The document discusses the anatomy and physiology of the inner ear balance system. It describes how the vestibular system in the inner ear, including the semicircular canals and otolith organs, helps maintain equilibrium and sense head movement and acceleration. It outlines various peripheral and central causes of dizziness or vertigo, such as BPPV, Meniere's disease, and stroke. Evaluation involves taking a history and performing a neurological exam and vestibular tests like the Dix-Hallpike maneuver and caloric testing. Treatment depends on the underlying cause but commonly involves rest, fluids, and medications to reduce symptoms during an acute episode.

1. Dr. Zaimal Shahan
PGT Department of ENT
Capital Hospital

2. SUBJECTIVE SENSE OF IMBALANCE
“Sensation as if the external world
is revolving around the patient or as if he
himself is revolving in space”

3.  How do we maintain
EQUILIBRIUM?

6.  The Bony Labyrinth lies in the petrous
temporal bone.
 Bony Labyrinth contains the membranous
labyrinth surrounded by a fluid called
perilymph
 Membranous Labyrinth consists of:
An Anterior Cochlear Duct HEARING
Posterior vestibular Apparatus:
 Utricle
 Sacculae BALANCE
 3 Semicircular Canals.

7.  Semicircular canals are
three small ring
structures each forming
2/3rd of a circle with a
dia. Of 6.5 mm,
containing endolymph.
 One end of each canal
is dilated “Ampula”
 Endolymph has a high K
and low sodium
Concentration & is
secreted by Stria
Vascularis and Dark
Cells.

8.  Five Vestibular Receptor organs
are present in the Vestibular
Labyrinth.
Two Maculae in utricle and saccule
(otolith organs) Monitor
Linear Acceleration.
Three Cristae Ampullares of
SSC Monitor Angular
Accleration.

9.  Each macula is found on floor of Utricle in horizontal plane &
medial wall of Saccule in Vertical plane.
 Macula supports a statoconial membrane which consists of small
Ca.Carbonate cryustals (otoconia) embedded in mucopolysaccharide
gel.
 Static tilt and linear acceleration results in movement of membrane
resulting in bending of hairs of hair cells and stimulation of nerve
endings.
 Crista Ampullaris are a crest of sensory epithelium lying at right
angles to the longitudinal axis of the canal and surrounded by a
bulbous gelatinous mass, the cupula.
 When head is rotated the endolymph within the ducts tends to
remain stationary. The resultant flow of endolymph with respect to
duct is resisted by elacticity of cupula which becomes deflected
bending hairs of sensory hair cells.

10.  The balance system (vestibular, visual,
and somatosensory) are a two sided push
and pull system.
In static neutral position, each side contributes
equal sensory information.
During movement ie., turning or tilt, there is a
temporary change in push and pull system
which is connected by appropriate reflexes and
motor outputs to the eyes (vestibulo0ocular
reflex), neck (vestibulo-cervical reflex), and
trunk and limbs (vestibulo0spinal reflex) to
maintain new position of head and body.

11. Normally there is balanced
input from both vestibular
systems
Vertigo develops from
asymmetrical vestibular
activity
Abnormal bilateral
vestibular activation
results in truncal ataxia

12.  ANATOMICAL
 DURATION OF VERTIGO
 NATURE OF VERTIGO

13. A.PERIPHERAL VESTIBULAR DISORDERS
BPPV
MENEIR’S DISEASE
VESTIBULAR NEURONITIS
LABYRINTHITIS
VESTIBULOTOXIC DRUGS
HEAD TRAUMA
PERILYMPH FISTULA
SYPHILIS
ACOUSTIC NEUROMA

14. B.CENTRAL VESTIBULAR DISORDERS
VERTEBROBASILAR INSUFFICIENCY
POSTERIOR INFERIOR CEREBELLAR ARTERY
SYNDROME
BASILAR MIGRAINE
CEREBELLAR DISEASE
MULTIPLE SCLEROSIS
TUMORS OF BRAINSTEM
EPILEPSY

16.  ROTATIONAL
 UNSTEADINESS

17.  BPPV
 LABYRINTH FISTULA
 VERTEBROBASILAR INSUFFICINCEY
 MENIERE’S DISEASE
 VESTIBULAR NEURONITIS
 TRAUMA
 LABYRINTHITIS
 METASTATIC DEPOSITS IN CP ANGLE

