CAUSES OF VERTIGOCAUSES OF VERTIGO

VERTIGOVERTIGO

Vertigo has been defined in a Vertigo has been defined in a number of ways: number of ways:

““Vertigo is a hallucination of Vertigo is a hallucination of movement”movement”

““Vertigo is a sensation as if the Vertigo is a sensation as if the external world is revolving around external world is revolving around the patient or as if he himself is the patient or as if he himself is

revolving in space.”revolving in space.”However it should not just be However it should not just be restricted to a sensation of restricted to a sensation of rotation, but should also include rotation, but should also include linear motion as in tending to linear motion as in tending to stagger to one side. stagger to one side. The term should be regarded as The term should be regarded as the symptom of a vestibular the symptom of a vestibular system lesion, whether peripheral system lesion, whether peripheral or central.or central.

““Dizziness is a disturbed sense of Dizziness is a disturbed sense of relationship to space, it is a relationship to space, it is a

sensation of unsteadiness with a sensation of unsteadiness with a feeling of movement within the feeling of movement within the

head, giddiness.”head, giddiness.”

Causes:Causes: A series of situations and abnormalities are able A series of situations and abnormalities are able

to cause it.to cause it. More than 100 different diseases are sometimes More than 100 different diseases are sometimes

accompanied by the complaint vertigo.accompanied by the complaint vertigo. Unfortunately though, it’s a fact that in 40% of Unfortunately though, it’s a fact that in 40% of

the people complaining of it, the cause never the people complaining of it, the cause never emerges- not even when the most advanced emerges- not even when the most advanced investigation techniques are used. investigation techniques are used.

Despite the lack of diagnosis, or even just some Despite the lack of diagnosis, or even just some idea of the way the complaint arose, in order to idea of the way the complaint arose, in order to help the patients it is necessary to provide some help the patients it is necessary to provide some kind of therapy to reduce the seriousness of the kind of therapy to reduce the seriousness of the complaint or at least to make it acceptable for the complaint or at least to make it acceptable for the patient. patient.

It is useful to subdivide vertiginous It is useful to subdivide vertiginous pateints into four main groups:pateints into four main groups: The positional VertigosThe positional Vertigos Vertigos as an isolated symptomVertigos as an isolated symptom Vertigo with deafness and tinnitusVertigo with deafness and tinnitus Vertigo with other signs of neurological Vertigo with other signs of neurological

disease. disease.

Causes:Causes:

The Positional VertigosThe Positional Vertigos BENIGN PAROXYSMAL POSTIONAL NYSTAGMUS.BENIGN PAROXYSMAL POSTIONAL NYSTAGMUS.

DISEQUILIBRIUM OF AGEING.DISEQUILIBRIUM OF AGEING. Ageing process also affects the vestibular apparatus and Ageing process also affects the vestibular apparatus and

pathological studies have demonstrated degenerative changes in pathological studies have demonstrated degenerative changes in the maculae and the cristae, also neuronal degeneration in other the maculae and the cristae, also neuronal degeneration in other parts of vestibular pathway. parts of vestibular pathway.

Vestibular tests are indicated only if there is doubt about the Vestibular tests are indicated only if there is doubt about the diagnosis. diagnosis.

Treatment is supportive and includesTreatment is supportive and includes Vasodilators and labyrinthine sedatives. CENTRALVasodilators and labyrinthine sedatives. CENTRAL

(MALIGNANT)POSITIONAL NYSTAGMUS.(MALIGNANT)POSITIONAL NYSTAGMUS. When the patient’s head is put in the critical position a coarse, When the patient’s head is put in the critical position a coarse,

variable nystagmus is set up.variable nystagmus is set up. The nystagmus has no latent period and is non-fatiquable.The nystagmus has no latent period and is non-fatiquable. Seen with tumors of posterior cranial fossa or mid-brain, with Seen with tumors of posterior cranial fossa or mid-brain, with

disseminated sclerosis and with vascular lesions. disseminated sclerosis and with vascular lesions. Vertigo is less than expected. Vertigo is less than expected.

