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![CRANIOCORPOGRAPHY
Developed by Claussen [1968]
Assessment of vestibulospinal system
Photographic recording of head and body movement during
gait testing
Evaluation includes Romberg, Tandem walking and
Unterburger’s test](https://image.slidesharecdn.com/vertigo-makingitsimple-150212071851-conversion-gate02/75/Vertigo-making-it-simple-18-2048.jpg)
![PARAMETER NORMAL RANGE-
LOWER BORDER
NORMAL RANGE-
UPPER BORDER
Longitudinal
displacement
30.03 cm 113.35 cm
Lateral sway 5.17 cm 16.15 cm
Angular deviation 55.13° (right) 48.37° (left)
Body spin 82.21° (right) 82.89° (left)
NORMAL PARAMETER OF
CCG
[CLAUSSEN]](https://image.slidesharecdn.com/vertigo-makingitsimple-150212071851-conversion-gate02/75/Vertigo-making-it-simple-20-2048.jpg)
![ Subject seated upright with eyes focused on an fixed object
Unpredictable , low amplitude [10 – 20°] head rotation with
high acceleration
Angular VOR generates compensatory eye movements
equal in amplitude and opposite in direction to stabilize
gaze
HIT : PROCEDURE](https://image.slidesharecdn.com/vertigo-makingitsimple-150212071851-conversion-gate02/75/Vertigo-making-it-simple-27-2048.jpg)
![POSTERIOR CANAL BPPVPOSTERIOR CANAL BPPV
Most common– posterior canal is most gravity dependent in
upright and supine position
Once debris enter the post. canal ,the cupula at the shorter
most dependent arm trap the debris.
Debris can exit only through the longer arm through the crus
commune [non-ampullary]](https://image.slidesharecdn.com/vertigo-makingitsimple-150212071851-conversion-gate02/75/Vertigo-making-it-simple-37-2048.jpg)
Uploaded byDr. Anita Bhandari
Vertigo - making it simple
1) Vertigo can be caused by issues in the inner ear lasting seconds to years, with the most common causes being BPPV, vestibular neuritis, and Meniere's disease. 2) A neurotological evaluation includes tests of the vestibulo-ocular, vestibulospinal, and otolith systems like head impulse testing, caloric testing, and subjective visual vertical to locate the source of imbalance. 3) BPPV is diagnosed and treated with particle repositioning maneuvers like Epley and Semont maneuvers to move calcium carbonate debris out of the semicircular canals. Other causes like cupulolithiasis may require different treatments.
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Vertigo - making it simple
- 1. VERTIGO – MAKING ITSIMPLE DR.ANITA BHANDARI CONSULTANT NEUROTOLOGIST VERTIGO AND EAR CLINIC, JAIPUR
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- 6. MATTER OF CONCERN Moreamenable to treatment -more sinister consequences
- 8. Seconds –late ototoxicity Minutes – BPPV, TIA Hours – Meniere’s disease , Migraine related vertigo Days – Vestibular neuritis Months – years - Hysterical
- 10. Spatial orientation Ocular stabilization Postural control EQUILIBRIUM
- 13. A batteryof tests Many systems to be evaluated to assess structural and functional integrity NEUROTOLOGICAL EVALUATION
- 14. For An ENTSpecialist, We look at the ears first. In vertigo --> eyes are most important
- 15. Otoliths actas gravito-inertial force detectors SVV is a psychophysical measure of the angle between perceptual vertical and true/gravitational vertical Also used to measure vestibular rehabilitation Compensated utricular hypofunction may be detected on dynamic SVV testing. The defect will be unmasked on eccentric rotation because any otolith function asymmetry will be enhanced. SVV
- 16. Pt isasked to adjust the orientation of a luminous bar until they perceive it as vertical SVV – saccule and its central pathways SVH – utricle and its central pathways Pinar et al reported changes in SVV and SVH in >25% pts of chronic dizziness concluding that evaluation of the otolith system is mandatory SUBJECTIVE VISUAL VERTICAL AND HORIZONTAL
- 17. SVV FINDING CONDITION Normalrange Upto 2° deviation Ipsiversive tilt – >2o peripheral vestibular disorder pontomedullary lesion thalamic lesion Controversive Pontomesencephalic lesion parietoinsular vest. lesion Migraine Abnormal, little literature
- 18. CRANIOCORPOGRAPHY Developed byClaussen [1968] Assessment of vestibulospinal system Photographic recording of head and body movement during gait testing Evaluation includes Romberg, Tandem walking and Unterburger’s test
