1. Going For A Spin A Guide to the Balance System Martyn Leggett

2. Peripheral Vestibular System Semicircular Canals Otolith Organs – Utricle – Saccule Vestibular Nerves Vestibular Nuclei

3. History Symptom Tempo Circumstance Past History

4. Symptoms Clear – Relatively easy to categorize Vague – Frustrating – Often the key to Psychological Cause

5. Symptom Disequilibrium – Loss or Lack of Stability – Loss of Vestibulospinal, Proprioception, Visual, Psychological Lightheadedness/Presyncope – Reduced Blood flow to Brain Sensation Rocking/Swaying (Mal de Debarquement) – Problem with Vestibular adaptation, Anxiety

6. Symptom Motion Sickness – Visuovestibular mismatch Nausea/ Vomiting – Stimulation of Medulla Oscillopsia – Severe Bilateral Loss of Vestibulo-ocular Reflex

7. Symptom Floating, Swimming, Rocking, Spinning inside Head – Anxiety, Depression Vertical Diplopia – Skew eye deviation Vertigo (Rotatory, Linear, Tilt) – Hallucination of Movement – Imbalance of Tonic Neural Activity to Vestibular Cortex

8. Tempo Seconds to Minutes – BPPV – Microvascular Compression 30 min-24 hours – Hydrops – Migraine 48-72 hours – Acute Vestibular Failure

9. Circumstance Precipitating Factors Occuring – Before – During – After Associated

10. Symptom Generation “One-off” Vestibular Event with Sequelae – Problems with Compensation Recurrent Vertigo Positional Vertigo Chronic Subjective Dizziness Syndrome – Psychological

11. Past History First Attack – Pathology Subsequent Attacks – Pathology – Decompensation

12. First Attack Acute Vestibular Loss – Most Severe Attack – May be only pathological event suffered Recurrent Vertigo – Not necessarily most severe attack “Have you ever had an attack which went on for days?”

13. Examination Physiology Pathophysiology Vestibulo-ocular reflex

14. Vestibulo-Ocular Reflex Maintains Steady Gaze during Head Movement Normal Activities – <550 ° /sec Responds up to – 6000 ° /sec Response Time – 5-7 msec

16. Nystagmus Cause – Tonic Imbalance Drift (Slow Phase) – Towards underactive side Correction (Fast Phase) – Away from underactive side Enhanced looking in direction of Fast Phase Enhanced in the absence of Ocular Fixation

17. Grades of Nystagmus First Degree – Looking in direction of Fast Phase Second Degree – Looking Straight ahead and in direction of Fast Phase Third Degree – All Three Positions

18. Clinical Examination Ocular Range of Movement Smooth Pursuit – Conjugate Movement – Jerky Movement Impaired Smooth Pursuit Nystagmus – Jerky Movement with Target Stationary

19. Clinical Examination Saccades – Abnormal- Cerebellar VOR Suppression Head Thrust – Horizontal

21. Clinical Examination Saccades – Abnormal- Cerebellar VOR Suppression Head Thrust – Horizontal Dynamic Visual Acuity

22. Clinical Examination Romberg – Vestibulo-spinal reflex – Proprioception Unterberger – Unreliable except within one week of Acute Dysfunction Dix-Hallpike

23. Anything Else Problem – Often Asymptomatic when seen – Abnormal Signs Disappeared Video Eye Movements when Symptomatic – 10 sec looking straight ahead – 10 sec looking to left – 10 sec looking to right Have They Nystagmus when Symptomatic?

24. Acute Vestibular Dysfunction Acute Tonic Imbalance – Acute Vertigo – Nystagmus – Nausea and Vomiting Recovery of Function Central Compensation – Static and Dynamic

26. Compensation Inhibition Prolonged use of Suppressant Medication Lack of Stimulation

27. Acute Vestibular Loss- Causes Trauma – Fractured Temporal Bone – Surgery

29. Acute Vestibular Loss- Causes Trauma – Fractured Temporal Bone – Surgery Labyrinthitis – Viral – Bacterial

32. Acute Vestibular Loss- Causes Trauma – Fractured Temporal Bone – Surgery Labyrinthitis – Viral – Bacterial Vestibular Neuronitis

