Vertigo Its Management & Its Management By Dr.H.T.Lathadevi M.S(ENT) Shree B.M.Patil Medical College Hospital & Research Centre Bijapur

What is Vertigo Giddiness /dizziness Light headedness. Sensation of floating in space. Unstable or uncertain gait. Loss of balance Ringing in the ears.

Vertigo Vertigo is a hallucination of self or environmental movement , a feeling of spinning Vertigo is a symptom and not a disease.

Body Balance System Maintenance of balance is a function of nervous system Balance is achieved by integrating information from 3 sources Vestibular labyrinth Eyes Proprioceptors located in muscles and joint Harmonious integration of these inputs in the brain is essential for maintenance of balance the vestibular labyrinth which is a small organ located in inner ear (changes in the position of the head in relation to the body) two eyes (changes in subject positions in relation to surroundings) some special receptors called Proprioceptors located in muscles and joint (changes in subject positions in relation to ground)

Disorder of Balance System Disorder may occur in one or more organs of the balance system Commonest site is labyrinth Labyrinth is susceptible to damage by numerous factors - Medicines ( e.g.gentamycin,streptomycin ) Infections Degenerative changes of aging Head trauma

Vertigo - Prevalence Present in about 5% of all patients consulting general practitioners Seen in 10-15% of patients seen by ENT specialist or neurologist The reasons for high prevalence -Vertigo is a symptoms which accompanies large number of diseases -More than 80 possible causes have been described Vertigo associated with - Congestive heart failure Cardiac arrhythmias Hypertension Cerebrovascular insufficiency Hypoglycemia Hypothyroidism Epilepsy Migraine Syncope

Vertigo- symptoms Giddiness /dizziness Light headedness. Sensation of floating in space. Unstable or uncertain gait. Loss of balance Ringing in the ears.

Vestibular System The vestibular apparatus which is responsible for sending messages is connected by vestibular nerve to vestibular nuclei situated in the brain. Adequate blood supply is necessary for proper functioning vestibular system Inadequate blood supply leads to improper functioning of the vestibular system Vertigo

Vestibular Function and Anatomy

Membranous and bony labyrinth embedded in petrous bone System of balance Membranous and bony labyrinth embedded in petrous bone 5 distinct end organs 3 semicircular canals: superior, lateral, posterior 2 otolith organs: utricle and saccule

Semicircular canals are orthogonal to each other Lateral canal inclined to 30 degrees Superior/postereor canals 45 degrees off of sagittal plane

Utricle is in horizontal plane Saccule is in vertical plane

Anatomy

There are five openings into area of utricle Saccule in spherical recess Utricle in elliptical recess

45% from AICA 24% superior cerebellar artery 16% basilar Two divisions: anterior vestibular and common cochlear artery

Superior vestibular nerve: superior canal, lateral canal, utricle Inferior vestibular nerve: posterior canal and saccule

Membranous labyrinth is surrounded by perilymph Endolymph fills the vestibular end organs along with the cochlea

Perilymph Similar to extracellular fluid K+=10mEQ, Na+=140mEq/L Unclear whether this is ultrafiltrate of CSF or blood Drains via venules and middle ear mucosa

Endolymph Similar to intracellular fluid K+=144mEq/L, Na+=5mEq/L Produced by marginal cells in stria vascularis from perilymph at the cochlea and from dark cells in the cristae and maculae Absorbed in endolymphatic sac which connected by endolymphatic, utricular and saccular ducts

Sensory structures Ampulla of the semicircular canals Dilated end of canal Contains sensory neuroepithelium, cupula, supporting cells

Cupula is gelatinous mass extending across at right angle Extends completely across, not responsive to gravity Crista ampullaris is made up of sensory hair cells and supporting cells

Sensory cells are either Type I or Type II Type I cells are flask shaped and have chalice shaped calyx ending One chalice may synapse with 2-4 Type I cells Type II cells – cylinder shaped, multiple efferent and afferent boutons

Hair cells have 50-100 stereocilia and a single kinocilium.

stereocilia are not true cilia, they are graded in height with tallest nearest the kinocilium.

Kinocilium is located on one end of cell giving each cell a polarity Has 9+2 arrangement of microtubule doublets Lacks inner dynein arms, and central portion of microtubules not present near ends – may mean they are immobile or weakly mobile

Each afferent neuron has a baseline firing rate Deflection of stereocilia toward kinocilium results in an increase in the firing rate of the afferent neuron Deflection away causes a decrease in the firing rate

kinocilia are located closest to utricle in lateral canals and are on canalicular side in other canals Ampullopetal flow (toward the ampulla) excitatory in lateral canals, inhibitory in superior/posterior canals Ampullofugal flow (away from the ampulla) has opposite effect

Semicircular canals are paired Horizontal canals Right superior/left posterior Left superior/right posterior Allow redundant reception of movement Explains compensation after unilateral vestibular loss

Otolithic organs Utricle and saccule sense linear acceleration Cilia from hair cells are embedded in gelatinous layer Otoliths or otoconia are on upper surface

