Clinic based management of vertigo

1. VERTIGO : EVALUATION OF
DIZZY PATIENT
• Dr Prasanna Datta
• Dept of ENT , MCH .
• Kolkata.

2. INTRODUCTION
• Vertigo is the illusion of motion, usually
rotational motion
• The word dizzy includes a broad range of
sensations from severe vertigo to momentary
light headedness.
• Light headedness is pre syncopal rather than
vestibular in origin.( Non vestibular form of
dizziness)

3. INCIDENCE OF DISEASE
• About 30-35% of the population experience
episodes of vertigo by the age of 65 years.
• It is a common complaint in clinical practice,
seen in about 10-15% of patients seen by an
Otorhinolaryngologist
• Diagnosis of the condition remains a challenge for
the family physician as well as among
otolaryngologists.

4. MANAGEMENT
• Good management depends upon an accurate
diagnosis.
• Initial approach to evaluate the dizzy patient is to
consider the categories of dizziness in the the
differential diagnosis.
• To determine whether the dizziness is vestibular or
non vestibular in origin

5. VESTIBULAR ORIGIN
Peripherial
One ear involved or
both ear involved
Central
Brain stem or brain

6. • A proper history and a detailed clinical
examination is followed by appropriate
investigations to come to a correct diagnosis.
• History of illness as emergent acute & chronic
helps to clinch the tentative underlying cause
of vertigo.
Acute dizziness - CNS hemorrhages and
infarcts need immediate intervention.
Trauma to inner ear or temporal bone and
bacterial labyrinthitis require urgent
treatment.

7. DIFFERENTIAL DIAGNOSIS
FOR VERTIGO
Vestibular disorders that cause Vertigo
Peripheral Central
Meniere’s disease VBI
BPPV PICAS
Vestibular neuronitis Basilar migraine
Labyrinthitis Cerebellar disease
Vestibulotoxic drugs Multiple sclerosis
Head trauma Tumours of brainstem
Perilymph fistula Epilespy
Syphilis Cervical vertigo
Acoustic neuroma

10. DURATION SPELL
Seconds BPPV,labyrinthine fistula
Cervical vertigo,VBI
Minutes TIA
Hours meneier’s disease
Days viral neuro labyrinthitis
Variable migraine

11. HISTORY TAKING
• Past H/O
Head injury –
Operation
Fever
• Personal H/O
BP (high or low)
Diabetes
Alcohol, tobaco
Otorrhea
Heart disease
Arthritis

12. CLINICAL EXAMINATION
• General medical examination
• Specific clinical exam. of vestibular pathology
Otological examination – fistula test
Vestibulo-ocular examination
Eye movements
Spontaneus nystagmus
Positional nystagmus
• Neuro otological examination
Romberg test
Tandem walking
Eye open
Eye closed
Fukuddas stepping test
positional nystagmus test DIX-HALLPIKE
maneuver

13. •
DIX HALLPIKE

15. INVESTIGATION
• ENG:recording of eye movements that allows precise
quantification of both physical and pathological nystagmus
Sponatanous nystagmus
Gaze nystagmus
Pendulam tracking test
Caloric test
• CCG-photo graphic recording of patient’s head and body
movements
Functional measurement of balance that reflexes
vestibulospinal function

16. • Rotatory test- Barany’s
technique- nystagmus
induced by sudden stop is 10
to 30 sec in duration in
normal subject.which is
fairly symmetrical in clock
wise and counter clock wise
in rotation.Gross
asymmetries in the
duration between the
responses to clockwise and
counter clockwise rotation
are taken as a vestibular
pathology.
• By ENG pre rotatory as well
as post rotatory nystagmus
is evaluated

17. PTA
SRT
SDS
Tone decay
• BERA –method of plotting electrical activities in response to auditory
or vestibular stimuli.
• Caloric test – kobrak’s cold caloric test
a)(2 to 5cc of ice cold water) to initiate
vertigo with labyrinthine type of nystagmus
b)10 to 20 cc of ice cold water initiate
nystagmus-canal paresis
c) No nystagmus or vertigo after 40 cc of ice cold
water –dead . labyrinthine
AUDIOMETRIC TEST

