Dr. Zaimal ShahanPGT Department of ENT

Capital Hospital

SUBJECTIVE SENSE OF IMBALANCE

“Sensation as if the external world is revolving around the patient or as if he

himself is revolving in space”

How do we maintain EQUILIBRIUM?

The Bony Labyrinth lies in the petrous temporal bone.

Bony Labyrinth contains the membranous labyrinth surrounded by a fluid called perilymph

Membranous Labyrinth consists of:An Anterior Cochlear Duct HEARING

Posterior vestibular Apparatus: Utricle Sacculae BALANCE 3 Semicircular Canals.

Semicircular canals are three small ring structures each forming 2/3rd of a circle with a dia. Of 6.5 mm, containing endolymph.

One end of each canal is dilated “Ampula”

Endolymph has a high K and low sodium Concentration & is secreted by Stria Vascularis and Dark Cells.

Five Vestibular Receptor organs are present in the Vestibular Labyrinth.

Two Maculae in utricle and saccule (otolith organs) Monitor Linear Acceleration.

Three Cristae Ampullares of SSC Monitor Angular

Accleration.

Each macula is found on floor of Utricle in horizontal plane & medial wall of Saccule in Vertical plane. Macula supports a statoconial membrane which consists of small

Ca.Carbonate cryustals (otoconia) embedded in mucopolysaccharide gel.

Static tilt and linear acceleration results in movement of membrane resulting in bending of hairs of hair cells and stimulation of nerve endings.

Crista Ampullaris are a crest of sensory epithelium lying at right angles to the longitudinal axis of the canal and surrounded by a bulbous gelatinous mass, the cupula. When head is rotated the endolymph within the ducts tends to

remain stationary. The resultant flow of endolymph with respect to duct is resisted by elacticity of cupula which becomes deflected bending hairs of sensory hair cells.

The balance system (vestibular, visual, and somatosensory) are a two sided push and pull system. In static neutral position, each side contributes

equal sensory information.During movement ie., turning or tilt, there is a

temporary change in push and pull system which is connected by appropriate reflexes and motor outputs to the eyes (vestibulo0ocular reflex), neck (vestibulo-cervical reflex), and trunk and limbs (vestibulo0spinal reflex) to maintain new position of head and body.

Normally there is balanced input from both vestibular systems

Vertigo develops from asymmetrical vestibular activity

Abnormal bilateral vestibular activation results in truncal ataxia

ANATOMICAL DURATION OF VERTIGO NATURE OF VERTIGO

A.PERIPHERAL VESTIBULAR DISORDERS BPPV MENEIR’S DISEASE VESTIBULAR NEURONITIS LABYRINTHITIS VESTIBULOTOXIC DRUGS HEAD TRAUMA PERILYMPH FISTULA SYPHILIS ACOUSTIC NEUROMA

B.CENTRAL VESTIBULAR DISORDERS

VERTEBROBASILAR INSUFFICIENCY POSTERIOR INFERIOR CEREBELLAR ARTERY

SYNDROME BASILAR MIGRAINE CEREBELLAR DISEASE MULTIPLE SCLEROSIS TUMORS OF BRAINSTEM EPILEPSY

ROTATIONAL

UNSTEADINESS

BPPV LABYRINTH FISTULA VERTEBROBASILAR INSUFFICINCEY MENIERE’S DISEASE VESTIBULAR NEURONITIS TRAUMA LABYRINTHITIS METASTATIC DEPOSITS IN CP ANGLE

DRUGS TRAVEL SICKNESS PERILYMPH FISTULA HYPERVENTILLATION VESTIBULAR INSUFFICIENCY CNS LESIONS

ROTATIONAL VERTIGO HEAD AND BODY MOVED IN PARTICULAR

DIRECTION LATENT PERIOD: FEW SECONDS LASTS NOT MORE THAN 30 SECONDS NO HEARING LOSS OR ANY OTHER

NEUROLOGICAL SYMPTOMS HISTORY OF EAR TRAUMA/EAR INFECTION

OTOCONIAL DEBRIS RELEASED FROM THE DEGENERATING MACULA

OTOCONIAL DEBRIS SETTLES ON CUPULA OF POSTERIOR SEMICIRCULAR CANAL

CERTAIN HEAD POSITIONS CAUSE DISPLACEMENT OF CUPULA HENCE VERTIGO

OTOCONIAL DEBRIS FLOATS FREELY IN THE SEMICIRCULAR CANAL

CERTAIN CHANGES IN HEAD POSITION CAUSE DISPLACEMENT AND VERTIGO

VERTIGO:FATIGUABLE

DIX HALLPIKE MANOEUVRE

TRIAD OF1.VERTIGO2.FLUCTUATIND HEARING LOSS3.TINNITUS

MAY BE ACCOMPANIED BY SENSE OF AURAL FULLNESS

ENDOLYMPHATIC HYDROPS CAUSE UNCLEAR

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 Viral may occur during course of an

exanthematous disease like mumps/measles exanthematous disease like mumps/measles or influenza type illness. or influenza type illness.

