2. • The vestibular organs sense head motion: canals sense
rotation; otoliths sense linear acceleration (including gravity).
• The central vestibular system distributes this signal to
oculomotor, head movement, and postural systems for gaze,
head, and limb stabilization..
• The visual system complements the vestibular system.
• Visuo-vestibular conflict causes acute discomfort.
• Peripheral and brainstem vestibular dysfunction causes
pathological sense of self-motion and visuo-vestibular
conflict.
3. The vestibular labyrinth answers two
questions basic to the human
condition
• Where am I going?
• Which way is up?
4. The vestibular labyrinth answers the two
questions basic to the human condition
by sensing
• Head angular acceleration (semicircular canals)
– Head rotation.
• Head linear acceleration (saccule and utricle)
– Translational motion.
– Gravity (and by extension head tilt).
7. Each vestibular organ has a sensor for
head acceleration, driven by hair cells
similar to those in the cochlea
• In the cochlea vibration induced by sound
deforms the hair cells.
• In the labyrinth acceleration deforms the hair
cells.
• In the semicircular canals the sensing organ is
the ampulla
9. Dizziness
• Dysequilibrium
• Vertigo (a sense of motion of person or the
visual surround)
• Presyncope (near-faint, light-headedness)
• Psychophysiologic dizziness (anxiety and
panic)
• Overlapping
• Motion sickness
10. Acute vertigo
• A result of vestibular imbalance
• Asymmetry in tonic activity within the
vestibular system
• Vegetative symptoms (nausea, vomiting, and
diaphoresis)
• Get worse with head movement
• Ataxia
11. Rotation reflects imbalance
• Semicircular canal
• Tendency to fall to the unaffected side (+ve)
Upright tilting Imbalance
• Otolith
• Tendency to fall to the affected side.
12. Central vestibular disorders
• Identifying these is critical
• *Common 25% older patients presenting to
ER with acute isolated vertigo have a
cerebellar infarction
• Life-threatening
• The earlier the Dx the better the Px
• Severe neurologic sequelae
*Acta Neurol Scand 91:43–48, 1995
13. For: Otolaryngologist
It is :
• Challenging
• have To differentiate central from peripheral
• May have both peripheral and central
components.
• Urgency of the workup
• Neurologic, medical, or psychiatric
14. When to suspect
Central ?peripheral
• Neurologic symptoms
• New severe headache
• Type of nystagmus
• Risk factors
• No improvement within 48 hours
15. Central nystagmus
• Multi-directional
• -ve Alexander's law
• Unaffected by removal of fixation
• Purely vertical or Purely torsional nystagmus
• Constant and does not wane with time
• Absence of a head thrust sign
• Multiple Gaze-evoked nystagmus (<30 degrees )
• Occasionally present in only one direction of gaze
similar to peripheral nystagmus.
16.
17. Gaze-paretic nystagmus
• Weakness of the extra-ocular muscles
OR
• their innervations
Gaze-evoked nystagmus
Gaze-evoked nystagmus is usually due to a defect in
the central neural integrators controlling gaze-
holding
18. Purely vertical or Purely torsional
nystagmus?????
-Yaw : Horizontal plan
-Pitch: Sagittal plane
-Roll: frontal plane
19.
20. Yaw (horizontal Plane)
• It is rare in Central vertigo
• More in BPPV, spontaneous nystagmus
(peripheral).
• Also in past pointing.
• Cane be caused by lesions in the area of
entrance of the vestibular nerve in the
medulla
21. Pitch (Saggital)
• It is common
• Related to area affection of bilateral
paramedian medulla, pontomedullary,
pontomesencephalic , or cerebellar flocculus.
• Down beats or up beats syndromes
22.
23. Roll (Vertical plane)
• It is indicative of unilateral lesion
• It is due to lesions from the vertical canals and
otoliths to vestibular nuclei, MLF (contra) and
integration centers for vertical and torsional
eye movements.
• Signs in the form of head tilt, vertical
convergence, ocular torsion, SVV
27. There are 3 major vestibular
reflexes
• Vestibulo-ocular reflex – keep the eyes still in
space when the head moves.
• Vestibulo-colic reflex – keeps the head still in
space – or on a level plane when you walk.
• Vestibular-spinal reflex – adjusts posture for
rapid changes in position.
