This document provides information about dizziness and balance disorders. It defines key terms like dizziness, vertigo, and oscilopsia. It then lists and describes common causes of dizziness including vestibular disorders, central disorders, medical disorders, drugs, and psychological factors. Specific vestibular disorders discussed include benign paroxysmal positional vertigo (BPPV), Meniere's disease, and vestibular neuronitis. Examination techniques are outlined including tests of nystagmus, vestibulospinal function, and the semicircular canals. Investigations and management approaches are also summarized, including pharmacotherapy, physical therapy, repositioning procedures, and surgery.

1. SHRAVAN ENT HOSPITAL
DR HITESH B SHAH(MS ENT)
www.shravanhospital.com
AMRELI

2. TERMS
 Balance- a complex interaction betn
vestibular,ocular,proprioceptive and CNS
to maintain head and body position in
relation to the environment
 Dizziness-nonspecific term includes
sense of imbalance(diseq),blacking
out(presyncope),lightheadednes,floating
sensation
 Vertigo-a hallucination of movement
rotatory/translational.
 Ossilopsia- blurring of vision with head
movement

3. BALANCE

4. CAUSES OF DIZZINESS
VESTIBULAR DISORDERS
CENTRAL DISORDERS
MEDICAL DISORDERS
DRUGS
PSYCHOLOGICAL
OTHER-PG.CERVICAL,TRAUMA

5. EAR

6. VESTIBULAR DISORDERS
 Benign paroxysmal positional
vertigo(BPPV)
 Meniere’s disease
 Vestibular nuronitis
 labyrinthitis

7. Central vestibular disorders
Tumors
Strokes
Multiples sclerosis
migrain

8. Medical disorders
GENERAL MEDICAL
---Infections, UTI. URTI
CARDIOVASCULAR
--- postural hypotention,arrhythmia,
myocardial infarction
HAEMATOLOGICAL
---anemia
ENDOCRINE/METABOLIC
---disbetes mellitus, thryroid dysfunction,
adrenal dysfunction
NUROLOGICAL
---Strokes,tumors and Parkinsons disease

9. DRUGS
Antihypertensives
Anti epileptics
Aminoglycosides

10. PSYCHIATRIC DISORDERS
 Dementia,
 Anxiety
 Depression

11. Other causes
Obstetric- pregnancy
Orthopedic-cervical vertigo
TRAUMA-barotrauma, post concussion
syndrome
blast

12. Periphral vestibular disorders
Acute periphral mechanical chronic
Vestibular neuronitis bppv Acoustic nuromas
labyrinthitis
Meniere’s disease Perilymph fistulas
labyrinthectomy Chronic periphral
Vestibular disorder
Vascular or
autoimmune
Superior semicircular
dehiscence
ototoxicity
Delayed
endolymphatic
hydrops

13. MENIERE’S DISEASE
 Idiopathic endolymphatic
hydrops(swelling of the membranous
labyrinth)
 Aural fullness
 Nausea
 Vomitting
Rx-
 Vestibular sedative ,antiemetics,fluid
electrolyte mx,(hydrochlorothiazide)
 Intratympanic steroid/gentamicin

14. Vestibular Neuronitis
 Viral infection of vestibular nerve or
vestibular(scarpa’s) ganglion
 Herpes simplex type 1
 Acute onset,severe,nausea,vomitting
 Preceded by a viral illness.
 3 weeks
Rx
 Hospitalisation,i.v.fluid, vest
sedative,anti
emetics,steroids,vestibular
rehabilitation

15. labyrinthitis
 Infection of entire labyrinth or entire 8th
nerve
 Viral/bacterial
 c/f same as vestb.nuritis with addition
of hearing loss and tinnitus
Rx
 BACTERIAL LABYRINTHITIS
 Antibiotics(meningitis,csom)

16. BPPV
 Most common type of periphral vertigo
 Dislodgement of calcium carbonate
crystals( otoliths) from the utricle into
the semicircular canals
 Episodic vertigo last for few seconds
upto a minute
 Dizziness when sudden turning of
head
 >40 yr.
 Diagnosis-Dix-Hallpike maneuver
 Rx-Epley’s maneuver

17. Dix-Hallpike Maneuver:

18. Epley maneuver – 90% successful

19. Otogenic vertigo
seconds Minutes to hrs Days to weeks
No auditory
symptoms
Hearing loss No auditory
symptoms
Triggered by head
posn
tinnitus After URTI
Otolith in PSC Fullness in ear
Usually spontaneous
Rotatory nystagmus Horizontal
nystagmus
Horizontal
nystagmus
BPPV Meniers’s disease Vestibular nuronitis

