Anatomy & physiology of vestibular system Acoustic Neuroma Vertebrobasilar Insufficiency Pediatric Vestibular Disorders Ménière’s Disease Migraine-Associated Vertigo Cervicogenic Dizziness Benign Paroxysmal Positional Vertigo Autoimmune Inner Ear Disease Age-related dizziness and imbalance

1. Vestibular Dysfunctions
10/9/2020 P/B:- NIYATI PATEL (PT) 1
DR. NIYATI N PATEL
MPT IN NEUROLOGICAL CONDITIONS

2. Vestibular System

3. INTRODUCTION
 The vestibular system is made up of:
 Vestibule (sensory organ) ( SCC+OTOLITH )
 Cranial NerveVIII
 Brainstem vestibular nuclei
 Cerebellar pathways
 Provides information about head motion and orientation
in respect to gravity.
 Generates eye movements to promote gaze stabilization
and postural righting responses involving the head and
trunk.

4.  PeripheralVestibular SystemFunctions

5. Vestibule (sensory organ)
1.Semicircular canals
 3 bony canals in each ear – Superior/Anterior,
Posterior, & Horizontal
 The canals are positioned at a 90° angle from one
another, with the horizontal canal tippedbackwards
20-30 degrees

6. THE PARTS OFTHE CANALS INCLUDE:
 Endolymph – fluid that fills the canals
 Ampulla - dilated space at the end of each canal
 Cupula - gel-like bud, embedded with sensory hair
cells, that sits within the ampullated (dilated) portion
of each canal
 Hair Cells – krinocilia and stereocilia
 The semicircular canals detect angular accelerations
of the head through displacement of the cupula

7.  2. Otolith Organs (Utricle and Saccule)
 These organs make up the medial portion of
the vestibule
 The semicircular canals originate from the
utricle
 Calcium carbonate crystals called otoconia are
attached to both the medial wall of the saccule
and floor of the utricle
 Otoconia – detects tilts and translations of the
head, because they respond primarily to linear
acceleration forces like gravity

9. Central vestibular System
 Vestibular cortex ( parietal & insular lobe 
vestibular cortex)
 Brainstem vestibular nuclei
 Cerebellar pathways

10. PHYSIOLOGY AND MOTOT CONTROL
1.Vestibular-ocular Reflex (VOR)
 TheVOR generates compensatory eye movements in order
to stabilize gaze during head motion (i.e. Rotation of head to
the left results in rightward compensatory eye movement)

11. 2.Balance and postural control
 The brain uses vestibular input to help it stabilize the head
and body in space through neck, trunk and hip muscle
activation
 Activation of distal muscles is primarily the responsibility of
the somatosensory system

12. 3.Vestibulo-spinal Reflex (VSR)
 Maintains vertical alignment of the trunk
 When the head tips in one direction, the body elongates tothat
side and shortens on the other

13. 4.Vestibulo-collic Reflex (VCR)
 Activates the neck musculature to stabilize the head in
space
 Compensates for displacements of the head that occur
during gait

14. 5.Push -Pull Mechanism
 Head movement and
direction compared
between two SSC.
 Exa: head is turned to the
right side
 Right horizontal SSC 
Increase firing rate
 Left horizontal SSC 
Decrease firing rate

15. MOVEMENTS
 SIDE ROTATION : HORIZONTAL SCC
 FLEXION-EXTENSION :ANTERIORSCC
 SIDE FLEXION : POSTERIOR SCC
 LINEAR MOVEMENT :UTRICLE
 UP DOWNACCELERATION:SACCULE

16.  References
 1.Walter,J.Vestibular Rehabilitation: Practical Management ofthe
Patient with Dizziness. Powerpoint presentation.
 2.Dizziness-and-balance.com BPPV link.Available at:
http://www.dizziness-and-balance.com.Accessed July 1, 2010.
 3.Physical rehabilitation.5th edition.Susan B.O Sullivan,Thomas
Schmidtz. F.A.DavisCompany

17. ACOUSTIC NEUROMA
 Also k/a vestibular schwanomma
 Benign tumor located on cranial nerve 8
 Features
Progressive hearing loss
Tinnitus
disequilibrium
 Treatment
Surgical excision of tumor
 Preoperative complication
Vertigo ( sacrificing all / part of the vestibular nerve)