18.  DRUGS
 TRAVEL SICKNESS
 PERILYMPH FISTULA
 HYPERVENTILLATION
 VESTIBULAR INSUFFICIENCY
 CNS LESIONS

20.  ROTATIONAL VERTIGO
 HEAD AND BODY MOVED IN PARTICULAR
DIRECTION
 LATENT PERIOD: FEW SECONDS
 LASTS NOT MORE THAN 30 SECONDS
 NO HEARING LOSS OR ANY OTHER
NEUROLOGICAL SYMPTOMS
 HISTORY OF EAR TRAUMA/EAR INFECTION

21.  OTOCONIAL DEBRIS RELEASED FROM THE
DEGENERATING MACULA

22.  OTOCONIAL DEBRIS SETTLES ON CUPULA OF
POSTERIOR SEMICIRCULAR CANAL
 CERTAIN HEAD POSITIONS CAUSE
DISPLACEMENT OF CUPULA HENCE VERTIGO

23.  OTOCONIAL DEBRIS FLOATS FREELY IN THE
SEMICIRCULAR CANAL
 CERTAIN CHANGES IN HEAD POSITION CAUSE
DISPLACEMENT AND VERTIGO

24.  VERTIGO:FATIGUABLE
 DIX HALLPIKE MANOEUVRE

25.  TRIAD OF
1.VERTIGO
2.FLUCTUATIND HEARING LOSS
3.TINNITUS
 MAY BE ACCOMPANIED BY SENSE OF AURAL
FULLNESS

26.  ENDOLYMPHATIC HYDROPS
 CAUSE UNCLEAR

27.  Inflammation of labyrinth dduuee ttoo aannyy ccaauussee..
 MMaayy bbee vviirraall oorr bbaacctteerriiaall..
 VViirraall mmaayy ooccccuurr dduurriinngg ccoouurrssee ooff aann
eexxaanntthheemmaattoouuss ddiisseeaassee lliikkee mmuummppss//mmeeaasslleess
oorr iinnfflluueennzzaa ttyyppee iillllnneessss..
 BBaacctteerriiaall llaabbyyrriinntthhiiss mmaayy bbee cciirrccuummssccrriibbeedd,,
sseerroouuss oorr ssuuppppuurraattiivvee iinn aa ccaassee ooff oottoorrrrhhooeeaa..
 IItt mmaayy aallssoo ooccccuurr dduurriinngg ccoouurrssee ooff mmeenniinnggiittiiss..

28.  Vestibular ssyymmppttoommss aarree vvaarriiaabbllee aanndd
ttiinnnniittuuss iiss ccoommmmoonn..
 DDiiaaggnnoossiiss iiss mmaaddee oonn tthhee bbaassiiss ooff rraaddiioollooggiiccaall
iinnvveessttiiggaattiioonnss..

29.  Non-Operative: Labyrinthine ccoonnccuussssiioonn oorr
ffrraaccttuurree ooff tteemmppoorraall bboonnee..
 PPoosstt--OOppeerraattiivvee:: AA ppeerriillyymmpphh ffiissttuullaa mmaayy
ooccccuurr aafftteerr eeaarr ssuurrggeerryy eesspp.. ssttaappeeddeeccttoommyy

30.  Tumors involving bbrraaiinnsstteemm,, cceerreebbeelllluumm oorr
mmiiddbbrraaiinn
 OOtthheerr ssiiggnnss ooff iinnttrraaccrraanniiaall ddiisseeaassee aarree ffoouunndd
 OOnn EENNGG nnyyssttaaggmmuuss iiss ffoouunndd ttoo bbee iirrrreegguullaarr
aanndd eennhhaanncceedd oonn eeyyee ooppeenniinngg..

31.  OOnnsseett iiss wwiitthh sseevveerree vveerrttiiggoo wwiitthh
ccoonnttrraallaatteerraall hheemmiiaannaallggeessiiaa..

32.  Episodes of vertigo wwiitthh ootthheerr ssiiggnnss ooff bbrraaiinn
sstteemm ddyyssffuunnccttiioonn..

33.  HISTORY:
DESCRIPTION
 Ask the patient to describe the problem
 True rotatory vertigo or dizziness.
 Severity
 Number of attacks
 Temporal pattern (continuous vs. episodic / short vs. prolonged)
 If associated with turning the head, lying supine, or sitting upright.
 Vestibular & cochlear symptoms (hearing loss either fluctuating or
progressive, tinnitus, ear pressure, nausea and vomiting)
 Degree of impairment during the attack
 Syncope:Transient loss of consciousness with loss of postural tone
 Presyncope: Lightheadedness-an impending loss of consciousness
 Psychiatric dizziness: Dizziness not related to vestibular dysfunction
 Disequilibrium: Feeling of unsteadiness, imbalance or sensation of
“floating” while walking

34. SECONDARY SYMPTOMS
 Tinnitis
 Hearing impairment
 Headache or visual symptoms.
 Neurological abnormalities
 Brainstem symptoms (diplopoia, dysarthria, facial
parenthesis, extremity numbness or weakness.)

