Vertigo Presentation

1. VERTIGO : Approach to Patient
DR. PIYUSH OJHA
DM RESIDENT
DEPARTMENT OF NEUROLOGY
GOVT MEDICAL COLLEGE, KOTA

2. EPIDEMIOLOGY
• Approximately 30% people - experience moderate to severe
dizziness at some point in their life (Neuhauser et al. 2005).
• 80% - seek medical care at some point.
• Though most people report nonspecific forms of dizziness,
nearly 25% of these people report true vertigo.
• Dizziness - Females > Males and older people
• In the United States, 7.5 million annual ambulatory visits to
physician offices, hospital OPDs, and emergency departments
for dizziness, making it one of the most common principal
complaints. (Burt and Schappert 2004).

3. HISTORICAL BACKGROUND
• Prosper Meniere (1861) - first to recognize the association of
vertigo with hearing loss and to localize the symptom to the
inner ear.
• Robert Barany (1906)
– First clinical description of BPPV in 1921.
– introduced Caloric testing - most widely used test of the
Vestibulo-ocular reflex (VOR).
– Nobel Prize for mechanism of caloric stimulation.

4. • Neuroimaging in 1970s greatly expanded understanding of
causes of dizziness/vertigo - prior to which, stroke was
considered an exceedingly rare cause of vertigo(Fisher 1967).
• Over the past 25 years - understanding of the mechanisms for
the common neuro-otological disorders has increased.
• BPPV – now readily identified and cured bedside.
• The Head-Thrust test – bedside test to identify a vestibular
nerve lesion, and has particular utility in helping distinguish
vestibular neuritis from a posterior circulation stroke
(Halmagyi and Curthoys 1988; Kattah et al. 2009; Newman-
Toker et al. 2008; Nuti et al. 2005)

5. • “Dizziness” refers to various abnormal sensations relating to
perception of the body’s relationship to space.
• Dizziness - may represent variety of symptoms including :
– Spinning or movement of the environment (True vertigo)
– Light-headedness or Presyncope, or
– Imbalance while walking
• Patients may also use the term for other sensations such as
visual distortion, nonspecific disorientation and anxiety.
DIZZINESS / VERTIGO

6. • In a classic paper, Drachman and Hart (1972) described four
subtypes of dizziness: Vertigo, Presyncopal lightheadedness,
Disequilibrium and other dizziness.

7. NORMAL ANATOMY & PHYSIOLOGY
• The Peripheral vestibular system consists of: -
– Three semicircular canals
– Otoloithic apparatus (Utricle and saccule) and
– The vestibular component of the eighth cranial nerve.
• The Semicircular canals sense angular movements.
• Utricle and saccule sense linear movements.

8. ANATOMY OF THE INTERNAL EAR

9. • The plane in which the eyes deviate as a result of vestibular
stimulation depends on the combination of canals that are
stimulated .
• Once vestibular signals leave the vestibular nuclei - divide into
vertical, horizontal, and torsional components.
• So a lesion of central vestibular pathways can cause a pure
vertical, pure torsional, or pure horizontal nystagmus.

11. HISTORY OF PRESENTING ILLNESS
• History and physical examination - the most important
information
• Often, patients have difficulty describing the exact symptom
experienced.
• The first step is to define the symptom.

12. • Following questions should also be enquired:
– Symptom constant or episodic
– Accompanying symptoms
– How did it begin (gradual / sudden)
– Aggravating or alleviating factors?
– If episodic, what was the duration and frequency of
attacks, and what were the triggers?
• One key point is that any type of dizziness may worsen with
position changes, but some disorders such as BPPV only occur
after position change.

14. CAUSES OF VERTIGO

15. CAUSES OF VERTIGO

16. • “Red flags” suggestive of a Central vestibular lesion :-
– Other central signs or symptoms
– Direction-changing nystagmus
– Vertical nystagmus
– A negative head-thrust test
– A skew deviation or
– Substantial stroke risk factors (Kattah et al. 2009)

17. RECURRENT POSITIONAL VERTIGO
• Positional vertigo - symptom being triggered, not simply
worsened, by certain positional changes.
• Most likely BPPV - but this is not the only possibility.
• Strong suspicion of BPPV when the positional vertigo is brief
(<1 minute), has typical triggers, and is unaccompanied by
other neurological symptoms.
• A burst of vertical torsional nystagmus - specific for BPPV of
the posterior canal (Aw et al. 2005).