- 19. Done indark room Pt is blindfolded Pt wears a helmet with LED lights Path of the pt is recorded using an SLR camera Result depends on vestibular system only as visuals cues cut off – pt is blindfolded and by stepping in one place, the soles intermittently lose contact with the floor thus reducing somatosensory input CCG : PROCEDURE
- 20. PARAMETER NORMAL RANGE- LOWERBORDER NORMAL RANGE- UPPER BORDER Longitudinal displacement 30.03 cm 113.35 cm Lateral sway 5.17 cm 16.15 cm Angular deviation 55.13° (right) 48.37° (left) Body spin 82.21° (right) 82.89° (left) NORMAL PARAMETER OF CCG [CLAUSSEN]
- 21. PATHOLOGY CCG FINDINGS Peripheralvestibular lesions Ipsilateral deviation Brainstem lesion, bilateral peripheral vestibulopathy Enlarged lateral sway, no angular deviation CPA tumors, PICA synd. Contralateral deviation, enlarged sway INTERPRETATIONS OF CCG
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- 25. Introduced byHalmagyi and Curthoy Simple, fast, reliable Tests scc function – can evaluate all 3 pairs Measures high freq. vestibular response in 3 dimensions HEAD IMPULSE TESTING
- 26. VHIT –using Video Frenzel glasses Test for gaze stabilization during rapid translation of head Assesses the peripheral utricular system and superior vestibular N A corrective saccade after VHIT indicates hypofunction of same side HEAD IMPULSE TEST
- 27. Subject seatedupright with eyes focused on an fixed object Unpredictable , low amplitude [10 – 20°] head rotation with high acceleration Angular VOR generates compensatory eye movements equal in amplitude and opposite in direction to stabilize gaze HIT : PROCEDURE
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- 29. Nystagmus indicatesan imbalance in vestibular tone between the 2 sides Not seen in bilateral vestibular dysfunction HEAD SHAKING TEST
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- 31. HEAD SHAKING –DOWN BEATING NYSTAGMUS
- 32. Functional testof VOR Comparison of visual acuity with head still to VA with head moving Reduction by 2 lines indicates dysfunction of VOR as seen in bilateral peripheral vestibulopathy Improvement with rehab will improve DVA Early sign of vestibular toxicity DYNAMIC VISUAL ACUITY TEST
- 33. BPPV AND PARTICLEREPOSITIONING MANEUVERS
- 34. The ampullacontains the cupula – a gelatinous mass with the same density as the endolymph.Cupula forms an impermeable barrier across the lumen of the ampulla. Hence the particles in scc may only exit via the end with no ampulla.
- 37. POSTERIOR CANAL BPPVPOSTERIORCANAL BPPV Most common– posterior canal is most gravity dependent in upright and supine position Once debris enter the post. canal ,the cupula at the shorter most dependent arm trap the debris. Debris can exit only through the longer arm through the crus commune [non-ampullary]
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- 42. SEMONTSEMONT’’S MANEUVERS MANEUVER Liberatory maneuver for pBPPV and cupulolithiasis Used to overcome otoconia jam after Epley’s maneuver
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- 45. BRANDT – DAROFFEXERCISESBRANDT – DAROFF EXERCISES Used as a home program Indications o Posterior canal cupulolithiasis o Persistant posterior canal canalithiasis Mechanism o Dislodge debris attached to cupula o Habituation through central compensation
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- 47. BRANDT – DAROFFEXERCISESBRANDT – DAROFF EXERCISES Things to remember o The exercises may dislodge more otoconia from the utricle causing an increase in symptoms. o May cause multiple canal involvement. o Important to hold for 30 seconds in each position.
- 49. HORIZONTAL SCC BPPVHORIZONTALSCC BPPV Pagnini-McClure maneuvre Geotropic nystagmus – debris are away from ampulla , side showing stronger nystagmus is the side involved Apogeotropic nystagmus – indicates cupulolithiasis
- 50. McCLURE PAGNINI MANEUVERMcCLUREPAGNINI MANEUVER SUPINE ROLL TESTSUPINE ROLL TEST
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- 55. VANUCCHI MANEUVERVANUCCHI MANEUVER Forced prolonged positioning Sleep in lateral position with healthy ear down for 12 hours.
