This document presents the case of a 46-year-old woman who experiences episodes of dizziness and vertigo. After examining the patient, the presenting doctor determines that she likely has benign paroxysmal positional vertigo (BPPV). BPPV is caused by debris in the inner ear that causes symptoms when the head is moved. The doctor confirms the diagnosis with tests like the Dix-Hallpike maneuver. Treatment options include exercises like the Epley maneuver to reposition the debris, as well as medications.
Please find the power point on Benign Paroxysmal Positional Vertigo (BPPV). I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
A detailed description of benign paroxysmal positional vertigo (BPPV): the symptoms, causes, diagnosis, and treatment methods.For more information, please visit www.everydayhearing.com
Please find the power point on Benign Paroxysmal Positional Vertigo (BPPV). I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
A detailed description of benign paroxysmal positional vertigo (BPPV): the symptoms, causes, diagnosis, and treatment methods.For more information, please visit www.everydayhearing.com
Intra Partum Cardiotocography - dr vivek patkardrvivekpatkar
Cardiotocography ( CTG )
is a procedure of graphically ( graph) recording fetal heart activity and uterine contractions ( Toco ) – both recorded in the same time scale simultaneously and continuously through uterine quiscience and contractions
Undergraduate course lectuers in Obstetrics&Gynecology
Prepared by DR Manal Behery
Assistant Professor in OB&GYNE ,Faculty of medicine,Zagazig University
Prof. Mridul Panditrao's Peri-operative Management of Jehovah's Witness Patient Prof. Mridul Panditrao
A case report of Emergency Peri-operative Mnagement of a Jehovah's Witness patient.
Because of their peculear religious belief, these patients do not accept Blood and It's products. This can pose serious problems to the Anesthesiologist.
Lecture on SexEd for Grade 7 female students
Instead of the usually awkward sex ed lecture, I included self-care in all aspects of health: physical, mental, emotional, social, and spiritual.
List of vaccines available in the market
This list includes trade name, manufacturer, common abbreviation, type and route of administration, and primary and booster doses for pediatric population. It also includes link to the vaccines' product information.
This is helpful especially for starting pediatricians
Presentation on Prevention and Management of Infants With Suspected or Proven Neonatal Sepsis
References:
American Academy of Pediatrics. Prevention and Management of Infants With Suspected or Proven Neonatal Sepsis, 2013.
American Academy of Pediatrics. Management of Neonates With Suspected or Proven Early-Onset Bacterial Sepsis, 2012.
This is Cristal Laquindanum’s 20 yr marketing plan, project submitted to her Marketing subject. She is currently a Year Level 8 (clinical clerk) in Ateneo School of Medicine and Public Health taking up double degree in Medicine and Masters in Business Administration.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
3. History of Present Illness CONSULT “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
4. Review of Systems No weight loss No cough and cold No rashes No changes in hair/nails No changes in color No nosebleeds No hemoptysis No chest pain No syncope No changes in bowel habits No history of trauma
5. Past Medical History Asthma, last attack years ago. No maintenance medications Hypertensionfor 5 years, on Metoprolol (Betaloc) 50 mg twice a day (Usual BP 130/80; Highest BP 160/90) UTI, took Cefuroxime No history of trauma to the skull or cervical spine No history of neurologic diseases
6. Family History No history of asthma, hypertension, diabetes, allergies, neurologic disorders
7. Personal Social History College graduate Works as a secretary Non smoker Non alcoholic beverage drinker Does not use illicit drugs
8. Physical Examination Awake, ambulatory but slow walking, not in cardiorespiratory distress BP: 130/70 HR: 74 RR: 19 Temp: 36.1 “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
9. HEENNT Anictericsclerae Pink conjunctivae No ptosis Pupils 3mm equal brisk reactive to light Intact tympanic membrane Midline septum, no nasal congestion No CLAD Neck veins not dilated Moist lips, moist buccalmucosa Nonhyperemic posterior pharyngeal wall No TPC
10. Chest/Lungs Symmetrical chest expansion Resonant on percussion Equal tactile and vocal fremiti No retractions No rales No wheezes “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
11. Heart Adynamicprecordium No heaves or thrills Apex beat is at 5th ICS MCL Normal rate, regular rhythm No murmurs “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
12. Abdomen Flat, soft abdomen No tenderness No organomegaly No masses Normoactive bowel sounds “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
13. Extremities Full pulses No edema, no cyanosis Good turgor No rashes, no lesions Equally distributed hair No clubbing CRT <2sec “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
14. Neuro Awake, coherent, cooperative Motor: 5/5 on all extremities Sensory: 100% on all extremities Gait: normal, slow No meningeal signs GCS 15 Cranial Nerves: intact (-) Romberg’s Test Can do Finger-to-nose-test Can do rapid alternating pronation-supination test (+) Nystagmus, fatigable “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
17. Initial Impression Benign Paroxysmal Positional Vertigo “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
18. Approach to Dizziness Dizziness and other sensations of imbalance are, along with headache, back pain, and fatigue, the most frequent complaints among medical outpatients “Dizziness” a feeling of rotation or whirling as well as non-rotatory swaying, weakness, faintness, light-headedness, or unsteadiness.
19. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
20. “The room is spinning” “I might faint” “I’m light-headed” “I might fall” “I’m just dizzy” “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
21. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
22. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
23. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
24. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
25. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
26. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
27. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
28. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
29. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
30. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
31. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
32. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
33. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum Clinical Characteristics of BPPV acute onset of vertigo and nystagmus induced by provocative positioning of the head with the affected ear down, brief latent onset period(1-30seconds), limited duration (15-30 seconds), characteristic rotary nystgamus in head hanging position, Reversal of nystagmus on upright siting position of shorter duration, and Fatigability of the response to the Dix-Hallpike (Barany- Nylan) manoeuvre with repeated positioning.
40. Anatomy The otholiths and the gelatinous otholitic membrane together form a mass of greater density than the endolymph. It is responsive to gravity, therefore, and transmits this motion to the cilia of the sensory cells.
41. Etiology Cupulolithiasis bits of calcium break off from the otolithic apparatus in the ear floating in the endolymph which can put pressure on the end organ, initiating an impulse from that ear Alter the specific gravity of the cupula making it sensitive to gravitational changes Posterior vertical semicircular duct
42. Etiology Canalithiasis Otoconia are dislodged from their usual position within the utricle, migrate over time into one of the semicircular canals When there’s head movement, the gravity-dependent movement of the “ear rocks” or otoconial debris causes pathological fluid endolymph displacement and a resultant sensation of vertigo.
43. Diagnostics Clinical diagnosis is dependent on an accurate history and a functional evaluation which includes the demonstration of a paroxysmal positioning nystagmus (observed best under Frenzel's glasses or electronystagmography (ENG)), accompanied by vertigo of short duration occuring after a brief latent period(1-5seconds),with the Dix-Hallpikemaneuver.
45. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
46. “MARY, GO ROUND” ENT-HNS Case Presentation By Cristal Ann Laquindanum
47. Treatment Initial treatment: therapeutic exercises – brisk positioning maneuvers or a defined sequence of head position designed to displace and reposition the canaliths. Epley Semont Brandt-Daroff
52. Treatment Pharmacotherapeutics The Phenothiazines: Promethazine Promethazine is the only phenothiazine that works against the nausea associated with vestibular imbalance and vertigo. Anticholinergic; can be given together with the antihistamines or the antiserotonin drugs BeladonnaAlkaloids Scopolamine – severe recurrent vertigo
53. Treatment Surgery Remains an option for the rare patient with disabling persistent disease Singular neurectomy to treat refractory BPPV was proposed by Gacek Generally effective, but technically difficult and the risk of hearing loss from the procedure may be as high as 41%
54. “Mary, Go Round” “Mary, Go Round” ENT-HNS Case Presentation By: Cristal Ann Laquindanum ASMPH Intern
Editor's Notes
Patient was watching TV lying down then suddenly felt dizzy when she sat up. Dizziness described as rotatory and feeling of loss of balance, lasted for about a minute and exacerbated by head movements. Patient decided to sleep it off but when she woke up she still had the same symptoms. Patient also complains of nausea but denies symptoms of hearing loss, tinnitus, loss of consciousness, headache, visual complaints, or diplopia. Patient did not take any medications nor sought consult. Persistence of symptoms prompted consult to this institution. Acute frequent rotatory vertigo exacerbated by head movementsNo hearing lossNo tinnitusNauseaNo traumaHypertensive, controlled; on Betablockers
"I feel as if I might faint," or "I feel giddy or light-headed." Some patients do faint or report that they have done so; others have never actually fainted (near-syncope). Pathophysiologically, both syndromes suggest several cardiovascular disorders that produce a generalized decrease in cerebral blood flow; there is no qualitative difference between syncope and near-syncope with respect to the differential diagnosis.Circulatory syndromes that should be considered in the differential include orthostatic hypotension, which may have a number of causes, most of them iatrogenic (e.g., antihypertensive agents and/or vasodilators). Cardiac arrhythmias are a very frequent cause of syncope and near-syncope. If the history suggests arrhythmic episodes, Holter monitoring may be required. Hypersensitive carotid sinus is relatively uncommon. Vasovagal attacks are otherwise known as the simple faint or the simple swoon. Neurocardiogenic syncope is probably due to over activity of the baroreceptor reflex such that brief periods of hypotension result in disproportionate bradycardia and hypotension resulting in decreased cerebral blood flow and consequent loss of consciousness.