Vertigo as an isolated symptom.Vertigo as an isolated symptom. VESTIBULAR NEURONITIS.VESTIBULAR NEURONITIS.

Severe vertigo of sudden onset may occur following a infection of the Severe vertigo of sudden onset may occur following a infection of the membranous labyrinth commonly viral. membranous labyrinth commonly viral.

Caloric tests usually show a canal paresis on the affeced side.Caloric tests usually show a canal paresis on the affeced side. Treatment is symptomaticTreatment is symptomatic Prognosis: Young recover quickly but an older person may be unsteady Prognosis: Young recover quickly but an older person may be unsteady

for months.for months. DISSEMINATED SCLEROSIS.DISSEMINATED SCLEROSIS.

Acute severe vertigo usually occuring in a diagnosed case of sclerosis.Acute severe vertigo usually occuring in a diagnosed case of sclerosis. DRUGS.DRUGS.

Aminoglycosides (streptomycin, kanamycin, gentamycin etc) are well Aminoglycosides (streptomycin, kanamycin, gentamycin etc) are well well known drugs and may cause both cochlear and vestibular damage.well known drugs and may cause both cochlear and vestibular damage.

Other drugs may give rise to symptom of unsteadiness likeOther drugs may give rise to symptom of unsteadiness like Labyrinthine sedatives, oestrogens, diuretics such as bendrofluazide BP and Labyrinthine sedatives, oestrogens, diuretics such as bendrofluazide BP and

frusemide BP and some antibiotics such as nalidixic acid, co-trimoxazole and frusemide BP and some antibiotics such as nalidixic acid, co-trimoxazole and metronidazole etc. metronidazole etc.

MISCELLANEOUS.MISCELLANEOUS. Unsteadiness may result from anaemia, hypotension, D.M, Unsteadiness may result from anaemia, hypotension, D.M,

Migraine, psychogenic causes and vertigenous aura of epilepsy Migraine, psychogenic causes and vertigenous aura of epilepsy etc. etc.

Vertigo plus Deafness plus TinnitusVertigo plus Deafness plus Tinnitus

MENIERE’S DISEASE.MENIERE’S DISEASE.American Academy of Ophthalmology and American Academy of Ophthalmology and Otolaryngology, Committee on Otolaryngology, Committee on Equilibrium defined Meniere’s disease as: Equilibrium defined Meniere’s disease as:

““It is a disease of membranous inner ear It is a disease of membranous inner ear characterized by deafness, vertigo and characterized by deafness, vertigo and

tinnitus which has its pathologic correlate tinnitus which has its pathologic correlate hydropic distension of endolymphatic hydropic distension of endolymphatic

system”.system”.

Etiology & Pathology:Etiology & Pathology: Distension of the endolymphatic compartments of the inner Distension of the endolymphatic compartments of the inner

ear (Endolymphatic Hydrops). It mainly affects the cochlear ear (Endolymphatic Hydrops). It mainly affects the cochlear duct and saccule and to a lesser extent the utricle and duct and saccule and to a lesser extent the utricle and semicircular canals. semicircular canals.

Etiology of this endolymphatic hydrops is unclear and various Etiology of this endolymphatic hydrops is unclear and various theories have been postulated including:theories have been postulated including:

Diagnosis: Diagnosis: Must be differentiated from acoustic neuroma, labyrinthitis etc. Must be differentiated from acoustic neuroma, labyrinthitis etc. Examination reveals a SNHL and recruitment is frequently Examination reveals a SNHL and recruitment is frequently

presentpresent Vestibular tests may be normal in the early case but later on Vestibular tests may be normal in the early case but later on

canal paresis or hypofunction is found on affected side. canal paresis or hypofunction is found on affected side. Treatment:Treatment:

Medical treatment with antihistamines, labyrinthine sedatives Medical treatment with antihistamines, labyrinthine sedatives and anxiolytics, fluid and salt restriction.and anxiolytics, fluid and salt restriction.

