1. Vertigo
Definition
Subjective sense of imbalance or hallucination of movement of patient’s body or patient ‘s environment.
Vertigo should be differentiated from other symptoms like light headedness and drop attack.
Light headedness: loss of equilibrium within ones head (feeling of faintness)
Drop attack: loss of extensor power and fall to the ground suddenly without loss of consciousness.

2. Physiology of vestibular system
There are 4 systems in the body responsible for maintaining the balance:
1- Inner ear (vestibular system)
2- Brain
3- proprioceptive system
4- Eyes
The vestibular system consists of 3 semicircular canals (lateral, superior and posterior) , utricle and saccule.
The semicircular canals responsible for sensation of the angular movement of the body in the space. Each canal is responsible for a plain in the space.
While the utricle and saccule respond to the gravitational and linear movements of the body.

3. Types and causes 1- Rotatory vertigo:
Basically vertigo can be described in one of two ways, either it is rotatory or not rotatory(unsteadiness).
Both can be subdivided according to the duration of the attack .
1- Rotatory vertigo:
A- seconds : episodic vertigo lasting few seconds to few minutes. Examples :
Benign paroxysmal positional vertigo BPPV
Vertibrobasillar insufficiency ( TIA)
Cervical spine disease : spondylosis, disc prolapse.
Post-concussional: head trauma

4. B- Hours : lasting few minutes to hours(less than 24 hour). Examples:
Menieres disease
Syphilitic labyrinthitis
Middle ear surgery
c- Prolonged : lasting weeks to months. Occurs when there is destruction of the inner ear or central connections. Examples:
Labyrinthitis
Vestibular neuritis
Trauma (head injury or surgery)
Tumours
Vascular lesions

5. 2- Unsteadiness ( non-ratatory)
A- seconds : physiological due to overload of the vestibular and central processing systems.
When the CNS overloaded with excessive impulses not only from the vestibular system but also from the visual and proprioceptive system imbalance will be experienced.
This may occur to any person if there is rapid movement or abnormal input into the brain especially visual.
B- hours to days: examples
Drugs ( anticonvulsants,tranqulizers)
Alcohol
Travel (motion)sickness. More common in children
Active chronic suppurative otitis media
Perilymph fistula

6. C- Prolonged :
week to months, due to vestibular inadequacy and is most often seen in the elderly and could be due to drugs or CNS lesions.

7. Another classification of vertigo
A- Peripheral
B- Central (CNS)
Peripheral: examples
1- BPPV
2- Meniere’s disease
3- labyrinthitis
4- vestibular neuritis
5- middle ear surgery
6- perilymph fistula
Central: examples
1- vertebrobasilar artery insufficiency
2- central tumors
3-head injury
4- multiple sclerosis
5- temporal lobe epilepsy
6- migraine

8. Benign Paroxysmal Positional Vertigo (BPPV)
Characterized by sudden attacks of rotatory vertigo lasting few seconds to minutes precipitated by sitting up, lying down or turning in bed (sudden head movement).
It is thought to be due to abnormal sensitivity of the posterior semicircular canal to free-floating dense particles (canaliths). These particles can be repositioned and symptoms resolved by special repositioning procedure (Eply maneuver).

9. Head trauma
may cause vertigo by different mechanisms :
1- post-concussional syndrome
2- benign paroxysmal positional vertigo
3- destructive labyrinthine lesion
4- perilymph fistula
5- secondary endolymphatic hydrops
6- functional

10. Presbystasis ( dysequilibrium of aging)
Age-related decline in peripheral vestibular function, visual acuity, proprioception and motor control has cumulative effect upon balance and is the most common cause of dysequilibrium.

11. Metabolic vertigo 1- hypothyroidism 2- DM

12. Multiple sclerosis
vertigo is the presenting symptoms in 10% of the patients or eventually appears during the course of the disease in as many as one-third of the cases.

13. Oscillopsia (Jumbling of the Panorama) Since our head bob up and down while walking, the vestibular system controls eye movement to maintain a constant horizon when walking. When there is bilateral absent vestibular function as seen with ototoxic drugs oscillopsia will happen, which is inability to maintain the horizon while walking.

