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Vertigo - making it simple

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making vertigo simple

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Vertigo - making it simple

  1. 1.  VERTIGO – MAKING IT SIMPLE DR.ANITA BHANDARI CONSULTANT NEUROTOLOGIST VERTIGO AND EAR CLINIC, JAIPUR
  2. 2. ETIOLOGY
  3. 3. MATTER OF CONCERN More amenable to treatment -more sinister consequences
  4. 4.  Seconds – late ototoxicity  Minutes – BPPV, TIA  Hours – Meniere’s disease , Migraine related vertigo  Days – Vestibular neuritis  Months – years - Hysterical
  5. 5.  Spatial orientation  Ocular stabilization  Postural control EQUILIBRIUM
  6. 6.  A battery of tests  Many systems to be evaluated to assess structural and functional integrity NEUROTOLOGICAL EVALUATION
  7. 7. For An ENT Specialist,  We look at the ears first.  In vertigo --> eyes are most important
  8. 8.  Otoliths act as gravito-inertial force detectors  SVV is a psychophysical measure of the angle between perceptual vertical and true/gravitational vertical  Also used to measure vestibular rehabilitation  Compensated utricular hypofunction may be detected on dynamic SVV testing. The defect will be unmasked on eccentric rotation because any otolith function asymmetry will be enhanced. SVV
  9. 9.  Pt is asked to adjust the orientation of a luminous bar until they perceive it as vertical  SVV – saccule and its central pathways  SVH – utricle and its central pathways  Pinar et al reported changes in SVV and SVH in >25% pts of chronic dizziness concluding that evaluation of the otolith system is mandatory SUBJECTIVE VISUAL VERTICAL AND HORIZONTAL
  10. 10. SVV FINDING CONDITION Normal range Upto 2° deviation Ipsiversive tilt – >2o peripheral vestibular disorder pontomedullary lesion thalamic lesion Controversive Pontomesencephalic lesion parietoinsular vest. lesion Migraine Abnormal, little literature
  11. 11. CRANIOCORPOGRAPHY  Developed by Claussen [1968]  Assessment of vestibulospinal system  Photographic recording of head and body movement during gait testing  Evaluation includes Romberg, Tandem walking and Unterburger’s test
  12. 12.  Done in dark room  Pt is blindfolded  Pt wears a helmet with LED lights  Path of the pt is recorded using an SLR camera  Result depends on vestibular system only as visuals cues cut off – pt is blindfolded and by stepping in one place, the soles intermittently lose contact with the floor thus reducing somatosensory input CCG : PROCEDURE
  13. 13. PARAMETER NORMAL RANGE- LOWER BORDER NORMAL RANGE- UPPER BORDER Longitudinal displacement 30.03 cm 113.35 cm Lateral sway 5.17 cm 16.15 cm Angular deviation 55.13° (right) 48.37° (left) Body spin 82.21° (right) 82.89° (left) NORMAL PARAMETER OF CCG [CLAUSSEN]
  14. 14. PATHOLOGY CCG FINDINGS Peripheral vestibular lesions Ipsilateral deviation Brainstem lesion, bilateral peripheral vestibulopathy Enlarged lateral sway, no angular deviation CPA tumors, PICA synd. Contralateral deviation, enlarged sway INTERPRETATIONS OF CCG
  15. 15. INCREASED SWAY
  16. 16. ANGULAR DEVIATION TO LEFT
  17. 17. ANGULAR DEVIATION TO LEFT
  18. 18.  Introduced by Halmagyi and Curthoy  Simple, fast, reliable  Tests scc function – can evaluate all 3 pairs  Measures high freq. vestibular response in 3 dimensions HEAD IMPULSE TESTING