Surgical treatment: Shunt operations. Surgical treatment: Shunt operations.

LABYRINTHITISLABYRINTHITIS Inflammation of labyrinth due to any cause.Inflammation of labyrinth due to any cause. May be viral or bacterial. May be viral or bacterial.

Viral may occur during course of an exanthematous disease like Viral may occur during course of an exanthematous disease like mumps/measles or influenza type illness. mumps/measles or influenza type illness.

Bacterial labyrinthis may be circumscribed, serous or suppurative in Bacterial labyrinthis may be circumscribed, serous or suppurative in a case of otorrhoea.a case of otorrhoea.

It may also occur during course of meningitis. It may also occur during course of meningitis. ACOUSTIC NEUROMAACOUSTIC NEUROMA

Vestibular symptoms are variable and tinnitus is common.Vestibular symptoms are variable and tinnitus is common. Diagnosis is made on the basis of radiological investigations. Diagnosis is made on the basis of radiological investigations.

SYPHILISSYPHILIS Can mimic Meniere’s disease.Can mimic Meniere’s disease.

LABYRINTHINE TRAUMALABYRINTHINE TRAUMA Non-Operative: Labyrinthine concussion or fracture of temporal Non-Operative: Labyrinthine concussion or fracture of temporal

bone.bone. Post-Operative: A perilymph fistula may occur after ear surgery Post-Operative: A perilymph fistula may occur after ear surgery

esp. stapedectomyesp. stapedectomy

MISCELLANEOUS CONDITIOSMISCELLANEOUS CONDITIOS Other conditions which give rise to these Other conditions which give rise to these

symptoms include wax impaction, symptoms include wax impaction, eustachian tube dysfunction, OME and eustachian tube dysfunction, OME and labyrinthine haemorrhage.labyrinthine haemorrhage.

Vertigo with signs of intracranial Vertigo with signs of intracranial disease. disease.

CNS NEOPLASMSCNS NEOPLASMS Tumors involving brainstem, cerebellum or midbrainTumors involving brainstem, cerebellum or midbrain Other signs of intracranial disease are foundOther signs of intracranial disease are found On ENG nystagmus is found to be irregular and On ENG nystagmus is found to be irregular and

enhanced on eye opening. enhanced on eye opening. POSTERIOR INFERIOR CEREBELLAR ARTERY POSTERIOR INFERIOR CEREBELLAR ARTERY

THROMBOSIS (LATERAL MEDULLARY SYNDROME)THROMBOSIS (LATERAL MEDULLARY SYNDROME) Onset is with severe vertigo with contralateral Onset is with severe vertigo with contralateral

hemianalgesia.hemianalgesia. VERTEBROBASILAR ISCHAEMIAVERTEBROBASILAR ISCHAEMIA

Episodes of vertigo with other signs of brain stem Episodes of vertigo with other signs of brain stem disfucntion. disfucntion.

Classification:Classification:(Old)(Old)

DIZZINESS

Vestibular Vertigo Non-Vestibular Vertigo

Peripheral Vestibular Ventral Vestibular

For both diagnosis and treatment it is practically useless.

Classification:Classification:(New)(New)

It is more appropriate It is more appropriate to use a to use a classification based classification based on the way the on the way the dizziness occurs:dizziness occurs:

Single attack of Single attack of vertigo which slowly vertigo which slowly disappearsdisappears

Paroxysmal vertigoParoxysmal vertigo Chronic vertigoChronic vertigo Dizziness spellsDizziness spells

Sudden serious short lastingSudden serious short lasting Brief dizziness spellsBrief dizziness spells Chronic not very severe persistent/ Chronic not very severe persistent/

protractedprotracted Sudden Severe Gradually Sudden Severe Gradually

diminishing. diminishing.