DELIVERED LECTURE AT COCHIN DURING APICON 2019

1. Approach to Vertigo
APICON, Kochi
7.2.2019
Dr V G Nadagouda. MD, MNAMS, FACP, FICP etc.
Consultant Physician & Echocardiologist
Hubballi (Karnataka)
I am thankful to Dr .G Narsimulu Dean ICP / API & his team
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2. Contents
• Introduction
• Causes & Evaluation of vertigo
• Special Tests
• Medical &
• Surgical measures
• Physical therapy
• Take Home
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3. Dizziness
Dizziness is a non-specific term;
Comprising 4 sub types ;
1. Dizziness/lightheadedness: A distorted sense of one’s spatial
relationship.
2. Vertigo: Hallucination of rotatory motion either of the
surroundings or himself in relation to the surroundings. The
chronic form is entitled “disequilibrium”
3. Unsteadiness: Difficulty with gait/Tendency to fall to one side.
4. Blackouts: Loss of consciousness
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4. Normal balance
● Requires –
I. Normally functioning vestibular system,
II. Visual system (called vestibulo-ocular reflex-VOR),
III. Proprioceptive system ( called vestibulo-spinal reflex-VSR).
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5. Prevalence -Vertigo
 1.8% in young adults to > 30% in the elderly
 Psychiatric causes make up the majority (55-70%).
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6. VERTIGO- Classification
It could be Peripheral (Otological),
Central (Neurological) or;
Combined.
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7. Involvement of labyrinth and vestibular nerve is
categorised as PV (peripheral vertigo),
while involvement of VN (vestibular nucleus) and
projections from the nucleus to cerebellum,
thalamus and cortical areas are CV (central vertigo).
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8. 1. Peripheral Causes 2. Central Causes
Benign paroxysmal positional vertigo(BPPV) --
18.6%
Vestibular migraine 11.2%; Basilar Migraine
Vestibular neuritis 7.7% Disorders of Mitochondria
Herpes zoster oticus (Ramsay Hunt syndrome) Cerebellar infarction and hemorrhage, TIA’s
Meniere's disease (Endolymphatic hydrops)-
Tumarkin’s otolithic crisis or Drop attacks seen.
9.6%
Cranio –vertebral (CV) junction lesions , Chiari
malformation
Perilymphatic fistula 0.6% Episodic ataxia type 2. It is a Calcium
channelopathy .Responds to Acetazolamide
Semicircular canal dehiscence syndrome
Tullio phenomenon +.(vertigo by loud sounds)
/Multiple sclerosis
Cogan's syndrome, Otitis media Epileptic vertigo
Acoustic neuroma Vestibular Schwannoma (Malignant CP angle
tumor)
; Vestibular Paroxysmia ( Also termed
vestibular neuralgia.
Medulloblastoma (Malignant tumor in children)
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9. Systemic causes of Vertigo (PV or CV)
• Toxic –drugs.
• CVS: Hypotension, presyncope
• Endocrine diseases (hypoglycemia & hypothyroidism / Addison's
disease)
• Vasculitis (eg.: collagen vascular disease, giant cell arteritis, )
• Hematological disorders
• Psychiatric disorders -- Hyperventilation, Panic attacks
• Simple Ageing –multifactorial in nature
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10. Medication that often causes dizziness (Toxic)
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11. The first step includes a complete history,
Physical Examination for Anemia , nystagmus, Blood Pressure, Otological
examination, herpetic lesion, & thorough Cardio vascular examination.
CNS examination:
Assessment of presence of vestibular dysfunction: vestibular ocular reflex –VOR; &
(Head impulse test, HIT),
Vestibulospinal assessment –VSR;(finger nose coordination for past pointing,
Romberg test,
Tandem walking / Gait : ie;(walking in a straight line;-heel to toe walking),
Fukuda stepping test : (FST-measures asymmetrical vestibulospinal reflex tone
resulting from labyrinthine dysfunction),
Assessment of nystagmus, and skew deviation.
- These tests will help to differentiate between central and peripheral vertigo.
Evaluation for Vertigo
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12. Diagnostic tests
• Dix-Hallpike maneuver, Lambert maneuver etc for BPPV
• Audiogram
• Electronystagmography (ENG),
• Videonystagmography(VNG),
• Electrocochleography (ECOG)
• Posturography)
# CT scan &
• MRI for acoustic neuroma & Neurogenic vertigo
Meniere’s
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13. Nystagmus Diagnosis Peripheral Central
Direction Unidirectional, never reverses
direction
Sometimes reverses direction
when patient looks in the
direction of slow movement
Type Horizontal with a torsional
component,
Can be any direction-
Horizontal (reverses
direction), torsional or vertical
Visual fixation Suppressed Not suppressed
Neurologic signs Absent Often present
Postural instability walking preserved Severe instability, patient often
falls when walking
Deafness or tinnitus May be present Absent
Head Impulse Sign “(H.I.T
Test”).
