vertigo topics for undergraduate ,mbbs/md/fcps

VERTIGO
Understanding the Causes
Symptoms, and Management.
PMC-13, C-
BATCH

• FATHIMA THAMANNA M P(Host)
• ARMAN HOSSEN
• MINHAJ- US- SIRAJ
• BUBLY ROY
• K.M. TOWSIFE ISLAM
• FOYZUNNESA KARIMA
• MD HASAN MIA
PRESENTED BY

•Defination of vertigo
•Classification of vertigo
•Anatomy & physiology of balance
•Pathophysiology of vertigo
•Symptoms & signs of vertigo
•Examinations & Investigation
•Management
•Rehabilitation of choronic vertigo
•WHAT WE
WILL
LEARN
TODAY-

Balance of the body during static or dynamic position is
maintained by 4 organs -
Vestibular apparatus Eye
Cerebellum
Posterior column of spinal
cord

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Function of vestibular system is to-
• Provide general orientation of the body with respec
to gravity
• Enable balance locomotion & body position
• Readjust autonomic functions after body
reorientation
• Ensure gaze stabilizer
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1. Visual Input for Orientation
• Provides information about body position in space relative to the
environment.
2. Assists in Postural Stability
• Helps maintain balance by coordinating with the vestibular and
proprioceptive systems.
3. Role of Visual Fixation
• Stabilizes gaze during head movement (via the Vestibulo-Ocular Reflex -
VOR).
4. Detects Movement and Direction
• Helps in detecting motion (e.g., moving horizon, shifting floor) to adjust
body posture.
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Function of the Brain in Balance-
1. Integration Center
• Receives signals from the vestibular system, visual system, and
proprioceptors.
• Combines information to assess body position and motion.
2. Cerebellum:
• Coordinates balance, posture, and fine motor control.
• Adjusts muscle activity for smooth movement.

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3. Brainstem:
• Processes vestibular input and initiates reflexes (e.g., vestibulo-
ocular reflex).
• Connects vestibular nuclei with eyes and limbs for quick
adjustments.
4. Cerebral Cortex:
• Provides conscious awareness of balance and spatial orientation.
• Helps plan and control voluntary movements.

“Vertigo is defined as an abnormal
perception of movement of the
environment or self, and occurs because
of conflicting visual, proprioceptive and
vestibular information about a person's
position in space”
Definiti
on
ref- Davidson,24th edition

Vertigo is the typical symptom caused by vestibular
dysfunction, and
most patients with vertigo have acute vestibular failure,
benign paroxysmal positional vertigo or Ménière's
disease. Central (brain) causes of
vertigo are rare by comparison, with the exception of
migraine.
VERTIGO

Central vertigo
classification
• Originates from the brainstem or cerebellum
Peripheral vertigo
• Originates from the vestibular apparatus
or
vestibular nerve (VIII cranial nerve)

• Vestibular migraine – common ENT central vertigo mimic.
• Central positional vertigo – nystagmus not fatigable, direction-
changing.
• Vertebrobasilar insufficiency – due to vascular compromise of
brainstem/cerebellum.
• Tumors affecting the vestibular nucleus or cerebellar pathways.
• Arnold-Chiari malformation – brainstem herniation
affecting balance centers.
causes of central
vertigo

• Stroke or TIA – especially involving the brainstem or
cerebellum.
• Multiple Sclerosis (MS) – demyelination in vestibular pathways.
• Tumors – cerebellopontine angle tumors (e.g., brainstem
glioma, ependymoma).
• Migraine (Vestibular migraine) – dizziness with or without
headache.
• Neurodegenerative diseases – Parkinson’s disease,
spinocerebellar ataxias.
• Epileptic vertigo – rare, seen in temporal lobe epilepsy.
• Trauma – concussion or diffuse axonal injury involving central
vestibular areas.
Wernicke’s encephalopathy – due to thiamine deficiency (often in
alcoholics).
causes of central
vertigo

• Nystagmus – especially vertical or direction-changing
gaze-evoked nystagmus (central sign).
• Internuclear ophthalmoplegia (INO) – seen in MS or
brainstem stroke.
• Skew deviation – vertical misalignment of the eyes
(often in brainstem lesions).
• Ocular migraine – transient vertigo with visual aura.
• Brainstem lesions – causing ocular movement
abnormalities.
Parinaud syndrome – vertical gaze palsy from
dorsal midbrain lesion.
causes of central
vertigo

• Ménière’s Disease
• Cholesteatoma
• Middle ear growth can erode inner ear
structures and cause vertigo.
• Perilymph Fistula - Abnormal connection
between inner ear and middle ear,
often after barotrauma or surgery.
CAUSES OF PERIPHERAL
VERTIGO

• Benign Paroxysmal Positional Vertigo (BPPV)
• Defect in bony canal of semicircular canal causing sound-
induced vertigo.
• Eustachian Tube Dysfunction or Otitis Media (less
commonly)
• Vestibular Neuritis
• Inflammation of the vestibular nerve, usually viral;
sudden severe vertigo without hearing loss.
• Labyrinthitis
• Infection of the labyrinth; vertigo with
hearing loss and tinnitus.

• Most common cause; triggered by head movements
due to displaced otoliths.
• Oscillopsia
• Vestibulo-ocular Reflex (VOR) Disruption
• Visual Vertigo (triggered by visual stimuli like
moving patterns, often in patients with vestibular
hypofunction)

• Episodic vertigo, fluctuating hearing loss, tinnitus,
and ear fullness; due to endolymphatic hydrops.
• Ototoxicity
• Damage from drugs (e.g., aminoglycosides, loop
diuretics).
• Trauma (e.g., Temporal bone fracture)
• Disruption of the vestibular apparatus.

