vertigo & its management by dr.h.t.lathadevi m.s(ent) shree b.m.patil medical college hospital...
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Vertigo &
Its ManagementBy
Dr.H.T.Lathadevi
M.S(ENT)Shree B.M.Patil Medical College Hospital &
Research Centre Bijapur
What is VertigoWhat is Vertigo Giddiness /dizziness
Light headedness.
Sensation of floating in space.
Unstable or uncertain gait.
Loss of balance
Ringing in the ears.
VertigoVertigo
Vertigo is a hallucination of self or environmental movement , a feeling of spinning
Vertigo is a symptom and not a disease.
Body Balance SystemBody Balance System Maintenance of balance is a function of nervous Maintenance of balance is a function of nervous
systemsystem
Balance is achieved by integrating information from Balance is achieved by integrating information from 3 sources3 sources
Vestibular labyrinthVestibular labyrinth
EyesEyes
Proprioceptors located in muscles and joint Proprioceptors located in muscles and joint
Harmonious integration of these inputs in the brain Harmonious integration of these inputs in the brain is essential for maintenance of balanceis essential for maintenance of balance
Disorder of Balance SystemDisorder of Balance System
Disorder may occur in one or more organs of the balance system
Commonest site is labyrinth
Labyrinth is susceptible to damage by numerous factors -
Medicines ( e.g.gentamycin,streptomycin )
Infections
Degenerative changes of aging
Head trauma
Vertigo - PrevalenceVertigo - Prevalence
Present in about 5% of all patients consulting general practitioners
Seen in 10-15% of patients seen by ENT specialist or neurologist
The reasons for high prevalence
-Vertigo is a symptoms which accompanies largenumber of diseases
-More than 80 possible causes have beendescribed
Vertigo- symptomsVertigo- symptoms Giddiness /dizziness
Light headedness.
Sensation of floating in space.
Unstable or uncertain gait.
Loss of balance
Ringing in the ears.
Vestibular System
Vestibular Function and Vestibular Function and AnatomyAnatomy
System of balanceSystem of balance Membranous and bony labyrinth Membranous and bony labyrinth
embedded in petrous boneembedded in petrous bone 5 distinct end organs5 distinct end organs
– 3 semicircular canals: superior, lateral, 3 semicircular canals: superior, lateral, posteriorposterior
– 2 otolith organs: utricle and saccule2 otolith organs: utricle and saccule
Semicircular canals Semicircular canals are orthogonal to are orthogonal to each othereach other
Lateral canal inclined Lateral canal inclined to 30 degreesto 30 degrees
Superior/postereor Superior/postereor canals 45 degrees off canals 45 degrees off of sagittal planeof sagittal plane
Utricle is in horizontal Utricle is in horizontal planeplane
Saccule is in vertical Saccule is in vertical planeplane
AnatomyAnatomy
There are five There are five openings into area of openings into area of utricleutricle
Saccule in spherical Saccule in spherical recessrecess
Utricle in elliptical Utricle in elliptical recessrecess
45% from AICA45% from AICA 24% superior 24% superior
cerebellar arterycerebellar artery 16% basilar16% basilar Two divisions: Two divisions:
anterior vestibular anterior vestibular and common cochlear and common cochlear arteryartery
Superior vestibular Superior vestibular nerve: superior canal, nerve: superior canal, lateral canal, utriclelateral canal, utricle
Inferior vestibular Inferior vestibular nerve: posterior canal nerve: posterior canal and sacculeand saccule
Membranous labyrinth is surrounded by Membranous labyrinth is surrounded by perilymphperilymph
Endolymph fills the vestibular end organs Endolymph fills the vestibular end organs along with the cochleaalong with the cochlea
PerilymphPerilymph– Similar to extracellular fluidSimilar to extracellular fluid– K+=10mEQ, Na+=140mEq/LK+=10mEQ, Na+=140mEq/L– Unclear whether this is ultrafiltrate of CSF or Unclear whether this is ultrafiltrate of CSF or
bloodblood– Drains via venules and middle ear mucosaDrains via venules and middle ear mucosa
EndolymphEndolymph– Similar to intracellular fluidSimilar to intracellular fluid– K+=144mEq/L, Na+=5mEq/LK+=144mEq/L, Na+=5mEq/L– Produced by marginal cells in stria vascularis Produced by marginal cells in stria vascularis
from perilymph at the cochlea and from dark from perilymph at the cochlea and from dark cells in the cristae and maculaecells in the cristae and maculae
