ENt

1. CAUSES OF VERTIGOCAUSES OF VERTIGO

2. VERTIGOVERTIGO
Vertigo has been defined in a numberVertigo has been defined in a number
of ways:of ways:
““Vertigo is a hallucination ofVertigo is a hallucination of
movement”movement”
““Vertigo is a sensation as if theVertigo is a sensation as if the
external world is revolving around theexternal world is revolving around the
patient or as if he himself is revolving inpatient or as if he himself is revolving in
space.”space.”
However it should not just be restrictedHowever it should not just be restricted
to a sensation of rotation, but shouldto a sensation of rotation, but should
also include linear motion as in tendingalso include linear motion as in tending
to stagger to one side.to stagger to one side.
The term should be regarded as theThe term should be regarded as the
symptom of a vestibular system lesion,symptom of a vestibular system lesion,
whether peripheral or central.whether peripheral or central.
““Dizziness is a disturbed sense ofDizziness is a disturbed sense of
relationship to space, it is a sensation ofrelationship to space, it is a sensation of
unsteadiness with a feeling ofunsteadiness with a feeling of
movement within the head, giddiness.”movement within the head, giddiness.”

3. Causes:Causes:
 A series of situations and abnormalities are able toA series of situations and abnormalities are able to
cause it.cause it.
 More than 100 different diseases are sometimesMore than 100 different diseases are sometimes
accompanied by the complaint vertigo.accompanied by the complaint vertigo.
 Unfortunately though, it’s a fact that in 40% of the peopleUnfortunately though, it’s a fact that in 40% of the people
complaining of it, the cause never emerges- not evencomplaining of it, the cause never emerges- not even
when the most advanced investigation techniques arewhen the most advanced investigation techniques are
used.used.
 Despite the lack of diagnosis, or even just some idea ofDespite the lack of diagnosis, or even just some idea of
the way the complaint arose, in order to help the patientsthe way the complaint arose, in order to help the patients
it is necessary to provide some kind of therapy to reduceit is necessary to provide some kind of therapy to reduce
the seriousness of the complaint or at least to make itthe seriousness of the complaint or at least to make it
acceptable for the patient.acceptable for the patient.

4. It is useful to subdivide vertiginous pateintsIt is useful to subdivide vertiginous pateints
into four main groups:into four main groups:
 The positional VertigosThe positional Vertigos
 Vertigos as an isolated symptomVertigos as an isolated symptom
 Vertigo with deafness and tinnitusVertigo with deafness and tinnitus
 Vertigo with other signs of neurologicalVertigo with other signs of neurological
disease.disease.
Causes:Causes:

5. The Positional VertigosThe Positional Vertigos
 BENIGN PAROXYSMAL POSTIONAL NYSTAGMUS.BENIGN PAROXYSMAL POSTIONAL NYSTAGMUS.
 DISEQUILIBRIUM OF AGEING.DISEQUILIBRIUM OF AGEING.
 Ageing process also affects the vestibular apparatus and pathologicalAgeing process also affects the vestibular apparatus and pathological
studies have demonstrated degenerative changes in the maculae andstudies have demonstrated degenerative changes in the maculae and
the cristae, also neuronal degeneration in other parts of vestibularthe cristae, also neuronal degeneration in other parts of vestibular
pathway.pathway.
 Vestibular tests are indicated only if there is doubt about the diagnosis.Vestibular tests are indicated only if there is doubt about the diagnosis.
 Treatment is supportive and includesTreatment is supportive and includes
 Vasodilators and labyrinthine sedatives. CENTRALVasodilators and labyrinthine sedatives. CENTRAL
 (MALIGNANT)POSITIONAL NYSTAGMUS.(MALIGNANT)POSITIONAL NYSTAGMUS.
 When the patient’s head is put in the critical position a coarse, variableWhen the patient’s head is put in the critical position a coarse, variable
nystagmus is set up.nystagmus is set up.
 The nystagmus has no latent period and is non-fatiquable.The nystagmus has no latent period and is non-fatiquable.
 Seen with tumors of posterior cranial fossa or mid-brain, withSeen with tumors of posterior cranial fossa or mid-brain, with
disseminated sclerosis and with vascular lesions.disseminated sclerosis and with vascular lesions.
 Vertigo is less than expected.Vertigo is less than expected.

