Vertigo sushmita

DIZZINESS $
VERTIGO
DR.SUSHMITA PAL
Sunday, May 09, 2010

ORIGIN :
from Latin word
“vertÖ”
“A spinning or whirling
sensation”

DEFINITIONS :
• A sensation of swaying or tilting
• A sense of spinning or motion of the environment
• A type of dizziness
• A symptom of illusory movement

Causes
Vestibular
 Peripheral
 Central
 Medical causes(BP/
Arrhythmia / angina/
hypoglycemia /
anemia/drugs , etc.)
 Psychiatric (phobic
disorders/
hyperventilation)
Non
Vestibular

• Peripheral
 BPPV
 Vestibular neuritis
 Meniere’s disease
 Ototoxic drugs
 Perilymph fistula
 SCD Syndrome
 Acute labyrinthitis
 Post concussion
 Motion sickness
 Acoustic neuroma
• Central
 Stroke(vertebro basilar
insufficiency,
Wallenberg syndrome)
 Cerebellar
disorders(tumors/
haemorrage)
 Multiple sclerosis
 Basilar artery migraine
 Vestibular migraine
 Cervical vertigo

APPROACH TO A DIZZY PATIENT
 Appropriate history ( type of vertigo , its
duration , triggering factors, certain
associated symptoms, its frequency)
Forms/types of vertigo: Rotatory Postural
Duration: Attacks/episodes Persistent
Triggers:
viz . Change in position
Yes No
Assosiated symptoms:
viz. hypoacusis, double
vision, ataxia
Yes Yes/No
Site of origin PERIPHERAL
(labyrinth/ vestibular
nerve)
CENTRAL
(Brain stem/cerebellum/
cortex)

General medical examination:
BP (for hypo and hypertension)
Cardiac examination : for arrhythmia , murmurs
and bruit.
Neurological examination : for cerebellar
integrity and CN examination.
Ophthalmological examination: for
papilloedema , nystagmus saccades/smooth
pursuit.
Audio vestibular examination : inspection of TM ,
TFT with or without Pure tone audiometry.
And an array of vestibular tests.

VEsTIbulAR AssEssmE NT
CliniCal tests
 Spontaneous
nystagmus
 Halmygi’s head thrust
test
 Fistula tests
 Past pointing/Gait
 Romberg’s test
 Positional test (Dix-
Hallpike maneuver)
laboratory tests
 Caloric tests
 Cold caloric/modified
Kobrak
 Fitzgerald Hallpike
bithermal caloric test
 Cold air caloric test
 Electronystagmography
 Rotation test
 Posturography
 Optokinetic test

MANAGEMENT OF VESTIBULAR
DISORDERS
 Physiotherapy : certain vestibular
exercises eg.
Semont’s/Epley’s
maneuver
 Medical management using vestibular
suppressants ( cinnarizine ,
promethazine) , vestibular vasodilators (
betahistine ) , anabolic steroids ,
antibiotics , etc.
 Psychological/psychiatric and
behavioral therapy
 Surgical management ( eg.
Endolymphatic decompression,
Resection of neuroma , etc.)

Patient with h/o momentory( about 10 sec) rotatory vertigo ,
as soon as he gets up from the bed or goes to bed
BENIGN POSITIONAL PAROXYSMAL VERTIGO
 Occurs with head movts or head roll
 No numbness/headache/ear symptoms
 Nausea/vomiting/oscillopsia may be +nt.
 Positional test is diagnostic.
Turn the head to Lt (45 degree) while sitting, then make him lie
down towards Rt, shake the head, and w/f nystagmus.
The nystagmus is rotatory / vertical, beating towards the
forehead.

Treatment:
• Liberatory movements : 3 times TID
turn the head to R side(nonaffected) 45 degrees ,
move the patient to lie towards opposite side (L)
again move him 180 degree away to lie on the
opposite side (R)
These movements accentuates the postural imbalance momentarily,
But it is actually beneficial within a span of 3 -4 days.
These movts are done to teach the otoconias in the ear.