35.  PREVIOUS HISTORY
 Injuries:
 Head trauma in the past (post traumatic hydrops)
 Hx. Of prior ear surgery (labyrinthine fistula,
perilymphatic fistula.)
 Drugs : Aminoglycosides, cisplatin, miocycline
 Stress situations
 Family illness
 Systemic Diseases:
 Hx. of DM (causes visual, proprioceptive, vascular
problems)
 HTN, cardiovascular and cerebrovascular diseases

36. GPE
Cardiovascular, BP (including orthostatic) in both
arms, pulse
Neurologic
ENT HEAD AND NECK EXAMINATION
Detailed ENT Examination
 Tympanic membrane for retraction, perforation,
Infection, cholesteatoma,valsalva
 Assess hearing on both sides
Detailed Head & Neck Examination
 Cranial nerves
 Bruits in the neck

38. SPECIFIC VESTIBULAR SYSTEM EXAM
(Balance tests need not be performed in acute vertigo)
 Nystagmus
 Corneal test
 Fistula test
 Postural tests
 Caloric tests
 Electronystagmography
 Cerebellar test

39.  Rhythmic slow and fast eye movements
 Direction named by fast component
 Slow component usually ipsilateral to
diseased structure
 Fast component due to cortical
correction

41.  Central
 Spontaneous nystagmus
that can not be
suppressed by fixation.
 Changes direction with
gaze.
 Purely vertical,
horizontal, or torsional
 Paroxysmal but Not
fatigable in Dix-hallpike
test, no latency, Lasting
longer than 60 sec. and
often vertical, may
change direction with
different head positions.
 Peripheral
 Suppressed by fixation
 Doesn’t change direction with
gaze.
 Horizontal, rotatory.Never
vertical.
 Paroxysmal but fatigable in
Dix-hallpike test, has latency,
lasts less than a minute,
doesn't change direction with
different head positions,

42.  loss of corneal reflex -- Cerrebelopontine Angle
 Pressing tragus
 Seigel’s pneumatic spectrum
 NYSTAGMUS OPPOSITE SIDE

43.  INTERPRETATION
POSITIVE: Fistula usually LATERAL SCC
NEGATIVE: Fistula present
 Dead labyrinth
 Fistula covered by
 Granulation tissue
 Cholesteatoma
 POSITIVE: no fistula
 Congenital Syphillis

45.  PERIPHERAL LESION:
sway to side of lesion
 CENTRAL LESION (Posteroir white column)
Instability

46.  Romberg normal
 1 heel of 1 foot in front of the other, arms
folded across chest
 INSTABILITY: Vestibular impairment

48.  Patient walks towards target
 Eyes open, then closed
 PERIPHERAL LESION: pt deviates on affected
side

49.  Unilateral Paralytic Labyrinthitis:
Patient deviates to ipsilateral side
 Active irrelative lesion:
not able to perform test for more than 3
seconds

51.  Patients eyes shut:30 seconds
 5 PACES forward,5 PACES backward
 STAR SHAPED: Unilateral Vestibular
Disorder

53.  Acute Unilateral Vestibular Disorders
 Deviation to 1 particular side

57.  Patient 45 degrees on couch
 Water 33degrees or 45 degrees
 Normal nystagmus
COLD: OPPOSITE
WARM: SAME

58. 1.CANAL PARESIS:
 Decreased duration of nystagmus
 both hot and cold
2.DEAD LABYRINTH:
 No nystagmoid response
3.DIRECTION PREPONDERANCE:
BY Both Hot and Cold
CENTRAL/PERIPHERAL lesion

59.  Now a routine investigation in Vertigo
 ADVANTAGES:
closed eyes nystagmus recorded
Small amplitude Nystagmus

60. SSaaffeettyy::
AAccuuttee VVeessttiibbuullaarr SSuupppprreessssiioonn::
VVeessttiibbuullaarr RReehhaabbiilliittaattiioonn::
MMeeddiiccaall && SSuurrggiiccaall MMaannaaggeemmeenntt::

61. Safety
Self-Care at Home
Avoid Driving , work on dangerous machinery/
fire.
Home therapy should only be undertaken if
patient has already been diagnosed with vertigo
and is under the close supervision of a doctor.

