neuro

1. MANAGEMENT
OF DIZZINESS
MELDI A. ANUTA, M.D., FPNA, FPCP
Davao Medical School Foundation
September 2021 - COVID 19 Pandemic

2. Commm, TINNITUS & VERTIGO
ANATOMY &
PHYSIOLOGY OF THE
VESTIBULAR SYSTEM

4. The n
THE AUDITORY & VESTIBULAR SYSTEM

7. THE INNER EAR

8. PERILYMPH - LOCATED
BETWEEN THE WALL OF
THE BONY &
MEMBRANOUS
LABYRINTH
ENDOLYMPH -
LOCATED WITHIN THE
MEMBRANOUS
LABYRINTH, WHICH
INCLUDES THE 3 SCC,
UTRICLE & SACCULE

9. SCALA VESTIBULI & SCALA TYMPANI -
PERILYMPHATIC SPACE IN THE COCHLEA IN
THE FORM OF 2 COILED TUBES

10. THE ORGAN OF CORTI

11. THE ORGAN OF CORTI
▪ END ORGAN OF HEARING (SOUND TO A.P.)
▪ SINGLE ROW OF INNER HAIR CELLS & 3 ROWS OF
OUTER HAIR CELLS (15,000 NEUROEPITHELIAL
CELLS)
▪ EACH HAIR CELL WITH ~60 STEREOCILIA
EMBEDDED IN THE TECTORIAL MEMBRANE

12. ORGAN OF CORTI
ORGAN OF CORTI
▪ SOUND —> BASILAR
MEMBRANE VIBRATES
—> STEREOCILIA BEND
—> HAIR CELLS
ACTIVATED —>
STIMULUS TO SENSORY
FIBERS OF THE
COCHLEAR NERVE

13. ▪ SEMICIRCULAR CANALS (SCC)
▪ UTRICLE
▪ SACCULE
CRISTA AMPULLA
VESTIBULAR APPARATUS

14. ▪ HHHHH
• CONTAIN THE SENSE ORGANS FOR THE
DETECTION OF ANGULAR & LINEAR
ACCELERATION
• FILLED WITH ENDOLYMPH & PERILYMPH
• SCC - EXCAVATED SPACES
OF THE TEMPORAL BONE
VESTIBULAR APPARATUS

15. CRISTA AMPULLA
VESTIBULAR DIVISION
▪ ARISES FROM CELLS IN THE
VESTIBULAR OR SCARPA
GANGLION
▪ BIPOLAR CELLS THAT
TERMINATE IN HAIR CELLS OF
THE SPECIALIZED SENSORY
EPITHELIUM
▪ SENSORY EPITHELIUM - IN THE
CRISTA AMPULLARIS & IN THE
MACULAE ACUSTICAE
(UTRICLE & SACCULE)

17. ▪ SPECIALIZED SENSORY EPITHELIUM OF A
SCC COVERED BY A SAIL-SHAPED
GELATINOUS MASS (CUPULA)
▪ SENSES DISPLACEMENT OF ENDOLYMPH
DURING HEAD ROTATION
CRISTA AMPULLA
CRISTA AMPULLA

18. ▪ LOCUS OF SENSORY EPITHELIUM IN THE
UTRICLE & SACCULE
▪ TIPS OF ITS HAIR CELLS IN CONTACT WITH
OTOLITHS, WHICH ARE EMBEDDED IN THE
CUPULA
▪ HAIR CELLS COVERED BY OTOLITHS
(CALCIUM CARBONATE CRYSTALS IN
GELATINOUS MATRIX)
MACULA
MACULA

19. MECHANISMS OF
AUDITORY & VESTIBULAR
FUNCTION

20. AUDITORY FUNCTION
SOUND WAVES
TRANSMITTED BY
THE T.M. & THE
OSSICLES TO THE
OVAL WINDOW
SOUND WAVES
SET UP IN THE
PERILYMPH OF
THE COCHLEA