Skew deviation of eyes –
Present
Absent
Absent
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14. Nystagmus Peripheral Disorders Central Disorders
Latent period before onset
of nstagmus
2 to 20 seconds None
Duration of nystagmus Less than 1 minute Greater than 1 minute
Fatigability Present on repetition No fatigue
Intensity of vertigo Severe Less severe, sometimes none
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15. Nystagmus
Usually, there is slow drift of the eyes in one direction
followed by quick jerk in the opposite direction. Nystagmus
is named after the direction of the fast component.
Alexander's law: Primary position nystagmus may be evident
with fast component opposite to the side of lesion, does
not change direction & it increases with an attempted gaze
towards the side of fast component
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16. BPPV , Canal pathology & Nystagmus
• Rotational / Torsional /Up beating Nystagmus: is caused by
Posterior canal pathology (Commonest-85%) & diagnosed
by EPLEY manoeuvre.
• Lateral or Horizontal Nystagmus : caused by Lateral canal
pathology (seen in 10% of cases)& diagnosed by Lambert
manoeuvre or the Pagnini- McClure supine test.
• Vertical /Down beating Nystagmus : caused by Superior or
Anterior canal pathology), least common incidence(5%) &
diagnosed by Deep head hanging manoeuvre.
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17. Diagnosis and Treatment
Benign Paroxysmal Positional Vertigo (BPPV)
It is idiopathic in nature & follows head injury ,or following
labrynthitis
Diagnosis -- Dix –Hallpike Test: or Nylen Barany Test .
Principle:
Severe nystagmus develops after assuming a particular head position
depending on the type of semi circular canal being involved.
These tests are carried on both sides of the head, first on the normal side
& then on the abnormal side.
Pts with severe neck disabilities should refrain from these test & instead
can undertake the Brandt daroff test.
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18. HINT’S Test.(Halmagyi-Curthoys test or the Halmagyi
test).
• HINTS is a 3 part Occulomotor test & stands for Head
Impulse test (HIT), Nystagmus & test of Skew . It helps in
detecting a central lesion with a sensitivity of 90%,which
is higher than MRI brain with diffusion sequences.
If any of these tests are positive , neurological evaluation
is warranted.
HIT can be quantitatively measured using video HIT.
A 5 step approach is more sensitive than 3 step HINTS,
which also includes looking for saccadic and pursuit eye
movements & use of Frenzels glasses.
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19. HINT’s Test---Step 1
Principle
Horizontal head impulse testing involves
rapid head rotation by the examiner
with the subjects vision fixed on a
nearby object (often the examiners
nose), the patients eyes should remain
fixed on the target. –Sitting Position
In case of Peripheral Vertigo
(PV), in which the VOR (vestibulo-ocular
Reflex) is impaired, rapid rotation of the
head towards the affected side will
result in loss of fixation and movement
of the eyes away from the target. This is
followed by a corrective saccades (jerky
movements) as the subject looks back
towards the target.
This is not seen in patients with central
vertigo.
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20. HINTS Test . Step 2 & 3
• Assess the type of Vertigo as discussed before, whether
peripheral or central , based on Nystagmus.
• Alternate eye cover testing may reveal skew deviation in
patients with central vertigo but not in peripheral vertigo .
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21. Frenzel glasses/goggles (Magnifying glasses) –
for easy diagnosis of nystagmus.
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22. ENG or VNG
ENG (which uses electrodes) or VNG (which uses
small cameras) can help determine if dizziness
is due to inner ear disease (PV) by measuring
eye movements while the head is placed in
different positions or the balance organs are
stimulated with water or air.
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23. Management
• Medical
• Surgical
• Physical Therapy
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24. Triage- titrate Approach to vertigo.
Presently it is a common practise to Triage a patient
with red flag signs that warrants early intervention
& accordingly take necessary steps in managing any
given condition.
- Timing: Denotes onset, duration and recurrent
nature of vertigo.
- Trigger : denotes the activity and the circumstances
under which vertigo develops and targeted
examination to identify the possible etiology.
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25. Medical Treatment:
It is tailored to the specific causes of vertigo.
Betahistine; Oral Adult: As betahistine HCl: Initially, 8-16 mg
tid. Maintenance: 24-48 mg daily.
These medications should not be used long term as they are
known to disrupt central compensatory mechanisms that
develop de-novo after chronic vertigo.
Patients should be warned about the side effects of drowsiness,
dry mouth and blurred vision.