20. CENTRAL CAUSES
MIGRAINE
 Headache,photophobia,aura and auditory
symptoms
 Rarely spontaneous nystagmus(vertical)
STROKE
 Wallenberg’s syndrome(PICA)-
ataxia,dysarthria,unilateral Horner’s
syndrome(ptosis,meiosis,anhidrosis)
 AICA-vertigo with unilat. Deafness
 Isolated pontine infarcts may present with
vertigo alone.
 Dx-CT SCAN, MRI

21. DRUGS
DRUG TYPE OF DIZZINES MECHANISM
Aminoglycoside,cisplat
in
Vertigo ,diseq. Damage to vestb
.h.cells
antiepileptics Vertigo,diseq. Cerebellar toxicity
tranquilizers intoxication CNS depression
Anti HT. cardiac drugs Near faint Postural hypotension
alcohol Intoxicn. Diseq. Cns deprn .cerebellar
tox. Gravity change.
anticoagulants vertigo Haemorrhage into
inner ear or brain
methotrexate diseq. Brainstem,cerebellar
tox
Urologic drugs Near faint Postural hypotn
Parkinsons drugs. Near faint Postural hypotn

22. Examination
General
b.p., temp. pallor. Postural hypotn.
ENT ex.-otoscope,tft.
Nurologic ex.
Nystagmus-a defect in the VOR results in
abnormal eye movements.
Fast & slow component
Pendular nyst- beats of similar velocity in
each direction(central)
Jerk nyst-quick and slow phase(periphral )

23. NYSTAGMUS
PERIPHRAL CENTRAL
DURATION TEMPORARY PERMANENT
CHARACTER UNIDIRECTIONAL MULTIDIRECTIONAL
OR DIRECTION
CHANGING
CONJUGATE DYSCONJUGATE
HORIZONTAL VERTICAL
REMOVAL OF OPTIC
FIXATION
ENHANCES INHIBITS OR
UNCHANGED

24. TESTS FOR VESTIBULOSPINAL
TRACT
 GAIT
 Asking the pt to walk toward a fixed point in a
normal manner
 -tendency to veer toward one side –periphral
disorder
 -ataxic or broad based, unsteady gait –cerebellar
lesion
 RHOMBERG’S TEST
 Pt stands upright with feet together,eyes closed
and hands stretched forward.
 Sway one side-periphral
 Inability to stand with feet together-central

25. CEREBELLAR TESTS
 PAST POINTING
 Pt is asked to touch examiners finger with
his index finger at different positions.
 RAPID ALTERNATIVE MOVT.
 pat the palm of one hand with the palm and
dorsum of the other hand alternatively
 --slownes of the limb on affected side to
perform the movtment(dysdiadochokinesia)

26. TESTS FOR SEMICIRCULAR CANAL
 DIX HALLPIKE MANEUVER
 VALSALVA TEST
 FISTULA TEST

27. INVESTIGATIONS
 FBC
 Cardiac enzymes
 Bl urea,serum el.
 Fbs
 Tft
 Vdrl
 PTA
 RADIOLOGY
 VNG

28. PRINCIPLES OF MANAGEMENT
 PHAMACOTHERAPY
 PHYSIOTHERAPY
 PARTICLE REPOSITIONING
PROCEDURES
 SURGICAL

29. PHARMACOTHERAPY
SYMPTOMATIC(ACU
TE ATTACKS)
VESTIBULAR
SEDATIVES
BENZODIAZEPINES DIAZEPAM,
LORAZEPAM
ANTIHISTAMINES
ANTICHOLINERGIC
MECLIZINE,DIMENH
YDRINATE
SCOPALAMINE
ANTI EMETICS METOCOOPRAMIDE PROCHLORPERAZIN
E (STEMETIL)
PHENOTHIAZINES

30. pharmacotherapy
DISEASE SPECIFIC
VESTIBULAR
NEURONITIS
STEROIDS PREDNISOLONE
MENIERE’S DIURETICS
BETAHISTINE
CA.CH.BLOCKERS
Hydrochlorothiazide
FLUNARIZINE
CINNAREZINE
CHRONIC
VESTIBULOPATHY IN
ELDERLY
PIRACETAM(NOOTR
OPIL)

31. pharmacotherapy
ADJUNCTIVE
PSYCHIATRIC SSRI FLUOXETINE(PROZA
C
TRICYCLIC ANTIDEP. AMITRYPTILLINE
COMPLEMENTARY GINKGO

32. VESTIBULAR REHABILITATION

33. Shravn ent and laser hospital

34. SHRAVAN ENT HOSPITAL
 THANK YOU