6. Vertigo as an isolated symptom.Vertigo as an isolated symptom.
 VESTIBULAR NEURONITIS.VESTIBULAR NEURONITIS.
 Severe vertigo of sudden onset may occur following a infection of theSevere vertigo of sudden onset may occur following a infection of the
membranous labyrinth commonly viral.membranous labyrinth commonly viral.
 Caloric tests usually show a canal paresis on the affeced side.Caloric tests usually show a canal paresis on the affeced side.
 Treatment is symptomaticTreatment is symptomatic
 Prognosis: Young recover quickly but an older person may be unsteady forPrognosis: Young recover quickly but an older person may be unsteady for
months.months.
 DISSEMINATED SCLEROSIS.DISSEMINATED SCLEROSIS.
 Acute severe vertigo usually occuring in a diagnosed case of sclerosis.Acute severe vertigo usually occuring in a diagnosed case of sclerosis.
 DRUGS.DRUGS.
 Aminoglycosides (streptomycin, kanamycin, gentamycin etc) are well well knownAminoglycosides (streptomycin, kanamycin, gentamycin etc) are well well known
drugs and may cause both cochlear and vestibular damage.drugs and may cause both cochlear and vestibular damage.
 Other drugs may give rise to symptom of unsteadiness likeOther drugs may give rise to symptom of unsteadiness like
 Labyrinthine sedatives, oestrogens, diuretics such as bendrofluazide BP and frusemideLabyrinthine sedatives, oestrogens, diuretics such as bendrofluazide BP and frusemide
BP and some antibiotics such as nalidixic acid, co-trimoxazole and metronidazole etc.BP and some antibiotics such as nalidixic acid, co-trimoxazole and metronidazole etc.
 MISCELLANEOUS.MISCELLANEOUS.
 Unsteadiness may result from anaemia, hypotension, D.M, Migraine,Unsteadiness may result from anaemia, hypotension, D.M, Migraine,
psychogenic causes and vertigenous aura of epilepsy etc.psychogenic causes and vertigenous aura of epilepsy etc.

7. Vertigo plus Deafness plus TinnitusVertigo plus Deafness plus Tinnitus
 MENIERE’S DISEASE.MENIERE’S DISEASE.
American Academy of Ophthalmology andAmerican Academy of Ophthalmology and
Otolaryngology, Committee on EquilibriumOtolaryngology, Committee on Equilibrium
defined Meniere’s disease as:defined Meniere’s disease as:
““It is a disease of membranous inner earIt is a disease of membranous inner ear
characterized by deafness, vertigo andcharacterized by deafness, vertigo and
tinnitus which has its pathologic correlatetinnitus which has its pathologic correlate
hydropic distension of endolymphatic system”.hydropic distension of endolymphatic system”.

8.  Etiology & Pathology:Etiology & Pathology:
 Distension of the endolymphatic compartments of the inner earDistension of the endolymphatic compartments of the inner ear
(Endolymphatic Hydrops). It mainly affects the cochlear duct and(Endolymphatic Hydrops). It mainly affects the cochlear duct and
saccule and to a lesser extent the utricle and semicircular canals.saccule and to a lesser extent the utricle and semicircular canals.
 Etiology of this endolymphatic hydrops is unclear and variousEtiology of this endolymphatic hydrops is unclear and various
theories have been postulated including:theories have been postulated including:
 Diagnosis:Diagnosis:
 Must be differentiated from acoustic neuroma, labyrinthitis etc.Must be differentiated from acoustic neuroma, labyrinthitis etc.
 Examination reveals a SNHL and recruitment is frequently presentExamination reveals a SNHL and recruitment is frequently present
 Vestibular tests may be normal in the early case but later on canalVestibular tests may be normal in the early case but later on canal
paresis or hypofunction is found on affected side.paresis or hypofunction is found on affected side.
 Treatment:Treatment:
 Medical treatment with antihistamines, labyrinthine sedatives andMedical treatment with antihistamines, labyrinthine sedatives and
anxiolytics, fluid and salt restriction.anxiolytics, fluid and salt restriction.
 Surgical treatment: Shunt operations.Surgical treatment: Shunt operations.