18. • Central positional nystagmus - disorders affecting the
posterior fossa, including tumors, cerebellar degeneration,
Chiari malformation, or MS.
• Nystagmus typically downbeating and persistent, though a
pure torsional nystagmus may occur as well.

19. PHYSICAL EXAMINATION
• A brief general medical examination is important.
• Postural Hypotension measurement.
• Orthostatic hypotension - probably the most common general
medical cause of dizziness among patients referred to
neurologists.
• Identifying an irregular cardiac rhythm may help.
• Other general examination measures to consider in individual
patients include a Visual assessment (adequate vision is
important for balance) and a musculoskeletal inspection
(significant arthritis can impair gait).

20. GENERAL NEUROLOGICAL EXAMINATION
• Very important in patients complaining of Vertigo because
vertigo can be the earliest symptom of a neurodegenerative
disorder (Lau et al. 2006)
• Can also be an important symptom of stroke, tumor,
demyelination, or other pathologies of the nervous system.
• The cranial nerves should be thoroughly assessed.

21. OCULAR MOTOR ASSESSMENT :-
• 1st step – Normal ocular movements & search for Nystagmus
• Nystagmus – objective accompaniment of vertigo and defined
as “rhythmic oscillation of the eyes, with a fast movement in
one direction and a slow movement in the other.”
• Nystagmus - classified as spontaneous, gaze-evoked, or
positional.
• The direction of nystagmus - conventionally described by the
direction of the fast phase, which is the direction it appears
to be “beating” toward.
• Fast component may be horizontal, vertical, rotatory, or any
combination of these.

22. • Spontaneous nystagmus can have either a peripheral or
central pattern.
• Central lesions can rarely mimic a “peripheral” pattern of
nystagmus (Lee and Cho, 2004; Newman-Toker et al., 2008).
• The peripheral pattern of spontaneous nystagmus is
unidirectional.
• Other characteristics of peripheral spontaneous nystagmus
are increase in velocity with gaze in the direction of the fast
phase, and decrease with gaze in the direction opposite of the
fast phase. (Alexander’s Law)

23. VESTIBULAR NERVE EXAMINATION
• A unilateral or bilateral vestibulopathy can be identified using
the Head-thrust test.
• In patients with normal vestibular function, the VOR results in
movement of the eyes in the direction opposite the head
movement.
• Therefore the patient’s eyes remain on the examiner’s nose
after the sudden movement.
• The test is repeated in the opposite direction.
• If a corrective saccade is observed bringing the patient’s eyes
back to the examiner’s nose after the head thrust, impairment
of the VOR in the direction of the head movement is
identified.

24. POSITIVE HEAD THRUST TEST

25. POSITIONAL TESTING
• Can help identify peripheral or central causes of vertigo.
• The most common positional vertigo – BPPV – due to free-
floating calcium carbonate debris - usually in the posterior
semicircular canal – occasionally horizontal canal and rarely
anterior canal.
• The characteristic burst of upbeat torsional nystagmus is
triggered in patients with BPPV by a rapid change from the
sitting-up position to supine head-hanging left or head-
hanging right (Dix–Hallpike test).
• A burst of nystagmus in the opposite direction (downbeat
torsional) occurs when the patient resumes the sitting
position.

26. DIX-HALLPIKE MANEUVRE

27. AUDITORY EXAMINATION
• Bedside Otoscopy examination.
• Finger rubs at different intensities and distances from the ear
are a rapid, reliable, and valid screening test for hearing loss
in the frequency range of speech (Torres-Russotto et al.
2009).
• If a patient can hear a faint finger rub stimulus at a distance of
70 cm (approximately one arm’s length) from one ear, then a
hearing loss on that side—defined by a gold-standard
audiogram threshold of greater than 25 dB at 1000, 2000, and
4000 Hz—is highly unlikely.
• On the other hand, if a patient cannot hear a strong finger rub
stimulus at 70 cm, a hearing loss on that side is highly likely.