"I feel as if I might fall.” This version of dizziness generally reflects one of two major categories of neurologic disease, apart from disorders of the vestibular system.146Cerebellar ataxia is due either to a primary disease of the cerebellum, e.g., cerebellum degeneration, or to a tumor in or near the cerebellum, e.g., in the cerebellopontine angle. Neurologic examination will ordinarily reveal such pathology.The multiple sensory deficits syndrome, reflects multiple abnormalities in the various sensory proprioceptive systems. When several of these systems fail in a given individual, the central nervous system receives conflicting proprioceptive input, with consequent dizziness. The typical patient is rather elderly, perhaps with some visual disorder due to cataracts, some auditory disorder due to presbyacusis, and peripheral neuropathy due to diabetes and/or chronic use of alcohol. Such a patient typically complains of dizziness at night, for instance, when the lights are out or dim and he or she has to go to the bathroom. On occasion, the patient may fall.The treatment of this extremely common syndrome is common sense: As many of the sensory abnormalities as can be corrected, should be. Cataracts and hearing disorders can be treated, and the progression of peripheral neuropathy can be prevented by abstinence from alcohol. You might also advise your patient to keep the lights on at night, which would help the visual system compensate for other sensory abnormalities. Such patients should not be treated with drugs that might sedate them, as antivertigo medications would do. Mistaking this syndrome for vertigo would, in fact, make matters worse.
There are patients who when asked, "What do you mean, dizzy?" respond, usually after a pause, "Dizzy." If the physician persists with "Do you mean you might faint?" or "Do you mean that you might fall?" or "Do you mean that the room spins?" the patient repeats, "No, I mean I'm dizzy." This disorder can only be called true dizziness, and it generally arises from various psychological disorders, most commonly anxiety (with or without hyperventilation) and/or depression.Affective disorders can often be recognized because of the effect that the patient has on the examiner. If you feel depressed or anxious yourself after spending time with a patient, it may well be because the patient is depressed or anxious. It is extremely important to recognize instances when dizziness represents a metaphor for depression, because treatment for vertigo is likely to exacerbate depression, whereas treatment for depression might dramatically relieve the dizziness.
The fourth and last category of disorder found in patients who complain of dizziness is true vertigo, or illusion of motion. Some patients insist that they themselves are moving, others- such as the one presented at the beginning of this chapter-that the environment is moving. In either case the patient says, "I feel as if I am tilting, rocking, or moving in some other way," or "I feel as if the room is spinning.”Vertigo indicates a disturbance in the vestibular system, which is responsible for keeping the central nervous system informed of the head's position in space, its relation to the pull ofgravity, and its acceleration in various planes.
The question is whether the vertigo is due to a disorder in the peripheral nervous system (the end organ or the peripheral nerve) or in the central nervous system (the brainstem or its projections to parts of the cerebral cortex, particularly the temporal lobe). Each lesion has its own differential diagnosis and treatment.
