The document discusses vestibular disorders and the anatomy and function of the inner ear's role in balance. It describes how the semicircular canals and otolith organs detect movement and orientation. Common causes of dizziness include Meniere's disease, BPPV, vestibular neuritis, and migraines. Diagnosis involves a case history and vestibular testing like VNG, rotary chair, and VEMPs. Treatment options depend on the underlying cause but may include medications, repositioning maneuvers, surgery, or vestibular rehabilitation therapy.

1. Vestibular Disorders
Ozarks Technical Community College
HIS 125

2. The Human Ear

The inner ear/labyrinth houses both the
organs of hearing and balance
Hearing=cochlea
 Balance=semicircular canals and otolith


Balance is the ability to maintain the body’s
center of gravity over its base of support

3. Anatomy

4. Anatomy of the Vestibular
System

5. Anatomy
•Semicircular Canals
•Detect rotation in the different planes
•3 canals
•Superior, Horizontal, Posterior
•Otolith Organs: contain otoconia (“ear
rocks”) in a gelatinous membrane to
stimulate hair cells to detect linear
accelerations
•Utricle: horizontal plane (side-to-side)
•Saccule: vertical plane (up and down,
front to back)

6. The VOR

Vestibulo-Ocular Reflex
stabilizes images on the retina during head
movement by producing an eye movement in the
opposite direction of the head movement
 This eye movement is called nystagmus
 Preserves the image on the center of the visual
field

 head
moves right, eyes move left

7. Three Inputs to the Brain

Our brain integrates information from the
following systems to help us keep our
balance:
 Vision
 Vestibular
 Proprioception (sensors in our feet)

8. Balance

9. Dizziness

For patients of all ages, the three most
common complaints to physicians are:
Headache
 Back Pain
 Dizziness


Dizziness is the #1 medical complaint in patients
over the age of 70

10. “Dizziness” is a vague term

Describe how you feel without using the
word “dizzy”
Swimmy feeling
 Lightheaded
 Heavy head
 Off-balance
 Dysequilibrium
 VERTIGO


11. Vertigo

Sensation of spinning
Subjective vertigo=the patient feels like they are
spinning
 Objective vertigo=the patient feels like the room
is spinning


Vertigo is most commonly associated with a true
vestibular disorder

12. A diagnostic conundrum…

LOTS of factors contribute to dizziness
Vision
 Vestibular
 Musculoskeletal/orthopedic
 Neurological factors (MS, stroke)
 Aging
 Cardiovascular issues
 Metabolic (diabetes, thyroid, dehydration)
 Medications
 Stress/anxiety


13. Most Common Vestibular
Disorders






Meniere’s disease
Benign paroxysmal positional vertigo (BPPV)
Vestibular neuritis
Vestibular labyrinthitis
Migraine
Or, if you are a college student…alcohol!

Alcohol is lighter than blood, so the hair cells float in the
endolymph. This causes the “bed spins” when you close
your eyes (take away vision) and lay down (feet off
ground=no proprioceptive cues)

14. Meniere’s Disease
Due to cochlear hydrops=overaccumulation
of endolymph in the cochlea
 Usually characterized by 4 symptoms:

Periodic episodes of rotary vertigo or dizziness
(lasts hours to days)
 Fluctuating, progressive, low-frequency hearing
loss (SNHL)
 Tinnitus (often a “roar” or “buzz”)
 A sensation of "fullness" or pressure in the ear


15. Common Audiogram in
Meniere’s Disease



From: www.hearinglink.org
In the early stages of
Meniere’s, the hearing
loss effects only the
low frequencies
As the disease
progresses, the
hearing loss will flatten
Usually results in poor
word recognition
scores

16. Meniere’s Disease
Cochlear Cross-Section
*Note the
displacement of
the vestibular
membrane due
to the
overabundance
of endolymph in
scala media
Hawkelibrary.com

17. Causes of Meniere’s Disease
Northern, J. Hearing Disorders (3rd ed)

18. Incidence
2/1000 persons
 Most commonly unilateral (~75%)
 Affects men and women equally
 Most common in the patient’s 40s and 50s


Diagnosed based on case history,
audiogram, other specialized tests that look
specifically at vestibular function

19. Two Subvarieties of Meniere’s
Disease

Cochlear Meniere’s disease
No vertigo
 Fluctuating and progressive SNHL
 Aural fullness/pressure
 May or may not have tinnitus


