Evaluation of giddiness

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• Introduction

• Classification of vertigo

• Evaluation

• Diagnosis

• Management

Evaluation of giddiness

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Introduction

• Dysequilibrium, unsteadiness, vertigo, and lightheadedness

• Vertigo is an illusory sense of motion

– Internal feeling

– Objects in the surroundings are moving or tilting

– Sense of motion

• Rotatory

• Linear

• Change in orientation relative to the vertical

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Introduction

• 9th Most common symptom

• Significant sorting problem

• Patients prefer a "symptom" oriented setting to a "cause" oriented setting

• Causes– Otologic (40-50%)

– Neurologic (10-30%)

– General medical (10-30%)

– Psychiatric/undiagnosed (15-50%)

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Classification

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Classification

• Duration of involvement

• Central & peripheral

• Topographical classification

• Non vestibular causes

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Duration of giddiness

• Short lived episodic rotatory vertigo (few sec)

– BPPV

– Labyrinthine fistula

– Caloric effect

– Alternobaric vertigo

– Post concussion syn

– Vertebrobasilar insufficiency

– Cervical vertigo

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Duration of giddiness

• Few minutes to < 24 hrs

– Meniere’s disease

– Syphilitic labyrynthitis

– Delayed endolymphatic hydrops

– Foll middle ear surgery

– Decompensation of previous vestibular lesion

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Duration of giddiness

• Prolonged rotatory vertigo– Vestibular neuronitis– Trauma

• Head injury• Ear surgery• Labyrinthectomy• Vestibular neuronectomy

– Labyrinthitis– Vascular lesions– Mets at CP angle

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Classification

• CENTRAL

– Cerebellopontine angle tumor

– Cerebrovascular disease

– Migraine

– Multiple sclerosis

– Cerebellar lesions

– Epilepsy

– Parkinsonism

– meningitis

• PERIPHERAL

– Acute labrynthitis

– Vestibular neuritis

– BPPV

– Cholesteatoma

– Meniere’s disease

– Ostosclerosis

– Perilymphatic fistula

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Non vestibular

System Disease

Endocrine Hypoglycaemia, adrenal failure, pheochromocytoma

CVS Vasovagal syncope, orthostatic hypotension, embolic disease, cardiac dysarythmias

Haematological Hyperviscosity syn, anaemia

Psychological Anxiety, phobias, panic attacks

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Post head injury

• Post concussion

• BPPV

• Destructive labyrinth lesions

• Perilymph fistula

• Delayed endolymphatic hydrops

• Functional

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Evaluation

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Evaluation - history

• Define

– patient's dizziness - Vertigo, Impulsion, lightheaded, oscillopsia, ataxia, confusion.

• Timing

– (BPPV-seconds, TIA-minutes, meniere’s -hours, Vestibular Neuronitis-Days, ototoxicity-years)

• Associations

– head motion or change in head position, hearing disturbance, headache, cognitive symptoms, relation to stress.

• Review of systems

– especially vascular risk factors and ear surgery.

• Family History

– Similar disorder ? Migraine

• Medication History

– present and past exposures to ototoxins, antihypertensives.

• Previous studies

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Topographical

Symptom Site of lesion

Tinnitus, hearing loss Peripheral (labyrinth / 8th CN)

Ear fullness, Tinnitus, hearing loss

Labyrinthine

5th,6th,7th CN CP angle

EAC vesicles 7th , 8th neuritis

Diplopia, 3rd,4th,6th , facial numbness, difficulty swallowig,choking

Brainstem

Uni / bilateral numbness, weakness, ataxia, long tract, hemianopia

Cerebral hemisphere

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Symptom DiagnosisAural fullness Acoustic neuroma; Ménière's disease

Ear or mastoid pain Acoustic neuroma; acute middle ear disease (e.g., otitis media, herpes zoster oticus)

Facial weakness Acoustic neuroma; herpes zoster oticus

Focal neurologic Cerebellopontine angle tumor; cerebrovascular disease; multiple sclerosis

Headache Acoustic neuroma; migraine

Associated symptoms & diagnosis

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Symptom diagnosis

Nystagmus Peripheral or central vertigo

Photophobia Migraine

Tinnitus Acute labyrinthitis; acoustic neuroma; Ménière's disease

Imbalance Acute vestibular neuronitis cerebellopontine angle tumor

Hearing loss Ménière's disease; perilymphaticfistula; acoustic neuroma; cholesteatoma, otosclerosis; TIA or stroke involving anterior inferior cerebellar artery,herpes zoster oticus

