VertigoDefinition:A sensation of rotation in which the subject him/herself feels rotating or the substances of his /her surrounding seem to be rotating.

Size of the problem:• Vertigo –common condition in adults • 5-10 % of all patients in general practice• 10-20% patients seen by otolaryngologists and

neurologists• 33 % of people by 65 years of age

VertigoCauses of Vertigo/ Dizziness/Imbalance:

A. Systemic medical conditionsEndocrine-Hypoglycemia, adrenal failureCardiovascular-Vasovagal, embolism, dysrrrythmiasHematological-Anemia, hyperviscosity

B. Neurological disordersCerebral--Multiple sclerosis, degeneration, drugsCerebellar-tumors, strokes, masses, bleedingPsychological-Anxiety, phobias, panic attacks

C. Peripheral labyrinth

VertigoCauses of Peripheral Vertigo• BPPV• Meniere’s Disease • Secondary endolymphatic hydrops• Labyrinthitis• Ototoxicity• Vestibular neuritis• Perilymph and labyrinthine fistula• Trauma to inner ear• Acoustic neuroma• Vascular lesions of the inner ear• Auto-immune inner ear disease• Superior SCC dehiscence

BPPV• The most common vestibular disorder• Incidence about 64/100000 population• Usually is self-limiting.• Originally described by Barany in 1921• Defined by Dix and Hallpike

B-Benign P-ParoxysmalP-PositionalV-Vertigo

Definition:A disorder characterized by brief attacks of vertigo precipitated by certain changes in head position with respect to gravity.

BPPVPathophysiology:Detached otoconia of maculae get either attached to the cupula or remain floating within the duct of a semicircular canal Canalolithiasis refers to mobile calcium carbonate debris that moves within the canal during certain head movements resulting in stimulation of the cupula, which in turn causes vertigo and nystagmus. This mechanism is the most commonCupulolithiasis occurs when the calcium carbonate material becomes attached to the cupula itself, rendering it sensitive to gravity.

BPPVPathophysiology contd…

Posterior----majorityLateral----some casesSuperior-----rare

BPPVEtiology:

Idiopathic- majority happen without apparent causeSecondary (predisposing factors)

Head traumaVestibular neuritisDegenerative disordersInfarction and inflammation of the labyrinthSurgical assault to the labyrinthProlonged bed rest

BPPVClinical features

Age: all ages most elderly, Sex: Female moreVertigo

May be intense, with nausea & vomiting, sudden Brief 10 -20 seconds but < 60 Frequent at times - patients constantly dizzyTypical movements of every day that trigger ;• rolling over in bed, getting up and out of bed • getting up abruptly, abrupt head movements• bending over as in tying shoe laces• craning head to take something of high shelf

No cochlear symptoms, No hearing lossNormal caloric tests

BPPVClinical features contd…

Positional test---(Dix-Hallpike maneuver)- characteristic

BPPVClinical features contd…

Positional test---(Dix-Hallpike)- characteristic• Nystagmus –direction according to canal affected • Latency- of several seconds (7-8 seconds)-several

seconds are necessary for the hydrodynamic drag of the particles to begin to pull on the affected cupula.

• Duration 5-10 seconds but < 30 seconds• Intense- in severity at times• Reversal of nystagmus after return to upright position• Fatigable

BPPVTreatment

A. Reassurance-Benign nature, prognosis, recurrenceB. CRP-Canalolilith repositioning procedures

Procedures vary depending upon the canal affected by BPPVI. Epley canalolith repositioning procedure II. Semont liberatory maneuverIII. Brandt-Daroff exercises.