TREATING MANEUVERS
EPLEY’S
Turn the head 45 degree hrztally
towards affected side
Tilt him backwards to horizontal
position, with yet the same
head tilt. Vertigo ppts. Maintain
the same position until vertigo
stops.( debris moves towards
the apex).
Head is turned 90 degree towards
unaffected side,also pt is rolled
towards unaffected side so
that face is towards the floor.
(debris moves back in the
canal, vertigo ppts).
Pt is seated with head down tilt of
30 degree, brings the otoconia
back in the utricle
SEMONT
Turn the head 45 degree hrztally
same towards unaffected side
Tilt 105 degree to make him lie on
affected side , head hanging &
nose pointed upwards(3
min).Debris moves to the apex
of the canal.
Now, moving him 180 degree
from aff to unaff side with nose
pointing downwards.Debris
moves towards the exit of the
canal.
He is slowly seated. Debris gets
back in the vestibule.

Patient with h/o rotatory vertigo , lasts for an hr to 7
hrs, usually once or twice a week, associated with
heaviness of ear/head & diminished hearing.
MENIERE’S DISEASE
• Tinnitus + aural fullness
• Vertigo lasts minimum for about 20 min.
• Best way to prevent the vertigo is to prevent the
hydrops
• Prophylactic Rx: Betahistine 48 mg TID : 9- 10 mths
Intratympanic injection of gentamycin

H/o rotatory vertigo , since 2 or 3 days , continous ,
with imbalance, nausea /vomiting +
VESTIBULAR NEURITIS
• High grade fever+ nt ; invariably with raised counts
• Lasts for 5 days to 2 or 3 wks
• Spontaneous oscillopsia +nt
• Hrztal nystagmus +nt towards healthy side
suppressed by visual fixation
• Pathological head thrust test
• +ve Romberg’s test (sway towards affected side)
• Viral etiology(HSV/HZV)
• While walking , surroundings are hazy/unable to
read, & while stable , everything is clear.

Management:
 Symptomatic treatment
 Vestibular suppresants for 3 – 5 days
eg. Dimenhydrinate,
Clonazepam,
Cinnarizine
 Increasing the inner ear circulation eg. Betahistine
 Treating the pathology using
MPA( 100 mg /day) +/- antivirals
 Vestibular exercises for 30 min TID : to improve the
central vestibular compensation

H/o recurrent attacks of rotatory vertigo , nausea+/-
vomiting,headache , lasting for min to hrs
VESTIBULAR MIGRAINE
• Other migrainous symptoms +nt
• During the attack :
pathological head thrust test + postural imbalance
• During the attack free period :
peripheral vestibular deficit signs are +nt
but not postural imbalance
•
o in the line of migraine (prophylaxis & treatment)
o And vestibular suppressants.

H/o postural vertigo , episodic, lasting for few minutes
PHOBIC POSTURAL VERTIGO
• Normal neurological signs
• Subjective instability of gait
( fear of falling)
• Vegetative disturbances
• Triggering factors: eg.
Crowd of people , entering a
car/lift/store/room
• Management :
i. Improves with alcohol
ii. SSRI eg. Fluvoxamine
iii. Psychoeducational +
Behavioral therapy
STROKE
• Neurological signs +nt
• Impaired Tandem walking
• Ataxia & other cerebellar
signs +nt
• H/o fall with injury +nt
• Spontaneous nystagmus +nt
• Principle of treatment is to
augment the circulation

• CERVICAL VERTIGO
Postural vertigo , associated with certain neck movements and
it lasts for few minutes , no neurological signs , X ray is
diagnostic in spondylosis.
Management : avoid chiropractic maneuvers
and Betahistine to improve vestibular circulation.
• MOTION SICKNESS
Physiological vertigo
Rotatory vertigo , triggered by motion due to mismatch of two
different stimulus (eye & vestibule) viz. car sickness, space
sickness , sea sickness etc.
• OTOTOXICITY
Due to the vestibulotoxic drugs eg. Streptomycin , gentamycin ,
tobramycin etc.
• BASILAR MIGRAINE :
postural vertigo + dysarthria + diplopia + tinnitus

THANK YOU

Vertigo sushmita

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