34. Virus Particles isolated in Scarpa’s Ganglion Superior Vestibular Nerve – Superior Canal – Horizontal Canal Inferior Vestibular Nerve – Posterior Canal

35. Management Vestibular Suppressants – Reduces Tonic Asymmetry – 48-72 hours Rehabilitation

36. Compensation Static Dynamic – Requires Stable input – Requires Stimulation Get off Suppressant Medication Start Exercises

37. Problems Incomplete Compensation Partial Decompensation Complete Decompensation

38. Decompensation Causes – Unusual Movement – Another Illness Management – Rehabilitation

39. Recurrent Vertigo Recurrent Pathological Events Recurrent Alteration of Tonic Activity Implies – Partial Damage – Recovery of Function Total Partial

40. Causes Migraine Meniere’s Vascular Loops Susac’s Syndrome Syphilis

41. Meniere’s Disease Episodic Vertigo – 20 min- 24 hours Fluctuating Low Tone Sensori-neural Hearing Loss Tinnitus Sensation Pressure in Ear

42. Stages Hearing returns to normal between Attacks Permanent Low Tone Loss – Worse during attack Permanent Loss – Doesn’t change

43. Diagnosis History Evidence of Canal Paresis Serial Audiometry

44. Variants Cochlear Hydrops – No Vestibular Symptoms Vestibular Hydrops – Probably Migraine Tumarkin Otolithic Crisis – Sudden Collapse

45. Management Medical Low salt Diet Cinnarizine in acute phase Betahistine – Dose: 8-16mg tds – High Dose: 96-160 mg tds

46. Non-Response to Medical Treatment Revisit Diagnosis – Why couldn’t it be Migraine? Surgical Options

47. Surgical Chemical Labyrinthectomy – Gentamicin Delivery – Grommet – Transtympanic Injection – Tympanotomy Apply directly to Round Window Membrane

48. Surgical Options Endolymphatic Sac Decompression Vestibular Nerve Section

49. Migrainous Vertigo Migraine without Aura Migraine with Aura – Migraine with Prolonged Aura Basilar Migraine Migraine Aura without Headache Childhood Periodic Syndromes Migrainous Infarction

50. Basilar Migraine Two or more:- Vertigo, Tinnitus,Hearing Loss, Ataxia, Dysarthria, Diplopia, Paraesthesia, Paresis Headache Vertigo – 5-60 min

51. Migraine Aura without Headache Past History Classical Migraine Family History Migraine Response to Triptans

52. Undiagnosed Recurrent Vertigo 30% Develop Migraine or BPPV Some Migraine Bilateral Involvement Vestibular Migraine, Meniere’s, Epilepsy, MS BPPV All may have atypical presentations

53. Differential Meniere’s BPPV TIAs Vestibular Epilepsy Perilymph Fistula

54. Case Study 1 Early 50’s 2 months Recurrent Dizziness

55. History Symptom – Mostly lightheadedness – Severe episodes- Spinning Tempo – 15-60 sec – Multiple Times a day

56. Symptoms Circumstance – Accompanying Palpitations – Causation Eating Solids

57. Examination ENT – Normal ECG – Normal

58. Test Feed Pre-Food – Heart Rate65 – BP132/70 Post Feed – Heart Rate120-160 – Rhythm Atrial Extrasystoles Flutter Rhythm Terminates with Increasing AV block

59. Case 2 52 yr old Female No Past History Dizziness Turned Suddenly Acute Rotatory Vertigo Nausea and Vomiting Given Cyclizine Referred to Hospital

60. Admission Severe Vertigo Severe Nausea and Vomiting No Nystagmus

62. Benign Paroxysmal Positional Vertigo

63. Causes Idiopathic Head Injury Vestibular Neuronitis Labyrinthitis Anterior Vestibular Artery Ischaemia

64. Idiopathic Highest Incidence – 6 th -7 th Decade >70 years – 25% patients presenting with “dizziness” had BPPV Referrals to Vestibular Clinic – 23% BPPV – Mean age 61

65. Idiopathic Undiagnosed – Increased Risk Falls – Impaired Daily Living General Medical Clinic – 9% Positive Dix-Hallpike Test but no balance complaints