Calcium carbonate or calcite Specific gravity of otolithic membrane is 2.71-2.94 Central region of otolithic membrane is called the striola

Saccule has hair cells oriented away from the striola Utricle has hair cells oriented towards the striola Striola is curved so otolithic organs are sensitive to linear motion in multiple trajectories

Central connections Scarpa’s ganglion is in the internal auditory canal Contains bipolar ganglion cells of first order neurons Superior and inferior divisions form common bundle which enters brainstem No primary vestibular afferents cross the midline

Afferent fibers terminate in the vestibular nuclei in floor of fourth ventricle Superior vestibular nucleus Lateral vestibular nucleus Medial vestibular nucleus Descending vestibular nucleus

Vestibular nuclei project to Cerebellum Extraocular nuclei Spinal cord Contralateral vestibular nuclei

Senses and controls motion Information is combined with that from visual system and proprioceptive system Maintains balance and compensates for effects of head motion

Vestibulo-ocular reflex Membranous labyrinth moves with head motion to right Endolymph moves utriculopetally Cupula on right canal deflected towards utricle causing increase in firing rate, left deflects away causing a decrease in firing rate. Reflex causes movement of eyes to the left with saccades to right Stabilizes visual image

If acceleration stops, and spin to right is at constant velocity, sensation of motion stops after 14-20 seconds as does nystagmus Cupula only takes 8-10 seconds to return to equilibrium position Vestibular integrator is the term for the prolongation and is mediated by the vestibular nuclei and cerebellum

Vestibulospinal Reflex Senses head movement and head relative to gravity Projects to antigravity muscles via 3 major pathways: Lateral vestibulospinal tract Medial vestibulospinal tract Reticulospinal tract

How do calorics work? Patient is lying down with horizontal canals oriented vertically (ampulla up) Cold water irrigation causes endolymph in lateral portion to become dense and fall causing deflection of cupula away from utricle with a decrease in the firing rate This causes nystagmus with fast phase (beat) away from the stimulus

With warm water irrigation column of endolymph becomes less dense, rises and causes deflection of cupula toward the utricle Results in increase firing rate and nystagmus which beats towards the stimulation COWS (cold opposite, warm same)

Investigations for vertigo Caloric Test Audiometry Electronystagmography (ENG) Craniocorpography (CCG) Brain -Stem Evoked Response Audiometry (BERA)

NYSTAGMUS Pendular Or Phasic Spontaneous Or Induced Horizontal Or Vertical

Electronystagmography (ENG) Basic test for balance system Assesses the integrity of - vestibular labyrinth & its connections with the eyes and certain parts of the brain which are concerned with the maintenance of balance Gives an idea of functional integrity of vestibulo-ocular reflex system It comprises tests like test for spontaneous nystagmus, the gaze nystagmus, pendulum tracking test & caloric test ENG test is capable of identifying lesion in the vestibulo-ocular reflex system ENG is the best test for identifying peripheral vestibular pathology Diagnostic efficiency is poor in non-labyrinthine lesion The popularity of ENG is attributed to the fact the most common lesions in balance system are in vestibular labyrinth

Caloric Test Caloric test involves instillation of hot or cold water into ear canal When labyrinth is stimulated, either by heat or cold, caloric nystagmus generally results Nystagmus produced by left & right eyes are assessed

Brain Stem Evoked Response Audiometry (BERA) A method of plotting electrical activities in response auditory or vestibular stimuli Electrical activities are measured by keeping the electrode on the scalp In BERA wave-form obtained from one particular site on the scalp (vertex), over specified duration of time of 10 milliseconds A method of plotting electrical activities from one particular area of the scalp in response auditory or vestibular stimuli at given point of time Electrical activities are measured by keeping the electrode on the scalp In BERA wave-form obtained from one particular site on the scalp (vertex), over specified duration of time of 10 milliseconds Interpretation of changes in the electrical activities to assess whether processing of the vestibular stimulus is normal or abnormal

Investigations - for structural integrity Tests to asses structural integrity of the system X rays CT scan MRI Newer imaging ethnologies - for visualization of functional or metabolic activity occurring in brain Positron emission tomography (PET) Single photon emission computed tomography (SPECT)

Vertigo - Possible circulatory causes Increased vascular resistance Increased blood viscosity due to - Reduced flexibility of RBCs Increased blood viscosity Reduced micro-circulation

Vertigo : Peripheral V/S Central PERIPHERAL CENTRAL Occurrence : Episodic . May be constant Severity : Proportionate . Disproportionate . Axis : Horizontal . Variable O Nyst. Type : Slow & Fast . Irregular phases Latency : 10 to 20 sec. . None Direction : Single . Changing Duration : Brief . Long Fatigue : Yes . No Hearing loss /Tinitus : Possible . No

ANATOMY OF BALANCE AND VERTIGO

Meniere’s syndrome Sudden onset & recurring episodes of vertigo Tinnitus Progressive deafness. Ischaemia of the inner ear. The cause is unknown - may be associated with dilation of the endolymphatic system due to increase in the amount of endolymph. There is often accompanying nausea and vomiting, and there may be sweating, weakness and faintness. Deafness and tinnitus may be intensified during the attack, which may last for a few minutes to several hours. Between attacks there is only nerve deafness with impaired vestibular function as shown by caloric tests. The frequency of attacks tends to decrease as deafness increases but the disease may last many years. Meniere’s disease progressively destroys the function of labyrinth and as this continues ear becomes more deaf and vertigo becomes less severe. Remission of attacks may occur for many months or years.

