making vertigo simple

1. 
VERTIGO – MAKING
IT SIMPLE
DR.ANITA BHANDARI
CONSULTANT NEUROTOLOGIST
VERTIGO AND EAR CLINIC,
JAIPUR

5. ETIOLOGY

6. MATTER OF CONCERN
More amenable to treatment -more sinister consequences

8.  Seconds – late ototoxicity
 Minutes – BPPV, TIA
 Hours – Meniere’s disease , Migraine related vertigo
 Days – Vestibular neuritis
 Months – years - Hysterical

10.  Spatial orientation
 Ocular stabilization
 Postural control
EQUILIBRIUM

13.  A battery of tests
 Many systems to be evaluated to assess structural and
functional integrity
NEUROTOLOGICAL
EVALUATION

14. For An ENT Specialist,
 We look at the ears first.
 In vertigo --> eyes are most important

15.  Otoliths act as gravito-inertial force detectors
 SVV is a psychophysical measure of the angle between perceptual
vertical and true/gravitational vertical
 Also used to measure vestibular rehabilitation
 Compensated utricular hypofunction may be detected on dynamic
SVV testing. The defect will be unmasked on eccentric rotation
because any otolith function asymmetry will be enhanced.
SVV

16.  Pt is asked to adjust the orientation of a luminous bar until they
perceive it as vertical
 SVV – saccule and its central pathways
 SVH – utricle and its central pathways
 Pinar et al reported changes in SVV and SVH in >25% pts of
chronic dizziness concluding that evaluation of the otolith system
is mandatory
SUBJECTIVE VISUAL
VERTICAL AND HORIZONTAL

17. SVV FINDING CONDITION
Normal range Upto 2° deviation
Ipsiversive tilt – >2o
peripheral vestibular disorder
pontomedullary lesion
thalamic lesion
Controversive Pontomesencephalic lesion parietoinsular
vest. lesion
Migraine Abnormal, little literature

18. CRANIOCORPOGRAPHY
 Developed by Claussen [1968]
 Assessment of vestibulospinal system
 Photographic recording of head and body movement during
gait testing
 Evaluation includes Romberg, Tandem walking and
Unterburger’s test

19.  Done in dark room
 Pt is blindfolded
 Pt wears a helmet with LED lights
 Path of the pt is recorded using an SLR camera
 Result depends on vestibular system only as visuals cues cut off –
pt is blindfolded and by stepping in one place, the soles
intermittently lose contact with the floor thus reducing
somatosensory input
CCG : PROCEDURE

20. PARAMETER NORMAL RANGE-
LOWER BORDER
NORMAL RANGE-
UPPER BORDER
Longitudinal
displacement
30.03 cm 113.35 cm
Lateral sway 5.17 cm 16.15 cm
Angular deviation 55.13° (right) 48.37° (left)
Body spin 82.21° (right) 82.89° (left)
NORMAL PARAMETER OF
CCG
[CLAUSSEN]

21. PATHOLOGY CCG FINDINGS
Peripheral vestibular lesions Ipsilateral deviation
Brainstem lesion, bilateral peripheral
vestibulopathy
Enlarged lateral sway, no angular deviation
CPA tumors, PICA synd. Contralateral deviation, enlarged sway
INTERPRETATIONS OF
CCG

22. INCREASED SWAY

23. ANGULAR DEVIATION TO
LEFT

24. ANGULAR DEVIATION TO
LEFT

25.  Introduced by Halmagyi and Curthoy
 Simple, fast, reliable
 Tests scc function – can evaluate all 3 pairs
 Measures high freq. vestibular response in 3 dimensions
HEAD IMPULSE TESTING

26.  VHIT – using Video Frenzel glasses
 Test for gaze stabilization during rapid translation of head
 Assesses the peripheral utricular system and superior
vestibular N
 A corrective saccade after VHIT indicates hypofunction of
same side
HEAD IMPULSE TEST