19. MENIERE'S DISEASE
 Diagnosed by a documented
 Low Frequency Hearing Loss
EpisodicVertigo
Sense Of Fullness InTheEar
 Tinnitus
 The symptoms gradually increase in severity &
then last 1 to 2 hrs / episode
 Pathophysiology
Increase in endolymphatic fluid cuasing
distension of the membranous tissues

22.  TRIGGERS
 Stress, Overwork, Fatigue, Emotional Distress,
Additional Illnesses, Pressure Changes, Certain
Foods,AndToo Much Salt InThe Diet.
 Medical treatment
 Diuretics [to control the amount of water in the
body]
 Reducing/preventing fluid buidup
 Diet
 Reduced sodium diet ( 2g/day or less)
 Avoid caffeine & alcohol

23.  Surgical treatment
Endolymphatic shunt placement [to prevent
fluid build up in inner ear]
Vestibular nerve section/ transtympanic
gentamycin injection [to stop abnormal
vestibular signal]
 Physical therapy
Gaze & postural stability exercise
Equilibrium exercise

24. MIGRAINE-RELATED DIZZINESS
 Vestibular migraine (VM) is vertigo
associated with a migraine’ either as a symptom
of migraine or as a related but neurological
disorder
 Also k/n as
 Migraine-associatedVertigo(MAV)
 MigrainousVertigo
 Migraine-relatedVestibulopathy

25.  Signs and symptoms
Vertigo
Motion sickness
Sensorineural Hearing Loss
 MEDICALTREATMENT
Acetazolamide
Calcium Channel

26. CERVICOGENIC DIZZINESS
 Cervicogenic dizziness is a syndrome of neck pain
accompanied by an illusory sense of motion and
disequilibrium
 Neck pain often accompanies dizziness
 Causes
Result of whiplash/head injury
Brain injury
Inner ear injury

28.  Pathophysiology
 The upper cervicle spine sends proprioceptive input to
the contralateral vestibular nucleus
 Symptoms
 Dizziness worse during head movement
 Dizziness worse after maintaining one head position
 Dizziness occurs after neck pain & accompanied by a
headache
[Dizziness usually present last minutes to hours]
 Imbalance increase with head movement / movement
of environment

29. VERTEBROBASILAR INSUFFICIENCY
 Dizziness due to vascular compromise
Causes
•Result of whiplash
/head injury
•Brain injury
•Inner ear injury
Symptoms
•Diplopia
•Dysarthria
•Syncope
•Headache
•Visual field deficit
•Vertigo
•nystagmus

32.  Test
Pt position:sitting
Procedure: pt leans forward & extends the neck
than rotated 450. check these symptoms
 Diplopia
 Dysarthria
 Syncope
 Headache
 Visual field dificit
 Vertigo
 nystagmus

34. AUTOIMMUNE INNER EAR DISEASE
 Immune system runs amok,self-attack of antigen-
antibody is referred to as an autoimmune
reaction.
 The immune system can attack the ear and some
other body parts (eye / attack the entire body)
 Autoimmune reaction creates a debris
 If the ear is not being directly attacked, it can end
up with debris transported from distant locations
and deposited by the circulation.

35.  Symptoms
Hearing loss
Vestibular symptoms
 More frequently in women than men and less
frequently in children and the elderly
 Medical treatment
Immuno suppression
Steroids

36. AGE RELATED DIZZINESS AND IMBALANCE
 The body has three primary sensory systems
that work together to create postural
stability.
 With normal brain function, the vestibular
system of the inner ear coordinates with the
visual system and proprioceptors.

