1. Vertigo and Dizziness

2. Vertigo and Dizziness Prevalence 1 in 5 adults report dizziness
Increases in elderly
Worsened by decreased visual acuity, proprioception and vestibular input

3. Vertigo and Dizziness Dizziness : Non-specific term, Could mean:
True Vertigo
Presyncope
Syncope
Lightheadedness (Wooziness)
Motion sensitivity
Giddiness
Unsteadiness
Weakness
Depression
Anxiety
Perception of movement
Peripheral or Central

4. Common Causes of Nonspecific Dizziness
referred more frequently than patients with true vertigo.
Drops in blood pressure:
dehydration
vasovagal attacks
autonomic neuropathy
Side effects or toxicity from medications
(medication itself or the result of lowering of the blood pressure.)

5. metabolic disturbances
panic attack:
nonspecific dizziness
sense of fear or doom
palpitations
sweating
shortness of breath
paresthesias
cardiac arrhythmias
metabolic disturbances

6. For differential diagnosis we must know the ways:
Vestibular Labyrinth
Vestibular nerve
Vestibular nucleus (Brainstem)
Inf ,mid, sup cerebellar peduncle
cerebellum
Cerebral connections

7. Vestibular Labyrinth Pathophysiology 3 semicircular canals
Complex interaction of visual, vestibular and proprioceptive inputs that the CNS integrates as motion and spatial orientation
3 semicircular canals
rotational movement
cupula
2 otolithic organs
utricle & saccule
linear acceleration
Macula

8. Vertigo-Differential Diagnosis
Etiologies of Vertigo
PERIPHERAL:
Cerumen impaction
BPPV
Perilymphatic fistula
Labyrintitis
Acute suppurative
Serous
Toxic
Chronic
Ménière’s
Vestibular neuronitis
Vestibular ganglionitis
Acoustic neuroma
CENTRAL
CNS infection ( BS,cerebellum)
Tumor (Benign or Neoplastic)
Cerebellar infarct
Cerebellar hemorrhage
Vertebrobasilar insufficiency
AICA syndrome
PICA syndrome
Multiple Sclerosis
Basilar artery migraine
Hypothyroidism
Hypoglycemia
Traumatic( post traumatic syn , BPPV)

9. Physiologic Vertigo “motion sickness”
A mismatch between visual, proprioceptive and vestibular inputs
Not a diseased cochleovestibular system or CNS

10. Vertigo-History Is it true vertigo? Pattern of onset and duration
Autonomic symptoms?
Pattern of onset and duration
Auditory disturbances?
Neurologic disturbances?
Was there syncope?
Is triggered by movement?
Unusual eye movements?
Any past head or neck trauma?
Past medical history?
Previous symptoms?
Prescribed and OTC medications?
Drug and alcohol intake?

11. Vertigo-Physical Exam
Auscultate for carotid bruits
Orthostatic vital signs
BP and pulse in both arms
Dix-Hallpike maneuver
Gross hearing
Weber-Rinne test
External auditory canal vesicles
Muscle strength
Gait and Cerebellar function
Cold caloric testing
Cerumen/FB in EAC
Otitis media
Pneumatic otoscopy
Tympanosclerosis or TM perforation
Nystagmus
Fundoscopic exam
Pupillary abnormalities
Extraocular muscles
Cranial nerves
Internuclear ophthalmoplegia

12. Nystagmus Rhythmic slow and fast eye movement
Direction named by fast component
Slow component due to vestibular or brainstem activity
Slow component usually ipsi-lateral to diseased structure
Fast component due to cortical correction
Horizontal / Vertical / Torsional

13. Caloric Test 30 cc water ( cold or warm ) in ear
Slow phase toward coldness
Correction by cortex away from coldness
If cortex & BS are normal COWS is formed
If BS is impaired NO ocular movement
If cortex is abnormal: toward cold/ away from warm ( impaired correction)

14. Vertigo-Characteristics
Peripheral
Central
Onset *
Sudden
Usually slow
Pattern*
Paroxysmal
Constant
Severity of Vertigo*
Intense
Usually mild
Exac.by movement*
Yes
Variable
Nystagmus*
Horizontorotary
Any
Laterality of Nystagmus*
Unilateral
Uni or bilat
Fatigablity* No
Fixation*
Habituation TM
May be abnormal
Normal
Auditory symptoms
CNS symptoms*
Absent
Present

15. Vertigo-Ancillary Tests
MRI
CT-if cerebellar mass, hemorrhage or infarction suspected
Audiometery & BAEP
Electroencephalography????