21. AUDITORY FUNCTION
WAVES ACT ON
THE SPIRAL
ORGAN OF
CORTI
THE COCHLEA
CONVERTS SOUND
WAVES INTO A.P.’S
IN COCHLEAR
NEURONS
(COCHLEAR
DIVISION OF CN 8)

22. VESTIBULAR FUNCTION
ANGULAR
ACCELERATION
LINEAR
ACCELERATION
(INCLUDING
GRAVITY)

23. VESTIBULAR FUNCTION
ANGULAR ACCELERATION
DISPLACEMENT OF HAIR
CELLS IMBEDDED IN THE
CUPULA
ACTIVATION OF HAIR CELLS
TRANSMISSION OF
ACTION POTENTIALS
TO THE VESTIBULAR
DIVISION OF C.N. VIII

24. VESTIBULAR FUNCTION
LINEAR ACCELERATION (INCLUDING GRAVITY)
DISPLACEMENT OF
OTOLITHS WITHIN THE
UTRICLE OR SACCULE
DISTORTION OF
HAIR CELLS
INCREASE OR
DECREASE IN
FREQUENCY OF ACTION
POTENTIALS IN THE
VESTIBULAR DIVISION
OF C.N. VIII

25. LINEAR ACCELERATION
UTRICLE (HORIZONTAL)
SACCULE (UP & DOWN,
FORWARD & BACK)

26. The n
ANGULAR
ACCELERATION
A.P. TRANSMITTED TO VESTIBULAR DIVISION
LINEAR ACCELERATION
OTOLITHS
INCREASE OR DECREASE IN FREQUENCY OF A.P. TO VESTIBULAR DIVISION
THE VESTIBULAR SYSTEM

27. CENTRAL CONNECTIONS
COCHLEAR OR ACOUSTIC
AND VESTIBULAR
DIVISIONS TRAVEL
TOGETHER
FIRST-
ORDER
AUDITORY
NEURONS
RUN IN THE
COCHLEAR
DIVISION
OF C.N. VIII
INFORMATION FROM
THE SPIRAL ORGAN
OF CORTI RELAYED
TO THE DORSAL AND
VENTRAL COCHLEAR
NUCLEI

28. FIRST-ORDER VESTIBULAR
NEURONS IN THE
VESTIBULAR DIVISION OF
C.N. VIII RELAY
INFORMATION FROM THE
UTRICLE, SACCULE, &
SEMICIRCULAR CANALS TO
THE VESTIBULAR NUCLEI
(BIPOLAR CELL BODIES LIE IN
THE VESTIBULAR GANGLION)
THE VESTIBULAR REFLEX PATHWAYS
COCHLEAR OR
ACOUSTIC AND
VESTIBULAR
DIVISIONS TRAVEL
TOGETHER

29. CENTRAL CONNECTIONS
COCHLEAR OR ACOUSTIC AND VESTIBULAR
DIVISIONS TRAVEL TOGETHER
PETROUSBONE
INTERNAL AUDITORY MEATUS
SUBARACHNOID SPACE IN THE CP ANGLE
EACH ENTERS THE BRAINSTEM SEPARATELY
AT THE PONTOMEDULLARY JUNCTION

30. SECOND-ORDER NEURONS FROM THE COCHLEAR NUCLEUS
IPSILATERAL
INFERIOR
COLLICULUS
LATERAL LEMNISCUS
CONTRALATERAL
INFERIOR
COLLICULUS
LATERAL LEMNISCUS
DECUSSATE IN THE
TRAPEZOID BODY
THIRD-ORDER NEURONS FROM THE INFERIOR
COLLICULUS ON EACH SIDE
MEDIAL GENICULATE BODY ON BOTH SIDES
FOURTH-ORDER NEURONS PASS THROUGH THE
INTERNAL CAPSULE AND AUDITORY RADIATION
AUDITORY CORTEX

