Vertigo --- Perception of false rotatory movements

1. VERTIGO
-- Prashiddha Dhakal
MBBS,KUSMS

2. Vertigo
• “Illusion” or “Hallucination” of movement.
Abnormal sense of motion
between patient & surrounding
PLUS
Loss of balance

3. • Patient often complain of DIZZINESS/GIDDINESS
which is a vague term & mayn’t always mean
vertigo.
• Most dizzy patients can be placed in to one of four
categories:
1. True Vertigo (50%)
2. Pre- syncope
3. Dysequillibrium
4. Vague lightheadedness

4. True Vertigo
•Loss of balance
PLUS
Abnormal sense of
motion between patient
& surrounding

5. Pre-syncope
• Transient sensation that a faint in about to
occur.
• May present as nausea ,weakness, SOB
or change in vision.

6. Dysequilibrium
• Loss of balance
• No sense of faintness.
• No abnormal sense of motion.

7. Vague lightheadedness
• Head discomfort due to:
1.Psychiatric disorders
2.Hyperventilation syndrome
3.Encephalopathies

8. How do we maintain equilibrium?
Visual input
Proprioceptiual
input
Vestibular input
labyrinths.
equilibrium

12. Sensory cortex

13. Causes of Vertigo
Central Peripheral

15. Evaluation of a patient with vertigo
1. Clinical tests
2. Laboratory tests

16. Clinical tests of vestibular function
1. Spontaneous Nystagmus
• Nystagmus- Involuntary,
rhythmic, oscillatory
movements of eyes.
• Procedure--
• May be horizontal,
vertical or rotatory
• Direction of nystagmus—
direction of fast component

17. • Nystagmus of peripheral
origin:
Suppressed by- Looking at a
fixed point
Enhanced by- Darkness or
Frenzel glasses (+20 D), both
of which abolish optic
fixation
Frenzel Glasses

18. 2. Fistula Test

19. • Normally, the test is NEGATIVE
• POSITIVE--- Erosion of horizontal semicircular
canal(Cholesteatoma), Abnormal opening in
oval window(Poststapedectomy fistula) or
round window (Rupture of round window
membrane)
• FALSE NEGATIVE--- When cholesteatoma
covers the fistula
• FALSE POSITIVE--- Congenital Syphilis &
Meniere’s disease (25% cases)

20. 3. Romberg Test
• Peripheral lesion-
Patient sways to the
side of lesion
• Central lesion-
Patient doesn’t sway

21. • Sharpened Rhomberg test
 If the Rhomberg test is
normal, this test is performed.
Inability to perform this test
indicates vestibular
impairment.

22. 4. Past-Pointing
Past pointing, Falling and the Slow component of nystagmus are all
in the same direction

23. 5. Hallpike Manoeuvre (Positional Test)

25. 6. Gait
Peripheral lesion- Patient deviates to affected
side.
7. Test of cerebellar function

26. LAB TESTS OF VESTIBULAR FUNCTION
• A. caloric test
• 1. modified kobrak test
• 2. fitzgerald-hallpike test
• 3. cold air caloric test
• B. Electronystagmograph
• C. optokinetic test
• D. rotation test
• E. galvinic test
• F. posturography

27. Caloric test
• Test of lateral semicircular canal
• Induce nystagmus by thermal stimulation
• Each labyrinth can be tested separately

28. Modified kobrak test
• Ear is irrigated with icewater for 60 s
• First with 5 ml then with 10,20 and 40
• If no response to 40 ml ,it indicates dead
labyrinth

29. Fitzgerald-hallpike test
• ears are irrigated for 40 s alternately with
water at 30 and 44 degree celcious
• Time taken is recorded in calorigram
• If no nystagmus, repeated at 20 degree
celcious for 4 min
• Depending on response of caloric test
• a.canal paresis
• b.directional preponderance

30. • A.canal paresis
• indicates response illicted from particular
canal is less than that of opposite side
• depressed function of ipslateral
labyrinth,vestibular nerve or vestibular nuclei

31. b. Directional perponderance
• Duration of nystagmus irrispective to rt or left
is considered.
• Right beating nystagmus is caused by LC and
RW
• Left beating nystagmus is caused by RC and
LW
• TOTAL RESPONSE = RW+RC+LW+LC

32. FORMULA FOR RB AND LB
NYSTAGMUS
• Right beating nystagmus=(LC+RW)/TR X100%
• Left beating nystagmus=(RC+LW)/TR X100%
• IF nystagmus >25 to 30% in one ear than
other ,then it is called directional
perponderance

33. • DP=RT BEATING – LEFT BEATING/TR
• RVR(relative vestibular reduction)=(RC+RW-
LC-LW)/TR
• RVR normally is <25%
• RVR > 40 % seen in vestibular neuritis

34. • 3. cold air caloric test
• Done when there is perforation of tympanic
membrane
• Dundas grant tube
• Ethyl chloride is used to cool air

35. Electronystagmography
• Recoding of nystagmus by
caloric,positional,rotational or optokinetic
stimulus
• Corneoretinal potential recorded

36. C. OPTOKINETIC TEST
• EYE movement ellicted by tracking of moving
field
• POSITIVE IN brainstem and cerebral lesion

37. E. Rotational test
• Patient seated in Brany’s revolving chair
• Rotated 10 turns in 20 second
• Normally nystagmus is for 25 to 40 second
• Used for pt with congenital anomalies where
calorie test is not possible
•

39. F. GALVANIC TEST
• VESTIBULAR TEST
• Differentiate from end organ lession from
vestibular nerve
• 1 mA current passed in one ear
• Normally person sways towards anodal
current

40. G. POSTUROGRAPHY
-- evaluate vestebular function by measuring
postural stability

41. VESTIBULAR NEURITIS
• A type of peripheral vestibular disorder
• A common cause of spontaneous vertigo
• Definition
– disorder in which there is sudden,
– spontaneous, isolated, total or subtotal loss of
afferent vestibular input from one labyrinth

42. • Etiology
– Viral infection of vestibular nerve
• Selective neuron loss in vestibular ganglia
– Virus
• Herpes Simplex virus type 1 (latent infection)

43. • Clinical manisfeststions
– Acute spontaneous vertigo
– Nausea, Vomitting
– Postural imbalance
– SYMPTOMS ARE TYPICALLY AGGRAVATED BY HEAD
MOVEMENT AND MINIMIZED BY KEEPING HEAD
STILL AND EYES CLOSED
– Symptoms gradually subside over the following
days

44. • In acute phase
– Spontaneous horizontal torsional nystagmus
• Unidirectional
• Quick phase towards unaffected side
• Suppressed by visual fixation

45. • Patients charcteristically rotate towards the
affected side when attempting to march on
the spot with their eyes closed
– POSITIVE FUKUDA / UNTENBERGER TEST

46. • Diagnosis
– Clinical diagnosis
– Investigations
• Subjective visual Horizontal (SVH) test
• Electronystagmography
• Caloric test
• Contrast MRI

47. • Differential Diagnosis
– Cerebellar infarction
-labyrinthine infarction
-autoimmune inner ear disease
-minner’s disease

48. Outcome and complication
• Symptoms gradually subsides
• Often patient complains of
• -oscillopsia
• -postural imbalance

49. Management
theraputic
-corticosteroids(methylprednisolone)
-antiviral(valacyclovir)
Vestibular rehabilation therapy
Early mobilization

50. Thank You