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

It may also occur during course of meningitis. It may also occur during course of meningitis.

Vestibular symptoms are variable and Vestibular symptoms are variable and tinnitus is common.tinnitus is common.

Diagnosis is made on the basis of radiological Diagnosis is made on the basis of radiological investigations. investigations.

Non-Operative: Labyrinthine concussion or Non-Operative: Labyrinthine concussion or fracture of temporal bone.fracture of temporal bone.

Post-Operative: A perilymph fistula may Post-Operative: A perilymph fistula may occur after ear surgery esp. stapedectomyoccur after ear surgery esp. stapedectomy

Tumors involving brainstem, cerebellum or Tumors involving brainstem, cerebellum or midbrainmidbrain

Other signs of intracranial disease are foundOther signs of intracranial disease are found On ENG nystagmus is found to be irregular On ENG nystagmus is found to be irregular

and enhanced on eye opening. and enhanced on eye opening.

Onset is with severe vertigo with Onset is with severe vertigo with contralateral hemianalgesia.contralateral hemianalgesia.

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

HISTORY:

DESCRIPTION Ask the patient to describe the problem

True rotatory vertigo or dizziness. Severity Number of attacks Temporal pattern (continuous vs. episodic / short vs. prolonged) If associated with turning the head, lying supine, or sitting upright. Vestibular & cochlear symptoms (hearing loss either fluctuating or

progressive, tinnitus, ear pressure, nausea and vomiting) Degree of impairment during the attack

Syncope:Transient loss of consciousness with loss of postural tone Presyncope: Lightheadedness-an impending loss of consciousness Psychiatric dizziness: Dizziness not related to vestibular dysfunction Disequilibrium: Feeling of unsteadiness, imbalance or sensation of

“floating” while walking

SECONDARY SYMPTOMS Tinnitis Hearing impairment Headache or visual symptoms. Neurological abnormalities

Brainstem symptoms (diplopoia, dysarthria, facial parenthesis, extremity numbness or weakness.)

PREVIOUS HISTORY Injuries:

Head trauma in the past (post traumatic hydrops) Hx. Of prior ear surgery (labyrinthine fistula,

perilymphatic fistula.) Drugs : Aminoglycosides, cisplatin, miocycline Stress situations Family illness Systemic Diseases:

Hx. of DM (causes visual, proprioceptive, vascular problems)

HTN, cardiovascular and cerebrovascular diseases

GPE Cardiovascular, BP (including orthostatic) in both

arms, pulse Neurologic

ENT HEAD AND NECK EXAMINATION Detailed ENT Examination

Tympanic membrane for retraction, perforation, Infection, cholesteatoma,valsalva

Assess hearing on both sides Detailed Head & Neck Examination

Cranial nerves Bruits in the neck

SPECIFIC VESTIBULAR SYSTEM EXAM (Balance tests need not be performed in acute vertigo)

Nystagmus Corneal test Fistula test Postural tests Caloric tests Electronystagmography Cerebellar test

Rhythmic slow and fast eye movements Direction named by fast component Slow component usually ipsilateral to

diseased structure Fast component due to cortical

correction

Central Spontaneous nystagmus

that can not be suppressed by fixation.

Changes direction with gaze.

Purely vertical, horizontal, or torsional

Paroxysmal but Not fatigable in Dix-hallpike test, no latency, Lasting longer than 60 sec. and often vertical, may change direction with different head positions.

Peripheral Suppressed by fixation

Doesn’t change direction with gaze.

Horizontal, rotatory.Never vertical.

Paroxysmal but fatigable in Dix-hallpike test, has latency, lasts less than a minute, doesn't change direction with different head positions,

loss of corneal reflex -- Cerrebelopontine Angle

Pressing tragus Seigel’s pneumatic spectrum NYSTAGMUS OPPOSITE SIDE

INTERPRETATION POSITIVE: Fistula usually LATERAL SCC

NEGATIVE: Fistula present Dead labyrinth Fistula covered by Granulation tissue Cholesteatoma

POSITIVE: no fistula Congenital Syphillis

PERIPHERAL LESION: sway to side of lesion

CENTRAL LESION (Posteroir white column) Instability

Romberg normal 1 heel of 1 foot in front of the other, arms

folded across chest INSTABILITY: Vestibular impairment

Patient walks towards target Eyes open, then closed PERIPHERAL LESION: pt deviates on affected

side

Unilateral Paralytic Labyrinthitis: Patient deviates to ipsilateral side

Active irrelative lesion: not able to perform test for more than 3

seconds

Patients eyes shut:30 seconds 5 PACES forward,5 PACES backward STAR SHAPED: Unilateral Vestibular

