1. Vertigo

2. วัตถุประสงค์
 1.ระบุอาการและอาการแสดงของกลุ่มอาการเวียนศีรษะที่
พบบ่อย ๆ ได้
 2.วินิจฉัยและวินจฉัยจำาแนกโรคได้จากประวัติและการ
ิ
ตรวจร่างกาย แยก peripheral vertigo ออกจาก
central vertigo ได้
 3.อธิบายแนวทางการส่งตรวจทางห้องปฏิบัติการเพือให้
่
ได้การวินิจฉัยโรคได้
 4.อธิบายหลักการและแนวทางในการรักษากลุ่มอาการ
เวียนศีรษะได้
 5.ประเมินขีดความสามารถในการดูแลผู้ป่วย และส่งต่อ

3.  การรักษาการสมดุลย์ของการทรงตัวต้อง
อาศัย
visual system
Proprioception
 vestibular system

4. Vertigo
 Illusionor hallucination of movement
 Vestibular system

5. Vertigo
 History taking
 Character of disorientation
 Time course of vertigo , duration
 Precipitating factors
 Associated symptoms : hearing loss , tinnitus , nausea ,
vomiting , diplopia , CNS symptoms
 Predisposing symptoms : general condition, trauma ,
drugs

6. Vertigo
 Physical examination
 ENT examination
 CNS examination
 Vestibular system examination :
 Unterberger test
 Caloric test
 Dix-Hallpike maneuver
 Evaluation of pathologic nystagmus

7. Vertigo
 Investigation
 Audiometry
 ABR : Auditory Brainstem Response
 ENG : Electronystagmography
 Others : CBC,U/A,FBS,electrolyte,cholesterol,
triglyceride,TFT,VDRL,CT scan ,MRI

8. Peripheral Central
 1.Onset sudden insidious
 2.Pattern episodic continuous
 3.Sensation frequent infrequent
of rotation
 4.Severity often intense seldom intense
 5.Duration min.,hr. mo. to yr.

9. Peripheral Central
 6.Influence of marked slight or none
head movement
 7.Syncope never rare
 8.Convulsion never rare
 9.Tinnitus common rare
 10.Deafness common rare

10. Peripheral Central
 11.Spontaneous may be may be
nystagmus present present
 12.Type of horizontal horizontal,
nystagmus vertical
 13.Other CNS rare common
involvement

11. Peripheral Cause of Vertigo
 BPPV
 Meniere’s disease
 Sudden hearing loss
 Vestibular neuritis
 Labyrinthitis

12. BPPV
 Benign paroxysmal positional vertigo
 The most common vestibular disorder
 Age range 11-84 yr. Mean age at onset 54 yr
 Cupulolithiasis
 Canalithiasis

15. BPPV
 Signs and Symptoms
 Vertigo and nystagmus
 Latency of onset , usually 2-6 sec.
 Short duration , usually less than 30 sec.
 Reversibility
 Fatigability
 Nausea , vomiting
 Dix-Hallpike maneuver

17. BPPV
 Cause
 Idiopathic
 Trauma
 Otitismedia
 Vestibular neuritis
 Meniere’s disease
 Otosclerosis

18. BPPV
 Cause
 Sudden SNHL
 CNS disease
 Vertebral basilar insufficiency
 Acoustic neuroma

19. BPPV
 Treatment
 Reassurance
 Medication : minor transquilizer
 Vestibular rehabilitation
Repositioning maneuver
 Surgery

22. Meniere’s disease
 Idiopathic endolymphatic hydrop
 Signs and symptoms
 Episodic vertigo lasting min to hr.
 Fluctuating hearing loss
 Tinnitus , fullness

23. Meniere’s disease
 Audiogram : low tone hearing loss
 ABR
 ENG
 Radiography

24. Meniere’s disease
 Treatment
 Vasodilator
 Cinnarizine , Dramamine
 K-sparing diuretic drug
 Stellate ganglion block
 Intratympanic gentamicin therapy
 Vestibular neurectomy

25. Sudden hearing loss
 Hearing loss : hr or day
 Vertigo
 Tinnitus
 Others : headache , URI symptoms
 Nystagmus
 Tuning fork
 Audiogram : unilateral SNHL