Associated symptoms & diagnosis

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Provoking Factors for Different Causes

Provoking factor Suggested diagnosis

Changes in head position Acute labyrinthitis; benign positional paroxysmal vertigo; multiple sclerosis; perilymphatic fistula

Spontaneous episodes Acute vestibular neuronitis; cerebrovascular disease (stroke or transient ischemic attack); (i.e., no consistent provoking factors) Ménière's disease; migraine; multiple sclerosis

Recent upper respiratory viral illness

Acute vestibular neuronitis

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Provoking factor Suggested diagnosis

Stress Psychiatric or psychological causes; migraine

Immunosuppression (e.g., immunosuppressive medications, advanced age , stress)

Herpes zoster oticus

Changes in ear pressure, head trauma, excessive straining, loud noises

Perilymphatic fistula

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Provoking Factors for Different Causes

Historical algorithm

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Examination

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Examination

• General Medical Examination

– Personality

– Anaemia

– Blood pressure

• Orthostatic changes in blood pressure or pulse, Hypertensive

– Cardiac

• Arrhythmia, murmur, bruit

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Examination

• Otologic Examination

– Middle ear pathology

– Hearing

• Neurotological examination

– Cranial nerves

– Motor power and reflexes, pathological reflexes (e.g. Babinski)

– Sensory (proprioception)

– Cerebellar signs

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Examination

• Cerebellar Tests

– Ataxia, atonia, and asthenia

– Intention tremor (tremor that increases on activity)

– Dyssynergia (incoordination)

– Dysmetria (overshooting or undershooting)

– Dysrhythmia (inability to repeat a rhythmic tap)

– Dysdiadochokinesis (difficulty with rapid alternating movements)

– Dysarthria (staccato or scanning speech)

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Examination

• Oculomotor examination

– Spontaneous nystagmus

• unilateral vestibular hypofunction +

• head is still, dampened by visual fixation

• increased or only becomes apparent when fixation is eliminated

• Slow phase

– Alexander’s law

– Grading nysagmus

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Examination

• Vestibular examination

– Specific T• Dix Hallpike T

• Fistula T

– Non Specific Test• ENG

• Rotation T

– Otolith Function T• Ocular counterrolling

• Parallel swing T

• Axis rotation T

– Whiplash T• Passive neck torsion T

• Static Neck Torsion

– Vestibulospinal T• Rhombergs T

• Untenberger T

• craniocorpography

• Posturography

• VEMP

– Others• Caloric T

• Head shaking T

• Hyperventillation

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Examination

• Dix hallpike T or Nylén-Bárány sign

– Procedure

• Head 45° turned

• Lowered & hyperextended -30 sec

– Rt Dix Hallpike

• Rt PSCC - Upbeat ,Torsional,

• Lt SSCC - Downbeat Torsional

– Lat SCC – modified T

• Geotropic, Ageotropic

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Examination• Nystamus

– Latency 5-10 s

– Max 1 minute

– Severe vertigo

– Fatigues rapidly

– Fatiguability

• A positive dix-hallpike maneuver has a 50-80 percent sensitivity

• Contra indications

– carotid stenosis

– vertebrobasilar vascular disease

– cervical spine disease

– spinal injury

– cardiovascular disease or cardiac dysrhythmia

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Examination

• Fistula T– Procedure

• Politzer bag

• Siegle otoscope

• Digital pressure

• Impedance bridge

– Bony fistula in a Lat semicircular canal

– Vestibulofibrosis• Hennebert's sign - +ve in > 25% of Ménière's patients

– Perilymph fistula of the oval or round window

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Caloric T

• Robert Barany in 1906• Nobel prize 1914 • Mechanism

– Barany • Convective flow

– Coats and Smith• direct effect of temperature on hair cells or vestibular-nerve

afferents

– Scherer and Clarke• thermal expansion of labyrinthine fluids will result in a

maintained cupular displacement

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Caloric T

• Tests– Fitzgerald hallpike Alternate binaural, bithermal T

– Air Caloric T

– Kobrak’s T

– Dunda’s T

• Fitzgerald hallpike T

– Testing procedure• Lat SCC

– closest to EAC

– oriented in the plane of the temperature gradient

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Caloric T

– Head elevated – 30 degree– Irrigation

• 250 ml, 60 cms high, over 60 sec• right warm, left warm, right cold, left cold• COWS – 2-3 mins• 10 mins - between successive irrigations