  19. 19.  VHIT – using Video Frenzel glasses  Test for gaze stabilization during rapid translation of head  Assesses the peripheral utricular system and superior vestibular N  A corrective saccade after VHIT indicates hypofunction of same side HEAD IMPULSE TEST
  20. 20.  Subject seated upright with eyes focused on an fixed object  Unpredictable , low amplitude [10 – 20°] head rotation with high acceleration  Angular VOR generates compensatory eye movements equal in amplitude and opposite in direction to stabilize gaze HIT : PROCEDURE
  21. 21. HEAD IMPULSE
  22. 22.  Nystagmus indicates an imbalance in vestibular tone between the 2 sides  Not seen in bilateral vestibular dysfunction HEAD SHAKING TEST
  23. 23. HEAD SHAKING TEST
  24. 24. HEAD SHAKING – DOWN BEATING NYSTAGMUS
  25. 25.  Functional test of VOR  Comparison of visual acuity with head still to VA with head moving  Reduction by 2 lines indicates dysfunction of VOR as seen in bilateral peripheral vestibulopathy  Improvement with rehab will improve DVA  Early sign of vestibular toxicity DYNAMIC VISUAL ACUITY TEST
  26. 26.  BPPV AND PARTICLE REPOSITIONING MANEUVERS
  27. 27.  The ampulla contains the cupula – a gelatinous mass with the same density as the endolymph.Cupula forms an impermeable barrier across the lumen of the ampulla. Hence the particles in scc may only exit via the end with no ampulla.
  28. 28. POSTERIOR CANAL BPPVPOSTERIOR CANAL BPPV  Most common– posterior canal is most gravity dependent in upright and supine position  Once debris enter the post. canal ,the cupula at the shorter most dependent arm trap the debris.  Debris can exit only through the longer arm through the crus commune [non-ampullary]
  29. 29. DIX-HALLPIKE MANEUVRE
  30. 30. POSTERIOR BPPV
  31. 31. EPLEYEPLEY’’S MANEUVERS MANEUVER
  32. 32. EPLEY’S MANEUVRE
  33. 33. SEMONTSEMONT’’S MANEUVERS MANEUVER  Liberatory maneuver for pBPPV and cupulolithiasis  Used to overcome otoconia jam after Epley’s maneuver
  34. 34. SEMONTSEMONT’’S MANEUVRES MANEUVRE
  35. 35. SEMONT’S MANEUVRE
  36. 36. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES  Used as a home program  Indications o Posterior canal cupulolithiasis o Persistant posterior canal canalithiasis  Mechanism o Dislodge debris attached to cupula o Habituation through central compensation
  37. 37. BRANDT-DAROFF EXERCISES
  38. 38. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES  Things to remember o The exercises may dislodge more otoconia from the utricle causing an increase in symptoms. o May cause multiple canal involvement. o Important to hold for 30 seconds in each position.
  39. 39. HORIZONTAL SCC BPPVHORIZONTAL SCC BPPV  Pagnini-McClure maneuvre  Geotropic nystagmus – debris are away from ampulla , side showing stronger nystagmus is the side involved  Apogeotropic nystagmus – indicates cupulolithiasis
  40. 40. McCLURE PAGNINI MANEUVERMcCLURE PAGNINI MANEUVER SUPINE ROLL TESTSUPINE ROLL TEST
  41. 41. McCLURE’S MANEUVRE
  42. 42. POSITIONAL – LATERAL BPPV
  43. 43. BARBECUE MANEUVRE
  44. 44. GUFONI MANEUVRE
  45. 45. VANUCCHI MANEUVERVANUCCHI MANEUVER  Forced prolonged positioning  Sleep in lateral position with healthy ear down for 12 hours.
