VertigoDone by :Ahlam Majali

Definition Vertigo is when a person feels like if they or the objects around them are moving when they are not.[1] Often it feels like a spinning or swaying movement.

An illusion or hallucination of movement which is usually rotation, either of oneself or the environment

( FALES SENSATION OF MOVEMENT)

It is often accompanied by pallor, sweating and vomiting. The objective sign of vertigo is nystagmus.

The body balance is maintained by inputs to the brain from 3 areas:

Inner ear(vestibular part) Eyes Proprioceptive organs

Dysfunction of any of these systems may lead to imbalance.

Classification

• Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the vestibular pathway

Central vertigo

If vertigo arises from the balance centers of the brain.

it is usually milder. has accompanying neurologic deficits such

as : – slurred speech– double vision or– pathologic nystagmus.

Central causes

1.inflammatory:meningitis,encephilitis2.Traumatic:head trauma3.Vascular:Thrombosis,hm’g,embolism4.Neoplastic:cerbellar tumors5.Degenerative:multiple sclerosis6.Other :epilepsy,Lateral medullary

syndrome:occulsion of PICA (Posterior inferior cerebellar artery)

Peripheral vertigo

Vertigo caused by problems with the inner ear or vestibular system is called "peripheral", "otologic" or "vestibular" .

The most common cause is benign paroxysmal positional vertigo

Any cause of inflammation such as common cold, influenza, and bacterial infections may cause transient vertigo if they involve the inner ear, chemical insults (e.g., aminoglycosides) physical trauma (e.g., skull fractures) and Motion sickness is sometimes classified as a cause of peripheral vertigo.

• Peripheral vertigo can be classified into:– Acute

• Acute vestibular neuritis • Labyrinthitis• Perilymph fistula

– Chronic • Meniere disease• BPPV• Acoustic neuroma.

Diagnosis The diagnosis of the cause of vertigo or imbalance

depends mostly on history, much on examination and little on investigation.

The particular questions to be asked relate to three areas:1 Timing: episodic, persistent.2 Aural symptoms: deafness, fluctuating or

progressive; tinnitus; earache discharge.3 Neurological symptoms: loss of consciousness;

weakness; numbness; dysarthria; diplopia; fitting

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A.N. Obydi

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Menière’s Disease Menière’s Disease Def. : Def. : an idiopathic condition in which there is distension of the an idiopathic condition in which there is distension of the membranous labyrinth by accumulation of endolymph (endolymphatic membranous labyrinth by accumulation of endolymph (endolymphatic hydrops). hydrops).

It can occur at It can occur at anyany age, but mostly 40 and 60 yrs. age, but mostly 40 and 60 yrs.

-Usually Usually uniunilateral but in 35% of cases it is lateral but in 35% of cases it is bibilateral . lateral .

-Menière’s disease is fortunately Menière’s disease is fortunately uncommonuncommon, but may be , but may be incapacitating.incapacitating.

Menière’s Disease Menière’s Disease Clinical Features : Clinical Features :

1.Vertigo is intermittent but may be profound, and usually causes vomiting. The vertigo lasts for a few hours, and is of a rotational nature.

2. Aural fullness may precede an attack by hours or even days.

3.SNHL : It is associated with loudness intolerance . Despite fluctuations, the deafness is usually steadily progressive and may become severe.

4.Tinnitus is constant but more severe before an attack.

The Caloric TestThe Caloric Test• Irrigation of the external meatus with water

7°above and later 7° below body temperature sets up currents of the endolymph in the semicircular canals.

• This causes nystagmus, and the duration of the nystagmus gives an index of the activity of the labyrinth.(slow toward the cold water )

• The nystagmus can be directly observed or recorded electrically (electronystagmography).

• This test is particularly valuable inthe diagnosis of Ménière’s disease and acoustic neuroma.

• A reduced or absent nystagmus is found (canal paresis).

caloric reflex test This test is particularly valuable in the diagnosis of Ménière’s disease andacoustic neuroma.

1-Pt lies supine with flexed head(30 degree) 2-Ear is washed with cold water(30 c) {7 below body temp}3-Rest 7 minutes4-Then ear is washed with worm water (44 c) {7 above body temp} 5-Each ear washed for 40 seconds

• Normal result nystagmus & vertigo last 90-120 sec • >90 sec hypofunction• no response dead ear

The nystagmus observed electrically (electronystagmography). A reduced or absent nystagmus is found (canal paresis)

TreatmentTreatmentGeneral and medical measuresGeneral and medical measuresIn an acute attack

1.Bed rest

2.Anti-emetic (e.g. Prochlorperzine IM or cinnarizine sublingual )

3.Anti-vertiginous agent ( Betahestine (Serc) )

Between attacks, various methods of treatment are useful:

1. Fluid and salt restriction.

2. Avoidance of smoking and excessive alcohol or coffee.

3. Regular therapy with betahistine hydrochloride

4. If the attacks are frequent, regular medication with labyrinthine sedatives, such as

cinnarizine, or prochlorperazine, are of value. Regular low-dose diuretic therapy may also be of benefit.

Surgical treatment1- Labyrinthectomy is effective in relieving vertigo, but should only be

performed in the unilateral case and when the hearing is already severely impaired.

2 -Drainage of the endolymphatic sac by the transmastoid route.

3 -Division of the vestibular nerve either by the middle fossa or by the retrolabyrinthine route; this operation preserves the hearing but is a more hazardous procedure.

