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VERTIGO- A PRACTICAL
     APPROACH
    DR.ANITA BHANDARI
MAINTENANCE OF BALANCE


                    PROPRIOCEPTIVE
EYES    INNER EAR
                       SYSTEM




        BRAIN
According to the National Institute of
Health, 42% of the population is said to
suffer from balance problems some time
in their life.
Vertigo, imbalance, dizziness, disequilibrium –
these are all terms used by the pt. to describe
   a sensation of altered orientation to the
                 environment.




            Affects day to day life




               Who to consult?
Challenging for the physician

Vague history

Vague complaints

Investigations ?

Etiology ?
OTOLOGICAL

 CENTRAL

 SYSTEMIC

UNKNOWN
• DURATION OF ILLNESS

• DURATION OF ATTACKS

• TRIGGERS

• ASSOCIATED SYMPTOMS
SECONDS – LATE OTOTOXICITY

MINUTES –BPPV, TIA

HOURS – MENIERE’S DISEASE ,
MIGRAINE

DAYS – VESTIBULAR NEURITIS

MONTHS TO YEARS- HYSTERICAL
CHANGE IN POSITION – BPPV



URI – VESTIBULAR NEURITIS


RAISED INTRATHORACIC
PRESSURE – PERILYMPH
FISTULA
AUDIOMETRY        CRANIOCORPOGRAPHY




                            -HELPS IN
ELECTRONYSTAGMOGRAP     DIFFERENTIATING
         HY           PERIPHERAL & CENTRAL
                           DISORDERS
28 YEAR OLD FEMALE


 INTENSE SPINNING ON GETTING UP
IN MORNING LASTING SEVERAL HRS.


   CANNOT GET UP FROM BED



            N/V ++



       NO HEARING LOSS
• TYMP. MEMBRANE – WNL

• NYSTAGMUS – LEFT BEATING SPONTANEOUS

• CRANIAL NERVES WNL




• GAIT –COULD NOT BE TESTED

• NO NEUROLOGICAL DEFICIT
Pathogenesis – viral infection of superior division of
                     vestibular N.




History – sudden onset of severe vertigo without hearing
             loss. Usually preceded by URI.


                     Investigations
                     Audiometry – WNL
                    ENG – canal paresis
                      CCG – rotation to the affected side
• CONTROL OF SYMPTOMS
• INITIALLY STRONG VEST. SEDATIVES – MECLIZINE ,
  PROCLOPERAZINE ,ALPRAZOLAM,
• ONDANSTERON – NOT MORE THAN 5 DAYS




• IF PT. SEEN WITHIN 2 DAYS OF ONSET – STEROIDS




• START VESTIBULAR REHABILITATION ASAP
41 YR. OLD MALE




RECURRENT EPISODES OF VERTIGO
SINCE 4 MONTHS WHICH LAST FOR FEW
HRS.




N/V+




HEARING LOSS AND RINGING IN RT.EAR
DURING THE ATTACK
TM – N

NO NYSTAGMUS

STEPPING TEST – 90* ROTATION TO
RT
AUDIOMETRY – LOW FREQ.
HEARING LOSS RE
ENG – HYPERACTIVE CALORIC
RESPONSE ON RT
MENIERE’S DISEASE
 Pathogenesis-
 endolymphatic hydrops




                            Dilated membranous
Normal membranous labyrinth labyrinth in Meniere's
                            disease (Hydrops)
SYMPTOMS

        • Fluctuating
          hearing loss
  TRIAD • Tinnitus
        • Vertigo
DURING ACUTE PHASE,
VEST.SEDATIVES MAY BE GIVEN –
MECLIZINE ,CINNARIZINE


LOW SALT ,HIGH K DIET



CARBONIC ANHYDRASE



BETAHISTINE
23 YR. OLD FEMALE

PERSISTANT FEELING OF
UNSTEADINESS

OFTEN EPISODES OF SPINNING

FREQ. HEADACHES WITH SENSORY
AMPLIFICATION

NO AURAL SYMPTOMS


HIGH STRUNG PERSONALITY
ENT – WNL


GAIT, STEPPING TEST –
WNL


AUDIO – WNL


ENG - WNL
• D/D –PHOBIAS, HYSTERIA




• ABORTIVE THERAPY -
  TRIPTANS


• PREVENTIVE THERAPY
• BETA BLOCKERS
• FLUNERIZINE
Multiple sclerosis

Cerebrovascular disorders

Migraine

Epilepsy
• 60 YR. MALE

• INTENSE SPINNING ON GETTING UP
  FROM BED

• N/V ++


• NO AURAL SYMPTOMS
TM- WNL


NO SPONTANEOUS NYSTAGMUS


GAIT WNL


NO NEUROLOGICAL DEFECIT


DIX-HALLPIKE MANEUVRE –
NYSTAGMUS ON LT
BENIGN- self-
                   limiting




                 POSITIONAL




PAROXYSMAL
                                 VERTIGO
– sudden onset
Canalolithiasis Theory
The Dix-Hallpike test
55 YR.OLD MALE

CHR. UNSTEADINESS SINCE SEVERAL MONTHS

INCREASED ON CHANGE OF POSITION

DECREASED HEARING BE

HYPERTENSIVE,DIABETIC

H/O ATT 10 YRS. AGO WITH STREPTOMYCIN
AUDIOMETRY –
MODERATE SNHL BE

CCG – WIDE BASED
  ATAXIC GAIT

 ENG –BILATERAL
 CANAL PARESIS


 NO NYSTAGMUS
ALONG WITH SYSTEMIC
DISORDERS

START VESTIBULAR
REHABILITATION


CONTROL HTN,DM


START NOOTROPIC AGENTS


AVOID VESTIBULAR SEDATIVES
Vertigo  a practical approach
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Vertigo a practical approach

