1. Vertigo Dr. Abdulrahman Alsanosi Associate professor Otolaryngology consultant Otologist, Neurotologist &Skull Base Surgeon Head of Otology / Neurotology Unit Director of cochlear implant program King Abdulaziz University Hospital

2. From: Antonieta Adiova Subject: monday - at 1-2pm Date: February 14, 2012 2:49:51 PM GMT+03:00 To: Abdulrahman Alsanosi, sanosi@hotmail.com Cc: Babylyn Erolin Palmero, amarfaj@hotmail.com, Dr. Saleh Aldhahri saldhahri@KSU.EDU.SAsaldhahri@KSU.EDU.SA dear dr. sanosi, just to informed you pls that your lecture will be at 1 pm until 2 pm...this coming monday and NOT in the morning pls....for they have Ophtha activities. thank you and Lyn will be with u coz im leaving tomorrow.. best regards

3. INTRODUCTION Dizziness is a common symptom that accounted for more than 5.6 million clinic visits in the United States 15% to 30% of patients, most often women and the elderly, will experience dizziness severe enough to seek medical attention at some time in their live

4. What are the components of balance system ?

5.  Inner ear (3 semicicular canals and otolith organ )  Cerebellum  Vision (VOR)  Proprioceptive

6. How does balance system work ?

7. Physiology Function of vestibular system:  Transform of the forces associate with head acceleration and gravity into a biological signals that the brain can use to develop subjective awareness of head position in space (orientation)  produce motor reflexes that will maintain posture and ocular stability

8. It is not surprisingly that vestibular lesion cause:  Imbalance  posture and gait imbalance  visual distortion (oscillopsia ).

9. oscillopsia

10. What is vertigo?

11. VERTIGO  The word "vertigo" comes from the Latin "vertere", to turn + the suffix "-igo", a condition = a condition of turning about).  It is an allusion of being moving or the world is moving too.

12. What are the questions to ask in history ?  Onset  Frequency  Duration  Associated auditory symptoms  Aggrevating and relieving factors  Ear disease or ear surgery  Trauma  Migraine  Ototoxic drug intake

13. Differential diagnosis A) peripheral vestibular loss B) central vestibular loss

14. What are the causes of peripheral vestibular loss ?

15. peripheral vestibular loss  Vestibular neuritis  Benign paroxysmal positional vertigo ( BPPV)  Meneires disease (Endolymphatic hydrop )

16. Vestibular neuritis  Viral infection of vestibular organ  Affect all ages but rare in childern  Affected patient presents acutely with spontaneous nystagmous,vertigo and nausea &vomiting  Patient requires only symptomatic treatment  It takes 3 weeks to recover from vestibular neuritis

17. Vestibualr neuritis

18.  BPPV( benign paroxysmal positional vertigo )

19. BPPV  The most common cause of vertigo in patient > 40 years  Repeated attacks of vertigo usually of short duration less than a minute.  Provoked by certain positions (rolling in beds, looking up,and head rotations)  Not associated with any hearing impairment

20. BPPV Diagnosis  History  Dix-Halpike maneuver

21. Endolymphatic hydrop (Meneire’s disease) Pathophysiology :  Unknown etiology  ↑ ↓production of fluid within inner compartment

22.  vertigo (minutes to hours )  Low frequency fluctuating SNHL  Tinnitus and fullness in the ear.  In 10 - 20% of cases the disease later involves the opposite ear

23. Meneire’s disease  Diagnosis -History -PTA

24. Meneire’s disease  Management -low-salt diet -Medical therapy - Meniett device's -Chemical perfusion -Surgery

25. SUMMARY TreatmentCourse of diseases hearingDuration of attack Diagnosis SymptomaticSelf limitednormalDaysVestibular N ExerciseRecurrentnormalSecondsBPPV Medical &surgical RecurrentAffectedMinutes to hoursMeneire’s diseaseM

29. What are the causes of central ?

30.  CVA (Cerebero vascular accident)  Brain tumor ( acoustic neuroma )  Multiple sclerosis

31. CVA  Elderly patient with chronic disease like (DM,HTN) with sudden attack of vertigo +neurological symptoms

32. Acoustic tumor  Benign tumor  Arise from vestibular devision of VIII Clinical presenatation:  Unilateral tinnitus  Hearing loss  Dizziness

33. Acoustic neuroma Diagnosis :  History  PTA ( Unilateral SNHL )  Radiology

34. diagnosis History is the most important key to diagnosis for a dizzy patient.

35. Investiagtions  PTA  Vestibular testing  CT SCAN  MRI

36. A dizzy patient may fit into one of the following scenarios

37. Scenario # 1 The patient who is having a first ever attack of acute spontaneous vertigo.  Acute vestibular neuritis  cerebellar infarction. How to differentiate ? - Clinically ( General appearance of patient /nystagmus/head impulse test) - Radiology

38. Scenario #2 The patient who has repeated attacks of vertigo, but is seen while well A- Recurrent spontaneous vertigo  Menière’s disease  Migraine induced vertigo  perilymph fistula B- Recurrent Positioning Vertigo  BPPV

39. Scenario #3 The patient who is off balance  Bilateral vestibulopathy  posterior fossa tumour

40. Take away message

41. Thank you