Download Vertigo - EPS 2013

Vertigo
Vertigo / Dizziness
 Sir Terence Cawthorne said:
“ Labyrinthine disturbance may make one
feel like the end of the world has
arrived….”
 Doctor said:
“ dealing with dizzy patient make me dizzy”
Definitions
 Dizziness (vertigo):
spinning or hallucination of movement.
 Imbalance :
unsteadiness.
 Light headedness :
orthostatic hypotension ,syncope.
Ear anatomy
Balance
Anatomy & Physiology
 Vestibular sense organ:
consists of :
*three semicircular canals
( posterior ,horizontal,
anterior). to detect:
angular acceleration.
*Utricle & saccule :( have
otoconia embedded in a gel
overlying the cilia, to
detect
linear acceleration.
Balance
Anatomy & Physiology
 Inner ear ( cochlea & vestibule & vestibular
nerve).
 Vestibular nuclei (brain stem).
 The two other inputs are:
*Vision.
*Proprioception (skin, joints ,muscle receptors
,mainly neck & ankles).
**The brain stem computerise these 3 inputs with
the help of cerebellum to maintain balance (head
& balance).
Balance
Anatomy & Physiology
Causes of Dizziness
 Otogenic (inner ear) : 50% (of dizziness causes).
 Central (neurological) :( 5%)
 Medical : (5%)
 Psychological :( 15%)
 Unknown : (25%).
Otogenic
(50% of all dizziness)
 BPPV :(50% of otogenic )
(begnin paroxysmal position vertigo) .
 Meniere :( 18% of otogenic).
 Vestibular neurinitis & Labyrinthitis:(14%).
 Acoustic neuroma :( 10%).
 Perilymph fistula : (rare).
 Bilateral vestibular loss :(rare).
Central or Neurological
(5% of all dizziness)
 Migraine , stroke :( 50% of neurological).
 MS :( %5).
 Cerebrum degeneration / chiari:(5%).
 Head injury.
 Meningitis.
 Brain abscess.
Medical
(5% of all dizziness)
 Hypo/ hypertension.
 Cardiac arrhythmia.
 Drugs.
Psychological
(15% of all dizziness)
 Anxiety.
 Panic.
 Phobia.
 Malingering.
Unknown
(25% of all dizziness)
 Multi sensory disequilibrium (elderly).
 Post trauma.
 Psychogenic.
How to diagnose?
 Confirm vertigo (spinning).

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Duration of vertigo:
For seconds < minute (BPPV)
For hrs < 24hr (Meniere ,migraine ..).
For days ( Labyrithitis , vestibular neurinitis, tumours).
 Otological signs (tinnitus, hearing loss, ear discharge, surgery,..)
 General health ,medication .
Examination


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Otological exam ( mandatory).
Neurological exam (mandatory- cranial nerves)
Nystagmus.
Vestibulo-ocular refluxes :
*Hallpike (posterior canal)
*Caloric test (horizontal canal)
*Nystagmus
*ENG test
 Vestibulo-spinal refluxes:
*Romberg
*Unterburger
*Gait
Investigations
 Audiogram ,tempanometry, acoustic
refluxes.
 Caloric test ,ENG (electronystagmography).
 MRI (acoustic neuroma).
 Blood tests (? medical ).
Treatment
 Medical treatment :
*to the causes.
*vestibular sedatives
(prochlorperazine, stemitil..)
*vestibular vasodilatations
(histamine analogues, betahistine.cinnerezin.).
Treatment
 Surgery:
*endolymphatic sac shunting
(damage hearing).
*vestibular neurectomy
(save hearing).
*Labyrinthectomy ( damage hearing):
-surgical.
-chemical / injection of gentamycin.
Treatment
 Vestibular rehabilitation:
*walking stick.
*spectacles.
*Eply manoeuvre (BPPV).
*cocksacy cawthorne exercises.
Eply & Brandt-Daroff
Manoeuvres
Re-positioning otolith for
BPPV
(Eply & Brandt-dorff manoeuvre)