4-Intra-tympanic gentamycin is helpful in reducing vestibular activity but

• with a 10% risk of worsening the hearing loss.• .

Vestibular NeuronitisVestibular Neuronitis- Acute onset of disabiling vertigo often accompanied by N&V and

imbalance which resolves over days leaving a residual imbalance which resolves in days to weeks .

- No asso. HL or tinnitus.

- Steady resolution takes place over a period of 6–12 weeks but the acute phase usually clears in 2 weeks.

Etiology : Etiology : Viral infection ( Mumps, Measles & HZ )

vestibular neuritis is usually treated symptomatically, meaning that medications are given for nausea (anti-emetics) .

Typical medications used are "Antivert (meclizine)", "Ativan (lorazepam) ", and "Valium (diazepam) ".

Steroids (prednisone, methylprednisolon) are also used for some cases.

Benign Positional Vertigo Benign paroxysmal positional vertigo is due to a

degenerative condition of the utricular neuroepithelium and may occur spontaneously or following head injury.

Attacks of vertigo are precipitated by turning the head so that the affected ear is undermost.

the vertigo occurs following a latent period of several seconds and is of brief duration.

BPPVBPPV EtiologyEtiology : :

- Due to canalithiasis or cupulolithiasis .

- 90% of cases affects the post. semicircular canal.

There is no hearing loss

Nystagmus will be observed

Steady resolution is to be expected over a period of weeks or months.

It may be recurrent.

It can often be relieved completely by the Epley manoeuvre of particle repositioning by sequential movement of the head to move the otolith particles away from the macula

BPPV diagnosis: Dix-Hallpike manoeuvre

This maneuver helps to differentiate peripheral positional vertigo from central vertigo.

The physician moves the patient from a sitting to a supine position, with the head rotated 45 degrees to one side and hanging off the table at 45 degrees.

The patient is then observed for vertigo and nystagmus.

The maneuver is repeated with the head turned to the other side.

Dix-hallpike maneuver• With peripheral positional vertigo ( benign positional

vertigo), the maneuver produces ( after 2-20 seconds ) :1. Vertigo ( lasting for 20sec )2. Rotary nystagmus 3. Fatigues with repetitive testing.4. Reversal of Nys. upon sitting up 5. Latency of 〜 20

• Variation of these features often indicates a central disorder.

The Epley maneuver

This repositioning procedure uses gravity to draw canaliths from the posterior semicircular canal to the vestibule, where they are absorbed.

This may require that the pt. wears a soft neck collar for support and sleep sitting up in a chair for a night

Acoustic neuroma Acoustic neuroma (vestibular schwannoma) is a slow-growing

benign tumour of the vestibular nerve that causes hearing loss , tinnitus and slow loss of vestibular function.

Imbalance rather than vertigo results. Diagnosis : MRI – will show a tumor that may be in the internal

auditory canal or extend through the meatus into the cerebellopontine angle

Treatment :microsurgical resection or conformal stereotactic radiosurgery.

Complications : Complications : 1. Facial nerve palsy

2. V1 sensory defecit ( corneal reflex )

Labyrinthitis

It is an inflammatory disease of the inner ear it could affect one or both ears . Clinically:

Disturbance of balance Hearing loss of varying degrees Nausea & vomitingTinnitus Otorrhea Otalgia Aural fullness Spontaneous Nystagmus toward the unaffected side.

Viral or bacterial infection can cause inflammation of the labyrinth in conjugation with either local or systemic infection

Autoimmune process may also cause labyrinthitis

Management viral labyrinthitis :bed rest and hydration . Pt. with severe nausea and vomiting :IV fluid and

antiemetic . Diazepam and other benzodiazepines are occasionally

helpful as vestibular suppressant . A short course of oral corticosteroids may be helpful. Bacterial labyrinthitis is treated with antibiotics based on

culture and sensitivity . Treat the symptoms as indicated

Perilymph fistula

result of spontaneous rupture of the round-window membrane or trauma to the stapes footplate.

perilymph fistula causes marked vertigo with tinnitus and deafness.

There is usually a history of straining, lifting or subaqua diving in the spontaneous cases.

treatment is by bed-rest initially, followed by surgical repair if symptoms persist

Ototoxic drugsOtotoxic drugs

- Such as gentamycin and other aminoglycoside antibiotics, can cause disabling ataxia by destruction of labyrinthine function.

- Such ataxia may be permanent and the risk is reduced by careful monitoring of serum levels of the drug, especially in patients with renal impairment.

Trauma to the labyrinthTrauma to the labyrinth

- Trauma to the labyrinth causing vertigo may complicate head injury, with or without temporal bone fracture.

Post-operative vertigoPost-operative vertigo

- Post-operative vertigo may occur after ear surgery, especially stapedectomy, and will usually settle in a few days.

Syphilitic labyrinthitisSyphilitic labyrinthitis

- Syphilitic labyrinthitis from acquired or congenital syphilis

- It is very rare but may cause vertigo and/or progressive deafness.

Vertebrobasilar InsufficiencyVertebrobasilar Insufficiency

- It may cause momentary attacks of vertigo precipitated by neck extension.

- The diagnosis is more certain if other evidence of brain stem ischemia, such as dysarthria or diplopia, is also present.

- Severe ischaemia may cause drop attacks without loss of consciousness.

THANX