16. Syndromic approach

17. Common Presentations of Vertigo
Acute Severe Vertigo
Recurrent Attacks of Vertigo
Recurrent Positional Vertigo

18. Acute Severe Vertigo Vestibular neuritis Stroke:
accompanying focal neurological symptoms
direction-changing nystagmus
vertical nystagmus
a negative head-thrust test,
substantial stroke risk factors
Vertebral artery dissection:
severe
sudden-onset occipital or neck pain,
additional neurological signs and symptoms

19. Acute Severe Vertigo labyrinthitis : If hearing loss accompanies
( auditory involvement does not exclude the possibility of a vascular cause, AICA supplies both the inner ear and brain.)
Ramsay Hunt syndrome:
hearing loss
facial weakness
outer ear vesicles characteristic of herpes zoster
acoustic neuroma
(only rarely is it associated with acute-onset vertigo)
Migraine
recurrent episodes
lack of progressive auditory symptoms)

20. Recurrent Attacks of Vertigo
Key diagnostic information : details of the attacks
Meniere disease:
recurrent vertigo
lasting longer than 20 minutes
unilateral auditory symptoms
Transient ischemic attacks (TIA) :
brief episodes (minutes) of vertigo,
vascular risk factors
other neurological symptoms,

21. Recurrent Attacks of Vertigo
Rotational vertebral artery syndrome
Migraine and the migraine equivalent, BRV,
history of similar symptoms
a normal examination
family or personal history of migraine headaches and/or BRV,
other migraine characteristics
typical triggers
lasting anywhere from seconds to days.
Vestibular paroxysmia: neurovascular cross-compression (NVCC), leads to vertiginous spells.
consistently seconds in duration
Multiple sclerosis
Seizure

22. Recurrent Positional Vertigo
Positional vertigo: the symptom being triggered, not simply worsened, by certain positional changes.
BPPV
but this is not the only possibility.
positional vertigo is brief (<1 minute)
typical triggers
unaccompanied by other neurological symptoms.
vertical torsional nystagmus
Vestibular neuritis
(often settle into a relatively comfortable position and then experience dramatic worsening with movement)

23. Recurrent Positional Vertigo
loss of one vertebral artery :
After head turns to the direction opposite the intact artery
Central types of nystagmus
migraine :
longer duration
nystagmus : central or peripheral type
benign
self-limited
not progressive

24. Pathway approach

25. Benign Paroxysmal Positional Vertigo
Extremely common (esp. in elderly or post traumatic)
Otoconia displacement
No hearing loss or tinnitus
Short-lived episodes brought on by rapid changes in head position
Usually a single position that elicits vertigo
Horizontorotary nystagmus with crescendo- decrescendo pattern after slight latency period
Less pronounced with repeated stimuli
Typically can be reproduced at bedside with positioning maneuvers

26. Otoconia in BPPV

27. Dix-Hallpike Maneuver
Figure 1. Dix-Hallpike maneuver (used to diagnose benign paroxysmal positional vertigo). This test consists of a series of two maneuvers: With the patient sitting on the examination table, facing forward, eyes open, the physician turns the patient's head 45 degrees to the right (A). The physician supports the patient's head as the patient lies back quickly from a sitting to supine position, ending with the head hanging 20 degrees off the end of the examination table. The patient remains in this position for 30 seconds (B). Then the patient returns to the upright position and is observed for 30 seconds. Next, the maneuver is repeated with the patient's head turned to the left. A positive test is indicated if any of these maneuvers provide vertigo with or without nystagmus.

28. Labyrinthitis Involves the cochlear and vestibular systems
Abrupt onset
Usually continuous
Four types of Labyrinthitis
Serous
Acute suppurative
Toxic
Chronic

29. Labyrinthitis Serous Acute suppurative labyrinthitis
Adjacent inflammation due to ENT or meningeal infection
Mild to severe vertigo with nausea and vomiting
May have some degree of permanent impairment
Acute suppurative labyrinthitis
Acute bacterial exudative infection in middle ear
Secondary to otitis media or meningitis
Severe hearing loss and vertigo
Treated with admission and IV antibiotics

30. Labyrinthitis Toxic Due to toxic effects of medications
Still relatively common
Mild tinnitus and high frequency hearing loss
Vertigo in acute phase
Ataxia in the chronic phase
Common etiologies
-Aminoglycosides -Vancomycin
-Erythromycin Barbiturates
-Phenytoin -Furosemide
-Quinidine -Salicylates
-Alcohol

31. Labyrinthitis Chronic
Localized inflammatory process of the inner ear due to fistula formation from middle to inner ear
Most occur in horizontal semicircular canal
Etiology is due to destruction by a cholesteatoma