31. • DIRECTLY TO THE
CEREBELLUM
• VESTIBULAR NUCLEUS TO
IPSILATERAL
VESTIBULOSPINAL TRACT
(SECOND-ORDER NEURONS)
• MLF TO CN 3,4,6 NUCLEI
(SECOND-ORDER NEURONS)
• TO THE TEMPORAL LOBE
(SECOND-ORDER NEURONS)
• TO THE CEREBELLUM
(SECOND-ORDER NEURONS)
VESTIBULAR NERVE
PATHWAYS

33. DEAFNESS, TINNITUS &
VERTIGO
RESULT FROM DISORDERS AFFECTING
THE AUDITORY & VESTIBULAR
APPARATUS OR THEIR CENTRAL
CONNECTIONS TRANSMITTED
THROUGH C.N. VIII

34. DIZZINESS
• “VERTIGO”
• “LIGHT-HEADEDNESS”
• “FAINTNESS”
• “IMBALANCE”

35. LIGHT-HEADEDNESS
• PRESYNCOPAL SENSATIONS
RESULTING FROM BRAIN
HYPOPERFUSION

36. • PERIPHERAL
DISORDERS THAT
AFFECTS THE
LABYRINTHS OR
VESTIBULAR NERVES
• DISRUPTION OF
CENTRAL
VESTIBULAR
PATHWAYS
VESTIBULAR DIZZINESS

37. THE VESTIBULAR
REFLEX
PATHWAYS

38. PRESYNCOPAL DIZZINESS
BRAIN HYPOPERFUSION
• CARDIAC DYSRHYTHMIA
• ORTHOSTATIC HYPOTENSION
• MEDICATION EFFECT

39. VERTIGO
• “ENVIRONMENT IS MOVING.”
• MAY RESULT FROM DISEASE OF THE
• LABYRINTH
• VESTIBULAR NERVE
• CENTRAL CONNECTIONS

40. VERTIGO
• AN ILLUSION OF ROTATORY
MOVEMENT DUE TO DISTURBED
ORIENTATION OF THE BODY IN
SPACE
• PHYSIOLOGICAL OR
PATHOLOGICAL

41. CAUSES OF VERTIGO
• LABYRINTHINE
• VESTIBULAR
• CENTRAL

42. LABYRINTHINE
• TRAUMA
• INFECTION
• BENIGN POSITIONAL VERTIGO
• MENIERE’S DISEASE
• DRUG-INDUCED
• STREPTOMYCIN
• QUININE
• SALICYLATE

43. • TRANSIENT ATTACKS OF VERTIGO
• ASSOCIATED WITH CHANGE IN HEAD
POSITION
• PRECIPITATED BY A RECUMBENT HEAD
POSITION (RIGHT OR LEFT)
• SELF-LIMITING
BENIGN POSITIONAL
VERTIGO

44. BENIGN POSITIONAL
VERTIGO
DEBRIS IN THE PSCC
INTRALABYRINTHINE PARTICLE CALCIUM
CARBONATE) FROM THE UTRICLE
DUE TO FREE-FLOATING
PARTICULATE MATTER
WITHIN THE PSCC OF THE
VESTIBULAR LABYRINTH
-presumably the
movement of the debris
causes alterations in
endolymphatic pressure &
thus cupular deflection

46. MENIERE’S DISEASE
EPISODIC ATTACKS OF VERTIGO
OCCURING IN THE MIDDLE AGE, LATER
ACCOMPANIED BY UNILATERAL
DEAFNESS
ENDOLYMPHATIC HYDROPS
TRIAD : DEAFNESS, TINNITUS, VERTIGO

47. VESTIBULAR
• VESTIBULAR NEURONITIS
• CP ANGLE TUMORS
• ACOUSTIC NEURILEMMOMA
• MENINGIOMA
• EPIDERMOID / DERMOID

48. VESTIBULAR NEURINITIS
ACUTE, PROLONGED VERTIGO
PROBABLE VIRAL INFECTION
SUDDEN ONSET FOLLOWED BY
GRADUAL IMPROVEMENT WITH
TIME

