Vertigo is a common condition characterized by a sensation of rotation or spinning. Common causes include BPPV, vestibular neuritis, Meniere's disease, and acoustic neuromas. BPPV is the most common cause and involves detached inner ear crystals that move within the semicircular canals and stimulate cupulae. Diagnosis is made using the Dix-Hallpike maneuver which provokes nystagmus. Treatment involves repositioning procedures like the Epley maneuver to move the crystals back into the vestibule. Vestibular neuritis is an inflammation of the vestibular nerve and causes violent vertigo on head movement that improves with time. Acoustic neuromas present with unilateral

1. Vertigo
Definition:
A sensation of rotation in which the subject him/herself
feels rotating or the substances of his /her surrounding
seem to be rotating.
Size of the problem:
• Vertigo –common condition in adults
• 5-10 % of all patients in general practice
• 10-20% patients seen by otolaryngologists and
neurologists
• 33 % of people by 65 years of age

2. Vertigo
Causes of Vertigo/ Dizziness/Imbalance:
A. Systemic medical conditions
Endocrine-Hypoglycemia, adrenal failure
Cardiovascular-Vasovagal, embolism, dysrrrythmias
Hematological-Anemia, hyperviscosity
B. Neurological disorders
Cerebral--Multiple sclerosis, degeneration, drugs
Cerebellar-tumors, strokes, masses, bleeding
Psychological-Anxiety, phobias, panic attacks
C. Peripheral labyrinth

3. Vertigo
Causes of Peripheral Vertigo
• BPPV
• Meniere’s Disease
• Secondary endolymphatic hydrops
• Labyrinthitis
• Ototoxicity
• Vestibular neuritis
• Perilymph and labyrinthine fistula
• Trauma to inner ear
• Acoustic neuroma
• Vascular lesions of the inner ear
• Auto-immune inner ear disease
• Superior SCC dehiscence

4. BPPV
• The most common vestibular disorder
• Incidence about 64/100000 population
• Usually is self-limiting.
• Originally described by Barany in 1921
• Defined by Dix and Hallpike
B-Benign
P-Paroxysmal
P-Positional
V-Vertigo
Definition:
A disorder characterized by brief attacks of vertigo precipitated
by certain changes in head position with respect to gravity.

5. BPPV
Pathophysiology:
Detached otoconia of maculae get either attached to the
cupula or remain floating within the duct of a semicircular
canal
Canalolithiasis refers to mobile calcium carbonate debris
that moves within the canal during certain head
movements resulting in stimulation of the cupula, which in
turn causes vertigo and nystagmus. This mechanism is the
most common
Cupulolithiasis occurs when the calcium carbonate
material becomes attached to the cupula itself, rendering
it sensitive to gravity.

6. BPPV
Pathophysiology contd…
Posterior----majority
Lateral----some cases
Superior-----rare

7. BPPV
Etiology:
Idiopathic- majority happen without apparent cause
Secondary (predisposing factors)
Head trauma
Vestibular neuritis
Degenerative disorders
Infarction and inflammation of the labyrinth
Surgical assault to the labyrinth
Prolonged bed rest

8. BPPV
Clinical features
Age: all ages most elderly, Sex: Female more
Vertigo
May be intense, with nausea & vomiting, sudden
Brief 10 -20 seconds but < 60
Frequent at times - patients constantly dizzy
Typical movements of every day that trigger ;
• rolling over in bed, getting up and out of bed
• getting up abruptly, abrupt head movements
• bending over as in tying shoe laces
• craning head to take something of high shelf
No cochlear symptoms, No hearing loss
Normal caloric tests

9. BPPV
Clinical features contd…
Positional test---(Dix-Hallpike maneuver)- characteristic

10. BPPV
Clinical features contd…
Positional test---(Dix-Hallpike)- characteristic
• Nystagmus –direction according to canal affected
• Latency- of several seconds (7-8 seconds)-several
seconds are necessary for the hydrodynamic drag of
the particles to begin to pull on the affected cupula.
• Duration 5-10 seconds but < 30 seconds
• Intense- in severity at times
• Reversal of nystagmus after return to upright position
• Fatigable

11. BPPV
Treatment
A. Reassurance-Benign nature, prognosis, recurrence
B. CRP-Canalolilith repositioning procedures
Procedures vary depending upon the canal affected by BPPV
I. Epley canalolith repositioning procedure
II. Semont liberatory maneuver
III. Brandt-Daroff exercises.
C. Singular neurectomy -transection of the nerve carrying
signals from the ampulla of the posterior semicircular canal.
D. Occlusion/Laser ablation of the posterior semicircular canal
E. Labyrynthine sedatives-symptomatic