  • 1. VERTIGO- A PRACTICAL APPROACH DR.ANITA BHANDARI
  • 2. MAINTENANCE OF BALANCE PROPRIOCEPTIVE EYES INNER EAR SYSTEM BRAIN
  • 3. According to the National Institute of Health, 42% of the population is said to suffer from balance problems some time in their life.
  • 4. Vertigo, imbalance, dizziness, disequilibrium – these are all terms used by the pt. to describe a sensation of altered orientation to the environment. Affects day to day life Who to consult?
  • 5. Challenging for the physician Vague history Vague complaints Investigations ? Etiology ?
  • 7. • DURATION OF ILLNESS • DURATION OF ATTACKS • TRIGGERS • ASSOCIATED SYMPTOMS
  • 8.
  • 9.
  • 10. SECONDS – LATE OTOTOXICITY MINUTES –BPPV, TIA HOURS – MENIERE’S DISEASE , MIGRAINE DAYS – VESTIBULAR NEURITIS MONTHS TO YEARS- HYSTERICAL
  • 11. CHANGE IN POSITION – BPPV URI – VESTIBULAR NEURITIS RAISED INTRATHORACIC PRESSURE – PERILYMPH FISTULA
  • 12. AUDIOMETRY CRANIOCORPOGRAPHY -HELPS IN ELECTRONYSTAGMOGRAP DIFFERENTIATING HY PERIPHERAL & CENTRAL DISORDERS
  • 13.
  • 14. 28 YEAR OLD FEMALE INTENSE SPINNING ON GETTING UP IN MORNING LASTING SEVERAL HRS. CANNOT GET UP FROM BED N/V ++ NO HEARING LOSS
  • 15. • TYMP. MEMBRANE – WNL • NYSTAGMUS – LEFT BEATING SPONTANEOUS • CRANIAL NERVES WNL • GAIT –COULD NOT BE TESTED • NO NEUROLOGICAL DEFICIT
  • 16.
  • 17.
  • 18. Pathogenesis – viral infection of superior division of vestibular N. History – sudden onset of severe vertigo without hearing loss. Usually preceded by URI. Investigations Audiometry – WNL ENG – canal paresis CCG – rotation to the affected side
  • 19. • CONTROL OF SYMPTOMS • INITIALLY STRONG VEST. SEDATIVES – MECLIZINE , PROCLOPERAZINE ,ALPRAZOLAM, • ONDANSTERON – NOT MORE THAN 5 DAYS • IF PT. SEEN WITHIN 2 DAYS OF ONSET – STEROIDS • START VESTIBULAR REHABILITATION ASAP
  • 20. 41 YR. OLD MALE RECURRENT EPISODES OF VERTIGO SINCE 4 MONTHS WHICH LAST FOR FEW HRS. N/V+ HEARING LOSS AND RINGING IN RT.EAR DURING THE ATTACK
  • 21. TM – N NO NYSTAGMUS STEPPING TEST – 90* ROTATION TO RT AUDIOMETRY – LOW FREQ. HEARING LOSS RE ENG – HYPERACTIVE CALORIC RESPONSE ON RT
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  • 23.
  • 24. MENIERE’S DISEASE  Pathogenesis- endolymphatic hydrops Dilated membranous Normal membranous labyrinth labyrinth in Meniere's disease (Hydrops)
  • 25. SYMPTOMS • Fluctuating hearing loss TRIAD • Tinnitus • Vertigo
  • 26. DURING ACUTE PHASE, VEST.SEDATIVES MAY BE GIVEN – MECLIZINE ,CINNARIZINE LOW SALT ,HIGH K DIET CARBONIC ANHYDRASE BETAHISTINE
  • 27. 23 YR. OLD FEMALE PERSISTANT FEELING OF UNSTEADINESS OFTEN EPISODES OF SPINNING FREQ. HEADACHES WITH SENSORY AMPLIFICATION NO AURAL SYMPTOMS HIGH STRUNG PERSONALITY
  • 28. ENT – WNL GAIT, STEPPING TEST – WNL AUDIO – WNL ENG - WNL
  • 29. • D/D –PHOBIAS, HYSTERIA • ABORTIVE THERAPY - TRIPTANS • PREVENTIVE THERAPY • BETA BLOCKERS • FLUNERIZINE
  • 30.
  • 32. • 60 YR. MALE • INTENSE SPINNING ON GETTING UP FROM BED • N/V ++ • NO AURAL SYMPTOMS
  • 33. TM- WNL NO SPONTANEOUS NYSTAGMUS GAIT WNL NO NEUROLOGICAL DEFECIT DIX-HALLPIKE MANEUVRE – NYSTAGMUS ON LT
  • 34. BENIGN- self- limiting POSITIONAL PAROXYSMAL VERTIGO – sudden onset
  • 37. 55 YR.OLD MALE CHR. UNSTEADINESS SINCE SEVERAL MONTHS INCREASED ON CHANGE OF POSITION DECREASED HEARING BE HYPERTENSIVE,DIABETIC H/O ATT 10 YRS. AGO WITH STREPTOMYCIN
  • 38. AUDIOMETRY – MODERATE SNHL BE CCG – WIDE BASED ATAXIC GAIT ENG –BILATERAL CANAL PARESIS NO NYSTAGMUS
  • 39. ALONG WITH SYSTEMIC DISORDERS START VESTIBULAR REHABILITATION CONTROL HTN,DM START NOOTROPIC AGENTS AVOID VESTIBULAR SEDATIVES