32. Ménière Disease First described in 1861
Triad of vertigo, tinnitus and hearing loss
Due to cochlear-hydrops
Unknown etiology
Possibly autoimmune
Abrupt, episodic, recurrent episodes with severe rotational vertigo
Usually last for several hours

33. Ménière Disease
Often patients have eaten a salty meal prior to attacks
May occur in clusters and have long episode- free remissions
Usually low pitched tinnitus
HL In low frequency tone
Symptoms subside quickly after attack
No CNS symptoms or positional vertigo are present

34. Vestibular Neuronitis
Suspected viral etiology
Sudden onset vertigo that increases in intensity over several hours and gradually subsides over several days
Mild vertigo may last for several weeks
May have auditory symptoms
Highest incidence in 3rd and 5th decades

35. Acoustic Neuroma
Peripheral vertigo that ultimately develops central manifestations
Tumor of the Schwann cells around the 8th CN
Vertigo with hearing loss and tinnitus
With tumor enlargement, it encroaches on the cerebellopontine angle causing neurologic signs
Earliest sign is decreased corneal reflex
Later truncal ataxia
Most occur in women during 3rd and 6th decades

36. Acoustic Neuroma

37. Central Vertigo-Differential
Vertebrobasilar Insufficiency
Atheromatous plaque
Subclavian Steal Syndrome
Wallenberg Syndrome
Drop attack
Cerebellar Hemorrhage
Multiple Sclerosis
Malignancy
Infection: cerebellitis/ abscess/ TB
Head Trauma
Neck Injury
Vertiginous seizure
Vestibulogenic seizure
Vertebrobasilar migraine

38. Vertebrobasilar Insufficiency

39. Vertebrobasilar Insufficiency
Important causes of central vertigo
Related to decreased perfusion of vestibular nuclei in brain stem
Vertigo may be a prominent symptom with ischemia in basilar artery territories
Unusual for vertigo to be only symptom of ischemia

40. Vertebrobasilar Insufficiency
Most commonly will also have:
-Dysarthria -Ataxia -Facial numbness
-Hemiparesis -Diplopia -Headache
Tinnitus and hearing loss unlikely
Vertical nystagmus is characteristic of a (superior colliculus) brain stem lesion

41. Subclavian Steal Syndrome
Rare, but treatable
Arm exercise on side of stenotic subclavian artery usually causes symptoms of intermittent claudication
Blood is shunted away from brainstem into ipsilateral vertebral artery
Classic history occurs only rarely

42. Vertebrobasilar Migraine
Syndrome of vertigo, dysarthria, ataxia, visual changes, paresthesias and LOC followed by headache
Distinguishing features of basilar artery migraine
-Symptoms precede headache
-History of previous attacks
-Family history of migraine
-No residual neurologic signs
Symptoms coincide with angiographic evidence of intracranial vasoconstriction

43. Cerebellar Hemorrhage
Neurosurgical emergency
Suspected in any patient with sudden onset headache, vertigo, vomiting and ataxia
May have gaze preference
Motor-sensory exam usually normal
Gait disturbance often not recognized because patient appears too ill to move

44. Multiple Sclerosis Vertigo is presenting symptom in 7-10%
Thirty percent develop vertigo in the course of the disease
May have any type of nystagmus
Internuclear ophthalmoplegia is virtually pathognomonic
Onset during 2nd to 4th decade
Rare after 5th decade
Usually will have had previous neurological symptoms

45. Head and Neck Trauma
Due to damage to the inner ear and central vestibular nuclei, most often labyrinthine concussion
Temporal skull fracture may damage the labyrinth or eighth cranial nerve
Vertigo may occur 7-10 days after whiplash
Persistent episodic flares suggest perilymphatic fistula
Fistula may provide direct route to CNS infection

46. Management
Mainstay of peripheral vertigo management are antihistamines that possess anticholinergic/ antihistaminic properties (short duration )
Cinnarizine- dimenhydrinate- Meclizine- Diphenhydramine-Promethazine-scopolamine

47. Management
VBI should be considered in any elderly patient with new-onset vertigo without an obvious etiology
Suppurative labrynthitis: admit and IV antibiotics
Toxic labrynthitis: stop offending agent if possible

48. Ménière : Low salt regiment \ Severe disease may require chemical ablation with gentamicin
Attempt Epley maneuver and assurance for BPPV

49. Epley Maneuver

50. Epley Maneuver

51. Epley Maneuver

52. Epley Maneuver

53. Epley Maneuver

54. Epley Maneuver

55. Epley Maneuver

56. Gans Repositioning Maneuver(GRM)

57. Exercise therapy at home

58. Summary Ensure you understand what the patient means by “dizzy”
Try to differentiate central from peripheral
Most can be discharged with antihistamines
Treatment according to the reason

60. Thanks For Your Attention