62.  Two components:
First, one must control the acute episode, and
Secondly, speed the recovery and prevent future
episodes.

63.  Vertigo can be treated symptomatically or
specifically.
Symptomatic treatment involves controlling
the acute symptoms and autonomic
complaints.
Specific treatment involves targeting the
underlying cause of the vertigo.
Some common types of vertigo have either established
or postulated patho- physiology and lend themselves to
specific treatment, others are still unknown and
symptomatic control is the only option.

64.  Characteristics of peripheral
vertigo and dizziness
 Characteristics of vertigo and
dizziness of central origin
 Recognizing stroke syndromes
that may present with dizziness
as a prominent feature
 Treatment considerations in
dizziness of
central origin
 Treatment of peripheral
vestibular dysfunction

65.  Management of acute vertigo includes:
 Bed rest,
 Fluids and
 Reassurance. Head movements can be particularly
distressing with peripheral vestibular dysfunction.
 Medications that suppress vestibular signs can be
helpful acutely. Four general classes of drugs are useful
in the treatment of vertigo and its associated
autonomic symptoms :-
 Anticholinergics, The most effective single drug for the
prophylaxis and treatment of motion sickness is the
anticholinergic scopolamine
 Antihistamines, Antihistamines include meclizine,
dimenhydrinate, and promethazine. The newer nonsedating
antihistamines do not enter the CNS and have no value in
the treatment of vertigo and motion sickness

66.  Antidopaminergics, such as prochlorperazine and
chlorpromazine act at the chemoreceptor trigger zone, reducing
neural impulses to the vomiting center. These drugs do not
prevent vertigo and motion sickness but may be useful in
treating the nausea and vomiting caused by these disorders
 Monoaminergic drugs include amphetamines and ephedrine.
They appear to potentiate the effects of scopolamine and may
be used in combination with one of the antihistamines for
intense symptoms or in those who do not respond adequately to
single-drug therapy
 Lastly, the benzodiazepine diazepam act as a vestibular
suppressant through the GABAergic system and can also
minimize the associated anxiety and panic that occurs with
vertigo.

69. After several days, gradual increased activity and
graded exercises can facilitate the adaptive
recovery of the vestibular system.
While pharmacologic treatment of the acute,
severe symptoms of vertigo is probably
beneficial, some experts feel that prolonged use
of these agents may actually retard the normal
compensatory mechanisms.

70. The choice of treatment will depend on the diagnosis.
 Vertigo can be treated with medicine
 Specific types of vertigo may require additional treatment and
referral:
 Bacterial infection of the middle ear requires antibiotics.
 Meniere disease, in addition to symptomatic treatment, people
might be placed on a low salt diet and may require medication used
to increase urine output.
 A hole in the inner ear causing recurrent infection may require
referral to an ear, nose, and throat (ENT) specialist for surgery.
 Several physical maneuvers can be used to treat conditions
like BPPV.

71. Vestibular Neuritis
 Since viral origin is implicated, treatment aimed at stopping
the inflammation has been proposed.
 Studies show that in patients on methylprednisolone, 90%
experienced a decrease in vertigo within 24 hours Most
patients will have spontaneous, complete symptomatic
recovery even only with supportive treatment.
 Patients who have persistent unsteadiness or motion
provoked symptoms may have incomplete central
compensation and should benefit from a customized
vestibular rehabilitation program.

72. Meniere’s Disease
 Diatary salt restriction and diuretics. Thiazide diuretics
are traditionally used for at least 3 months
 Vasodilators. IV histamine, isosorbide dinitrate,
cinnarizine (calcium antagonist) and betahistine (oral
histamine analogue) have all been used with anecdotal
success
 In some patient’s there is thought to be an association of
immune-mediated phenomena. Systemic and
intratympanic glucocorticoids, cyclophosphamide, and
methotrexate have all been used by clinicians.
 For intractable disease with disabling vertigo despite
medical treatment, vestibular surgery should be
considered.
 The chemical labyrinthectomy, or transtympanic
gentamicin (intratympanic aminoglycoside, allows
treatment of unilateral disease without producing
systemic toxicity or affecting the opposite ear.

73. Benign Paroxysmal Positional Vertigo (BPPV)
 Semont et al proposed a liberatory maneuver as a single
treatment alternative. The reported cure rates are 84%
after one, and 93% following two treatments.
 Epley proposed a canalith repositioning procedure Epley
reported 80% cure after one treatment and 100%
improvement after multiple sessions in 30 patients.
 Brandt and Daroff designed habituation exercises
requiring the patient to move into the provoking
position repeatedly, several times a day. They report a
98% success rate after 3 to 14 days of exercises.