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26. Other Medications
Antihistamines
• Meclizine :25-50mg ,TID
Dimenhydrinate :50mg, 1-2 times a daily
Promethazine: 25mg, 2-3 times daily(also can be given rectally &IM)
Benzodiazepines
• Diazepam : 2.5mg, 1-3 times daily
Clonazepam: 0.25mg, 1-3 times daily
Anticholinergic
• Scopolamine transdermal Patch
• Diuretics
Selective serotonin reuptake inhibitors:
Citalopram & Escitalopram, act by increasing serotonergic activity.
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27. Low –sodium (1000mg/d) diet
• Antimigrainous drugs (Ergot preparations, cinnarazine,
Flunarizine,ets)
• Methylprednisolone:( for 3 weeks)
--- 100mg daily , tapered to 10 mg in 3weeks.
 Anti virals : Acyclovir or Valacyclovir for Herpes Zoster Oticus
 Cabamazepine or Oxcarbazepine – Vestibular Paroxysmia (Also called
Vestibular Neuralgia),similar to Trigeminal neuralgia)
 Beta blockers ,Topiramate & Valproic acid ----For Vestibular
Migraine.
 Acetazolamide : ----- For, Episodic Ataxia syndrome 2.
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28. Physical Therapy
• Repositioning maneuvers
• Vestibular rehabilitation
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29. BPPV– Repositioning treatment
Particular Repositioning Maneuvers (PRM)
– Epley maneuver (most commonly practiced)
– Brandt Daroff exercises (for those who have neck
problems)
– Also available are Semont ,Lempert, Gufoni, Foster
maneuver etc.
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30. Canalith repositioning.
It consists of several simple and slow movements of head
which moves particles from the fluid filled semicircular canals of
the inner ear into an open area the vestibule, where these
particles remain silent. are resorbed & vertigo disappears.
Each position is held for about 30 seconds after any symptoms
or abnormal eye movements stop.
This procedure is usually effective after one or two treatments.
( This is different from canal plugging)
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31. Surgical options in Vertigo:
• Is undertaken in intractable cases of vertigo. They are;
• Reparative surgery:
• • Middle ear surgery:---- For Perilymph Fistula
• • Sac decompression & Endolymphatic shunt.---- Meniere’s
• Ablative surgery :
• • Labyrinthectomy
• • Vestibular Nerve Section
• • Canal Plugging
• • Chemical destruction of vestibular nerve by injecting Trans
tympanic Gentamycin or steroids around the round window .
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32. Canal Plugging surgery
Plugging produces single canal paresis.
Success above 95%. It is alternative to singular neurectomy
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33. Vestibular Rehabilitation therapy
 The three modes of rehabilitation are habituation,
adaptation and substitution (HAS).
 In habituation, repeated stimuli decreases vertigo
 Substitution utilises visual and proprioceptive cues to
combat vertigo.
 Adaptation aims to improve VOR (vestibulo ocular reflex)
gain.
 However In one study vestibular rehabilitation did not
score over chemotherapy for treating vertigo.
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34. Exercises
Brandt Daroff Exercises
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35. These exercises should be performed for two weeks, three times
per day. This will add up to 52 sets. In most persons, complete
relief from symptoms is obtained after 30 sets or about 10
days.
Suggested schedule for exercise.
Suggested precautions during the days of exercise.
Sleeping Position:
Sleep semi recumbent for the next two nights. This means sleep with your
head halfway between being flat and upright (a 45 degree angle).this is
most easily done by using a recline chairs or cushions.
Time Exercise Duration
Morning 5 repetitions 10 Minutes
Noon 5 repetitions 10 Minutes
Evening 5 repetitions 10 Minutes
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37. Other important Precautions:
- During the day try to keep your head vertical
- Do not go to hairdresser or dentist when on exercise.
- Avoid exercise that require lot of head movement
- While men shave under their chin, only bend the body
forward and keep head vertical.
- Use two pillows when you sleep
- Avoid sleeping on the side that causes vertigo or dizziness
- Don’t turn your head far up or far down.
At one week after treatment, put yourself in the position that
usually makes you dizzy. Take precaution that you don’t get
hurt in the bargain.
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40. Vertigo / Rotatory Chair- Useful in
diagnosing & treating vertigo
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41. Chiropraxy (upper cervical care)
• It is a non pharmacological therapy which uses heat,
massage , acupuncture , spinal manipulation
exercises & physical therapy, to treat vertigo.
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42. Take Home
• Beset with vertigo, focus on the timing and triggers of
symptoms, particularly if episodic, persisting or provoked by
positional head changes to diagnose the cause.
• Differentiate between central and peripheral vertigo.
• An audiogram is useful.
• All patients with vertigo need definitive diagnosis & appropriate
treatment, but do benefit from vestibular sedatives ( short
courses preferred) & Physical therapy.
• Surgery is rarely required.
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43. “Interactions”
THANK YOU
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