30. Duration of the Symptoms
• Short rotatory or postural vertigo attacks
lasting for seconds to minutes, TIA and
basilar/vestibular migraine.
• Persistent rotatory or postural vertigo hours to
days, in infarction, haemorrhage, or MS with
corresponding deficit
• Days and weeks usually corresponding to
permanent damage to brain stem or
cerebellum
41. Migraine Headaches
• 20,000 Patients Diagnosed with Migraine
Who had HA at least once per year
– 17.6% Adult females
– 5.7 % Adult males
– 4% children
• 18% had HA one or more per month
• Highest prevalence 35-45 years
• Lowest prevalence > 50 years
• Of those in the 20,000 deserving Dx of Migraine only
– 29% males and 41% females aware
Prevalence Study
42. Migraine Events
• Migraines are Neurological events
• Most common symptoms is Headache
• Events can range from no pain to severe pain
with permanent ischemic damage
• Most common non-pain form of a migraine is
visual, but any aura symptom can occur in the
absence of pain, including dizziness
43. Migraine Events
HIS Classification
• Migraine without aura
• Migraine with aura
• Migraine with prolonged aura
– one Symptom lasts > 60 min but < 7 days
• Basilar migraine
• Migraine aura without headache
• Childhood periodic syndromes
• Migrainous infarction
44. Migraine Head Ache History Clues
• Head pain localizes
• May be associated with eyes
• Throbbing
• Light or sound sensitivity - motion sickness especially
in childhood
• Scintillating lights - with or without pain
• Family members with migraine
• Mild to severe - hormonal and food triggers
• Headache with caffeine withdrawal
45. Migraine classification - IHS
• Migraine without aura (“Common migraine”)
– At least five attacks meeting the criteria below
• Duration 4-72 hours
• Headache has at least two of the following:
– Unilateral location
– Pulsating quality
– Moderate to severe intensity (inhibits or prohibits daily activities)
– Aggravation with physical activity that increases intra-cranial pressure,
eg. Walking stairs, straining,, etc
• During headache at least one of the following:
– Nausea and / or vomiting
– Photophobia and / or phonophobia
46. Migraine classification - IHS
• Migraine with aura (“Classic migraine”)
– Meets criteria for Migraine without aura with the following
addition
• Reversible neurological dysfunction
• Gradual onset over minutes, lasting < 1 hour
• Headache before, during or up to 1 hour after aura
• Migraine aura without headache (“acephalgic migraine”,
“migraine equivalent”)
– Aura as described above - head pain never develops. Rarely can
last for hours
47. Migraine classification - IHS
• List of symptoms that constitute an aura
– Bilateral visual distortions
– Paresthesia
– Muscle weakness / coordination loss
– Fluctuant hearing, unilateral or bilateral
– Tinnitus, unilateral or bilateral
– Lightheadedness / imbalance to true vertigo -
movement provoked or spontaneous
48. Basilar Migraine (Basilar Artery Migraine)
• Meets criteria of Migraine with aura but has two or more of
the following auras
– Visual symptoms affecting all fields
– Dysarthria
– Vertigo
– Tinnitus
– Hearing loss
– Diplopia
– Ataxia
– Bilateral sensory changes or weakness
– Decreased consciousness
Migraine classification - IHS
49. Vestibular Migraine Study
(Cutrer & Bahol) 91 patients
• Symptoms
70% true vertigo
30% dizziness, imbalance, rocking, motion
sensitivity
• Relationship to headache
5% consistently preceding or during headache
65% variable
30% completely independent
50. Duration of Vertigo Spells in Migraine (Cutrer and
Baloh, 1992)
• Seconds 7%
• Minutes to 2 hours 31%
• 2 - 6 hours 5%
• 6 – 24 hours 8%
• > 24 hours 49%
(weeks of motion sickness punctuated by vertigo)
51. Migraine vs Meniere’s
• Migraine
– Spontaneous Vertigo
– Unilateral tinnitus and
fluctuant hearing
– Permanent progressive
hearing loss unlikely
– Mild ENG findings
including mild
asymmetry
– Duration of vertigo
seconds to days
• Meniere’s
– Spontaneous Vertigo
– Unilateral tinnitus and
fluctuant hearing
– Permanent progressive
hearing loss likely
– Mild to significant ENG
findings - mild to
significant asymmetry
– Duration >20 min <24
hours