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

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

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

4. 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)

5. 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

6. 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

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

8. 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

9. Vestibular Function and Anatomy

10. 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

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

12. Utricle is in horizontal plane
Saccule is in vertical plane

13. Anatomy

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

15. 45% from AICA
24% superior cerebellar artery
16% basilar
Two divisions: anterior vestibular and common cochlear artery

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

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

18. 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

19. 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

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

21. 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

22. 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

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

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

25. 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

26. 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

29. 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

30. 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

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

33. Calcium carbonate or calcite
Specific gravity of otolithic membrane is
Central region of otolithic membrane is called the striola

34. 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

36. 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

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

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

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

40. 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

41. If acceleration stops, and spin to right is at constant velocity, sensation of motion stops after 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

42. 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

43. 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

44. 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)

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

46. NYSTAGMUS Pendular Or Phasic Spontaneous Or Induced
Horizontal Or Vertical

47. 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

48. 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

49. 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

50. 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)

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

53. 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 : to 20 sec None
Direction : Single Changing
Duration : Brief Long
Fatigue : Yes No
Hearing loss
/Tinitus : Possible No

54. ANATOMY OF BALANCE AND VERTIGO

55. 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.

56. Meniere's Disease

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

58. 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

59. 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 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 years
BPPV results from freely moving crystals of calcium carbonate usually within the semicircular canals

60. BPPV

61. DIX-HALL-PIKE’S TEST

62. EPLEY’S MANEUVER

63. 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

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

65. 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

66. 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 ( yr.) : 1/2 tablet three times a day

67. 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

68. Vestibular Rehabilitation Exercises
Co-ordinated head, body & eye movement helps to ameliorate the patient’s symptoms
Exercises should be performed 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

69. Vestibular Rehabilitation Exercises (contd.)
Exercises should be performed 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

70. Vestibular Rehabilitation Exercises (contd.)
Exercises should be performed 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

72. ANATOMY OF BALANCE AND VERTIGO