74. Vertebrobasilar insufficiency (VBI)
 VBI is characterized by vertigo, diplopia, dysarthria, gait
ataxia and bilateral sensory and motor disturbance.
Symptoms of transient ischemia are alarming but generally
benign as there is rich collateral blood supply and a relatively
low incidence of stroke. Antiplatelet therapy is warranted
usually with aspirin.
Migraine
 Treatment includes modifying risk factors, abortive medical
therapy, and prophylaxis. These patients should avoid
nicotine products, exogenous estrogens, and foods that
exacerbate symptoms
 Exercise programs and stress reduction are also important.
Ergots, sumatriptin, and midrin are helpful in aborting acute
attacks.
 Prophylactic medical therapy can be started if migraines
occur several times a month (aspirin, ibuprofen, lithium,
calcium channel blockers, amitryptiline and beta blockers).

76.  In perilymph fistula, surgery may be used
to plug a leak in the inner ear.
 In the microvascular compression
syndrome, surgery may be used to move
a blood vessel off of the vestibular nerve.
 In Meniere’s Disease, shunt surgery is
intended to improve inner ear plumbing.
All treatments for Meniere's disease must
be compared with the natural history the
disease, where 60% of patients are in
remission by six months.

77.  For Meniere's disease, destructive procedures
are associated with better control of vertigo
than shunt surgery, showing good control in
over 90% of patients followed for five or more
years.
 The vestibular nerve section.
 Transtympanic gentamicin treatment
 Labyrinthectomy

78.  Acoustic Neuroma Surgery
 For Benign Paroxysmal Positional Vertigo
 Selective posterior canal plugging offers a
reasonable surgical approach to intractable
symptoms.
 Singular neurectomy, an older procedure, is less
popular because it produces hearing loss in 7 to 17%
of patients and fails in 8 to 12%.
 Vestibular rehabilitation therapy is
appropriate in all patients who have had
destructive treatment.

79.  Selection of the best type depends on both
the diagnosis and health care situation.
Indications:
 Specific interventions for (BPPV)
 The Epley and Semont maneuvers
 The Brandt-Daroff exercises
 General interventions for vestibular loss
 Empirical treatment for common situations where the
diagnosis is unclear
 Post-traumatic vertigo
 Multifactorial disequilibrium of the elderly

80. Office Treatment of BPPV:
The Epley and Semont Maneuvers
 Are both intended to move debris out of the
sensitive part of the ear (posterior canal) to a
less sensitive location. Each maneuver takes
about 15 minutes to complete.
 Semont maneuver: It involves a procedure
whereby the patient is rapidly moved from
lying on one side to lying on the other.
 Epley Maneuver: It involves sequential
movement of the head into four positions,
staying in each position for roughly 30 seconds

81. Home Treatment Of
BPPV:
Brandt-Daroff Exercises
 The Brandt-Daroff Exercises
is a method of treating BPPV,
usually used when the office
treatment fails. They
succeed in 95% of cases.

82. Cawthorne Cooksey Exercises:
 Sitting
 Eye movements and head movements
 Shoulder shrugging and circling
 Bending forward and picking up objects from the ground
 Standing
 Eye, head and shoulder movements as before
 Changing form sitting to standing position with eyes open and shut
 Throwing a small ball from hand to hand (above eye level)
 Throwing a ball from hand to hand under knee
 Changing from sitting to standing and turning around in between
 Moving about (in class)
 Circle around center person who will throw a large ball and to whom it will
be returned
 Walk across room with eyes open and then closed
 Walk up and down slope with eyes open and then closed
 Walk up and down steps with eyes open and then closed
 Any game involving stooping and stretching and aiming such as bowling and
basketball
Dix and Hood, 1984 and Herdman, 1994; 2000.

83.  T'ai Chi, a Chinese
exercise routine similar
to ballet is one such
method.
 Sports activities such as
golf, bowling, or
recreational walking can
also be used for
rehabilitation.

84.  Anywhere between 15 and 50% of patients evaluated by
tertiary care "dizziness" clinics go undiagnosed. In this
situation, it is often useful to have an organized
approach to try out all reasonable interventions.
 This includes both medications as well as a one- or two-month
enrollment in a balance/vestibular rehabilitation
program, for patients who have chronic symptoms.
 Similarly, patients with central vestibular problems (for
example, a cerebellar cerebrovascular accident) are
highly unlikely to benefit from medication or therapy.
Nevertheless, these patients are usually so impaired that
it seems ill advised not to try out all possible modalities.