Vertigo of central origin results from lesions of the central vestibular apparatus (including the brainstem vestibular nuclei and their central connections).Of the central causes, vertebrobasilar insufficiency closely ressembles BPPV.Vertigo of peripheral origin includes conditions affecting the peripheral vestibular apparatus (including the internal ear labyrinth and the vestibular portion of the acoustic nerve)or the proprioceptive sense organs of the cervical spine.Peripheral Rapid-phase nystagmus away from lesionSlow-phase nystagmus toward lesionEnvironment spinning away from lesionRomberg’s sign toward lesion
Peripheral Rapid-phase nystagmus away from lesionSlow-phase nystagmus toward lesionEnvironment spinning away from lesionRomberg’s sign toward lesion
Vestibular neuronitis, or acute vestibulopathy, is thought to be pathogenetically identical to labyrinthitis but without any hearing symptomatology. If the patient has vertigo unaccompanied by a hearing abnormality, it is strictly speaking impossible to be sure whether the disease is cochlear or retrocochlear. However, its natural history is also benign, and it clears up completely in three to six weeks, which makes a retrocochlear illness very unlikely.Ménière’s disease is caused by a cryptogenic hydrops of the endolymph such that there is intermittent swelling of the semicircular ducts, with damage to the hair cells. An attack of Ménièr’s syndrome is classically characterized by a dull ache in the region of the mastoid process or around the ear associated with severe tinnitus, a cochlear kind of sensory neural hearing loss, and a classic peripheral type of vestibular syndrome with severe spinning vertigo. It is identical in almost every respect with an acute attack of labyrinthitis. However, it does not clear up completely in three to six weeks, and patients are left with residual hearing loss. Several months or years later a similar attack may occur, leaving the patient with even more severe hearing loss. Tinnitus, a nonspecific sign of auditory system disorder, is a major problem for these patients, who can be terribly disabled for weeks at a time by the vertigo that accompanies acute attacks.
Ménière’s disease is caused by a cryptogenic hydrops of the endolymph such that there is intermittent swelling of the semicircular ducts, with damage to the hair cells. An attack of Ménièr’s syndrome is classically characterized by a dull ache in the region of the mastoid process or around the ear associated with severe tinnitus, a cochlear kind of sensory neural hearing loss, and a classic peripheral type of vestibular syndrome with severe spinning vertigo. It is identical in almost every respect with an acute attack of labyrinthitis. However, it does not clear up completely in three to six weeks, and patients are left with residual hearing loss. Several months or years later a similar attack may occur, leaving the patient with even more severe hearing loss. Tinnitus, a nonspecific sign of auditory system disorder, is a major problem for these patients, who can be terribly disabled for weeks at a time by the vertigo that accompanies acute attacks.
is thought to be a result of viral infection of the endolymph and perilymphaffecting both the vestibular and cochlear components of the system. The usual history is viral illness followed by acute onset of severe spinning vertigo and sensory neural deafness with tinnitus. Despite its severe onset, labyrinthitis is a benign illness, which resolves completely in three to six weeks. Patients regain normal hearing and vestibular function.Vestibular neuronitis, or acute vestibulopathy, is thought to be pathogenetically identical to labyrinthitis but without any hearing symptomatology. If the patient has vertigo unaccompanied by a hearing abnormality, it is strictly speaking impossible to be sure whether the disease is cochlear or retrocochlear. However, its natural history is also benign, and it clears up completely in three to six weeks, which makes a retrocochlear illness very unlikely.
The specific clinical characteristics of BPPV include:1)acute onset of vertigo and nystagmus induced by provocative positioning of the head with the affected ear down,2)Vertigo and nystagmus having a brief latent onset period(1-30seconds),3)Vertigo and nystagmus of limited duration (15-30 seconds),4) characteristic rotary nystgamus in head hanging position,5)Reversal of nystagmus on upright siting position of shorter duration, and6) Fatiguability of the response to the Dix-Hallpike (Barany- Nylan) manoeuvre with repeated positioning.
The specific clinical characteristics of BPPV include:1)acute onset of vertigo and nystagmus induced by provocative positioning of the head with the affected ear down,2)Vertigo and nystagmus having a brief latent onset period(1-30seconds),3)Vertigo and nystagmus of limited duration (15-30 seconds),4) characteristic rotary nystgamus in head hanging position,5)Reversal of nystagmus on upright siting position of shorter duration, and6) Fatiguability of the response to the Dix-Hallpike (Barany- Nylan) manoeuvre with repeated positioning.
Each inner ear contains 3 SCCs oriented in 3 perpendicular planes;
The post SCC is directed along the axis of the petrous bone (app 45 to the sagittal and coronal plane) and is roughly vertical. The lateral (horizaontal SCC is tilted approximately 30 upward from the horizontal plane at its anterior end when the head is inanorma upright pisition. When caloric testing is done in the supine position, the head is elevated by about 30 so that the lateral canal lies vertically.