– Absorbed in endolymphatic sac which Absorbed in endolymphatic sac which connected by endolymphatic, utricular and connected by endolymphatic, utricular and saccular ductssaccular ducts
Sensory structuresSensory structures
Ampulla of the semicircular canalsAmpulla of the semicircular canals Dilated end of canalDilated end of canal Contains sensory neuroepithelium, cupula, Contains sensory neuroepithelium, cupula,
supporting cellssupporting cells
Cupula is gelatinous Cupula is gelatinous mass extending mass extending across at right angleacross at right angle
Extends completely Extends completely across, not responsive across, not responsive to gravityto gravity
Crista ampullaris is Crista ampullaris is made up of sensory made up of sensory hair cells and hair cells and supporting cellssupporting cells
Sensory cells are either Sensory cells are either Type I or Type IIType I or Type II
Type I cells are flask Type I cells are flask shaped and have chalice shaped and have chalice shaped calyx ending shaped calyx ending
One chalice may synapse One chalice may synapse with 2-4 Type I cellswith 2-4 Type I cells
Type II cells – cylinder Type II cells – cylinder shaped, multiple efferent shaped, multiple efferent and afferent boutonsand afferent boutons
Hair cells have 50-100 stereocilia and a single kinocilium.
stereocilia are not true cilia, they are graded in height with tallest nearest the kinocilium.
Kinocilium is located on one end of cell Kinocilium is located on one end of cell giving each cell a polaritygiving each cell a polarity
Has 9+2 arrangement of microtubule Has 9+2 arrangement of microtubule doubletsdoublets
Lacks inner dynein arms, and central Lacks inner dynein arms, and central portion of microtubules not present near portion of microtubules not present near ends – may mean they are immobile or ends – may mean they are immobile or weakly mobileweakly mobile
Each afferent neuron has a baseline firing Each afferent neuron has a baseline firing raterate
Deflection of stereocilia toward kinocilium Deflection of stereocilia toward kinocilium results in an increase in the firing rate of results in an increase in the firing rate of the afferent neuronthe afferent neuron
Deflection away causes a decrease in the Deflection away causes a decrease in the firing ratefiring rate
kinocilia are located closest to utricle in kinocilia are located closest to utricle in lateral canals and are on canalicular side lateral canals and are on canalicular side in other canalsin other canals
Ampullopetal flow (toward the ampulla) Ampullopetal flow (toward the ampulla) excitatory in lateral canals, inhibitory in excitatory in lateral canals, inhibitory in superior/posterior canals superior/posterior canals
Ampullofugal flow (away from the Ampullofugal flow (away from the ampulla) has opposite effectampulla) has opposite effect
Semicircular canals are Semicircular canals are pairedpaired– Horizontal canalsHorizontal canals– Right superior/left posteriorRight superior/left posterior– Left superior/right posteriorLeft superior/right posterior– Allow redundant reception Allow redundant reception
of movementof movement– Explains compensation Explains compensation
after unilateral vestibular after unilateral vestibular lossloss
Otolithic organsOtolithic organs
Utricle and saccule sense linear Utricle and saccule sense linear accelerationacceleration
Cilia from hair cells are embedded in Cilia from hair cells are embedded in gelatinous layer gelatinous layer
Otoliths or otoconia are on upper surfaceOtoliths or otoconia are on upper surface
Calcium carbonate or Calcium carbonate or calcitecalcite
0.5-30um0.5-30um Specific gravity of Specific gravity of
otolithic membrane is otolithic membrane is 2.71-2.942.71-2.94
Central region of Central region of otolithic membrane is otolithic membrane is called the striolacalled the striola
Saccule has hair cells Saccule has hair cells oriented oriented awayaway from from the striolathe striola
Utricle has hair cells Utricle has hair cells oriented oriented towardstowards the the striolastriola
Striola is curved so Striola is curved so otolithic organs are otolithic organs are sensitive to linear sensitive to linear motion in multiple motion in multiple trajectoriestrajectories
Central connectionsCentral connections
Scarpa’s ganglion is in the internal Scarpa’s ganglion is in the internal auditory canalauditory canal