C. Singular neurectomy -transection of the nerve carrying signals from the ampulla of the posterior semicircular canal.

D. Occlusion/Laser ablation of the posterior semicircular canal E. Labyrynthine sedatives-symptomatic

BPPVEpley canalolilith/ particle repositioning procedure The most commonly used for posterior canal BPPV • Seated position with the head turned toward the

affected ear

• The otoconial particles have settled into the lowest portion of the posterior SCC duct

BPPVEpley canalolilith/ particle repositioning procedure Rapidly lower the patient to Dix-Hallpike position (reclined 30 degrees beyond the level of the table)

• The otoconial particles move and come to rest at midpoint of duct

• Leave the patient in this position for 40 seconds after the nystagmus subsides

BPPVEpley canalolilith/ particle repositioning procedure Slowly roll the patient to the opposite side pausing briefly every 45 degrees until the affected ear is up

• The otoconial particles are entering into the crus communis

BPPVEpley canalolilith/ particle repositioning procedure Slowly roll the patient onto the right shoulder

• The otoconial particles are falling via the crus communis into the vestibule

BPPVEpley canalolilith/ particle repositioning procedure

Turn the head another 90° and the procedure is completed by sitting the patient upright

• The otoconial particles are repositioned back into the vestibule

BPPVEpley canalolilith/ particle repositioning procedure Contraindications of Epley procedure:

Severe neck disease Severe carotid stenosis

Post-procedure instructions:• Wait 10 minutes before allowing the patient to go

home• Do not let the patient drive home if possible• Not to let patient sleep with affected ear down• For one week avoid positions which would usually

provoke the vertigo• Not to lift heavy objects for about a week

Vestibular neuritis(Epidemic vertigo)

Definition: Self limiting inflammation of the vestibular part of the vestibule-cochlear nerve

Etiology:– Unknown but neurotropic viruses– Herpes simplex virus is thought to exist in

latent form in human vestibular ganglia.

Vestibular neuritis

Clinical features:– H/O preceding sore throat and other acute URTI – Both sexes are equally affected– Between the ages of 30 and 50– Vertigo• Violent, rotatory with nausea and vomiting • Aggravated by head movement • Less by keeping the head still and eyes shut.• Lasting several days • Recovery can take months

Vestibular neuritis

Clinical features contd…. • Nystagmus is typically unidirectional with the

quick phases beating towards the unaffected side.• Typical absence of auditory symptoms • Absence of other neurological symptoms and

signs.• Unilateral reduced or absent caloric response

Vestibular neuritis

Treatment:Symptomatic by labyrinthine sedatives

Prochlorperazine---5 mg TDSCinnarazine----25 mg TDSPromethazine----25 mg TDS

• Early mobilization and vestibular rehabilitation exercises facilitate compensation

Acoustic Neuroma(Vestibular Schwannoma)

• Commonest CPA angle tumour- about 78 %• Accounts -8-10 % of all intracranial tumour• Benign non-capsulated tumour arising from

schwann cells at glial –neurilemmal junction in IAM

• 60-80 % of which arise from the superior vestibular nerve

Acoustic Neuroma(Vestibular Schwannoma)

Clinical features:• Slow growing –no vertigo usually• Unilateral SNHL, sometimes sudden and / or

tinnitus• Trigeminal nerve involvement - numbness of face• Headache, ataxia and facial weakness -advanced

A patient presenting with an asymmetrical SNHL of unknown origin should be considered to suffer from a VS unless proved otherwise

Acoustic Neuroma(Vestibular Schwannoma)

Investigations:• High tone SNHL• Poor speech discrimination test• Tone decay test positive• Tests of recruitment negative• Canal paralysis but normal if from inferior

vestibular • Abnormal ABR• Gadolinium enhanced MRI diagnostic

Acoustic Neuroma(Vestibular Schwannoma)

Treatment:• Surgery – Various approaches

TranslabyrinthineMiddle fossaRetrosigmoid

• Streotactic radiotherapy ( Gamma Knife ) in less than 3 cm single high dose of radiation with precise targeting

Perilymph and labyrinthine fistula

Perilymph fistulaLeak through round and oval window

Following Severe nose blowingStrenuous exerciseBarotrauma/ Surgical trauma

Labyrinthine fistulaLeak through an abnormal third window

Following Chronic ear disease/surgery

Perilymph and labyrinthine fistula

Clinical FeaturesBrief episodes of vertigo with progressive SNHLSudden or fluctuating hearing loss at timesTinnitusFistula sign positive-in minority of patients

Treatment Removal of the causeConservative initially-bed rest, head elevation Sealing of the leak

Vascular lesions of the inner ear

• Arterial occlusion• Venous occlusion• Vascular loops

Selective or combined cochlear or vestibular symptoms