18. IMAGING
• Conventional Xrays
Xray mastoids , laws lateral view
Xray skull per orbital view
X ray PNS, water’s view
Xray cervical spine AP, lateral view
• MRI &MRI angiographic study
• CT / CT angiographic study
• EEG
• EMG
• NCV

19. HAEMATOLOGICAL STUDY
• Routine blood test :Hb%,TLC,DLC,blood
for sugar (F) & PP,
serum cholesterol,
serum triglyceride.
• Serological test for syphilis
• Thyroid function test

23. VESTIBULAR DISORDERS
DIAGNOSTIC CONSEPT AND
ALGORITHMS
• Benign paroxysmal positional vertigo (BPPV)
• Vestibular neuritis
• Benign paroxysmal vertigo of childhood
• Motion sickness
• Meniere’s disease / endolymphatic hydrops
• Labyrinthine disease of metabolic origin
• Autommune inner ear disease
• Otoxicity
• Vestibular schwannoma

24. PHYSICAL EXERCISE
REGIMENS
Habituation and adaptive response and sensory
substitution
Vestibular rehabilitation refers to a structural
programme of treatment aimed at expediting and
enhancing vestibular compensation and
rendering dizzy patient ,asymptomatic such that
they can return to full occupational and social
activities.
Systemic exercise programme eg. Cawthorne-
cooksey exercises
Specific therapies Epley maneuvere( canalolith
repositioning method), Semont maneuvere

25. Cawthrone cooksey exercise
EXERCISES IN BED : EYE
MOVEMENTS
Looking up and then down

26. EXERCISES IN BED : EYE
MOVEMENTS
Looking alternately left and right

27. Convergence Exercises

28. EXERCISES IN BED : HEAD
MOVEMENTS
Bending alternately forward and backward

29. EXERCISES IN BED : HEAD
MOVEMENTS
Turning alternatively to the left and then right

30. EXERCISES IN SITTING POSITION
Shrugging and rotating shoulders

31. EXERCISES IN SITTING POSITION
Bending forward and picking up objects from the floor

32. EXERCISES IN SITTING POSITION
Turning head and trunk alternately to the left and the right

33. EXERCISES IN STANDING
POSITION
Changing from sitting to standing, initially with eyes
open and then with the eyes closed

34. Throwing a small (ping
pong) ball in an arc from
hand to hand and following
it with the eyes

35. Throwing a small ball from hand to hand under the knee

36. EXERCISES WHILE WALKING
Throwing and catching the ball while walking

37. EXERCISES WHILE WALKING
Walking around in the room with eyes open and closed

38. EXERCISES WHILE WALKING
Walking up and down a flight of stairs

39. EXERCISES WHILE WALKING
Playing any game involving bending,
stretching and aiming with the ball

40. OFFICE TREATMENT OF BPPV: The Epley
maneuver
•

41. from sitting position to ipsilateral lateral position. After 1 to
1.5 minute patient is moved 180 to the contralateral lateral
position

42. INSTRUCTIONS FOR PATIENTS AFTER OFFICE
TREATMENTS
•

43. HOME TREATMENT OF BPPV
Brandt –Daroff exercises

44. A Retrospective study in ENT
dept, MCH. For Vestibular
Exercises
N = 48 patients (male 20, female 28) diagnosed
as BPPV.
Study period – Nov. 2005 – Nov 2006.
Patients – randomly assigned to one of three
groups.
Follow up visit - 1 week, 2 weeks and 3 months.

45. Group 1 : Semont’s maneuver followed by post treatment
(n = 16) instruction (sleep in sitting position for 2
nights
plus then normal side for next 5 nights)
Success rate : 75% (n = 12) after one treatment.
Group 2 : Apley’s maneuver followed by post treatment
(n = 16) instruction
Success rate : 87.5% (n = 14) after one treatment
Group 3 : Brandt-Daroff maneuver (repeated positioning
(n = 16) exercises 3 times a day for 2 weeks)
Success rate : 56.25% (n = 9)
Overall success rate of vestibular rehabilitation exercises
is73% (approx)

46. CONCLUSION
Some important point to remember
• Vertigo is a symptom not a disease.
• In most vertigo underlying cause is simple
• Art of history taking for correct diagnosis is
essential.
• Vestibular rehabilitation exercises help a lot to
relieve vertigo.