Vertigo sushmita

DIZZINESS $ VERTIGODR.SUSHMITA PAL

Sunday, May 09, 2010

ORIGIN : from Latin word

“vertÖ”

“A spinning or whirling sensation”


DEFINITIONS :• A sensation of swaying or tilting

• A sense of spinning or motion of the environment

• A type of dizziness

• A symptom of illusory movement




Causes Vestibular

Peripheral

Central


Medical causes(BP/ Arrhythmia / angina/ hypoglycemia / anemia/drugs , etc.)

Psychiatric (phobic disorders/ hyperventilation)

Non Vestibular

• Peripheral

BPPV

Vestibular neuritis

Meniere’s disease

Ototoxic drugs

Perilymph fistula

SCD Syndrome

Acute labyrinthitis

Post concussion

Motion sickness

Acoustic neuroma

• Central

Stroke(vertebro basilar insufficiency, Wallenberg syndrome)

Cerebellar disorders(tumors/ haemorrage)

Multiple sclerosis

Basilar artery migraine

Vestibular migraine

Cervical vertigo


APPROACH TO A DIZZY PATIENT Appropriate history ( type of vertigo , its

duration , triggering factors, certain associated symptoms, its frequency)


Forms/types of vertigo: Rotatory Postural

Duration: Attacks/episodes Persistent

Triggers: viz . Change in position

Yes No

Assosiated symptoms:viz. hypoacusis, double

vision, ataxia

Yes Yes/No

Site of origin PERIPHERAL(labyrinth/ vestibular

nerve)

CENTRAL(Brain stem/cerebellum/

cortex)

General medical examination: BP (for hypo and hypertension)Cardiac examination : for arrhythmia ,

murmurs and bruit.Neurological examination : for cerebellar

integrity and CN examination.

Ophthalmological examination: for papilloedema , nystagmus saccades/smooth pursuit.

Audio vestibular examination : inspection of TM , TFT with or without Pure tone audiometry. And an array of vestibular tests.


Vestibular assessme ntClinical tests Spontaneous

nystagmus

Halmygi’s head thrust test

Fistula tests

Past pointing/Gait

Romberg’s test

Positional test (Dix-Hallpike maneuver)

Laboratory tests Caloric tests

Cold caloric/modified Kobrak

Fitzgerald Hallpike bithermal caloric test

Cold air caloric test

Electronystagmography

Rotation test

Posturography

Optokinetic test


MANAGEMENT OF VESTIBULAR DISORDERS

Physiotherapy : certain vestibular exercises eg. Semont’s/Epley’s maneuver

Medical management using vestibular suppressants ( cinnarizine , promethazine) , vestibular vasodilators ( betahistine ) , anabolic steroids , antibiotics , etc.

Psychological/psychiatric and behavioral therapy

Surgical management ( eg. Endolymphatic decompression, Resection of neuroma , etc.)


Patient with h/o momentory( about 10 sec) rotatory vertigo , as soon as he gets up from the bed or goes to bed


BENIGN POSITIONAL PAROXYSMAL VERTIGO

Occurs with head movts or head roll

No numbness/headache/ear symptoms

Nausea/vomiting/oscillopsia may be +nt.

Positional test is diagnostic.

Turn the head to Lt (45 degree) while sitting, then make him lie down towards Rt, shake the head, and w/f nystagmus.

The nystagmus is rotatory / vertical, beating towards the forehead.

Treatment:• Liberatory movements : 3 times TID

turn the head to R side(nonaffected) 45 degrees ,

move the patient to lie towards opposite side (L)

again move him 180 degree away to lie on the

opposite side (R)

These movements accentuates the postural imbalance momentarily, But it is actually beneficial within a span of 3 -4 days.

These movts are done to teach the otoconias in the ear.


TREATING MANEUVERS

EPLEY’S

Turn the head 45 degree hrztally towards affected side

Tilt him backwards to horizontal position, with yet the same head tilt. Vertigo ppts. Maintain the same position until vertigo stops.( debris moves towards the apex).