EYE CAUSES OF VERTIGO
1. Refractive Errors (Uncorrected or Sudden Change in Glasses
Hypermetropia, myopia, astigmatism
Large or sudden change in prescription → visual distortion → sensory
mismatch → vertigo-like symptoms.
Often worse with progressive lenses or bifocals.
2. Ocular Muscle Imbalance
Strabismus (latent or manifest)
Convergence insufficiency or excess
Causes double vision, blurred focus → disorientation, dizziness.

3. Ocular Motor Nerve Palsies
CN III, IV, or VI palsy → diplopia and disturbed spatial orientation.
Can be due to microvascular ischemia, trauma, or raised intracranial
pressure.
4. Nystagmus of Ocular Origin
Congenital nystagmus or acquired nystagmus from ocular pathology → visual
instability → perceived vertigo.
5. Vestibulo-ocular Reflex Disorders
Disruption of the reflex pathway due to ocular or vestibular dysfunction →
impaired gaze stabilization.

6. Binocular Vision Disorders
Poor binocular coordination after head injury or eye surgery → causes
“swimming” vision and vertigo-like symptoms.
7. Cataract or Corneal Opacities
Especially when unilateral or asymmetric — causes unequal visual input →
brain interprets mismatched signals as dizziness.
8. Aniseikonia
Significant difference in image size between two eyes (e.g., after cataract
surgery in one eye) → spatial disorientation and vertigo.
9. Rapid Onset Monocular Vision Loss
Sudden loss of input from one eye (e.g., retinal detachment, CRAO) →
imbalance in visual-vestibular processing.

• Duration, frequency, and triggers of vertigo
• Associated symptoms: hearing loss, tinnitus,
nausea, vomiting, headache, diplopia
• Physical exam: Dix-Hallpike test, Head Impulse
Test, Romberg’s test
Management
History and Examination

1. Radiological
• X-ray mastoid Stenver’s view
• Submento -vertical view CA axial
2. CT scan / MRI
3. Audiometry
• PTA
• SRT
• Impedance
INVESTIGATIONS

4.Angiogram
5. Ultrasound of vessels
6. Laboratory tests
• Caloric test
• Electronystagmography
• Rotation test
INVESTIGATIONS

X-ray mastoid Stenver’s view

Treatment
• reassurance
• bed rest
• cessation of smoking
• less salt intake
• avoid excessive intake of water
• avoid of stress
• avoid activities like flying,
underwater driving
general
managem
ent
Vestibular rehabilitation therapy (VRT)
Psychological support if anxiety is a
component

Rehabilitation
1. Gaze stabilization exercises
2. Balance exercises
3. Habituation exercises
4. Repositioning maneuvers
5. Epely’s maneuvers

Ménière’s
Disease
Treatment based on Causes
Medications:
Prochlorperazine (15–75 mg/day)
Diuretics (e.g., hydrochlorothiazide)
In case of acute attacks - Vestibular suppressants
(e.g., cinnarizine, promethazine, diazepam)
FOR RESISTANT CASES
• Intratympanic steroid injection or gentamicin
• Long-term follow-up and hearing evaluation
• Surgery (rare): Endolymphatic sac decompression or
labyrinthectomy

Benign Paroxysmal Positional Vertigo
(BPPV)
• Patient reassurance
• No long-term medications required
• Epley Maneuver (repositioning crystals)
Short-term vestibular suppressants:
• Cinnarizine 25–75 mg/day
• Betahistine 16–48 mg/day

Vestibular Neuronitis
• Vestibular suppressants: Meclizine, promethazine, or
cinnarizine for 3–5 days
• Antiviral drugs (if viral suspected, e.g., herpes simplex)
• Anti-emetics if vomiting present (Ondansetron or
domperidone)
• Steroids ( prednisolone tapering dose)
• Vestibular rehabilitation exercises after acute phase

Labyrinthitis
• Antibiotics (if bacterial)
• Antiviral drugs (if viral suspected, e.g., herpes
simplex)
• Corticosteroids (e.g., prednisolone tapering dose)
• Vestibular suppressants and antiemetics
• Vestibular rehabilitation therapy

Cerebrovascular Causes
Posterior circulation stroke or TIA-
• MRI of Brain + MRA or CT Angiogram
• Aspirin/clopidogrel, statins, BP control
• Anticoagulants (if cardioembolic stroke)
Migraine-Associated Vertigo
History of migraine + vertigo
Treat as vestibular migraine:
Acute: NSAIDs, triptans
Prevention: Propranolol, flunarizine, amitriptyline

Systemic Causes
• Anemia
CBC, correct iron/B12 deficiency
• Hypoglycemia / Hyperglycemia
Check blood sugar, manage
accordingly

Drug-Induced Vertigo
• Aminoglycosides, anticonvulsants,
antihypertensives, antidepressants
• Review and adjust medications

PROF. DR. ABDUL AZIM
MBBS, FCPS (ENT)
HOD, Ear, Nose, Throat & Head Neck
Surgery Department
GRATEFUL TO OUR TEACHERS AND MENTORS
FOR THEIR GUIDANCE AND SUPPORT
ASSOC. PROF. DR. MD.
SAZEDUL ISLAM SAZED
MBBS, CCD, DLO
ASSOC. PROF. DR. MD.
RAFIQUL ISLAM
MBBS (R.U) DO (D.U)
HOD, OPTHALMOLOGY DEPT.
Dr. Ratindra Nath
Mondal (Ratin)
MBBS, FCPS (Medicine)
Asso Pro of Medicine
Dr. Md. Anoarur
Rahman Anon
MBBS (CMC), DLO (ENT)
Register

thank
YOU
FOR YOUR ATTENTION.
"peace be
upon you"

vertigo topics for undergraduate ,mbbs/md/fcps

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