HOW TO MANAGE PATIENTS WITH VERTIGO? Andradi S. Department of Neurology. University of Indonesia, Jakarta disampaikan dalam Simposium PIT IDI Kota Bogor

1. HOW TO MANAGE PATIENTS
WITH VERTIGO ?
Andradi S.
Department of Neurology.
University of Indonesia, Jakarta

2. OUTLINES
1. Vertigo vs Dizziness
2. Vertigo:
- Types
- Pathophysiology
- Causes
3. Approach to Patients with Vertigo
- Diagnosis
- Treatment

3. VERTIGO vs DIZZINESS
DIZZINESS : is a balance disorder.
VERTIGO : is one of the types of Dizziness

4. Body Balance is Controlled by 3 Sensory Systems:
Vestibular, Visual, Proprioceptive
VISUAL
(Eye)
VESTIBULAR
PROPRIOCEPTIVE
(Muscle, joint, skin)
(Labyrinth)
CENTRAL NERVOUS SYSTEM
(Coordination, integration)
Control of eye
movement
Postural control
by muscle
BALANCE
dysfunction
Imbalance /Dizziness
Goebel JA. Otolaryngol Clin North Am 2000;33:483–93.
Shepard NT, Solomon D. Otolaryngol Clin North Am 2000;33:455–69

5. BALANCE DISORDER / DIZZINESS
Four Types
Vestibular
Vertigo
Non-vestibular
Vertigo
Disequilibrium
Presyncope
Sensation:
“Spinning”
Sensation:
“Floating”
“Swaying”
“Rocking “
Sensation:
“Falling”
 Unstable
 Disappear when
sitting
Sensasi:
“Fainting”
Sistem:
Vestibular
Sistem:
Visual
Proprioseptive
Psychogenic
Sistem:
Spinal
• Peripheral nerve
Cerebellar
Sistem:
Cardiovascular

6. DIZZINESS : Frequency
40% Peripheral vestibular dysfunction
10% Central brainstem vestibular lesion
25% Presyncope or disequilibrium
15% Psychiatric disorder
10% Unknown cause
December 4, 2001, Swedish Family Medicine, Dobrina Okorn, MD

7. OUTLINES
1. Vertigo vs Dizziness
2. Vertigo:
- Types
- Causes
3. Approach to Management of Patients with Vertigo
- Diagnosis
- Treatment

8. VERTIGO
Vertigo is an ilusion of movement in which a subject feels
him-/herself or the surrounding object is moving.
Two types:
I. Vestibular Vertigo ( “spinning” vertigo / “true” vertigo)
Vestibular dysfunction
II. Vertigo Nonvestibular (“non-spinning” vertigo)
Visual dysfunction
Proprioceptive dysfunction

9. VERTIGO
VESTIBULAR vs NONVESTBIULAR
VESTIBULAR
(vestibular system)
NONVESTIBULAR
(visual & proprioceptive)
Sensation
Spinning, rotating
Swaying, floating, rocking
lightheaded
Duration
Episodic
Constant
Precipitating factor
Head or body movement
Stress, hiperventilation,
cardiac arrhythmia
Associated symptoms
Nausea, vomit, tinitus,
deafness, oscillopsia
Paleness, paresthesia,
syncope

10. VESTIBULAR VERTIGO
“True Vertigo”; “Spinning Vertigo”

12. Balance requires information of similar
intensity from both vestibular systems
Head movement
Activation of cells
in left
vestibular system
Activation of cells
in right vestibular
system
Central nuclei
10
10
Normally, the input from left and right vestibular
system is of similar intensity (e.g. of size ‘10’)

13. Peripheral vestibular vertigo
Dysfunction of vestibular apparatus, vestibular nerve
Central nuclei
5
10

14. Central Vestibular Vertigo
dysfunction in central processing
Central nuclei
10
10

15. Vestibular Vertigo
Two types
1. Peripheral Vertigo
Lesion site: - Inner ear (canalis semicircularis, sacculus, utriculus)
- N. vestibularis.
2. Vertigo Sentral
Lesi site: - Brainstem (nucleus vestibularis)
- Serebelum
- Talamus
- Korteks serebri