Disorder

Acute Unilateral Vestibular Disorders Deviation to 1 particular side

Patient 45 degrees on couch Water 33degrees or 45 degrees Normal nystagmus

COLD: OPPOSITE WARM: SAME

1.CANAL PARESIS: Decreased duration of nystagmus

both hot and cold

2.DEAD LABYRINTH: No nystagmoid response

3.DIRECTION PREPONDERANCE: BY Both Hot and Cold

CENTRAL/PERIPHERAL lesion

Now a routine investigation in Vertigo ADVANTAGES:

closed eyes nystagmus recorded Small amplitude Nystagmus

Safety: Safety: Acute Vestibular Suppression:Acute Vestibular Suppression:Vestibular Rehabilitation:Vestibular Rehabilitation:Medical & Surgical Management:Medical & Surgical Management:

Avoid Driving , work on dangerous machinery/ fire.

Home therapy should only be undertaken if patient has already been diagnosed with vertigo and is under the close supervision of a doctor.

SafetySelf-Care at Home

Two components: First, one must control the acute episode, and Secondly, speed the recovery and prevent future

episodes.

Vertigo can be treated symptomatically or specifically.

Symptomatic treatment involves controlling the acute symptoms and autonomic complaints.

Specific treatment involves targeting the underlying cause of the vertigo.

Some common types of vertigo have either established or postulated patho- physiology and lend themselves to specific treatment, others are still unknown and symptomatic control is the only option.

Characteristics of peripheral vertigo and dizziness

Characteristics of vertigo and dizziness of central origin

Recognizing stroke syndromes that may present with dizziness as a prominent feature

Treatment considerations in dizziness of central origin

Treatment of peripheral vestibular dysfunction

Management of acute vertigo includes: Bed rest, Fluids and Reassurance. Head movements can be particularly

distressing with peripheral vestibular dysfunction. Medications that suppress vestibular signs can be

helpful acutely. Four general classes of drugs are useful in the treatment of vertigo and its associated autonomic symptoms :- Anticholinergics, The most effective single drug for the

prophylaxis and treatment of motion sickness is the anticholinergic scopolamine

Antihistamines, Antihistamines include meclizine, dimenhydrinate, and promethazine. The newer nonsedating antihistamines do not enter the CNS and have no value in the treatment of vertigo and motion sickness

Antidopaminergics, such as prochlorperazine and chlorpromazine act at the chemoreceptor trigger zone, reducing neural impulses to the vomiting center. These drugs do not prevent vertigo and motion sickness but may be useful in treating the nausea and vomiting caused by these disorders

Monoaminergic drugs include amphetamines and ephedrine. They appear to potentiate the effects of scopolamine and may be used in combination with one of the antihistamines for intense symptoms or in those who do not respond adequately to single-drug therapy

Lastly, the benzodiazepine diazepam act as a vestibular suppressant through the GABAergic system and can also minimize the associated anxiety and panic that occurs with vertigo.

After several days, gradual increased activity and graded exercises can facilitate the adaptive recovery of the vestibular system.

While pharmacologic treatment of the acute, severe symptoms of vertigo is probably beneficial, some experts feel that prolonged use of these agents may actually retard the normal compensatory mechanisms.

The choice of treatment will depend on the diagnosis.

Vertigo can be treated with medicine Specific types of vertigo may require additional treatment and

referral:

Bacterial infection of the middle ear requires antibiotics.

Meniere disease, in addition to symptomatic treatment, people might be placed on a low salt diet and may require medication used to increase urine output.

A hole in the inner ear causing recurrent infection may require referral to an ear, nose, and throat (ENT) specialist for surgery.

Several physical maneuvers can be used to treat conditions like BPPV.

Vestibular Neuritis Since viral origin is implicated, treatment aimed at stopping

the inflammation has been proposed. Studies show that in patients on methylprednisolone, 90%

experienced a decrease in vertigo within 24 hours Most patients will have spontaneous, complete symptomatic recovery even only with supportive treatment.

Patients who have persistent unsteadiness or motion provoked symptoms may have incomplete central compensation and should benefit from a customized vestibular rehabilitation program.

Meniere’s Disease

Diatary salt restriction and diuretics. Thiazide diuretics are traditionally used for at least 3 months

Vasodilators. IV histamine, isosorbide dinitrate, cinnarizine (calcium antagonist) and betahistine (oral histamine analogue) have all been used with anecdotal success

In some patient’s there is thought to be an association of immune-mediated phenomena. Systemic and intratympanic glucocorticoids, cyclophosphamide, and methotrexate have all been used by clinicians.

