vertigo

1. Vertigo
Done by :Ahlam Majali

4. Definition
Vertigo is when a person feels like if they or the objects
around them are moving when they are not.[1]
Often it feels like
a spinning or swaying movement.
An illusion or hallucination of movement which is usually
rotation, either of oneself or the environment
( FALES SENSATION OF MOVEMENT)
It is often accompanied by pallor, sweating and vomiting.
The objective sign of vertigo is nystagmus.

5. The body balance is maintained by inputs
to the brain from 3 areas:
Inner ear(vestibular part)
Eyes
Proprioceptive organs
Dysfunction of any of these systems may
lead to imbalance.

6. Classification
• Vertigo is classified into either peripheral
or central depending on the location of the
dysfunction of the vestibular pathway

7. Central vertigo
 If vertigo arises from the balance centers of
the brain.
 it is usually milder.
 has accompanying neurologic deficits such
as :
– slurred speech
– double vision or
– pathologic nystagmus.

8. Central causes
1.inflammatory:meningitis,encephilitis
2.Traumatic:head trauma
3.Vascular:Thrombosis,hm’g,embolism
4.Neoplastic:cerbellar tumors
5.Degenerative:multiple sclerosis
6.Other :epilepsy,Lateral medullary
syndrome:occulsion of PICA (Posterior
inferior cerebellar artery)

9. Peripheral vertigo
 Vertigo caused by problems with the inner ear or vestibular
system is called "peripheral", "otologic" or "vestibular" .
 The most common cause is benign paroxysmal positional
vertigo
 Any cause of inflammation such as common cold, influenza,
and bacterial infections may cause transient vertigo if they
involve the inner ear, chemical insults (e.g., aminoglycosides)
physical trauma (e.g., skull fractures) and Motion sickness is
sometimes classified as a cause of peripheral vertigo.

10. • Peripheral vertigo can be classified into:
– Acute
• Acute vestibular neuritis
• Labyrinthitis
• Perilymph fistula
– Chronic
• Meniere disease
• BPPV
• Acoustic neuroma.

12. Diagnosis
 The diagnosis of the cause of vertigo or imbalance
depends mostly on history, much on examination
and little on investigation.
 The particular questions to be asked relate to three
areas:
1 Timing: episodic, persistent.
2 Aural symptoms: deafness, fluctuating or
progressive; tinnitus; earache discharge.
3 Neurological symptoms: loss of consciousness;
weakness; numbness; dysarthria; diplopia; fitting

13. 1
2
3

14. A.N. Obydi
4
5
6

15. Menière’s DiseaseMenière’s Disease
Def. :Def. :
an idiopathic condition in which there is distension of thean idiopathic condition in which there is distension of the
membranous labyrinth by accumulation of endolymph (endolymphaticmembranous labyrinth by accumulation of endolymph (endolymphatic
hydrops).hydrops).
It can occur atIt can occur at anyany age, but mostly 40 and 60 yrs.age, but mostly 40 and 60 yrs.
-UsuallyUsually uniunilateral but in 35% of cases it islateral but in 35% of cases it is bibilateral .lateral .
-Menière’s disease is fortunatelyMenière’s disease is fortunately uncommonuncommon, but may be, but may be
incapacitating.incapacitating.

16. Menière’s DiseaseMenière’s Disease
Clinical Features :Clinical Features :
1.Vertigo is intermittent but may be profound, and usually causes
vomiting. The vertigo lasts for a few hours, and is of a rotational
nature.
2. Aural fullness may precede an attack by hours or even days.
3.SNHL : It is associated with loudness intolerance . Despite
fluctuations, the deafness is usually steadily progressive and may
become severe.
4.Tinnitus is constant but more severe before an attack.

17.  The Caloric TestThe Caloric Test
• Irrigation of the external meatus with water
7°above and later 7° below body temperature sets up
currents of the endolymph in the semicircular
canals.
• This causes nystagmus, and the duration of the
nystagmus gives an index of the activity of the
labyrinth.(slow toward the cold water )
• The nystagmus can be directly observed or recorded
electrically (electronystagmography).
• This test is particularly valuable inthe diagnosis of Ménière’s disease and
acoustic neuroma.
• A reduced or absent nystagmus is found (canal paresis).

18. caloric reflex test
 This test is particularly valuable in the diagnosis of Ménière’s disease and
acoustic neuroma.
1-Pt lies supine with flexed head(30 degree)
2-Ear is washed with cold water(30 c) {7 below body temp}
3-Rest 7 minutes
4-Then ear is washed with worm water (44 c) {7 above body temp}
5-Each ear washed for 40 seconds
• Normal result nystagmus & vertigo last 90-120 sec
• >90 sec hypofunction
• no response dead ear
 The nystagmus observed electrically (electronystagmography).
 A reduced or absent nystagmus is found (canal paresis)

19. TreatmentTreatment
General and medical measuresGeneral and medical measures
In an acute attack
1.Bed rest
2.Anti-emetic (e.g. Prochlorperzine IM or cinnarizine
sublingual )
3.Anti-vertiginous agent ( Betahestine (Serc) )

20. Between attacks, various methods of treatment are
useful:
1. Fluid and salt restriction.
2. Avoidance of smoking and excessive alcohol or coffee.
3. Regular therapy with betahistine hydrochloride
4. If the attacks are frequent,
 regular medication with labyrinthine sedatives, such as
cinnarizine, or prochlorperazine, are of value.
 Regular low-dose diuretic therapy may also be of benefit.

21. Surgical treatment
1- Labyrinthectomy is effective in relieving vertigo, but should only be
performed in the unilateral case and when the hearing is already
severely impaired.
2 -Drainage of the endolymphatic sac by the transmastoid route.
3 -Division of the vestibular nerve either by the middle fossa or by the
retrolabyrinthine route; this operation preserves the hearing but is a
more hazardous procedure.
4-Intra-tympanic gentamycin is helpful in reducing vestibular
activity but
• with a 10% risk of worsening the hearing loss.
• .