16. VESTIBULAR VERTIGO
PERIPHERAL vs CENTRAL
Symptom
Peripheral
Central
Vertigo episodes
Mild severe
Chronic and
unremitting
Symptom onset
Sudden
Gradual
Imbalance
Mild/mod.
Severe
Nausea, vomiting
Severe
Varying
Auditory symptoms
Common
Rare
Neurological symptoms
Rare
Common
Changes in mental status/
consciousness
Infrequent
Sometimes
Compensation/resolution
Rapid
Slow
Baloh RW. Otolaryngol Head Neck Surg 1998;119:55–9. Puri V, Jones E. J Ky Med Assoc 2001;99:316–21.

17. CAUSES OF VERTIGO
PERIPHERAL
– Canalithiasis (BPPV)
– Neuritis vestibularis
/labyrinthitis
– Meniere’s disease
– Trauma
– Ototoxic drugs
(aminoglycosides)
CENTRAL
50%
25%
10%
– Vascular (vertebrobasilar
stroke)
50%
– Demyelinating (multiple
sclerosis)
– Drugs
(anticonvulsant, alcohol,
hypnotic)

18. OUTLINES
1. Vertigo vs Dizziness
2. Vertigo:
- Types
- Causes
3. Approach to Management of Patients with Vertigo
- Diagnosis
- Treatment

19. Approach to Management of Patient with Vertigo
Patient complaint (pusing, mabuk)
Step 1
Verify : “VERTIGO” or NOT?
No
Yes
step 2
Identify : TYPE of VERTIGO
Step 3
Establish: DIAGNOSIS / ETIOLOGY
Step 4
Planning
THERAPY
Headache, stress,
other dizziness

20. STEP 1 and STEP 2
Verifying and Identifying Types of Dizziness
QUESTION :
“Apakah anda terasa mau pingsan ?” ( “Pingsan / fainting”)
• PRESYNCOPE
“Apakah anda merasa kedua tungkai tidak stabil, dan menjadi stabil kalau
duduk ?”
• DYSEQUILIBRIUM
(“ Jatuh / falling”)
“Apakah lingkungan anda kelihatannya berputar, atau anda sendiri terasa
berputar ?”
- VESTIBULAR VERTIGO”
(“ Berputar / spinning”)
“ Apakah merasa lingkungan bergoyang, atau anda sendiri terasa
bergoyang ?”
• VERTIGO NONVESTIBULAR
(“Melayang / light-headed”)
“Apakah anda merasa gugup atau cemas ?
• PSYCHOGENIC
(“ Melayang / light-headed”)

21. STEP 3
ESTABLISHING DIAGNOSIS AND ETIOLOGY OF
VERTIGO
1. History taking
2. Physical examination
a. General PhysicaL Examination
b. Routine Neurologic Examination
c. Bed-side Neuro-otologic examination
3. Investigations (as indicated)
- ENG, EEG, EMG, CTScan, MRI, MRA
- Laboratory

22. 1. HISTORY TAKING
Sensation
- Spinning, rocking, swaying, swimming, light-headed ?
Temporal profile
- Onset, duration, course.
Head/body position
- Occurs on lying, turning, rising, sitting up, standing, nodding,
bending, head turning
Associated symptoms
Tinnitus, deafness, cranial nerves
symptoms, hemiparesis, hemihipesthesia, hemiataxia.
Past history
- Head injury, stroke, cardiac and pulmonar disorders, CNS
infection, ENT diseases, psychiatric disorder.
Medication
Drugs that may give rise to dizziness, including
garamycin, sedative, tranquilizer.