49. • ISCHEMIC OR HEMORRHAGIC STROKE /
VERTEBROBASILAR INSUFFICIENCY
• DEMYELINATION
• TUMORS
• TRAUMA
• INFECTION
• NEURODEGENERATION
• SYRINGOBULBIA
CENTRAL CAUSES OF
VERTIGO

50. INFARCT, BRAINSTEM

51. INFARCT, CEREBELLUM

52. HEMORRHAGE, CEREBELLUM

53. DEMYELINATION, PONS

54. TUMOR, CEREBELLUM

55. SYRINGOBULBIA

56. CEREBELLAR DEGENERATION

57. • ATAXIA
• DROP ATTACKS / SEIZURES
• AUDITORY HALLUCINATIONS
SUGGEST CENTRAL LESION

58. SUGGEST BRAINSTEM LESION
• DIPLOPIA
• DYSARTHRIA
• DYSPHAGIA
• DEAFNESS
• DIZZINESS
• DECREASED FACIAL SENSATION
• DECREASED FACIAL MOVEMENT
PLUS
• HEMIPARESIS
• HYPERREFLEXIA
• HYPERTONIA / SPASTICITY
• PATHOLOGIC REFLEXES

59. PSYCHOGENIC VERTIGO

60. QUESTIONS
• “IS IT DANGEROUS?”
• “IS IT VESTIBULAR?”
• “PERIPHERAL? OR CENTRAL?”

61. APPROACH
• HISTORY
• PHYSICAL EXAMINATION

62. DECIDE IF
• PERIPHERAL?
• CENTRAL?
• SYSTEMIC?

63. HISTORY
• DELINEATE NATURE
• UNILATERAL OR BILATERAL
• ACUTE OR CHRONIC
• ACCOMPANYING SYMPTOMS

64. • BP EVALUATION
• EYE MOVEMENTS
• VESTIBULAR FUNCTION
• HEARING & EAR EXAMINATION
• TUNING FORK TESTS
• NYSTAGMUS
• HEAD IMPULSE TEST
• DIX-HALLPIKE MANEUVER
• DYNAMIC VISUAL ACUITY
PHYSICAL EXAMINATION

65. THE DIX-HALLPIKE TEST OF A PATIENT WITH BPPV AFECTING THE R EAR

66. TUNING FORK TESTS
TYPE OF
DEAFNESS
CONDUCTIVE SENSORINEURAL
RINNE’S TEST BC > AC AC > BC
WEBER’S TEST DEAF EAR GOOD EAR
SCHWABACH’S
TEST
NORMAL OR
PROLONGED
BC WORSE THAN
EXAMINER’S
WHAT IT MEANS EXTERNAL EAR
OBSTRUCTION
MIDDLE EAR
DISEASE
COCHLEAR LESION
(OTOSCLEROSIS,
MENIERE’S, DRUG,
NOISE)
AUDITORY NERVE
LESION
(MENINGITIS, CPA
TUMOR, TRAUMA)
PONTINE LESION

67. PERIPHERAL CENTRAL
DIRECTION OF
NYSTAGMUS
UNIDIRECTIONAL; FAST
PHASE AWAY FROM
LESION; MIXED
VERTICAL-TORSIONAL
BIDIRECTIONAL;
CHANGES DIRECTION
WITH GAZE; PURE
VERTICAL OR PURE
TORSIONAL
EFFECT OF VISUAL
FIXATION TO
NYSTAGMUS
INHIBITED NOT SUPPRESSED
HEAD IMPULSE SIGN PRESENT ABSENT
HEARING LOSS UNILATERAL USUALLY BILATERAL
BRAINSTEM OR
CEREBELLAR
FINDINGS
ABSENT PRESENT
FEATURES OF PERIPHERAL AND CENTRAL VERTIGO