22. Vestibular NeuronitisVestibular Neuronitis
- Acute onset of disabiling vertigo often accompanied by N&V and
imbalance which resolves over days leaving a residual imbalance
which resolves in days to weeks .
- No asso. HL or tinnitus.
- Steady resolution takes place over a period of 6–12 weeks but the
acute phase usually clears in 2 weeks.
Etiology :Etiology : Viral infection ( Mumps, Measles & HZ )

23.  vestibular neuritis is usually treated symptomatically,
meaning that medications are given for nausea (anti-
emetics) .
 Typical medications used are "Antivert (meclizine)",
"Ativan (lorazepam) ", and "Valium (diazepam) ".
 Steroids (prednisone, methylprednisolon) are also used
for some cases.

24. Benign Positional Vertigo
 Benign paroxysmal positional vertigo is due to a
degenerative condition of the utricular neuroepithelium
and may occur spontaneously or following head injury.
 Attacks of vertigo are precipitated by turning the head so
that the affected ear is undermost.
 the vertigo occurs following a latent period of several
seconds and is of brief duration.

25. BPPVBPPV
 EtiologyEtiology ::
- Due to canalithiasis or cupulolithiasis .
- 90% of cases affects the post. semicircular canal.

26.  There is no hearing loss
 Nystagmus will be observed
 Steady resolution is to be expected over a period of
weeks or months.
 It may be recurrent.
 It can often be relieved completely by the Epley
manoeuvre of particle repositioning by sequential
movement of the head to move the otolith particles away
from the macula

27. BPPV diagnosis: Dix-Hallpike
manoeuvre
This maneuver helps to differentiate
peripheral positional vertigo from
central vertigo.
The physician moves the patient from
a sitting to a supine position, with the
head rotated 45 degrees to one side
and hanging off the table at 45
degrees.
The patient is then observed for
vertigo and nystagmus.
The maneuver is repeated with the
head turned to the other side.

28. Dix-hallpike maneuver
• With peripheral positional vertigo ( benign positional
vertigo), the maneuver produces ( after 2-20 seconds ) :
1. Vertigo ( lasting for 20sec )
2. Rotary nystagmus
3. Fatigues with repetitive testing.
4. Reversal of Nys. upon sitting up
5. Latency of 〜 20
• Variation of these features often indicates a central
disorder.

29. The Epley maneuver
This repositioning procedure uses gravity to draw
canaliths from the posterior semicircular canal to the
vestibule, where they are absorbed.
 This may require that the pt. wears a soft neck collar
for support and sleep sitting up in a chair for a night

31. Acoustic neuroma
 Acoustic neuroma (vestibular schwannoma) is a slow-growing
benign tumour of the vestibular nerve that causes hearing loss ,
tinnitus and slow loss of vestibular function.
 Imbalance rather than vertigo results.
 Diagnosis : MRI – will show a tumor that may be in the internal
auditory canal or extend through the meatus into the
cerebellopontine angle
 Treatment :microsurgical resection or conformal stereotactic
radiosurgery.
 Complications :Complications :
1. Facial nerve palsy
2. V1 sensory defecit ( corneal reflex )

32. Labyrinthitis
 It is an inflammatory disease of the inner ear it could affect one or both ears .
 Clinically:
Disturbance of balance
Hearing loss of varying degrees
Nausea & vomiting
Tinnitus
Otorrhea
Otalgia
Aural fullness
Spontaneous Nystagmus toward the unaffected side.
 Viral or bacterial infection can cause inflammation of the labyrinth in conjugation
with either local or systemic infection
 Autoimmune process may also cause labyrinthitis

33. Management
 viral labyrinthitis :bed rest and hydration .
 Pt. with severe nausea and vomiting :IV fluid and
antiemetic .
 Diazepam and other benzodiazepines are occasionally
helpful as vestibular suppressant .
 A short course of oral corticosteroids may be helpful.
 Bacterial labyrinthitis is treated with antibiotics based on
culture and sensitivity .
 Treat the symptoms as indicated

34. Perilymph fistula
result of spontaneous rupture of the round-window
membrane or trauma to the stapes footplate.
 perilymph fistula causes marked vertigo with
tinnitus and deafness.
 There is usually a history of straining, lifting or
subaqua diving in the spontaneous cases.
 treatment is by bed-rest initially, followed by
surgical repair if symptoms persist

35. Ototoxic drugsOtotoxic drugs
- Such as gentamycin and other aminoglycoside antibiotics, can
cause disabling ataxia by destruction of labyrinthine function.
- Such ataxia may be permanent and the risk is reduced by careful
monitoring of serum levels of the drug, especially in patients with
renal impairment.

36. Trauma to the labyrinthTrauma to the labyrinth
-Trauma to the labyrinth causing vertigo may complicate
head injury, with or without temporal bone fracture.

37. Post-operative vertigoPost-operative vertigo
-Post-operative vertigo may occur after ear surgery,
especially stapedectomy, and will usually settle in a few
days.

38. Syphilitic labyrinthitisSyphilitic labyrinthitis
- Syphilitic labyrinthitis from acquired or congenital syphilis
- It is very rare but may cause vertigo and/or progressive deafness.

39. Vertebrobasilar InsufficiencyVertebrobasilar Insufficiency
-It may cause momentary attacks of vertigo precipitated by
neck extension.
-The diagnosis is more certain if other evidence of brain
stem ischemia, such as dysarthria or diplopia, is also
present.
-Severe ischaemia may cause drop attacks without loss of
consciousness.

40. THANX