Vestibular Meniere’s disease
Spells of vertigo
 No hearing loss
 May have aural pressure


20. Meniere’s Treatment

Medication


Diuretic/Water pill=reduces fluid buildup in body
Vestibular suppressant




Steroids
Ototoxic medications
Meniere’s Diet


Meclizine, valium, dramamine
Restrict intake of salt, MSG, alcohol, chocolate, caffeine
Surgery



Endolymphatic shunt
Labyrinthectomy
VIII Nerve Section

21. BPPV

Benign Paroxysmal Positional Vertigo
Most common complaint: “I get dizzy when I roll
over in bed”
 Due to loose otoconia floating in the semicircular
canals
 Diagnosed with Dix-Hallpike Test

 characterized
by rotary nystagmus and vertigo which
lasts several seconds

Treatment

Canalith repositioning =putting loose otoconia back
where they belong
 Epley manuever

22. Neuritis vs. Labyrinthitis
Usually viral inflammation of inner ear cavity
 Vestibular Neuritis=inflammation of nerve



Sudden onset vertigo (hours to days), nausea,
and vomiting
Vestibular Labyrinthitis=inflammation of inner
ear/labyrinth

Same symptoms as neuritis AND otologic
symptoms
 Hearing
 Tinnitus
Loss

23. Treatment for VN or VL
Patient will spontaneously recover after a
period of days to weeks
 Medications to reduce dizziness and nausea


Antibiotics won’t help because this is not usually
a bacterial infection
BPPV is very common after a case of VN or
VL (Epley manuever)
 For those patient’s that do not recover
spontaneously:


VESTIBULAR REHABILITATION

24. Vestibular Rehabilitation
May be performed by an audiologist
 More commonly performed by a physical
therapist
 Aids in compensation of the brain after a
vestibular insult, which makes the patient
feel better faster
 Uses exercises that result in varying inputs
to the visual, vestibular and somatosensory
systems
 Improves functional balance


25. Migraine-Associated Dizziness

Very common cause of dizziness


May not get a physical headache, but
instead the migraine manifests itself as
vestibular symptoms (vertigo, ear pressure,
tinnitus, nausea)


Approximately 35% of migraine patients have
some vestibular syndrome at one time or another
Commonly misdiagnosed as Meniere’s disease
Commonly accompanied by sound and light
sensitivity

26. Other Otologic Conditions that
Cause Dizziness
Superior Semicircular Canal Dehiscence
 Perilymph Fistula
 Vestibular schwannoma/acoustic neuroma

These conditions may result in:

Tullio Effect = sound-induced vertigo/nystagmus

Hennebert’s Phenomenon = pressure-induced
vertigo/nystagmus

27. How do we know if vertigo is
due to a vestibular weakness?

Case History


Onset, duration, ear symptoms, nausea
Audiologic and vestibular evaluation
Puretone and immittance audiometry
 Video- or electro-nystagmography
 Rotary chair testing
 Computerized dynamic posturography
 Vestibular-evoked myogenic potential (VEMP)
 Electrocochleography (ECoG)


28. Videonystagmography (VNG)

Most common tool to assess vestibular function.
Consists of 3 subtests:
Oculomotor testing: the patient follows a visual
target with their eyes . Looking for nystagmus and
abnormal patterns.
 Positional testing: checking for BPPV
 Caloric testing: irrigate ears with water of calibrated
temperature, which stimulates the horizontal SCC
so we can see how well the vestibular system
works. The GOLD STANDARD for identifying the
affected ear in a vestibular disorder.


29. Rotary Chair Testing


Preferred test method
for children
Cannot provide ear
specific information

30. Computerized Dynamic
Posturography

Sensory Organization
Test


Varying inputs to the 3
systems: vision, vestibular,
proprioception
Motor Control Test
Measures reaction time to
disturbance of the platform
(pulling the rug out from
under them)
 Assesses fall risk


31. VEMP (vestibular-evoked
myogenic potential)

Loud click sound in
test ear and we
measure resulting
muscle reflex in
neck

Abnormal VEMP in
patient’s with
Meniere’s, perilymph
fistula, SSCD

32. ECoG (electrocochleography)
Loud click in test
ear and we record
the electrical
potential from the
cochlea
 Abnormal ECoG in
pt with Meniere’s,
perilymph fistula,
SSCD
