vertigo
DESCRIPTION
Vertigo --- Perception of false rotatory movementsTRANSCRIPT
![Page 1: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/1.jpg)
VERTIGO
-- Prashiddha Dhakal MBBS,KUSMS
![Page 2: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/2.jpg)
Vertigo
• “Illusion” or “Hallucination” of movement.
Abnormal sense of motion
between patient & surrounding
PLUS
Loss of balance
![Page 3: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/3.jpg)
• 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- syncope3. Dysequillibrium4. Vague lightheadedness
![Page 4: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/4.jpg)
True Vertigo
•Loss of balance
PLUS
Abnormal sense of motion between patient & surrounding
![Page 5: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/5.jpg)
Pre-syncope
• Transient sensation that a faint in about to occur.
• May present as nausea ,weakness, SOB or change in vision.
![Page 6: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/6.jpg)
Dysequilibrium
• Loss of balance
• No sense of faintness.
• No abnormal sense of motion.
![Page 7: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/7.jpg)
Vague lightheadedness• Head discomfort due to:
1.Psychiatric disorders
2.Hyperventilation syndrome
3.Encephalopathies
![Page 8: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/8.jpg)
How do we maintain equilibrium?
Visual input
Proprioceptiual
input
Vestibular input
labyrinths.
equilibrium
![Page 9: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/9.jpg)
![Page 10: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/10.jpg)
![Page 11: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/11.jpg)
![Page 12: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/12.jpg)
Sensory cortex
![Page 13: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/13.jpg)
Causes of Vertigo
Central Peripheral
![Page 14: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/14.jpg)
![Page 15: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/15.jpg)
Evaluation of a patient with vertigo
1. Clinical tests
2. Laboratory tests
![Page 16: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/16.jpg)
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
![Page 17: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/17.jpg)
• Nystagmus of peripheral origin:
Suppressed by- Looking at a fixed pointEnhanced by- Darkness or Frenzel glasses (+20 D), both of which abolish optic
fixation
Frenzel Glasses
![Page 18: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/18.jpg)
2. Fistula Test
![Page 19: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/19.jpg)
• 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)
![Page 20: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/20.jpg)
3. Romberg Test
• Peripheral lesion- Patient sways to the side of lesion
• Central lesion- Patient doesn’t sway
![Page 21: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/21.jpg)
• Sharpened Rhomberg test If the Rhomberg test is
normal, this test is performed.Inability to perform this test
indicates vestibular impairment.
![Page 22: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/22.jpg)
4. Past-Pointing
Past pointing, Falling and the Slow component of nystagmus are all in the same direction
![Page 23: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/23.jpg)
5. Hallpike Manoeuvre (Positional Test)
![Page 24: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/24.jpg)
![Page 25: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/25.jpg)
6. GaitPeripheral lesion- Patient deviates to affected
side.
7. Test of cerebellar function
![Page 26: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/26.jpg)
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
![Page 27: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/27.jpg)
Caloric test
• Test of lateral semicircular canal• Induce nystagmus by thermal stimulation• Each labyrinth can be tested separately
![Page 28: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/28.jpg)
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
![Page 29: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/29.jpg)
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
![Page 30: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/30.jpg)
• 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
![Page 31: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/31.jpg)
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
![Page 32: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/32.jpg)
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
![Page 33: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/33.jpg)
• 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
![Page 34: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/34.jpg)
• 3. cold air caloric test• Done when there is perforation of tympanic
membrane• Dundas grant tube • Ethyl chloride is used to cool air
![Page 35: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/35.jpg)
Electronystagmography
• Recoding of nystagmus by caloric,positional,rotational or optokinetic stimulus
• Corneoretinal potential recorded
![Page 36: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/36.jpg)
C. OPTOKINETIC TEST
• EYE movement ellicted by tracking of moving field
• POSITIVE IN brainstem and cerebral lesion
![Page 37: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/37.jpg)
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•
![Page 38: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/38.jpg)
![Page 39: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/39.jpg)
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
![Page 40: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/40.jpg)
G. POSTUROGRAPHY
-- evaluate vestebular function by measuring postural stability
![Page 41: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/41.jpg)
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
![Page 42: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/42.jpg)
• Etiology– Viral infection of vestibular nerve
• Selective neuron loss in vestibular ganglia
– Virus• Herpes Simplex virus type 1 (latent infection)
![Page 43: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/43.jpg)
• 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
![Page 44: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/44.jpg)
• In acute phase– Spontaneous horizontal torsional nystagmus
• Unidirectional• Quick phase towards unaffected side• Suppressed by visual fixation
![Page 45: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/45.jpg)
• Patients charcteristically rotate towards the affected side when attempting to march on the spot with their eyes closed – POSITIVE FUKUDA / UNTENBERGER TEST
![Page 46: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/46.jpg)
• Diagnosis– Clinical diagnosis– Investigations
• Subjective visual Horizontal (SVH) test• Electronystagmography• Caloric test• Contrast MRI
![Page 47: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/47.jpg)
• Differential Diagnosis– Cerebellar infarction
-labyrinthine infarction -autoimmune inner ear disease -minner’s disease
![Page 48: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/48.jpg)
Outcome and complication
• Symptoms gradually subsides• Often patient complains of• -oscillopsia• -postural imbalance
![Page 49: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/49.jpg)
Management
theraputic -corticosteroids(methylprednisolone) -antiviral(valacyclovir)Vestibular rehabilation therapy
Early mobilization
![Page 50: Vertigo](https://reader033.vdocuments.us/reader033/viewer/2022061303/5492e267b47959610c8b474b/html5/thumbnails/50.jpg)
Thank You