26. Sudden hearing loss
 Cause
 Known cause : Syphilis, Meniere’s disease,multiple
sclerosis , acoustic neuroma
 Unknown : เชื่อว่าเกิดจากvirus,ความผิดปกติของหลอด
เลือด autoimmune disease, labyrinthine membrane
rupture ( LMR)

27. Sudden hearing loss
 Treatment
 Bed rest
 Repeat audiogram
 Steroid
 Vasodilator
 Heparin

28. Vestibular neuritis
 Vertigo เป็นทันทีทนใดและเป็นอยู่นาน
ั
 Spontaneous nystagmus
 มักมีไข้หวัดนำามาก่อน
 มักเดินเซข้างทีมี lesion
่
 Audiogram : normal
 Caloric test : canal paresis or nonresponsive

29. Vestibular neuritis
 Treatment
 Rest
 Dramamine , diazepam
 Steroid
 Physical therapy : Cawthorne-Cooksey exercise

30. Labyrinthitis
 Virus : mump, measles, Herpes
 Bacteria : syphilis , OM ,meningitis
 TB more often a complication of Tubercuolus
meningitis than of Tuberculous otitis media.
 Syphilis : congenital , acquire
Fluctuating episodes of hearing loss and vertigo

31. Acoustic neuroma
 Acoustic schwannoma
 Schwann cell tumor of vestibular part of CN VIII มักเกิด
บริเวณ Internal acoustic canal แล้วยื่นเข้าไปบริเวณ CP
angle
 Initially,slowly progressive hearing loss and tinnitus .
 Postural imbalance or disequilibrium.

32. Acoustic neuroma
 Once the lesion compress the brainstem and
vestibulocerebellum ,central compensation becomes
impaired : vertigo , ataxia.
 Audiogram : unilateral SNHL
 ABR
 Caloric test : hypofunction
 MRI
 Treatment : surgery, radiation

33. Central cause of vertigo
 1.Vertebrobasilar insufficiency
 Elderly
 Atherosclerosis
 Vertigo
 Nausea,vomiting
 Ataxia
 Visual illusion ,visual field defect, diplopia, headache

34. Central cause of vertigo
 1.1Brainstem TIA
 1.2Wallenberg’s syndrome ( Lateral medullary
infartion )
 1.3Acute posterior cerebellar infarction
 1.4Acute inferior cerebellar infarction

35. Central cause of vertigo
 2.Cerebellar hemorrhage
 Vertigo
 Nausea, vomiting
 Headache
 Stiffness of neck, incoordination
 50% loss of consciousness in 24 hr.

36. Central cause of vertigo
 3.Vestibular migraine
 Episodes of vertigo
 Increased sensitivity to motion during the attack and
increased susceptibility to motion sickness in between
attacks
 In 33% of pt episodic vertigo is not associated with
headache.

37. Central cause of vertigo
 3.Vestibular migraine
 In 33% vertigo is associated with visual symptoms ,
dysarthria , tinnitus, decreased hearing , diplopia,
ataxia, bilateral paraesthesia, bilateral paresis or
decreased level of consciousness

38. Central cause of vertigo
 3.Vestibular migraine
 Treatment
Acute attack : analgesic , antiemetic
Prophylaxis for migraine attack : beta-blocker,
calcium antagonist

39. Central cause of vertigo
 4. Multiple sclerosis
 Vertigo without hearing loss
 Optic neuritis, transverse myelitis, others brainstem
signs

40. Central cause of vertigo
 5.Vestibular epilepsy
 Dysequilibrium with rotational or linear vertigo
 Accompany by body , head and eye rotation with or
without nystagmus
 May associated with mild nausea(vomiting not typical )

41. Medical treatment
 1.Labyrinthine suppressant
 Decreased vertigo , nausea, vomiting
 1.1 Antihistamine : dimenhydrinate,meclizine
 1.2 Antiemetic : prochlorperazine (Compazine),
diphenidol
 1.3 Anticholinergic : scopolamine
 1.4 Minor tranquilizer : diazepam

42. Medical treatment
 2.Vasodilator
 B-histine , cinnarizine
 3.Steroid