– Results• Jonkees, Maas & philipzoon Formula

– Canal paresis– Directional preponderance

• Significant– UW of greater than 20%– DP of greater than 25%

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Caloric T

• Air caloric T

• Kobrak’s T

• Dundas Grant cold air Caloric T

– Ethylene chloride sprayed

– Cloth wrapped Coiled copper tube

– Air blown through coil

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Examination

• Untenberger’s T

– Stepping T, 1938

– Blindfolded stretched arms

– Spot Stepping 90 steps in 1 min

– Inferance

• Displacement – 2 mts

• Angular deviation – 70- R, 50 – L

• Angular rotation – 85 – R, 60 – L

• Lateral sway – 15 cms

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Examination

• Rhomberg’s T

– Sensory From cerebellar

– Sway > 10 cms

• Craniocorpography

– Crude Test

– Dark room

– Stepping T

– Rhomberg’s T

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Examination

• Cervicogenic Vertigo

– Vascular theory

– Neurosensory theory

• Whiplash T

– Passive neck torsion T

• Head mobile

– Static Neck Torsion

• Body mobile

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Lab tests

• Electronystagmography– Defn

– Mechanism• CRP

– Electrode placement• 1 channel

• 2 channel

• 4 channel

– Criteria• Eye movt to have a slow & fast phase

• Amplitude > 20 microvolts

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ENG

• Saccade T

• Tracking T

• Optokinetic T

• Gaze T

• Positional T

• Caloric T

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ENG

• Gaze T

– N – end point nystagmus > 40 degree

– Vertical N – CNS pathology

– Horizontal N

• B\L , equal – CNS

• B\L , unequal – CNS

• Unilateral - peripheral

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VNG

• Method of oculography

• Frenzel glasses with VNG apparatus

• Video recording

– Torsional movt

– No artefacts as in ENG

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ENG Vs VNG

• ENG

– 50 – 1000 Hz recordable

– Eyes closed / open

– Artefacts +

– Torsional Nyst -

– Calibration difficult

– Cheap

• VNG

– 60 Hz only

– Eyes open

– No Artefacts

– Torsional Nyst +

– Calibration easy

– Expensive

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Rotatory Chair

• Principle

• Testing procedures

• Indications– Bilateral canal paresis

– Inconclusive/equivocal ENG reults

– Testing of special populations (pediatric, handicapped)

– Evaluation of vestibular compensation

– Ototoxicity management

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Posturography

• Nasher & Black

– Sensory organisation

– Motor coordination

• Procedure

– Sensory organisation chart

– Motor coordination T

• Sudden movement

• emg of gastrocnemius

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VEMP

• Vestibulo-collic reflex– Unilateral reflex

– Procedure• 3 electrodes

• 95 -105 dB

• emg of SCM

– Uses• Acoustic neuroma

• Vestibular neuritis

• Sup SCC dehiscence

• Tulio phenomenon

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VEMP

Pathology VEMP Response

Meniere's disease Absent, reduced, enhanced

Superior canal dehiscence syndrome Enhanced

Neurolabyrinthitis Absent, reduced

Vestibular neuritis Absent, reduced

Migraine Absent, reduced, delayed

Spinocerebellar degeneration Absent, delayed

Multiple sclerosis Absent, delayed

Brainstem stroke Absent, delayed

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Diagnosis

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BPPV

• Vertigo without auditory symptoms

• Severe vertigo < 1 min

• Triggerred by head movt

• Latent period after head movement

• Dix hallpike is confirmatory

• ENG

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Vestibular neuronitis

• Vertigo without auditory symptoms

• Lasts for > 24 hrs

• h/o preceding URTI

• Unilateral

• Caloric T - Canal paresis

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Meniere’s disease

• Episodic vertigo with fluctuant hearing loss

• Vertigo lasting upto 20 min

• Tinnitus with aural fullness

• Electrocochleography

• Glycerol dehydration T

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Thank you

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