23. 2. PHYSICAL EXAMINATIONS
a. General Physical Examinations
Searching for pathology related to current dizziness complaint:
- Hypertension, hypotension
- Cardiovascular disorder
- Pulmonary disease
- Malignancy

24. 2. PHYSICAL EXAMINATION
b. Routine Neurologic Examination
- Mental
- Cranial nerves
- Motor system
- Sensory system
- Autonomic system

25. 2. PHYSICAL EXAMINATION
c. Bedside Neurootologic Examination
I. Otologic examination
II. Hearing testing
III. Vestibular examination

26. I. Otologic Examination
• External ear
• Tympanic membrane

27. II. Hearing Testing
- Using tuning forks
- For differentiating conductive and sensorineural hearing loss
√ RINNE test
√ WEBER test

28. III. VESTIBULAR EXAMINATION
1. Eye Movement Test
2. Examination of Balance and Coordination

29. 1. EYE MOVEMENT TESTS
- Aim: to evaluate Vestibulo-ocular Reflex (VOR)
- Manifestation: Nystagmus
- Examinations:
- ● Spontaneous nystagmus
- ● Gazed-evoked nystagmus
- ● Head thrust test
- ● Head shaking test
- ● Dix Hallpike ( for BPPV)

31. 2. EXAMINATION OF BALANCE AND COORDINATION
A. Test for BALANCE
1. Seated : hold out arms and legs, eyes open/eyes closed
2. Stand: Romberg test, sharpened Romberg test
3. Gait :
broad-based gait
4. Tandem walking, past-pointing, Fukuda test, Babinski-Weil test.
B. Test for COORDINATION (cerebellum)
1. Upper extremity
a. Finger- to- nose
b. Finger-nose-finger
c. Adiadochokinesis
d. Rebound phenomen
2. Lower extremity
a. Heel-knee-shin
b. Repetitive heel tapping
c. Rebound phenomenon
3. Ocular dysmetria

32. THERAPY OF VERTIGO
I. Etiologic
Pharmacologic therapy
Surgery
II. Symptomatic
Pharmacologic therapy
III. Rehabilitative
Vestibular Rehabilitation Therapy (VRT)
IV. Prevention of aggravating factor
Diet control
Life-style modification
V. Physical Conditionng Exercise

33. I. ETIOLOGIC TREATMENT

34. TREATMENT OF THE CAUSES OF VERTIGO
CAUSE
Peripheral Cause
TREATMENT
BPPV
Canalith repositioning manoeuvre (Brandt-Daroff, Epley,
Semont
Labyrinthine concussion
Vestibular rehabilitation
Meniere’s disease
Low-salt diet, diuretic, surgery, transtympanic gentamicin
Labyrinthitis
Antibiotics, removal of infected tissue, vestibular rehabilitation
Perilymph fistula
Bed rest, avoidance of straining
Vestibular neuritis
Brief course of high-dose steroids, vestibular rehabilitation
CENTRAL CAUSE
Migraine
Beta-blockers, calcium channel blockers, tricyclic amines
Vascular disease
Control of vascular risk factors, e.g., antiplatelet agents
CPA tumours
Surgery
Baloh RW. Lancet 1998;352:1841–6. Goebel JA. Otolaryngol Clin North Am 2000;33:483–93.

35. II. SYMPTOMATIC TREATMENT

36. Symptomatic PharmacologicTreatment
I. ANTIVERTIGO
1.Vestibular Suppressant
a. Ca antagonist : Flunarizin
b. Vasodilator : Betahistine
c. Tranquilizer : diazepam, haloperidol, sulpiride, clonazepam
d. Antihistamine : Difenhidramine, meclizine.
2. CNS stimulant
Ephedrin, amphetamin
II. ANTIEMETIC
1. Anticholinergic : atropine, scopolamine
2. Antidopaminergic: : Prochlorperazine, metoclopramide.
3. Antihistamine: Difenhidramine
III. PSYCHOAFFECTIVE
Clonazepam, diazepam for anxiety and panic attack

