPV  CNS infection (TB, Syphillis) Labyrintitis  Tumor (Benign or Neoplastic) › Acute suppurative  Cerebellar infarct › Serous  Cerebellar hemorrhage › Toxic  Vertebrobasilar insufficiency › Chronic  AICA/ PICA syndrome Vestibular neuronitis  Multiple Sclerosis Vestibular ganglionitis  Basilar artery migraine Ménière’s  Hypothyroidism / Acoustic neuroma Hypoglycemia Perilymphatic fistula  Traumatic Cerumen impaction  Hematologic (Waldenstroms) 18
  19. 19.  Is it true vertigo?  Abn eye movements? Autonomic symptoms?  Past H/O trauma? Onset and duration  Past medical history? Auditory disturbances?  Previous symptoms? Neurologic  Drug hx disturbances?  Alcohol intake? Was there syncope? 19
  20. 20.  Cerumen/FB in EAC  BP and pulse in both arms Extauditory canal  Orthostatic vital signs vesicles  Auscultate for carotid bruits Otitis media  Cranial nerves Pneumatic otoscopy  Pupillary abnormalities Tympanosclerosis  Fundoscopic exam Gross hearing  Extraocular muscles TM perforation  INO Weber-Rinne test  Muscle strength Nystagmus  Gait and Cerebellar Dix-Hallpike maneuver function 20
  21. 21.  Inner ear  Brain stem › Hearing loss › Loss of consciousness › Tinnitus › Memory disturbance › Aural fullness › Hemiplegia/ hemi › Otalgia paresis, hemi sensory › Otorrhoea loss › Cranial nerve palsy Vii th nerve › Dysarthria, dysphagia › Facial weakness  Cerebellum C-P angle › Inco-orndination › Clumsiness › Impaired facial sensation › Dysarthria › Clumsiness › Dysarthria › Inco-orndination 21
  22. 22. With the pt sitting on the examination table, facingforward, eyes open, the physician turns the pts head 45degrees to the right (A).The physician supports the pts headas the pt lies back quickly from a sitting to supineposition, ending with the head hanging 20 deg off the end ofthe examination table. The pt remains in this position for 30sec(B). Then the pt returns to the upright position and isobserved for 30 sec. Next, the maneuver is repeated with thepts head turned to the left. A +ve test is indicated if any ofthese maneuvers provide vertigo with or without nystagmus. 22
  23. 23. Position-1 23
  24. 24. 24
  25. 25. 25
  26. 26. 26
  27. 27. Peripheral CentralOnset Sudden Usually slowSeverity of Vertigo Intense Usually mildPattern Paroxysmal ConstantExac. by movement Yes VariableAutonomic Frequent VariableLaterality Unilateral Uni or bilatNystagmus Horizontorotary AnyFatigable/Fixation Yes NoAuditory symptoms Yes NoTM May be abnormal NormalCNS symptoms Absent Present 27
  28. 28.  Glucose and ECG in the “dizzy” patient Cold caloric testing Electronystagmography and audiology CT- if cerebellar mass, hemorrhage or infarction suspected MRI – for postr circulation stroke Angiography for suspected VBI 28
  29. 29.  Labyrinthine Disorders › Most common cause of true vertigo › Five entities  Benign paroxysmal positional vertigo (BPPV)  Labyrinthitis  Ménière disease  Vestibular neuronitis  Acoustic Neuroma 29
  30. 30.  Extremely common Otoconia displacement No hearing loss or tinnitus Short-lived episodes Pptd by rapid changes in head position Usually a single position that elicits vertigo Horizontorotary nystagmus Crescendo-decrescendo pattern after a latency period Less pronounced with repeated stimuli Can be reproduced at bedside maneuvers 30
  31. 31. 31
  32. 32.  Associated hearing loss and tinnitus Involves the cochlear and vestibular systems Abrupt onset Usually continuous Four types of Labyrinthitis › Serous › Acute suppurative › Toxic › Chronic 32
  33. 33.  Serous › Adjacent inflammation due to ENT or meningeal infection › Mild to severe vertigo with nausea and vomiting › May have some degree of permanent impairment Acute suppurative labyrinthitis › Acute bacterial exudative infection in middle ear › Secondary to otitis media or meningitis › Severe hearing loss and vertigo 33
