2. Questions
• Define vertigo. Classify vertigo according to its
duration.
• Write down the characteristics of peripheral vertigo.
• How will you investigate peripheral vertigo?
• How do you differentiate BPPV from central vertigo?
3. Introduction
• Illusion of motion of self or the surrounding
• Mostly a symptom of vestibular lesion
• Vertigo
– Rotatory : Vestibular lesion
– Tilt / Drop : Otolith dysfunction
– Unsteadiness : Miscellaneous
4. •Types of vertigo
–Objective : the patient has the sensation
that objects in the environment are moving
–Subjective : the patient feels as if he or she
is moving
–Pseudovertigo : an intensive sensation of
rotation inside the patient's head
5. • Vertigo must not be confused with
– Dizziness
– Light Headedness
– Blackouts
– Fainting xzcvbn,m
– BGiddiness
– Disequilibrium
• Dizziness occurs due to CNS, CVS , ANS, GIT ,
Psychiatric disorders etc.
6. Main Categories of Dizziness
Category Description %of patients
Vertigo False sense of motion,
possibly spinning sensation
45 to 54
Disequilibrium Off-balance Up to 16
Presyncope Feeling of losing
consciousness or black out
Up to 14
Lightheadedness Vague symptoms, possibly
feeling disconnected with the
environment
~10
7. Etiology of vertigo
Vest. end organ Vest . Nerve Central
Peripheral (Account for 85% of cases) Accounts for 15% cases
Erosion Inflammation Inflammation
Irritation Degeneration Degeneration
Vascular Vascular Vascular
Degeneration Trauma
Trauma Neoplasm
Inflammation
Neoplasm
Metabolic
Autoimmune
9. History
• The most important clue to diagnosis
• Most important points
– Duration : seconds, minutes, hours
– Associated hearing loss
– Episodic/ continuous
– Association to head movement
16. Vestibular function tests
• Spontaneous nystagmus / Gaze nystagmus
• Head thrust test
• Head shake test
• Positional test /Positioning test- Dix Hallpike
• Fistula test
• Valsalva / hyperventilation / loud noise
• Romberg's test – normal / sharpened
• Tandem walk test
17. Features Peripheral Central
1. Nystagmus character
a. Direction Fixed Changes
b. Duration Short (days) Long (weeks)
c. Effect of optic fixation Inhibited Unchanged
d. Latency Present Absent
2. Imbalance Mild Severe
3. Nausea & vomiting Severe Variable
4. Deafness & tinnitus Common Rare
5. Neurological deficit Rare Common
18. Provoking factor Causes
Change in head position B.P.P.V., labyrinthitis, multiple
sclerosis
Sudden standing up from
sitting position
Orthostatic hypotension
Sudden neck movement Cervical spondylosis, VBI
Recent URTI Vestibular neuronitis
Stress Psychogenic, migraine
Change in ear pressure Perilymph fistula
21. Investigations
1. Vestibular
– Caloric Test
•Fitzgerald Hallpike Bithermal Caloric Test
•Modified Kobrak’s Test
•Dundas Grant Test
– Electronystagmography
– Rotation Chair Testing
– Dynamic Posturography
22. Investigations
2. Audiological
– PTA, Glycerol Dehydration Test
– ECoG
– BERA
3. Radiological
– X Ray Cervical Spine
– Doppler USG Carotico -Vertebral System
– HRCT Temporal Bone
– MRI Brain
4. Serological : TPHA, Autoantibodies
23. Caloric test
• Basic Vestibular function test
• Principle:
– On irrigation of EAC with warm/cold water
temperature changes in labyrinth which causes
convection current formation in inner ear fluids
– Endolymph moves under convection current
influence and stimulates the labyrinth
– Nystagmus is seen
24.
25. Fitzgerald - Hallpike
• Bithermal Caloric Test
• Patient kept supine with head elevated 30o (Makes
HSCC vertical & more sensitive)
• Each ear is irrigated with both warm & cold water
(Warm water : 44o C, Cold water : 30o C)
• Rate of Irrigation : 500ml/ min
• Duration of Irrigation : 60-90 sec or when nystagmus
occurs whichever is early.
• Amount of Irrigation usually: 300- 350 ml.
26. •Wait 10 minutes before changing ear or water to allow
temperature to get normal
•Note Nystagmus Direction & Duration
28. • Direction Nystagmus “COWS”
– Cold : Opposite Side
– Warm :Same Side
• Duration of Nystagmus is calculated from start of
irrigation to end of Nystagmus (Normal 90-140 Sec)
• Calculation of results : The nystagmus elicited in 2
ears using warm / cold stimulus is compared
mathematically using Jonkee’s formula