37. How to Choose Antivertigo Drug ?

38. Vestibular Suppressant
Clinical evidence
Drugs with sedative effect may disturb central
compensation mechanism
Ideal Drug
√ Effective in suppressing vertigo
√ Non-sedative
does not disturb central
compensation

39. Ideal Vestibular Suppressant
a. Ca antagonist : Flunarizin
b. Vasodilator : Betahistine
c. Tranquilizer : diazepam, haloperidol,
sulpiride, clonazepam
d. Antihistamin : Difenhidramine, meclizine.
a, c, d
b (Betahistine)
Sedative effect !!
- No sedative effect !!

40. III. REHABILITATIVE THERAPY

41. VESTIBULAR REHABILITATION THERAPY (VRT)
TYPES
I. Specific VRT for BPPV
II. Balance exercises
III. Gaze Stabilization Exercises
IV. Visual Dependence Exercises
V. Physical conditioning exercise

42. BPPV
Benign Paroxysmal Positional Vertigo

43. Vestibular Rehabilitation Therapy
1. Specific Interventions for BPPV
a. Semont maneuver
b. Epley maneuver
c. Brandt Daroff Exercise

44. a. Semont Maneuver

45. b. Epley maneuver
30 sec
30 sec
30 sec
Other name:
• Canalith repositioning
• Particle repositioning

46. c. Brandt Daroff maneuver
-Each position 30 sec or vertigo subsides
in < 30 sec
-If Vertigo >30 sec  sit up 30 sec other
side
Time
Exercise Duration
--------------------------------------------Morning
5X
10 min
Noon
5X
10 min
Evening
5X
10 min
---------------------------------------------

47. IV. AGGRAVATING FACTORS

48. PREVENTION OF AGGRAVATING FACTOR
Control of Nutrition and Life-style:
-
• Adequate food and diet
-
• Avoid excessive alcohol, tobacco
-
• Medicine: sedative, ototoxic, opioid
-
• Sleeping, working position.

49. V. PHYSICAL CONDITIONING EXERCISE
Recommend doing one or more of the following, 3 times a week:
- Walking on a treadmill (1 mile)
- Brisk walking outdoors (1 mile or more)
- Riding a stationary bicycle
- Swimming

50. INTEGRATED VESTIBULAR THERAPY

51. Therapeutic Modalities Options:
1. Symptomatic treatment
2. Treatment for Specific Conditions
3. Rehabilitative therapy
4. Prevention of aggravating factor
SINGLE THERAPY
or
INTEGRATED THERAPY ?

52. Single Therapy
•Etiologic or Specific treatment is paramount, but it does not offer
the patient a significant improvement or vertigo symptoms
resolution when used alone
• Symptomatic drug therapy bring improvement in 75.1% of the
patients with peripheral vestibulopathies and 39.8% of the
patients with central vestibular disorders
• Vestibular rehabilitation therapy were efficient in 51.1% of
patient when used alone
• Diet and feeding habit change improve vertigo in 42.2% patients
with vestibulopathies
Gananca et al. Brazilian Journal of Otorhinolaryngology 2007;73(1):12-8

53. INTEGRATED THERAPY
Integrated Vestibular Therapy (IVT)
A combination therapeutic modalities of Specific
Treatment, Symptomatic Treatment, Vestibular
Rehabilitaton Therapy, Diet Control and Life-style
changes, brought about 96 % of vertigo improvement.

54. CONCLUSIONS
Balance function depends on the integrity of vestibular, visual and
somatosensory systems.
Disorder of these system (s) leads to dizziness, which includes 4 types:
Vestibular Vertigo, Nonvestibular Vertigo, Presyncope, and Disequilibrium.
Treatment of vertigo includes etiologic, symptomatic, vestibular
rehabilitative therapies, dietary and life habit control, and conditioning
physical exercise.
Integrated Vestibular Therapy (IVT) proved to bring better resolution of
vertigo compared to single therapy