68. VERTIGO
CENTRAL PERIPHERAL
NYSTAGMUS - often purely
horizontal, vertical, or torsional and
usually changes direction with
changes in the position of the gaze.
NYSTAGMUS - typically horizontal with
a torsional (rotational) component;
does not change direction with a
change in gaze
Associated neurologic signs such as
dysarthria, incoordination, numbness,
or weakness suggest a central origin.
HEAD-THRUST TEST -"catch-up"
saccades occur after head thrusts in one
direction but not after those in the other
direction, this indicates the presence of a
peripheral vestibular lesion on that side
Patients with vertigo of central
origin are often unable to stand
without support.
Patients with an acute peripheral
vestibular lesion typically can stand,
although they will veer toward the side
of the lesion

69. PERIPHERAL VS CENTRAL NYSTAGMUS
PERIPHERAL CENTRAL
VERTIGO & NAUSEA PRONOUNCED MILD
DIRECTION OF
NYSTAGMUS
MIXED TORSIONAL-VERTICAL
MIXED TORSIONAL-HORIZONTAL
MAYBE PURE HORIZONTAL
PURE HORIZONTAL
PURE VERTICAL
PURE TORSIONAL
INFLUENCE OF GAZE DOES NOT CHANGE DIRECTION
WITH GAZE
DIRECTION CHANGES WITH GAZE
VISUAL FIXATION INHIBITS NYSTAGMUS DOES NOT AFFECT NYSTAGMUS
LATENCY FOLLOWING
REPOSITIONING
MANEUVER
UP TO 20 SECONDS BRIEF
DIRECTION CHANGING
WITH REVERSAL OF HEAD
POSITION
PRESENT & CHARACTERISTIC ABSENT
HEARING LOSS / TINNITUS VARIABLY PRESENT ABSENT
SIGNS OF BRAINSTEM OR
CEREBELLAR DISEASE
ABSENT GENERALLY PRESENT

70. • AUDIOMETRY
• ELECTRONYSTAMOGRAPHY OR
VIDEONYSTAMOGRAPHY
• CALORIC TESTING
• NEUROIMAGING
ANCILLARY TESTS

71. TREATMENT OF VERTIGO
ANTIHISTAMINES
MECLIZINE 25 TO 50 MG TID
DIMENHYDRINATE (GRAVOL) 50 MG OD OR BID
PROMETHAZINE 25 TO 50 MG SUP OR IM
BENZODIAZEPINES
DIAZEPAM 2.5 MG OD TO TID
CLONAZEPAM 0.25 MG OD TO TID
PHENOTHIAZINES
PROCHLORPERAZINE 5 MG IM OR 25 MG SUP

72. TREATMENT OF VERTIGO
ANTICHOLINERGIC
SCOPOLAMINE TRANSDERMAL PATCH
SYMPATHOMIMETICS
EPHEDRINE 25 MG / DAY
COMBINATION
EPHEDRINE / PROMETHAZINE 25 MG / DAY EACH
EXERCISE THERAPY
REPOSITIONING MANEUVERS
VESTIBULAR REHABILITATION
OTHERS
DIURETICS OR LOW-SALT (1 G/DAY DIET)
ANTIMIGRAINOUS DRUGS
INNER EAR SURGERY
GLUCOCORTICOIDS

73. NONPHARMACOLOGIC
MANAGEMENT
VESTIBULAR EXERCISE PROGRAM
typically includes exercises
designed to improve ocular
stability and balance
IN BPPV – free floating particles
are moved from the PSCC to
another location within the
vestibular labyrinth

74. SURGERY IN BPPV
•AN OPTION FOR RARE PATIENTS WITH SEVERE,
INTRACTABLE SYMPTOMS THAT ARE UNRESPONSIVE TO
BEDSIDE TREATMENT MANEUVERS
•2 PROCEDURES TO DISABLE THE POST. SCC
•SINGULAR NEURECTOMY – CN 8 fibers that form a
synapse with the hair cells of the posterior semicircular
canal are severed
•POST. SCC OCCLUSION- goal is to interfere with the
physiologic mechanism by which head movement is
sensed by the posterior semicircular canal without
damaging the other structures of the labyrinth or the
cochlea
•BOTH PROCEDURES HAVE HIGH SUCCESS RATES

76. THANK YOU