28. • The whisper test can also be used to assess hearing at the
bedside (Bagai et al. 2006).
• For this test, the examiner stands behind the patient to
prevent lip reading and occludes and masks the nontest ear,
using a finger to rub and close the external auditory canal.
• The examiner then whispers a set of three to six random
numbers and letters.
• Overall, the patient is considered to have passed the
screening test if they repeat at least 50% of the letters and
numbers correctly.
• Tunic Fork tests – Weber and Rinne test

29. IMAGING
• To rule out central causes of vertigo.
• CT scan can rule out a large mass with exception of smaller
lesions due to artifact and poor resolution in the posterior
fossa (Chalela et al., 2007).
• MRI - imaging modality of choice, expensive
• BPPV, vestibular neuritis, or Meniere disease - do not require
an imaging.
• Patient having focal neurological symptoms or having
unexplained neurological deficits or an otherwise rapid,
unexplained progression of symptoms - MRI should be
strongly considered.

30. COMMON DISORDERS CAUSING
VERTIGO

31. VESTIBULAR NEURITIS
• Rapid onset of severe vertigo, nausea, vomiting, and
imbalance.
• Symptoms gradually resolve over several days, but some
symptoms can persist for months.
• Etiology - probably viral.
• Benign and self-limited
• Diagnosis - Peripheral vestibular pattern of nystagmus and a
positive head-thrust test in the setting of a rapid onset of
vertigo without other neurological symptoms.

32. • The mainstay of treatment is symptomatic.
• A course of corticosteroids has been shown to improve
recovery of the caloric response but has not been shown to
improve the functional or symptom outcome (Fishman et al.
2011).
• Vestibular physical therapy can help patients compensate for
the vestibular lesion
VESTIBULAR NEURITIS

33. BENIGN PAROXYSMAL POSITIONAL VERTIGO
(BPPV)
• Most common cause of vertigo in the general population.
• Patients typically experience brief episodes of vertigo when
getting in and out of bed, turning in bed, bending down and
straightening up, or extending the head back to look up.
• Repositioning maneuvers are highly effective in removing the
debris from the canal, though recurrence is common.
• Once the debris is out of the canal, patients are instructed to
avoid extreme head positions to prevent the debris from re-
entering the canal.
• Patients can also be taught to perform a repositioning
maneuver if they have a recurrence of the positional vertigo.
• Medication not indicated, as it is a mechanical problem.

34. MENIERE DISEASE
• Characterized by recurrent attacks of vertigo associated with
auditory symptoms (hearing loss, tinnitus, aural fullness)
during attacks.
• Gradually followed by progressive hearing loss.
• Attacks variable in duration, mostly lasting > 20 minutes, and
associated with severe nausea and vomiting.
• Course of disease highly variable.
• For some patients, the attacks are infrequent and decrease
over time, but for others they can become debilitating.

35. • Occasionally auditory symptoms are not appreciated by the
patients or identified by interictal audiograms early in the
disorder.
• But eventually patients develop these features, usually within
the first year.
• Usually unilateral, Bilateral in about 1/3 patients.
• Endolymphatic hydrops or expansion of the endolymph
relative to the perilymph regarded as the etiology, though
exact cause unclear.

36. • Some patients with confirmed disease experience abrupt
episodes of falling to the ground, without loss of
consciousness or associated neurological symptoms (Otolithic
catastrophes of Tumarkin).
• Patients report the sensation of being pushed or thrown to
the ground often resulting in fractures or other injuries.
• Bedside interictal examination - may identify asymmetrical
hearing
• Head-thrust test is usually normal.

37. • Treatment – includes aggressive low-salt diet and diuretics
(Poor evidence).
• Long-term administration of Betahistine-dihydrochloride
(3 X 48 mg/d for 12 mo) have been reported to have positive
effects on the frequency of attacks.
– The goal of therapy is freedom from attacks for at least 6
months; then the dosage can be slowly reduced every 3
months, depending on the course.
– Long-term treatment, often for many years.
• Intratympanic gentamicin injections can be effective and are
minimally invasive.
• Sectioning of the vestibular nerve and destruction of the
labyrinth are other procedures (Minor et al. 2004).