37.  Pathological changes
 Number of nerve cells in the vestibular system
decreases after about age 55.
 Blood flow to the inner ear also decreases with
age.
 When the vestibular system is damaged, an
individual may experience dizziness and balance
problems

38.  CAUSES
 Impaired Inner Ear Function
 Cardiovascular Health
 Neurological Disease
 Arthritis
 Mental Status
 Nutrition
 ImpairedVision
 Lifestyle and Environmental factors

39. PEDIATRIC VESTIBULAR DISORDER
 It is due to disruption of vestibular system.
 Symptoms
Vertigo
Dizziness
Oscillopsia
Gaze instability
Delayed development
Diminished balance
Other motor disabilities

40.  INVESTIGATION
Otolaryngologist
Audiologist for specific laboratory testing

41. BENIGN PAROXYSMAL POSITIONAL
VERTIGO (BPPV)
 Benign – it is not life-threatening
 Paroxysmal – it comes in sudden, brief spells
 Positional – it gets triggered by certain head positions
or movements
 Vertigo – a sense of rotational movement
 Benign paroxysmal positional vertigo (BPPV) is a
disorder of the inner ear characterized by episodes
of vertigo triggered by changes in head position.
 Incidence of 107 per 100,000 per year.

42. INCIDENT
 Accounts for 20% of dizziness cases presenting to
ENT office
 Frequently seen in elderly
 50% of all dizziness in elderly is due to BPPV

43. TYPICAL PRESENTATION
 Transient episodes of vertigo (<1 minute)
 Initiated by position change
 Characterized by periods of exacerbation
and remission
 Usually unilateral
 Symptoms include dizziness,imbalance,
difficulty concentrating & nausea

44. PATHOLOGY
 Semicircular Canals (SCC)Filled with endolymph
 Detect rotational movement
 Endolymph exerts pressure on Cupula (sensory
receptor at SCC base) & sends impulses to brain
 Otolith in the semicircular canals shift causing
the cupula to send false positional signals to the
brain

46. ETIOLOGY
 Idiopathic (unknown causes)
 Natural age-related degeneration of otolithic
membrane
 Head injuries (concussions,whiplash)
 Other possible causes
 Ear viruses, migraine, earsurgery

47.  It is very commonly triggered by things like
Rolling over in bed
Getting in and out of bed
Tipping the head to look upward
Bending over
Quick head movements

48. Mechanism of BPPV based on location of
SCC & types of nystagmus
SCC CUPULOLITHIASIS CANALITHIASIS
RIGHT
POSTERIOR
PERSISTENCE UBN &
RIGHT TORSION
TRANSIENT UBN &
RIGHT TORSION
LEFT
POSTERIOR
PERSISTENCE UBN &
LEFT TORSION
TRANSIENT UBN &
LEFT TORSION
RIGHT
ANTERIOR
PERSISTENCE DBN &
RIGHT TORSION
TRANSIENT DBN &
RIGHT TORSION
LEFT ANTERIOR PERSISTENCE DBN &
LEFT TORSION
TRANSIENT DBN &
LEFT TORSION
HORIZONTAL PERSISTENCE
AGEOTROPIC
TRANSIENT
GEOTROPIC

49. Special tests
 Hallpic dix test ( post scc)
 Side lying test
 Hallpike & roll test ( horizontal scc)

50. HALLPIC DIX TEST

51. DIAGNOSIS IS BASED ON A
POSITIVE DIX-HALLPIKE
 BPPV Nystagmus Classifications
Counterclockwise –horizontal canal BPPV
Clockwise –horizontal canal BPPV
Down beating –superior canal BPPV
Up beating –posterior canal BPPV

52. TYPICAL CHARACTERISTICS OF
NYSTAGMUS
 Latency-10-40 seconds
 Paroxysmal
 Duration < 1 minute
 Fatigues with repetition
 Nystagmus may reverse in upright position

53. SIDE LYING TEST

54. INTERVENTIONS
 Wait/see –symptoms may subside within 2
months
 Medication (little benefit)
 Habituation exercises (Brandt-Daroff)
 Surgery
 Canalith Repositioning Procedures (CRP)
 Epley and Semont maneuvers
 Move otoconia from posterior canal into
utricle (90% success rate)

55. BILATERAL BPPV
 Much less common
 If you see it, usually will see with head
trauma
 Harder to clear—generally will have
multiple visits

56.  References
 1. Physical rehabilitation. 5th edition. Susan B.O
Sullivan,Thomas Schmidtz. F.A.Davis Company
 2.Vestbular disorders association –net source
 3. Dizziness-and-balance.com BPPV link. Available at:
http://www.dizziness-and-balance.com. Accessed July
1,2010.