27.  Subject seated upright with eyes focused on an fixed object
 Unpredictable , low amplitude [10 – 20°] head rotation with
high acceleration
 Angular VOR generates compensatory eye movements
equal in amplitude and opposite in direction to stabilize
gaze
HIT : PROCEDURE

28. HEAD IMPULSE

29.  Nystagmus indicates an imbalance in vestibular tone
between the 2 sides
 Not seen in bilateral vestibular dysfunction
HEAD SHAKING TEST

30. HEAD SHAKING TEST

31. HEAD SHAKING – DOWN
BEATING NYSTAGMUS

32.  Functional test of VOR
 Comparison of visual acuity with
head still to VA with head moving
 Reduction by 2 lines indicates
dysfunction of VOR as seen in
bilateral peripheral vestibulopathy
 Improvement with rehab will
improve DVA
 Early sign of vestibular toxicity
DYNAMIC VISUAL ACUITY
TEST

33. 
BPPV AND PARTICLE REPOSITIONING
MANEUVERS

34.  The ampulla contains the cupula – a gelatinous mass with the same
density as the endolymph.Cupula forms an impermeable barrier
across the lumen of the ampulla. Hence the particles in scc may only
exit via the end with no ampulla.

37. POSTERIOR CANAL BPPVPOSTERIOR CANAL BPPV
 Most common– posterior canal is most gravity dependent in
upright and supine position
 Once debris enter the post. canal ,the cupula at the shorter
most dependent arm trap the debris.
 Debris can exit only through the longer arm through the crus
commune [non-ampullary]

38. DIX-HALLPIKE
MANEUVRE

39. POSTERIOR BPPV

40. EPLEYEPLEY’’S MANEUVERS MANEUVER

41. EPLEY’S MANEUVRE

42. SEMONTSEMONT’’S MANEUVERS MANEUVER
 Liberatory maneuver for pBPPV and cupulolithiasis
 Used to overcome otoconia jam after Epley’s maneuver

43. SEMONTSEMONT’’S MANEUVRES MANEUVRE

44. SEMONT’S MANEUVRE

45. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES
 Used as a home program
 Indications
o Posterior canal cupulolithiasis
o Persistant posterior canal canalithiasis
 Mechanism
o Dislodge debris attached to cupula
o Habituation through central compensation

46. BRANDT-DAROFF
EXERCISES

47. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES
 Things to remember
o The exercises may dislodge more otoconia from the utricle
causing an increase in symptoms.
o May cause multiple canal involvement.
o Important to hold for 30 seconds in each position.

49. HORIZONTAL SCC BPPVHORIZONTAL SCC BPPV
 Pagnini-McClure maneuvre
 Geotropic nystagmus – debris are away from ampulla , side
showing stronger nystagmus is the side involved
 Apogeotropic nystagmus – indicates cupulolithiasis

50. McCLURE PAGNINI MANEUVERMcCLURE PAGNINI MANEUVER
SUPINE ROLL TESTSUPINE ROLL TEST

51. McCLURE’S MANEUVRE

52. POSITIONAL – LATERAL
BPPV

53. BARBECUE MANEUVRE

54. GUFONI MANEUVRE

55. VANUCCHI MANEUVERVANUCCHI MANEUVER
 Forced prolonged positioning
 Sleep in lateral position with healthy ear down for 12 hours.

56. CUPULOLITHIASISCUPULOLITHIASIS
 Coined by Schuknetch
 Rare , more common in horizontal canal
 Caused by otoliths attached to cupula of scc
 When cupula is horizontal no vertigo
 When non-horizontal constant input persistant
dizziness
 Nystagmus : persistant non-fatiguable as long as patient is in
the same position

57. SUBJECTIVE BPPVSUBJECTIVE BPPV
 No nystagmus is detected but patient feels dizzy on
provocative tests
 PRP beneficial
 Reasons
o Subtle nystagmus
o Fatigued nystagmus
o Inadequate neural signal to stimulate the VOR