- 56. CUPULOLITHIASISCUPULOLITHIASIS Coined bySchuknetch Rare , more common in horizontal canal Caused by otoliths attached to cupula of scc When cupula is horizontal no vertigo When non-horizontal constant input persistant dizziness Nystagmus : persistant non-fatiguable as long as patient is in the same position
- 57. SUBJECTIVE BPPVSUBJECTIVE BPPV No nystagmus is detected but patient feels dizzy on provocative tests PRP beneficial Reasons o Subtle nystagmus o Fatigued nystagmus o Inadequate neural signal to stimulate the VOR
- 58. CONTRAINDICATIONS OFCONTRAINDICATIONS OF PARTICLEREPOSITIONINGPARTICLE REPOSITIONING Cervical spine problems Uncontrolled hypertension Retinal detachment
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- 60. NO COMMON TREATMENTFOR ALL PATIENTS. Therapeutic approach requires recognition of the pathomechanism Detailed history Clinical examination Neurotological tests Imaging
- 61. Aim Of VertigoTherapy Elimination of Vertigo Enhancement/non-compromise of “Vestibular compensation” Reduction of Psychoaffective syndromes Nausea and Vomiting Anxiety Thomas Brandt – Vertigo; A mutlisensory system disorder, 2nd edition. Springer –Verlag- London 2002
- 62. Vestibular Suppressants Rascol Oet al, Drugs 1995; 50: 777-91 Lacour M. Curr Med Res Opion 2006; 22: 1651-9 Reduction in the symptom of vertigo comes at a price of reduction in vestibular function
- 63. Treatment with VestibularSuppressants Suppressants reduce activity at intact side and thus hamper recovery by VC Not recommended for long term use They should be discontinued as soon as possible Lacour M. Curr Med Res Opion 2006; 22: 1651-9 Vestibular Nuclei INTACT DAMAGED
- 64. Vestibular Suppressants Usefulfor prevention of nausea and reduce vomiting (generally to be used for not more that 1-3 days) post an event Should be discontinued as soon as possible after event subsides They are not to be used chronically or for prophylaxis against subsequent attacks Lacour M. Curr Med Res Opion 2006; 22: 1651-9 Goebel J. Otolaryngol Clin N Am 2000; 33: 483-93 Brandt T, Vertigo. Its Multisensory Syndromes, 2nd Ed: Pg 49-61
- 65. ANTI-CHOLINERGIC DRUGS Suppress spontaneousfiring of Vestibular nuclei 2ND & 3RD order neurons Reticulo-vestibular pathway
- 66. ANTI- HISTAMINICS Histamineis not a major neurotransmitter in the vestibular pathway It exerts effect by acting on H1 receptors antagonist Structure of H1 receptors is similar to Muscaranic receptors Drug which blocks H1 receptors will also have an anti- cholinergic effect
- 67. Cinnarizine: Mechanism ofAction Drugs of Today, 1982;18(1):27-42 Ca+2 Channel Blocker
- 68. BETAHISTINE Historically seen thathistamine relieved vertigo. However had to be given IV and had serious side effects. Betahistine is a histamine analogue having the advantages of histamine like action without its side effects.
- 70. DRUG COMBINATIONS Anti-histaminicsare H1 receptor antagonists Betahistine is H1receptor agonist and H3 receptor antagonist Hence these drugs should not be combined.
- 71. VESTIBULAR REHABILITATION VRT comprisesof a series of maneuvers designed to stimulate the vestibular system. These movements which in the initial stages provoke vertigo, are combined with exercises involving eye movements and postural changes which encourage vestibular compensation.
- 72. TAILORING THE REGIMEN Vestibulo-ocular system Vestibulospinal system Otolithic system
- 73. Pts areasked to perform repeated head ,eye and body movements which will help the brain recalibrate the relationship between visual, vestibular and proprioceptive signals.
- 74. Bouncing onSwiss balls or mini-tramps may be advocated to build up the otolith-ocular reflex as well as otolith-postural reflexes.
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- 76. CENTRAL COMPENSATION Adaptation– ability to regain spatial orientation Substitution – as there is a derangement in function, using different pathways to maintain equilibrium Habituation – repeated maneuvres aimed at stimulating the sensory mismatch and lead to desensitization.