  34. 34.  Toxic › Due to toxic effects of medications › Still relatively common › Mild tinnitus and high frequency hearing loss › Vertigo in acute phase › Ataxia in the chronic phase › Common etiologies -Aminoglycosides -Vancomycin -Erythromycin -Barbiturates -Phenytoin -Furosemide -Quinidine -Salicylates -Alcohol 34
  35. 35.  Chronic › Localized inflammatory process of the inner ear due to fistula formation from middle to inner ear › Most occur in horizontal semicircular canal › Etiology is due to destruction by a cholesteatoma 35
  36. 36.  Suspected viral etiology Sudden onset vertigo that increases in intensity over several hours and gradually subsides over several days Mild vertigo may last for several weeks May have auditory symptoms Highest incidence in 3rd and 5th decades 36
  37. 37.  Usually virally mediated-most often VZV Affects vestibular ganglion, but also may affect multiple ganglions May be mistaken as BPPV or Ménière disease Ramsay Hunt Syndrome -Deafness -Vertigo -Facial Nerve Palsy -EAC Vesicles 37
  38. 38.  First described in 1861 Triad of vertigo, tinnitus and hearing loss Due to cochlea-hydrops › Unknown etiology › Possibly autoimmune Abrupt, episodic, recurrent episodes with severe rotational vertigo Usually last for several hours 38
  39. 39.  Often patients have eaten a salty meal prior to attacks May occur in clusters and have long episode-free remissions Usually low pitched tinnitus Symptoms subside quickly after attack No CNS symptoms or positional vertigo are present 39
  40. 40.  Peripheral vertigo with central manifestations Tumor of the Schwann cells around the 8th CN Vertigo with hearing loss and tinnitus With tumor enlargement, it encroaches on the cerebellopontine angle causing neurologic signs Earliest sign is decreased corneal reflex Later truncal ataxia Most occur in women during 3rd and 6th 40
  41. 41.  Central Vertigo › Vertebrobasilar › Head Trauma Insufficiency › Neck Injury  Atheromatous plaque › Temporal lobe seizure  Subclavian Steal Syndrome › Vertebro basilar  Drop Attack migraine  Wallenberg Syndrome › Metabolic › Cerebellar Hemorrhage abnormalities › Multiple Sclerosis  Hypoglycemia 41
  42. 42.  Important causes of central vertigo Related to decreased perfusion of vestibular nuclei in brain stem Vertigo may be a prominent symptom with ischemia in basilar artery territories Unusual for vertigo to be only symptom of ischemia 42
  43. 43.  Most commonly will also have: -Dysarthria -Ataxia -Facial numbness -Hemiparesis -Diplopia -Headache Tinnitus and hearing loss unlikely Vertical nystagmus is characteristic of a (superior colliculus) brain stem lesion Up to 30% of TIA’s are VBI with pontine symptoms and a focal neurologic lesion 43
  44. 44.  Abruptly falls without warning, but does not loose consciousness Believed to be caused by transient quadraparesis due to ischemia at the pyramidal decussation 44
  45. 45.  Rare, but treatable Arm exercise on side of stenotic subclavian artery usually causes symptoms of intermittent claudication Blood is shunted away from brainstem into ipsilateral vertebral artery Classic history occurs only rarely 45
  46. 46.  Occlusion of PICA Relatively common cause of central vertigo Associated Symptoms: › nausea › Vomiting › Nystagmus › ataxia › Horner syndrome › palate, pharynx and laryngeal paresis › loss of pain and temperature on ipsilateral face and contralateral body 46
  47. 47.  Neurosurgical emergency Suspected in any patient with sudden onset headache, vertigo, vomiting and ataxia May have gaze preference Motor-sensory exam usually normal Gait disturbance often not recognized because patient appears too ill to move 47