14. Motion sickness
Believed to be due to a conflict between what your eyes see and your inner ear sense.
Could be due to a travel in the car, train, ship or boat, airplane or even during watching TV or playing video games.
Treatment: proper positioning in the vehicle
antihistamines, anticholinergic agents

15. Drugs
1- Aminoglycosides
2- Tranqulizers
3- Anticonvulsants

16. Vertebrobasilar insufficiency (TIA)
Due to atherosclerosis or spasm of the vertebrobasilar arterial system. Characterized by brief rotatory vertigo with hemiparesis, visual disturbances, vomiting and facial numbness. More common in the elderly. Symptoms occur due to drop in the blood supply to the vestibular nuclei and surrounding structures.
TIA should be considered in any elderly patient with short duration vertigo until proved otherwise.

17. Cervical vertigo
Cervical spondylosis and disc prolapse might cause irritation of the vertebral sympathetic plexus by the herniated disc and osteophytes, and this in tune will cause a spasm or contraction of the vertebrobasilar arterial system. Temporary ischemia then give rise to vertigo.
Loss of proprioception in the neck is another mechanism of vertigo in cervical spondylosis or disc prolapse.

18. Vertiginous Epilepsy
Dysequilibrium could be part of the aura in a major jacksonian seizure or as a part of the petit mal seizure.
Anti-convulsant drugs might cause vertigo as well.

19. Vertigo with Migraine
Vertebrobasilar migraine will cause impairment of the arterial circulation of the brainstem including the vestibular nuclei.
A positive family history is obtained in more than 50% of these patients.

20. Vestibular Neuritis
Usually begins with a non-specific viral illness followed by severe sudden onset of vertigo with nausea and vomiting.
There is: no loss of consciousness
no hearing loss
no associated neurological deficit
The patient initially had spontaneous nystagmus to the contralateral side. In most of the patients there will be spontaneous remission.

21. Management
History
The diagnosis of the underlying cause of vertigo is usually made on the basis of history in 80% of cases, while subsequent examination and investigations are normally used to confirm the diagnosis.
Points should be asked for:
Description of the attack: is it a real vertigo?
Nature (rotatory or not)
Duration
Onset
Progression
Recurrence
Precipitating factors
Associated ear symptoms
History of other systems
History of trauma or ear surgery
Drug history: anticonvulsants and tranquilizers.
Alcohol intake
Past-medical history: some diseases related to cardiovascular system, cervical spines, DM and anemia might give rise to symptoms similar to vertigo.

22. Examination
1- Thorough Ear, Nose and Throat examination
2- Cranial nerves exam.
3- Cerebellar function exam.
4- Gait, balance and positional tests (Dix-Hallpike).
5- Examination for nystagmus.
6- Examination of other systems especially CNS,CVS and Cervical spines.

23. Investigations
The only investigation that is required routinely is pure tone audiometry. Other investigations : (not required routinely)
1- Electric response audiometry
2- Electronystagmogram
3- Blood investigations (complete blood count, biochemical investigations, thyroid function tests, serological tests).
4- Radiological investigations : plain,CTS and MRI of the mastoid region, cervical spine and the brain.
5- Caloric test: each ear stimulated by water warmer and cooler than body temperature. The cool stimulus will produce nystagmus whose fast phase is away from the stimulated ear. The warm stimulus produce nystagmus with the fast phase toward the stimulated ear. (COWS)

24. Treatment 1- Treat or eliminate the cause
2- Suppress the vestibular system: labyrinthine sedative drugs as:
a- cinnarizine (stugeron)
b- prochloperazine (stemetel)
c- cyclizine
d- benzodiazepines (diazepam and lorazepam)
e- betahistine
3- Reassurance : usually self-limiting.
4- Wait for compensation: the CNS will take over and compensate the vestibular disorder after passage of simple time period.
5- Eliminate the offending labyrinth: labyrinthectomy or vestibular nerve section may be the treatment of choice in case there is no response to all modes of treatment and failure of compensation.

25. Thank you