12. BPPV
Epley canalolilith/ particle repositioning procedure
The most commonly used for posterior canal BPPV
• Seated position with the head turned toward the
affected ear
• The otoconial particles have settled into the lowest
portion of the posterior SCC duct

13. BPPV
Epley canalolilith/ particle repositioning procedure
Rapidly lower the patient to Dix-Hallpike position (reclined
30 degrees beyond the level of the table)
• The otoconial particles move and come to rest at
midpoint of duct
• Leave the patient in this position for 40 seconds after
the nystagmus subsides

14. BPPV
Epley canalolilith/ particle repositioning procedure
Slowly roll the patient to the opposite side
pausing briefly every 45 degrees until the affected
ear is up
• The otoconial particles are entering into the crus
communis

15. BPPV
Epley canalolilith/ particle repositioning procedure
Slowly roll the patient onto the right shoulder
• The otoconial particles are falling via the crus
communis into the vestibule

16. BPPV
Epley canalolilith/ particle repositioning procedure
Turn the head another 90° and the procedure is
completed by sitting the patient upright
• The otoconial particles are repositioned back into
the vestibule

17. BPPV
Epley canalolilith/ particle repositioning procedure
Contraindications of Epley procedure:
Severe neck disease Severe carotid stenosis
Post-procedure instructions:
• Wait 10 minutes before allowing the patient to go
home
• Do not let the patient drive home if possible
• Not to let patient sleep with affected ear down
• For one week avoid positions which would usually
provoke the vertigo
• Not to lift heavy objects for about a week

18. Vestibular neuritis
(Epidemic vertigo)
Definition:
Self limiting inflammation of the vestibular
part of the vestibule-cochlear nerve
Etiology:
– Unknown but neurotropic viruses
– Herpes simplex virus is thought to exist in
latent form in human vestibular ganglia.

19. Vestibular neuritis
Clinical features:
– H/O preceding sore throat and other acute URTI
– Both sexes are equally affected
– Between the ages of 30 and 50
– Vertigo
• Violent, rotatory with nausea and vomiting
• Aggravated by head movement
• Less by keeping the head still and eyes shut.
• Lasting several days
• Recovery can take months

20. Vestibular neuritis
Clinical features contd….
• Nystagmus is typically unidirectional with
the quick phases beating towards the
unaffected side.
• Typical absence of auditory symptoms
• Absence of other neurological symptoms
and signs.
• Unilateral reduced or absent caloric
response

21. Vestibular neuritis
Treatment:
Symptomatic by labyrinthine sedatives
Prochlorperazine---5 mg TDS
Cinnarazine----25 mg TDS
Promethazine----25 mg TDS
• Early mobilization and vestibular rehabilitation
exercises facilitate compensation

22. Acoustic Neuroma
(Vestibular Schwannoma)
• Commonest CPA angle tumour- about 78 %
• Accounts -8-10 % of all intracranial tumour
• Benign non-capsulated tumour arising from
schwann cells at glial –neurilemmal junction in
IAM
• 60-80 % of which arise from the superior
vestibular nerve

23. Acoustic Neuroma
(Vestibular Schwannoma)
Clinical features:
• Slow growing –no vertigo usually
• Unilateral SNHL, sometimes sudden and / or
tinnitus
• Trigeminal nerve involvement - numbness of face
• Headache, ataxia and facial weakness -advanced
A patient presenting with an asymmetrical SNHL of
unknown origin should be considered to suffer from a VS
unless proved otherwise

24. Acoustic Neuroma
(Vestibular Schwannoma)
Investigations:
• High tone SNHL
• Poor speech discrimination test
• Tone decay test positive
• Tests of recruitment negative
• Canal paralysis but normal if from inferior
vestibular
• Abnormal ABR
• Gadolinium enhanced MRI diagnostic

25. Acoustic Neuroma
(Vestibular Schwannoma)
Treatment:
• Surgery – Various approaches
Translabyrinthine
Middle fossa
Retrosigmoid
• Streotactic radiotherapy ( Gamma Knife )
 in less than 3 cm
 single high dose of radiation with precise targeting

26. Perilymph and labyrinthine fistula
Perilymph fistula
Leak through round and oval window
Following
Severe nose blowing
Strenuous exercise
Barotrauma/ Surgical trauma
Labyrinthine fistula
Leak through an abnormal third window
Following
Chronic ear disease/surgery

27. Perilymph and labyrinthine fistula
Clinical Features
Brief episodes of vertigo with progressive SNHL
Sudden or fluctuating hearing loss at times
Tinnitus
Fistula sign positive-in minority of patients
Treatment
Removal of the cause
Conservative initially-bed rest, head elevation
Sealing of the leak

28. Vascular lesions of the inner ear
• Arterial occlusion
• Venous occlusion
• Vascular loops
Selective or combined cochlear or vestibular
symptoms