Each SCC has a dilation at its utricular end called the ampulla
The ampulla contains the sensory cell system of the associated SCC, consiting of crista and cupula (a sail-like tower, the cupula, that detects the flow of fluid within the SCC). Due to inertial lag of the endolymph, angular acceleration of the head causes a deflection of the cupula that displaces the sensory cilia within it. The cupular motion is a bowing rather than a swinging door type of movement and it is this delection that stimulates the vestibular sensory cells
A rotational stimulus is amplified in the vestibular nuclei by a “push-pull mechanism” resulting from the mirror-image arrangement of the right and left semicircular canal systems. The inhibition of neural discharges in the semicircular canals on one side (“push”) is accompanied by an increase discharge rate on the opposite side (“pull”) (Probst, 2006The vestibular system is active even when you’re not moving. Signals are sent all the time. There is therefore a resting firing rate.There is no such thing as a positive or negative firing rate but you can make it go faster or slower than the resting rate.It is because of the fact that you have a resting firing rate and they’re both active at the same time which will cause vertigo when one has a problem. Because one is still active and the other is not it will make the eyes move in a certain direction
The vestibular apparatus contains two additional sensory regions called the static maculae. The hair-cell cilia in these regions are embedded in a gelatinous material called the otolithic membrane. This membrane is studded with otoliths, which are calcium carbonate crystals. The otolithic organs are sensitive to linear acceleration. These forces cause the relatively inert otolithic membrane to shift in relation to the layer of sensory cells. The otolithic apparatus senses the position of the head in space
CupulolithiasisTwo major theories have been proposed to explain benign vertigo. The theory of cupulolithiasis maintains that bits of calcium break off from the otolithic apparatus in the ear, perhaps as a consequence of aging or minor head trauma. If these bits of calcium are floating in the endolymph, they can, in certain positions, put pressure on the end organ, which initiates an impulse arising from that ear. Since the calcium tends to fall into the most dependent of the three semicircular ducts, the cupulolithiasis tends to affect the posterior vertical semicircular duct resulting in rotatory nystagmus maximum when the affected ear is down.
Within thelabyrinth of the inner ear lie collections of calcium crystals known as otoconia. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position). When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris (colloquially "ear rocks") within the affected semicircular canal causes abnormal (pathological) fluid endolymph displacement and a resultant sensation of vertigo. This more common condition is known as canalithiasis.
(observed best under Frenzel's glasses or electronystagmography (ENG))
Dix-HallpikePlacing patient’s head over the end of the table typically evokes a rotary nystagmus to one side after a latnent period of about 10 sec. The nystagmus increases for about 30 sec, then diminishes (crescendo-decrescendo nystagmus). When the patient is brought back to an upright position, a smiliarnystagmus occurs in the opposite direction. This positional nystagmus is fatigable and disappears after several repetitions of the maneuver
Dix-Hallpike maneuver to elicit benign positional vertigo (originating in the right ear). The maneuver begins with the patient seated and the headturnedtoonesideat45degrees(A),whichalignstherightposteriorsemicircularcanalwiththesagittalplaneofthehead.Thepatientisthenhelped toreclinerapidlysothattheheadhangsovertheedgeofthetable
Still turned 45 degrees from themidline. Within several seconds, this elicits vertigo and nystagmus that is right beating with a rotary (counterclockwisecomponent. An important feature of this type of “peripheral” vertigo is a change in the direction of nystagmus when the patient sits up again with his head still rotated. If no nystagmus is elicited, the maneuver is repeated after a pause of 30 s, with the head turned to the left
A home exercise program (Brandt-Daroff exercises, see Patient information sheet later on) will often provide relief after several days but it must be emphasised to patients that the symptoms will need to be provoked during these exercises for subsequent improvement to occur. These exercises probably work by flushing out the otoconial deposits, which are either reabsorbed or displaced to other parts of the labyrinth.Alternatively, single treatment manoeuvres (Epley and Semont) can be used and have similar success rates. These techniques take some practice to master. The interested reader is referred to a discussion and step by step instruction of these techniques. These manoeuvres and the Brandt-Daroff exercises are curative in more than 90% of cases. Surgery is rarely required.
The patient begins in an upright sitting posture, with the legs fully extended and the head turned 45 degrees towards the affected side.The patient then quickly lies down backwards with the head held approximately in a 30 degree neck extension (Dix-Hallpike position) where the affected ear faces the ground.Remain in this position for approximately 30 seconds.The head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground, all while maintaining the 30 degree neck extension.Remain in this position for approximately 30 seconds.Keeping the head and neck in a fixed position, the individual rolls onto their shoulder, in the direction that they are facing.Remain in this position for approximately 30 seconds.Finally, the individual is slowly brought up to an upright sitting posture, while maintaining the 45 degree rotation of the head.Hold sitting position for up to 30 seconds.