  48. 48.  Vertigo is presenting symptom in 7-10% 30% develop vertigo in the course of the disease May have any type of nystagmus INO is virtually pathognomonic Onset during 2nd to 4th decade Rare after 5th decade Usually have had previous neurological 48
  49. 49.  Due to damage to the inner ear and central vestibular nuclei, most often labyrinthine concussion Temporal skull fracture may damage the labyrinth or eighth cranial nerve Vertigo may occur 7-10 days after whiplash Persistent episodic flares suggest perilymphatic fistula Fistula may provide direct route to CNS infection 49
  50. 50.  Syndrome of vertigo, dysarthria, ataxia, visual changes, paresthesias followed by headache Distinguishing features of basilar artery migraine - Symptoms precede headache - History of previous attacks - Family history of migraine - No residual neurologic signs Symptoms coincide with angiographic evidence of intracranial vasoconstriction 50
  51. 51.  Hypoglycemia › Suspected in any patient with diabetes with associated headache, tachycardia or anxiety Hypothyroidism › Clinical picture of vertigo, unsteadiness, falling, truncal ataxia and generalized clumsiness 51
  52. 52.  Based on central / peripheral causes VBI should be considered in any elderly patient with new-onset vertigo without an obvious etiology Neurological or ENT consult for central vertigo Suppurative labrynthitis - admit and IV antibiotics 52
  53. 53.  Severe Ménière disease may require chemical ablation with gentamicin Attempt Epley maneuver for BPPV Mainstay of peripheral vertigo management are antihistamines that possess anticholinergic properties -Meclizine -Diphenhydramine -Promethazine -Droperidol -Scopolamine 53
  54. 54. 54
  55. 55.  Understand what the patient means by “dizzy” Differentiate central from peripheral › Often there is significant overlap Not every patient needs a head CT Central causes are usually insidious and more severe while peripheral causes are mostly abrupt and benign 55
  56. 56. 56
  57. 57. a. Diminishes with fixationb. Unidirectional fast componentc. Can be horizontorotary or verticald. Nystagmus increases with gaze in direction of fast componente. Can be accentuated by head movement 57
  58. 58. c. Can be horizontorotary or vertical Peripheral nystagmus is typically horozonto-rotary, not pure horizontal or rotary and is definitely not vertical. 58
  59. 59. a. Does not change with gaze fixationb. Can be unidirectional or bidirectionalc. Can be horizontal, rotary or verticald. Nystagmus increases with gaze in direction of fast componente. Can be dramatically accentuated by head movement 59
  60. 60. e. Can be dramatically accentuated by head movement Vertigo and nystagmus produced by central causes does not significantly worsen with head movement 60
  61. 61. a. Vestibular neuronitisb. Acute labrynthitisc. BPPVd. Acoustic neuromae. Ménière Disease 61
  62. 62. c. BPPV will not have associated hearing loss or tinnitus All of the other responses will have hearing loss and tinnitus to varying degrees 62
  63. 63. 4. The Dix-Halpike maneuver is useful in the treatment of BPPV?True or False ? 63
  64. 64. False The Dix-Halpike is used to precipitate the nystagmus if the nystagmus and vertigo have resolved so a correct diagnosis can be made. The Epley maneuver is used to relocate the otoliths and therefore treat the BPPV 64
  65. 65. 5. All of the following have been implicated in causing vertigo : True or False ? 1. Loop diuretics 2. Anticonvulsants 3. Aminoglycosides 4. NSAIDS 5. Fluoroquinolones 65
  66. 66. TrueMany everyday medications can cause vertigo which is easily reversible if recognized. 66
  67. 67. 67
  68. 68. 68
  69. 69. 69
  70. 70. 70
  71. 71. 71
  72. 72. 72
  73. 73. 73
  74. 74. 74
  75. 75. 75
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×