1. Dizziness CAUSES AND MANAGEMENT DR. MOHAMMAD HODAN DLO. FRCS, KSUF, SAUDI BOARD ENT Consultant Security Forces Hospital Riyadh, Saudi Arabia

2.  Vertigo defined as an illusion of movement in which the subject feeling is either that he is moving in space or that the outer world is moving around him.

3. Physiology of Balance  Three systems involve in balance:  Visual  Proprioceptive  Vestibular

4. Vestibular System  Consist of 5 sensory organs  3 semicircular canals: Lateral,Posterior and superior (crista – ampularis)  Otolith organs – Utricle and saccule (macula)

6.  Semicircular canals responsible for angular acceleration  Otolithic organs – responsible for linear acceleration

7.  Crista ampularis and macula consist of vestibular hair cells embedded into gelatinom mass contains otolith  There are 23000 hair cells in the tree cristae and 40000 hair cells in the two macule  Each sensory hair cells bearing 50 – 100 thin sterocilia and single thick and long kinocilium

12.  Each afferent neuron has base line firing rate  Deflection of stereocilia toward kinocilium result in an increase in the firing rate of afferent neuron and vice versa

15.  Information is integrated with that from visual and proprioceptive system resulting in maintainance of balance through:  Vestibulo-ocular reflex  Vestibulo spinal (cervical) reflex

16. Vestibulo ocular reflex  Function of VOR is to generate eye movements which is equal in amplitude but opposite in direction to head movements causing them in order to stabilize the image formed on the retina during head movements

20. Approach to Dizzy Patient History: A.Quality of Symptoms Patients usually express wide variety of symptoms as dizziness: 1)Vertigo – usually rotatory movement. It usually suggest peripheral vestibular disorder. 2)Disequilibrium or imbalance – pt. Usually complain of unsteadiness related to ambulation - Peripheral nervous system or cerebellar disorder. 3)Presyncope – feeling of faintness or impending loss of consciousness - cardiovascular disorder. 4)Lightheadness: nonspecific sensation of unsteadiness or floating - variable causes including Hypoglycemia, Hyperventilation, anemia drugs and even vestibular. 5)Uncomfortable sense of shifting or bobbing of viewed object (oscillopsia) => bilateral vestibular damage

21. History: B.Duration of Symptoms  Sudden onset or intermittent symptoms usually indicate peripheral cause  Constant and progressively worsening symptoms indicated central cause

22. Duration of individual Attach  Vertigo lasting seconds:  Benign Paroxysmal positional vertigo (BPPV)  Vertebrobasilar insufficiency  Labyrinthine fistula  Vertigo last minutes to hours  Menieres Disease  Secondary endolymphatic hydrops  Post middle ear surgery  Decompansation of previous vestibular lesion

23. Duration of individual Attach cont ’ d.  Vertigo last for days:  Vestibular neuronitis  Post – labyrinthectomy  Head injury  Labyrinthitis  Vascular lesion  CPA tumours

24. Associated Symptoms  Hearing loss, ear fullness, tinnitus ear discharge indicate peripheral vestibular pathology  Blurred vision, diplopia, dysarthria,incontinence, motor or sensory deficit, convulsion or loss of conciousness all indicate CNS pathology  Nusea or vomiting -> indicate severity and more common with peripheral causes

25.  Exacerbating factors  Head movement -> BPPV  Closing the eye -> peripheral vestibular pathology  Loud noise-> Perilymph fistula  Anxiety attack-> Psychological  Drug history – ototoxic medication e.g. aminoglycoside chemotherapy  Anti hypertensive  Anti convulsants  Alcohol

27. GENERAL MEDICAL HISTORY

28.  Systemic illness such as DM  Vascular dis.- Hypertension - H/O C.V.A. - Subclavian steal syn.  Cardiac dis.- Rheumatic heart (Aortic stenosis) - I.H.D. - Arrhythmia  Infection dis.- Syphilis, Viral, Bacterial

29.  Haemotological Disease such Polycythemia, anemia  Stabilizing sensory organ disorder e.g.  Referaction occular errors  Peripheral nerve dis.  Joint dis.  Psychiatric proplem  Depression  Panic disorder  Anxiety

30. EXAMINATION  Otological examination (tuning fork) for hearing assessment including fistula test  Cranial nerve examination  Blood pressure and pulse  Romberg ’ s test (balance test)  Cerebullar function test  Neck examination for carotid artery disease and range of motion  Nystagmus – the only objective manifestation of vertigo

34. Nystagmus  It is defined as involuntary repetitive movement of eyes, having slow and fast phase  Spontaneous nystagmus seen when eyes are in resting position  Gaze evoked nystagmus  Induced nystagmus by head shaking test or caloric test  Positional nystagmus by Hallpike maneuver

35. Positional nystagmus BPPV Central type Latent period2 – 20 secnone Adaptationdisappears in 50 secpersists Fatiguabilitydisappears on repetitionpersists Vertigoalways presenttypically absent Direction of nystagmusto undermost earvariable Incidencerelatively commonrelatively uncommon

37. Investigation  Screening blood test: Include CBC-diff, ESR, TFT, lipid profile, syphilis screening and serology for autoimmune disease if indicated.  P.T.A. to detect any hearing loss  ABR if asymmetrical hearing loss present  CT/MRI indicated if there is unexplained neurological finding or retrocochlear hearing loss  ECG with rhythm strip

42. Special Vertibular Investigation  Electronystagmography ENG use to record eye movement and this is possible because of electric potential difference between Retina (-ve) and cornea (+ve)  Caloric test It is the only test in which both lateral SCC function can be examined separately

47.  Chiar test VOR comparing eye velocity to head velocity ( ie – chair) -> any asymmetry of response indicate vestibular syst defect.  Dynamic Posturography It assess equilibrium as whole, test is not diagnostic for specific disease entities but usefull in:  Monitoring patient progress in vestibular rehabilitation programme  Specific patterns of response is well established in malingering or Psychiatric disorder

52. Vestibular Neuritis  Sudden onset of pheripheral vertigo  No hearing loss  Vertigo last for days to weeks  Usually preceeded by URTI  Supportive therapy + steroid

53. Meniere ’ s Disease  Classically presented with:  Recurrent vertigo  Flactuating SNHL  Tinnitus  Aural fullness

54. Intra Tympanic Therapy  (ITS) intra Tympanic steroid  (ITAG) Intra Tympanic Aminoglycoside (Chemical Labyrinthectomy)

60. BPPV surgery  Singular neurectomy  PSCC occlusion

62. THANK YOU!