Brandt-Daroff ExercisesStep 1. Sit on edge of bed, turn head slightly to left side (approximately 45 degrees).Step 2. Lie down quickly on right side (so that the back of the head rather than the front is resting on the bed). Wait for 20-30 seconds or for any dizziness to resolve.Step 3. Sit up straight, again waiting for 20-30 seconds or for any dizziness to resolve. Step 4. Turn head slightly to right side and repeat sequence in opposite direction. Continue as above for 10 minutes (five or more repetitions to each side).
Antiserotonin- And Antihistamine-TypeThere are three categories of drugs for treating true vertigo. Antiserotonin- and antihistamine-type drugs include dimenhydrinate, diphenhydramine, meclizine, and cyclizine. All of these drugs are effective if the dosage is adequate—about 50 mg every six hours (see Table 2). They produce major sedation as their side effect, but this is usually of no concern: Patients who have been dizzy and vomiting for hours tend to be more than happy to go to sleep.The Phenothiazines: PromethazinePromethazine is the only phenothiazine that works against the nausea associated with vestibular imbalance and vertigo. Other phenothiazines, useful for chemical nausea, are of no help whatsoever in this setting. Promethazine may be effective primarily because it is an anticholinergic, not because it is a phenothiazine; it is useful also because it can be given together with the antihistamines or the antiserotonin drugs. A combination of promethazine and antihistamine is particularly effective for acute vertigo.BeladonnaAlkaloidsA belladonna alkaloid, usually scopolamine, is used only for severe recurrent vertigo (e.g., in difficult cases of Ménière's disease) because it is a dangerous drug with many cardiovascular and psychiatric side effects. Transdermally absorbed scopolamine, although helpful for motion sickness, is of inadequate dosage for use in treating an acute vestibular syndrome.
Antiserotonin- And Antihistamine-TypeThere are three categories of drugs for treating true vertigo. Antiserotonin- and antihistamine-type drugs include dimenhydrinate, diphenhydramine, meclizine, and cyclizine. All of these drugs are effective if the dosage is adequate—about 50 mg every six hours (see Table 2). They produce major sedation as their side effect, but this is usually of no concern: Patients who have been dizzy and vomiting for hours tend to be more than happy to go to sleep.Cinnarizine – antihistamineBetahistine - phenethylamine and histamine.The Phenothiazines: PromethazinePromethazine is the only phenothiazine that works against the nausea associated with vestibular imbalance and vertigo. Other phenothiazines, useful for chemical nausea, are of no help whatsoever in this setting. Promethazine may be effective primarily because it is an anticholinergic, not because it is a phenothiazine; it is useful also because it can be given together with the antihistamines or the antiserotonin drugs. A combination of promethazine and antihistamine is particularly effective for acute vertigo.BeladonnaAlkaloidsA belladonna alkaloid, usually scopolamine, is used only for severe recurrent vertigo (e.g., in difficult cases of Ménière's disease) because it is a dangerous drug with many cardiovascular and psychiatric side effects. Transdermally absorbed scopolamine, although helpful for motion sickness, is of inadequate dosage for use in treating an acute vestibular syndrome.
Antiserotonin- And Antihistamine-TypeThere are three categories of drugs for treating true vertigo. Antiserotonin- and antihistamine-type drugs include dimenhydrinate, diphenhydramine, meclizine, and cyclizine. All of these drugs are effective if the dosage is adequate—about 50 mg every six hours (see Table 2). They produce major sedation as their side effect, but this is usually of no concern: Patients who have been dizzy and vomiting for hours tend to be more than happy to go to sleep.The Phenothiazines: PromethazinePromethazine is the only phenothiazine that works against the nausea associated with vestibular imbalance and vertigo. Other phenothiazines, useful for chemical nausea, are of no help whatsoever in this setting. Promethazine may be effective primarily because it is an anticholinergic, not because it is a phenothiazine; it is useful also because it can be given together with the antihistamines or the antiserotonin drugs. A combination of promethazine and antihistamine is particularly effective for acute vertigo.BeladonnaAlkaloidsA belladonna alkaloid, usually scopolamine, is used only for severe recurrent vertigo (e.g., in difficult cases of Ménière's disease) because it is a dangerous drug with many cardiovascular and psychiatric side effects. Transdermally absorbed scopolamine, although helpful for motion sickness, is of inadequate dosage for use in treating an acute vestibular syndrome.