Meniere's Disease

Clinical Features Deafness Tinnitus Episodic vertigo Autonomic –Nausea, vomiting, Diaphoresis Aural pressure

Managrment Medical-Vestibular sedatives Vascular-Increase blood supply-Betahistine Carbogen Alter electrolytic balance-Frusemide,Glycerol Hydrochlorothiadize Surgical-Endolymphatic sac decompression, Vestibular neurectomy, Ultrasonic destruction Reassurance Vestibular rehabilitation exercises

Benign Paroxysmal Positional Vertigo BPPV results from freely moving crystals of calcium carbonate (Otoconia) usually within the semicircular canals BPPV develop with change in position This type of vertigo can be sequelae of head trauma or vestibular neuritis Most common in age group of 60-70 years BPPV develop with change in position Typically when turning over in bed, getting in and out of bed, or extending the headache back to look upwards This type of vertigo can be sequelae of head trauma or vestibular neuritis more common in women Most common in age group of 60-70 years BPPV results from freely moving crystals of calcium carbonate usually within the semicircular canals

BPPV

DIX-HALL-PIKE’S TEST

EPLEY’S MANEUVER

General management of vertigo Management of patients suffering from vertigo or vertiginous syndrome should consist of…. Elimination of the underlying cause Symptomatic relief. Methods: Drug treatment Vestibular rehabilitation exercises Surgical

Drug treatment Labyrinthine suppressant/ Ca++ entry blocker Cinnarizine Vasodilators Betahistine Antihistaminics Meclizine, Promethazine Sedatives / tranquilizers Diazepam

Cinnarizine Selective Antivasoconstrictant, Ca ++ entry blocker Antivertiginous activity due to Suppressant action on vestibular labyrinth. Anti-vasoconstrictant activity. Lowering of blood viscosity by improving the flexibility of the RBC’s. Cinnarizine sedates the excited labyrinth. It prevents the excessive Ca ++ ion transport from the endolymph to the vestibular sensory cells and thereby balances the impulses reaching the vestibular nuclei. Cinnarizine prevents and removes vasoconstriction prevents the Ca ++ influx into the smooth muscle cells However, cinnarizine is a selective antivasoconstrictor i.e. it acts only where vasoconstriction occurs. Improves flexibility of RBCs Increased calcium uptake by RBCs results in loss of flexibility of RBCs membrane Loss of flexibility of RBCs results in increased viscosity of blood Cinnarizine inhibits calcium uptake into the RBCs which leads to improved flexibility of RBCs Thus, Cinnarizine decreases the hyperviscosity of blood & improves microcirculations Cinnarizine lowers the hyperviscosity of blood viscosity - - by improving RBCs flexibility -but does not affect RBCs concentration (hematocrit) & Plasma viscosity Cinnarizine normalizes the blood viscosity after treatment & improves the microcirculations

Cinnarizine Presentation: Tablet of 25 mg / 75 mg Dosage : 1-2 tablets of 25 mg two to three times a day or as directed by the physician. Children (5 - 12 yr.) : 1/2 tablet three times a day

Betahistine Histamine analogue. Vasodilator-increases blood flow Indicated for vertigo. Side effects : headache, rash, g.i. disturbances. Steal effect Contraindicated in asthma, peptic ulcer Dose : 8 to16 mg. tid

Vestibular Rehabilitation Exercises Co-ordinated head, body & eye movement helps to ameliorate the patient’s symptoms Exercises should be performed 5 - 10 minutes twice or thrice daily. Exercises of eye movement Exercises in sitting position like Shrugging & rotating shoulders Bending forward & picking up the objects from the floor Exercises in standing position like Changing from sitting to standing initially with eyes open & then with eyes shut repeatedly for 15 times

Vestibular Rehabilitation Exercises (contd.) Exercises should be performed 5 - 10 minutes twice or thrice daily. Exercises of eye movement Exercises in sitting position like Shrugging & rotating shoulders Bending forward & picking up the objects from the floor Exercises in standing position like Changing from sitting to standing initially with eyes open & then with eyes shut repeatedly for 15 times

Vestibular Rehabilitation Exercises (contd.) Exercises should be performed 5 - 10 minutes twice or thrice daily. Exercises of eye movement Exercises in sitting position like Shrugging & rotating shoulders Bending forward & picking up the objects from the floor Exercises in standing position like Changing from sitting to standing initially with eyes open & then with eyes shut repeatedly for 15 times

ANATOMY OF BALANCE AND VERTIGO