58. CONTRAINDICATIONS OFCONTRAINDICATIONS OF
PARTICLE REPOSITIONINGPARTICLE REPOSITIONING
 Cervical spine problems
 Uncontrolled hypertension
 Retinal detachment

59. 
PHARMACOTHERAPY OF
VERTIGO

60. NO COMMON TREATMENT FOR
ALL PATIENTS.
Therapeutic approach requires recognition of the
pathomechanism
 Detailed history
 Clinical examination
 Neurotological tests
 Imaging

61. Aim Of Vertigo Therapy
 Elimination of Vertigo
 Enhancement/non-compromise of “Vestibular compensation”
 Reduction of Psychoaffective syndromes
 Nausea and Vomiting
 Anxiety
Thomas Brandt – Vertigo; A mutlisensory system disorder, 2nd
edition. Springer –Verlag- London 2002

62. Vestibular Suppressants
Rascol O et al, Drugs 1995; 50: 777-91
Lacour M. Curr Med Res Opion 2006; 22: 1651-9
Reduction in the
symptom of vertigo
comes at a price of
reduction in
vestibular function

63. Treatment with Vestibular Suppressants
 Suppressants
reduce activity at
intact side and
thus hamper
recovery by VC
 Not recommended
for long term use
 They should be
discontinued as
soon as possible
Lacour M. Curr Med Res Opion 2006; 22: 1651-9
Vestibular
Nuclei
INTACT DAMAGED

64. Vestibular Suppressants
 Useful for prevention of nausea and reduce
vomiting (generally to be used for not more
that 1-3 days) post an event
 Should be discontinued as soon as possible
after event subsides
 They are not to be used chronically or for
prophylaxis against subsequent attacks
Lacour M. Curr Med Res Opion 2006; 22: 1651-9
Goebel J. Otolaryngol Clin N Am 2000; 33: 483-93
Brandt T, Vertigo. Its Multisensory Syndromes, 2nd
Ed: Pg 49-61

65. ANTI-CHOLINERGIC DRUGS
Suppress spontaneous firing of
 Vestibular nuclei
 2ND
& 3RD
order neurons
 Reticulo-vestibular pathway

66. ANTI- HISTAMINICS
 Histamine is not a major neurotransmitter in the vestibular
pathway
 It exerts effect by acting on H1 receptors antagonist
 Structure of H1 receptors is similar to Muscaranic receptors
 Drug which blocks H1 receptors will also have an anti-
cholinergic effect

67. Cinnarizine: Mechanism of Action
Drugs of Today, 1982;18(1):27-42
Ca+2 Channel
Blocker

68. BETAHISTINE
Historically seen that histamine relieved vertigo.
However had to be given IV and had serious
side effects.
Betahistine is a histamine analogue having the
advantages of histamine like action without its
side effects.

70. DRUG COMBINATIONS
 Anti-histaminics are H1 receptor antagonists
 Betahistine is H1receptor agonist and H3 receptor antagonist
 Hence these drugs should not be combined.

71. VESTIBULAR
REHABILITATION
 VRT comprises of a series of maneuvers designed to
stimulate the vestibular system. These movements which in
the initial stages provoke vertigo, are combined with
exercises involving eye movements and postural changes
which encourage vestibular compensation.

72. TAILORING THE REGIMEN
 Vestibulo-ocular system
 Vestibulospinal system
 Otolithic system

73.  Pts are asked to perform repeated head ,eye and body
movements which will help the brain recalibrate the relationship
between visual, vestibular and proprioceptive signals.

74.  Bouncing on Swiss balls or mini-tramps may be advocated to build
up the otolith-ocular reflex as well as otolith-postural reflexes.

75. ON TRAMPOLINE

76. CENTRAL COMPENSATION
 Adaptation – ability to regain spatial orientation
 Substitution – as there is a derangement in function, using
different pathways to maintain equilibrium
 Habituation – repeated maneuvres aimed at stimulating the
sensory mismatch and lead to desensitization.