For intractable disease with disabling vertigo despite medical treatment, vestibular surgery should be considered.

The chemical labyrinthectomy, or transtympanic gentamicin (intratympanic aminoglycoside, allows treatment of unilateral disease without producing systemic toxicity or affecting the opposite ear.

Benign Paroxysmal Positional Vertigo (BPPV)

Semont et al proposed a liberatory maneuver as a single treatment alternative. The reported cure rates are 84% after one, and 93% following two treatments.

Epley proposed a canalith repositioning procedure Epley reported 80% cure after one treatment and 100% improvement after multiple sessions in 30 patients.

Brandt and Daroff designed habituation exercises requiring the patient to move into the provoking position repeatedly, several times a day. They report a 98% success rate after 3 to 14 days of exercises.

Vertebrobasilar insufficiency (VBI) VBI is characterized by vertigo, diplopia, dysarthria, gait

ataxia and bilateral sensory and motor disturbance. Symptoms of transient ischemia are alarming but generally benign as there is rich collateral blood supply and a relatively low incidence of stroke. Antiplatelet therapy is warranted usually with aspirin.

Migraine Treatment includes modifying risk factors, abortive medical

therapy, and prophylaxis. These patients should avoid nicotine products, exogenous estrogens, and foods that exacerbate symptoms

Exercise programs and stress reduction are also important. Ergots, sumatriptin, and midrin are helpful in aborting acute attacks.

Prophylactic medical therapy can be started if migraines occur several times a month (aspirin, ibuprofen, lithium, calcium channel blockers, amitryptiline and beta blockers).

In perilymph fistula, surgery may be used to plug a leak in the inner ear.

In the microvascular compression syndrome, surgery may be used to move a blood vessel off of the vestibular nerve.

In Meniere’s Disease, shunt surgery is intended to improve inner ear plumbing. All treatments for Meniere's disease must be compared with the natural history the disease, where 60% of patients are in remission by six months.

For Meniere's disease, destructive procedures are associated with better control of vertigo than shunt surgery, showing good control in over 90% of patients followed for five or more years.

The vestibular nerve section. Transtympanic gentamicin treatment Labyrinthectomy

Acoustic Neuroma Surgery For Benign Paroxysmal Positional Vertigo

Selective posterior canal plugging offers a reasonable surgical approach to intractable symptoms.

Singular neurectomy, an older procedure, is less popular because it produces hearing loss in 7 to 17% of patients and fails in 8 to 12%.

Vestibular rehabilitation therapy is appropriate in all patients who have had destructive treatment.

Selection of the best type depends on both the diagnosis and health care situation.

Indications: Specific interventions for (BPPV)

The Epley and Semont maneuvers The Brandt-Daroff exercises

General interventions for vestibular loss Empirical treatment for common situations where the

diagnosis is unclear Post-traumatic vertigo Multifactorial disequilibrium of the elderly

Office Treatment of BPPV:

The Epley and Semont Maneuvers

Are both intended to move debris out of the sensitive part of the ear (posterior canal) to a less sensitive location. Each maneuver takes about 15 minutes to complete.

Semont maneuver: It involves a procedure whereby the patient is rapidly moved from lying on one side to lying on the other.

Epley Maneuver: It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds

Home Treatment Of BPPV:

Brandt-Daroff Exercises

The Brandt-Daroff Exercises is a method of treating BPPV, usually used when the office treatment fails. They succeed in 95% of cases.

Cawthorne Cooksey Exercises: Sitting

Eye movements and head movements Shoulder shrugging and circling Bending forward and picking up objects from the ground

Standing Eye, head and shoulder movements as before Changing form sitting to standing position with eyes open and shut Throwing a small ball from hand to hand (above eye level) Throwing a ball from hand to hand under knee Changing from sitting to standing and turning around in between

Moving about (in class) Circle around center person who will throw a large ball and to whom it will

be returned Walk across room with eyes open and then closed Walk up and down slope with eyes open and then closed Walk up and down steps with eyes open and then closed Any game involving stooping and stretching and aiming such as bowling and

basketball Dix and Hood, 1984 and Herdman, 1994; 2000.

T'ai Chi, a Chinese exercise routine similar to ballet is one such method.

Sports activities such as golf, bowling, or recreational walking can also be used for rehabilitation.

Anywhere between 15 and 50% of patients evaluated by tertiary care "dizziness" clinics go undiagnosed. In this situation, it is often useful to have an organized approach to try out all reasonable interventions.

This includes both medications as well as a one- or two-month enrollment in a balance/vestibular rehabilitation program, for patients who have chronic symptoms.

Similarly, patients with central vestibular problems (for example, a cerebellar cerebrovascular accident) are highly unlikely to benefit from medication or therapy. Nevertheless, these patients are usually so impaired that it seems ill advised not to try out all possible modalities.