  46. 46. CUPULOLITHIASISCUPULOLITHIASIS  Coined by Schuknetch  Rare , more common in horizontal canal  Caused by otoliths attached to cupula of scc  When cupula is horizontal no vertigo  When non-horizontal constant input persistant dizziness  Nystagmus : persistant non-fatiguable as long as patient is in the same position
  47. 47. SUBJECTIVE BPPVSUBJECTIVE BPPV  No nystagmus is detected but patient feels dizzy on provocative tests  PRP beneficial  Reasons o Subtle nystagmus o Fatigued nystagmus o Inadequate neural signal to stimulate the VOR
  48. 48. CONTRAINDICATIONS OFCONTRAINDICATIONS OF PARTICLE REPOSITIONINGPARTICLE REPOSITIONING  Cervical spine problems  Uncontrolled hypertension  Retinal detachment
  49. 49.  PHARMACOTHERAPY OF VERTIGO
  50. 50. NO COMMON TREATMENT FOR ALL PATIENTS. Therapeutic approach requires recognition of the pathomechanism  Detailed history  Clinical examination  Neurotological tests  Imaging
  51. 51. Aim Of Vertigo Therapy  Elimination of Vertigo  Enhancement/non-compromise of “Vestibular compensation”  Reduction of Psychoaffective syndromes  Nausea and Vomiting  Anxiety Thomas Brandt – Vertigo; A mutlisensory system disorder, 2nd edition. Springer –Verlag- London 2002
  52. 52. Vestibular Suppressants Rascol O et al, Drugs 1995; 50: 777-91 Lacour M. Curr Med Res Opion 2006; 22: 1651-9 Reduction in the symptom of vertigo comes at a price of reduction in vestibular function
  53. 53. Treatment with Vestibular Suppressants  Suppressants reduce activity at intact side and thus hamper recovery by VC  Not recommended for long term use  They should be discontinued as soon as possible Lacour M. Curr Med Res Opion 2006; 22: 1651-9 Vestibular Nuclei INTACT DAMAGED
  54. 54. Vestibular Suppressants  Useful for prevention of nausea and reduce vomiting (generally to be used for not more that 1-3 days) post an event  Should be discontinued as soon as possible after event subsides  They are not to be used chronically or for prophylaxis against subsequent attacks Lacour M. Curr Med Res Opion 2006; 22: 1651-9 Goebel J. Otolaryngol Clin N Am 2000; 33: 483-93 Brandt T, Vertigo. Its Multisensory Syndromes, 2nd Ed: Pg 49-61
  55. 55. ANTI-CHOLINERGIC DRUGS Suppress spontaneous firing of  Vestibular nuclei  2ND & 3RD order neurons  Reticulo-vestibular pathway
  56. 56. ANTI- HISTAMINICS  Histamine is not a major neurotransmitter in the vestibular pathway  It exerts effect by acting on H1 receptors antagonist  Structure of H1 receptors is similar to Muscaranic receptors  Drug which blocks H1 receptors will also have an anti- cholinergic effect
  57. 57. Cinnarizine: Mechanism of Action Drugs of Today, 1982;18(1):27-42 Ca+2 Channel Blocker
  58. 58. BETAHISTINE Historically seen that histamine relieved vertigo. However had to be given IV and had serious side effects. Betahistine is a histamine analogue having the advantages of histamine like action without its side effects.
  59. 59. DRUG COMBINATIONS  Anti-histaminics are H1 receptor antagonists  Betahistine is H1receptor agonist and H3 receptor antagonist  Hence these drugs should not be combined.
  60. 60. VESTIBULAR REHABILITATION  VRT comprises of a series of maneuvers designed to stimulate the vestibular system. These movements which in the initial stages provoke vertigo, are combined with exercises involving eye movements and postural changes which encourage vestibular compensation.
  61. 61. TAILORING THE REGIMEN  Vestibulo-ocular system  Vestibulospinal system  Otolithic system
  62. 62.  Pts are asked to perform repeated head ,eye and body movements which will help the brain recalibrate the relationship between visual, vestibular and proprioceptive signals.
  63. 63.  Bouncing on Swiss balls or mini-tramps may be advocated to build up the otolith-ocular reflex as well as otolith-postural reflexes.
  64. 64. ON TRAMPOLINE
  65. 65. CENTRAL COMPENSATION  Adaptation – ability to regain spatial orientation  Substitution – as there is a derangement in function, using different pathways to maintain equilibrium  Habituation – repeated maneuvres aimed at stimulating the sensory mismatch and lead to desensitization.

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