Head is turned 90 degree towards unaffected side,also pt is rolled towards unaffected side so that face is towards the floor.(debris moves back in the canal, vertigo ppts).

Pt is seated with head down tilt of 30 degree, brings the otoconia back in the utricle

SEMONTTurn the head 45 degree hrztally

same towards unaffected side

Tilt 105 degree to make him lie on affected side , head hanging & nose pointed upwards(3 min).Debris moves to the apex of the canal.

Now, moving him 180 degree from aff to unaff side with nose pointing downwards.Debris moves towards the exit of the canal.

He is slowly seated. Debris gets back in the vestibule.



Patient with h/o rotatory vertigo , lasts for an hr to 7 hrs, usually once or twice a week, associated with heaviness of ear/head & diminished hearing.

MENIERE’S DISEASE

• Tinnitus + aural fullness

• Vertigo lasts minimum for about 20 min.

• Best way to prevent the vertigo is to prevent the hydrops

• Prophylactic Rx: Betahistine 48 mg TID : 9- 10 mths

Intratympanic injection of gentamycin


H/o rotatory vertigo , since 2 or 3 days , continous , with imbalance, nausea /vomiting +

VESTIBULAR NEURITIS

• High grade fever+ nt ; invariably with raised counts

• Lasts for 5 days to 2 or 3 wks

• Spontaneous oscillopsia +nt

• Hrztal nystagmus +nt towards healthy side suppressed by visual fixation

• Pathological head thrust test

• +ve Romberg’s test (sway towards affected side)

• Viral etiology(HSV/HZV)

• While walking , surroundings are hazy/unable to read, & while stable , everything is clear.


Management:

Symptomatic treatment

Vestibular suppresants for 3 – 5 days

eg. Dimenhydrinate,

Clonazepam,

Cinnarizine

Increasing the inner ear circulation eg. Betahistine

Treating the pathology using

MPA( 100 mg /day) +/- antivirals

Vestibular exercises for 30 min TID : to improve the central vestibular compensation


H/o recurrent attacks of rotatory vertigo , nausea+/- vomiting,headache , lasting for min to hrs

VESTIBULAR MIGRAINE

• Other migrainous symptoms +nt

• During the attack :

pathological head thrust test + postural imbalance

• During the attack free period :

peripheral vestibular deficit signs are +nt

but not postural imbalance

•

o in the line of migraine (prophylaxis & treatment)

o And vestibular suppressants.


H/o postural vertigo , episodic, lasting for few minutes

PHOBIC POSTURAL VERTIGO

• Normal neurological signs

• Subjective instability of gait

( fear of falling)

• Vegetative disturbances

• Triggering factors: eg. Crowd of people , entering a car/lift/store/room

• Management :

i. Improves with alcohol

ii. SSRI eg. Fluvoxamine

iii. Psychoeducational + Behavioral therapy

STROKE

• Neurological signs +nt

• Impaired Tandem walking

• Ataxia & other cerebellar signs +nt

• H/o fall with injury +nt

• Spontaneous nystagmus +nt

• Principle of treatment is to augment the circulation


• CERVICAL VERTIGO

Postural vertigo , associated with certain neck movements and it lasts for few minutes , no neurological signs , X ray is diagnostic in spondylosis.

Management : avoid chiropractic maneuvers

and Betahistine to improve vestibular circulation.

• MOTION SICKNESS

Physiological vertigo

Rotatory vertigo , triggered by motion due to mismatch of two different stimulus (eye & vestibule) viz. car sickness, space sickness , sea sickness etc.

• OTOTOXICITY

Due to the vestibulotoxic drugs eg. Streptomycin , gentamycin , tobramycin etc.

• BASILAR MIGRAINE :postural vertigo + dysarthria + diplopia + tinnitusSunday, May 09, 2010


THANK YOU

Health & Medicine

Vertigo sushmita