38. FAMILIAL BILATERAL VESTIBULOPATHY
• Patients typically have brief attacks of vertigo (seconds)
followed by progressive loss of peripheral vestibular function
leading to imbalance and oscillopsia, usually by the fifth
decade.
• Recurrent attacks of vertigo may cause damage to vestibular
structures, leading to progressive vestibular loss.
• Bedside head-thrust test may show bilateral corrective
saccades when vestibulopathy is severe.
• As the vestibulopathy becomes more severe, attacks of
vertigo become less frequent and eventually cease.
• No gene mutations identified till date.

39. PHARMACOTHERAPY OF VERTIGO

40. VESTIBULAR SUPPRESSANTS

42. • GINKGO BILOBA IN VERTIGO :-
– A multicenter clinical trial was performed to compare the
efficacy and safety of Ginkgo biloba extract EGb 761 and
betahistine at recommended doses in patients with vertigo.
– 106 patients were randomly assigned to double-blind treatment
with EGb 761 (240 mg per day) or betahistine (32 mg per day)
for 12 weeks.
– Two drugs were similarly effective in the treatment of vertigo,
but EGb 761 was better tolerated.
– Ginkgo biloba extract EGb 761 enhances cerebral and vestibular
blood flow by decreasing blood viscosity .
– It improves neuronal plasticity as well as mitochondrial function
and energy metabolism and protects neurons from oxidative
damage.
Treatment of Vertigo: A Randomized, Double-Blind Trial Comparing Efficacy and Safety
of Ginkgo biloba Extract EGb 761 and Betahistine : International Journal of Otolaryngology
Volume 2014 (2014)

43. • PIRACETAM IN VERTIGO :-
– Piracetam has been shown to be effective in vertigo of
both central and peripheral origin.
– Thought to act on vestibular and oculomotor nuclei in the
brain stem and thus on the central control of balance
enhancing mechanisms of compensation and habituation.
– Piracetam alleviates vertigo after head injury, vertigo of
central origin as, for example, in vertebrobasilar
insufficiency and in peripheral vestibular disorders,
especially in middle-aged and elderly subjects.
– Piracetam decreases the frequency but probably not the
severity of exacerbations in patients with chronic or
recurrent vertigo.
– The usual dosage of piracetam in vertigo is 2.4-4.8 g daily.

44. CANAL REPOSITIONING
THERAPIES (CRT)

45. EPLEY’S MANEUVRE FOR POSTERIOR CANAL BPPV

46. SEMONT MANEUVRE FOR TREATMENT OF
POSTERIOR CANAL BPPV

47. LEMPERT (BBQ) MANEUVRE
FOR HORIZONTAL CANAL BPPV

48. ROLL MANEUVRE
FOR HORIZONTAL CANAL BPPV

49. GUFONI MANEUVRE
FOR HORIZONTAL CANAL BPPV

50. DEEP HANGING MANEUVRE
FOR ANTERIOR CANAL BPPV

51. VESTIBULAR REHABILITATION THERAPY

52. BRANDT-DAROFF EXERCISES

53. CAWTHORNE COOKSEY EXERCISES
• Were devised in 1940s.
• Mainly for unilateral vestibular lesions.
• Initially, the exercises performed are slow gradually increasing
speed as patient tolerates the movement.
• The patient should experience an increase in symptoms with
movement.
• Exercises performed for at least 1 minute several times each
day for adaptation to occur.
• Advantage - low-cost and effective.

57. 1. With object fixed & head moving
2. With head fixed & object moving
3. With both head and object moving in opposite direction
4. With object fixed and subject asked to jump up and down
slowly on a Trampoline (Otolothic stimulation)

60. THANK YOU

61. REFERENCES
• Bradley’s Neurology in clinical practice 7th edition
• Adams & Victor’s Principles of Neurology 10th edition
• Localization in Clinical Neurology: Brazis :6th edition
• DeJong’s The Neurologic examination : 7th edition
• Vertigo – A clinical approach : Medicine Update 2010
• Practice Parameter: Therapies for benign paroxysmal
positional vertigo (an evidence-based review)

62. REFERENCES
• Vestibular Rehabilitation : An Overview : HS Writer
• Seminars in Neurology : Neuro-otology
• An update on pharmacotherapy of vertigo : J. Chem.
Pharm. Res., 2010, 2(3):381-386