This document discusses the evaluation of vertigo. It defines vertigo and classifies it according to duration. It describes the characteristics of peripheral vertigo such as associated hearing loss, episodic nature, and association with head movement. The document outlines tests used to investigate peripheral vertigo, including the caloric test and Fitzgerald-Hallpike test, and how to differentiate between peripheral vertigo and central vertigo based on features like nystagmus characteristics and neurological deficits.

1. Evaluation of
vertigo
Dr Krishna Koirala
2020-06- 22

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

8. Evaluation
•History
•Physical examination
•Investigations

9. History
• The most important clue to diagnosis
• Most important points
– Duration : seconds, minutes, hours
– Associated hearing loss
– Episodic/ continuous
– Association to head movement

10. Rotatory vertigo
Seconds Hours Days/weeks
Deafness
•Labyrinthine
fistula
No deafness
•BPPV
•Cervical Vertigo
•Vertebrobasilar
Insufficiency
Deafness
•Endolymphatic
hydrops
•Syphilis
•Meniere’s disease
No deafness
•Rec. vestibulopathy
•Decompensation
Deafness
•Labyrinthitis
No deafness
•Vestibular
neuronitis
•Head injury
•Infarction

11. Unsteadiness
Seconds Hours Days/weeks
• Visual
• Vestibular
•Proprioception
• Perilymph Fistula
•Drugs
•Functional
• Age Related
•Drugs
•Trauma
•Infarction
•Tumors
•Psychogenic

12. • Episodic
– Labyrinthine fistula
– BPPV
– Cervical vertigo
– Vertebrobasilar artery
insufficiency
– Endolymphatic hydrops
– Rec. Vestibulopathy
– Caloric stimulation
– Decompensation
• Non - episodic
– Labyrinthitis
– Vestibular neuronitis
– Central lesions
– Psychogenic

13. Peripheral vertigo
Duration of
episodes
Auditory Symptoms
Present
Auditory Symptoms
Absent
Seconds Perilymph Fistula BPPV
Hours Meniere’s syndrome
Syphilis
Recurrent
vestibulopathy
Vestibular migraine
Days Labyrinthitis
Labyrinthine concussion
Vestibular neuronitis
Months Vesti. Schwannoma
Ototoxicity
Head trauma,
Psychogenic

14. •Postural / movements
•BPPV
•Cervical vertigo
•Vertebrobasilar artery insufficiency
•Loud sound /straining
•SSCC dehiscence syndrome
•Perilymph fistula
•Hyperventilation
•Anxiety, panic disorder, multiple sclerosis

15. Examination
• Ear examination
– Tuning fork tests
– Vestibular function tests
• Ophthalmic examination
– Optokinetic movements
– Smooth pursuit movements
– Saccades
• Neurological examination including cerebellar
function tests

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

19. Associated
symptoms
Causes
Deafness + tinnitus
+ aural fullness
Meniere’s disease
Imbalance Vestibular neuronitis, Acoustic neuroma
Headache Migraine, Acoustic neuroma
Focal neurological
findings
Acoustic neuroma, Central vascular
causes
Ear discharge Labyrinthitis, 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

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

27. Procedure

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

29. • Calculating % Canal Paresis
CP% = ( RW + RC ) – ( LW + LC ) X 100
( RW+ RC + LW + LC )
> 20 % is significant
• Calculating % Directional Preponderance
DP% = (RW + LC) – (RC + LW) X 100
RW+ RC + LW + LC
> 25 % is significant