9.  LABYRINTHITISLABYRINTHITIS
 Inflammation of labyrinth due to any cause.Inflammation of labyrinth due to any cause.
 May be viral or bacterial.May be viral or bacterial.
 Viral may occur during course of an exanthematous disease likeViral may occur during course of an exanthematous disease like
mumps/measles or influenza type illness.mumps/measles or influenza type illness.
 Bacterial labyrinthis may be circumscribed, serous or suppurative in a caseBacterial labyrinthis may be circumscribed, serous or suppurative in a case
of otorrhoea.of otorrhoea.
 It may also occur during course of meningitis.It may also occur during course of meningitis.
 ACOUSTIC NEUROMAACOUSTIC NEUROMA
 Vestibular symptoms are variable and tinnitus is common.Vestibular symptoms are variable and tinnitus is common.
 Diagnosis is made on the basis of radiological investigations.Diagnosis is made on the basis of radiological investigations.
 SYPHILISSYPHILIS
 Can mimic Meniere’s disease.Can mimic Meniere’s disease.
 LABYRINTHINE TRAUMALABYRINTHINE TRAUMA
 Non-Operative: Labyrinthine concussion or fracture of temporal bone.Non-Operative: Labyrinthine concussion or fracture of temporal bone.
 Post-Operative: A perilymph fistula may occur after ear surgery esp.Post-Operative: A perilymph fistula may occur after ear surgery esp.
stapedectomystapedectomy

10.  MISCELLANEOUS CONDITIOSMISCELLANEOUS CONDITIOS
 Other conditions which give rise to theseOther conditions which give rise to these
symptoms include wax impaction, eustachiansymptoms include wax impaction, eustachian
tube dysfunction, OME and labyrinthinetube dysfunction, OME and labyrinthine
haemorrhage.haemorrhage.

11. Vertigo with signs of intracranialVertigo with signs of intracranial
disease.disease.
 CNS NEOPLASMSCNS NEOPLASMS
 Tumors involving brainstem, cerebellum or midbrainTumors involving brainstem, cerebellum or midbrain
 Other signs of intracranial disease are foundOther signs of intracranial disease are found
 On ENG nystagmus is found to be irregular and enhanced onOn ENG nystagmus is found to be irregular and enhanced on
eye opening.eye opening.
 POSTERIOR INFERIOR CEREBELLAR ARTERYPOSTERIOR INFERIOR CEREBELLAR ARTERY
THROMBOSIS (LATERAL MEDULLARY SYNDROME)THROMBOSIS (LATERAL MEDULLARY SYNDROME)
 Onset is with severe vertigo with contralateral hemianalgesia.Onset is with severe vertigo with contralateral hemianalgesia.
 VERTEBROBASILAR ISCHAEMIAVERTEBROBASILAR ISCHAEMIA
 Episodes of vertigo with other signs of brain stem disfucntion.Episodes of vertigo with other signs of brain stem disfucntion.

12. Classification:Classification:
(Old)(Old)
DIZZINESS
Vestibular Vertigo Non-Vestibular Vertigo
Peripheral Vestibular Ventral Vestibular
For both diagnosis and treatment it is practically useless.

13. Classification:Classification:
(New)(New)
It is more appropriate toIt is more appropriate to
use a classificationuse a classification
based on the way thebased on the way the
dizziness occurs:dizziness occurs:
 Single attack ofSingle attack of
vertigo which slowlyvertigo which slowly
disappearsdisappears
 Paroxysmal vertigoParoxysmal vertigo
 Chronic vertigoChronic vertigo
 Dizziness spellsDizziness spells

14.  Sudden serious short lastingSudden serious short lasting
 Brief dizziness spellsBrief dizziness spells
 Chronic not very severe persistent/Chronic not very severe persistent/
protractedprotracted
 Sudden Severe Gradually diminishing.Sudden Severe Gradually diminishing.