66. Canal Involved Posterior – 76% Anterior – 13% Posterior or Anterior – 6% Horizontal 5%

67. Symptoms Vertigo Light-headedness Floating Sensation

68. Vertigo Lying Down Getting Up Rolling Over in Bed Looking Up

69. Light-Headedness Floating Sensation Hours Days

70. Forms Canalithiasis – Otoconia floating in Canal – Move to most dependent part of canal – Pull on Cupula ceases when Otoconia stop moving Cupulolithiasis – Otoconia stuck to Cupula – Gravitational Distortion of Cupula persists as long as position maintained – Some Vestibular Adaptation occurs

71. Dix-Hallpike Test Latent Period – 3-40 sec Nystagmus Fatigues Adaptation with repeat testing

72. Nystagmus Upbeat Torsional – Upper Pole beating towards undermost Ear

76. Treatment Particle Repositioning Manoeuvre – Epley Liberatory Manoeuvre – Semont Slam-Dunk Brandt-Daroff Exercises – Habituation

78. Treatment Canalithiasis – Epley Cupulolithiasis – Liberatory – Re-test – If now Canalithiasis – Epley

79. Other Nystagmus Not Posterior Canal BPPV Horizontal Jerk Nystagmus – Horizontal Canal BPPV

80. Horizontal Canal BPPV Roll Test Lie on Back- Head 20-30 degrees up Turn quickly to Right or Left Observe for Nystagmus Move Head slowly back to Neutral Position Wait 20-30 sec Repeat on opposite side

81. Results Effect turning to both sides Stimulating in one direction Inhibiting in opposite direction One side – More severe symptoms – More Pronounced Nystagmus – Longer duration of Nystagmus

82. Treatment Canalithiasis – Bar-B-Que Roll – Appiani Manoeuvre Cupulolithiasis – Casani Manoeuvre

83. Bar-B-Que Manoeuvre Turn head to affected side – Wait 15 seconds after symptoms stop Turn head 90 degrees to the Vertical – Wait as before Another 90 degrees – Wait Another 90 degrees – Wait

84. CHRONIC SUBJECTIVE DIZZINESS SYNDROME

85. Precise(ish) Symptoms True Vertigo Light Headed Presyncope Pressure Sensation Postural Imbalance Ataxia

86. Psychogenic Symptoms Chronic Heavy Head Light Headed Tightness in Head Floor Rising and Falling

87. CSD Symptoms >3 months – Non-vertigo dizziness – Light Headed – Heavy Headed – Feeling inside head spinning – Feeling Floor moving – Disassociation from Environment

88. CSD Symptoms Chronic Hypersensitivity – One’s own movement – Movement of Objects in Environment Exacerbation of Symptoms – Situation of Complex Visual Stimuli – Supermarket – Computer screen

89. Age and Sex Age – Adolescent to Old Age – Peak 40-60 Sex – Female 2 - Male 1

90. Pathogenesis Psychological Problem – 93% General Anxiety Panic Attacks/ Phobia Minor Anxiety

91. Pathogenesis Few – Depression – Post Traumatic Stress Disorder – Hypochondriasis – Conversion Disorder

92. Relationship with Neuro-otological or Neurological Conditions Many had – Vestibular Neuronitis – Migraine – BPPV Acute Vestibular Problem Precipitates Acute Anxiety Requirement – Treat underlying Psychopathology

93. Otogenic CSD No Prior History of Anxiety Anxiety precipitated by Neuro-otologic Illness

94. Psychogenic CSD Dizziness develops during Anxiety attack

95. Interactive CSD Prior History of Anxiety CSD Develops or worsens after – Acute Vestibular Event – Transient Mild Rotatory Vertigo

96. Continuing Problem Psychological Process plays Principal Role in Sustaining – Symptoms – Functional Impairment

97. Key to Therapeutic Success Address Psychological Problems

98. Treatment Psycho-education Most Believe – Physical Disorder Need – Explanation of how Psychological Disease produces and sustains Physical Symptoms

99. Pharmacology SSRI Complete Remission50% Positive Effect70% Initial Increase in Symptoms – Benzodiazepines may help in first few weeks 20% intolerant

100. Other Treatments Cognitive Behaviour Therapy Vestibular Rehabilitation