Contains bipolar ganglion cells of first Contains bipolar ganglion cells of first order neuronsorder neurons
Superior and inferior divisions form Superior and inferior divisions form common bundle which enters brainstemcommon bundle which enters brainstem
No primary vestibular afferents cross the No primary vestibular afferents cross the midlinemidline
Afferent fibers terminate in the vestibular Afferent fibers terminate in the vestibular nuclei in floor of fourth ventriclenuclei in floor of fourth ventricle– Superior vestibular nucleusSuperior vestibular nucleus– Lateral vestibular nucleusLateral vestibular nucleus– Medial vestibular nucleusMedial vestibular nucleus– Descending vestibular nucleusDescending vestibular nucleus
Vestibular nuclei project toVestibular nuclei project to– CerebellumCerebellum– Extraocular nucleiExtraocular nuclei– Spinal cordSpinal cord– Contralateral vestibular nucleiContralateral vestibular nuclei
Senses and controls Senses and controls motionmotion
Information is Information is combined with that combined with that from visual system from visual system and proprioceptive and proprioceptive systemsystem
Maintains balance and Maintains balance and compensates for compensates for effects of head motioneffects of head motion
Vestibulo-ocular reflexVestibulo-ocular reflex– Membranous labyrinth Membranous labyrinth
moves with head motion to moves with head motion to rightright
– Endolymph moves Endolymph moves utriculopetallyutriculopetally
– Cupula on right canal Cupula on right canal deflected towards utricle deflected towards utricle causing increase in firing causing increase in firing rate, left deflects away rate, left deflects away causing a decrease in firing causing a decrease in firing rate.rate.
– Reflex causes movement of Reflex causes movement of eyes to the left with eyes to the left with saccades to rightsaccades to right
– Stabilizes visual imageStabilizes visual image
Vestibulospinal ReflexVestibulospinal Reflex
Senses head movement and head relative Senses head movement and head relative to gravityto gravity
Projects to antigravity muscles via 3 major Projects to antigravity muscles via 3 major pathways:pathways:– Lateral vestibulospinal tractLateral vestibulospinal tract– Medial vestibulospinal tractMedial vestibulospinal tract– Reticulospinal tractReticulospinal tract
How do calorics work?How do calorics work? Patient is lying down with Patient is lying down with
horizontal canals oriented horizontal canals oriented vertically (ampulla up)vertically (ampulla up)
Cold water irrigation causes Cold water irrigation causes endolymph in lateral portion to endolymph in lateral portion to become dense and fall causing become dense and fall causing deflection of cupula away from deflection of cupula away from utricle with a decrease in the utricle with a decrease in the firing ratefiring rate
This causes nystagmus with This causes nystagmus with fast phase (beat) away from fast phase (beat) away from the stimulusthe stimulus
With warm water irrigation With warm water irrigation column of endolymph becomes column of endolymph becomes less dense, rises and causes less dense, rises and causes deflection of cupula toward the deflection of cupula toward the utricleutricle
Results in increase firing rate Results in increase firing rate and nystagmus which beats and nystagmus which beats towards the stimulationtowards the stimulation
COWS (cold opposite, warm COWS (cold opposite, warm same)same)
Investigations for vertigo
Caloric Test
Audiometry
Electronystagmography (ENG)
Craniocorpography (CCG)
Brain -Stem Evoked Response Audiometry (BERA)
Pendular Or Phasic
Spontaneous Or Induced
Horizontal Or Vertical
Electronystagmography (ENG) Basic test for balance system
Assesses the integrity of
- vestibular labyrinth & its connections with the eyes andcertain parts of the brain which are concerned with themaintenance of balance
Gives an idea of functional integrity of vestibulo-ocular reflex system
It comprises tests like test for spontaneous nystagmus, the gaze nystagmus, pendulum tracking test & caloric test
Caloric Test
Caloric test involves instillation of hot or cold water into ear canal
When labyrinth is stimulated, either by heat or cold, caloric nystagmus generally results
Nystagmus produced by left & right eyes are assessed
Brain Stem Evoked Response Audiometry (BERA)
A method of plotting electrical activities in response auditory or vestibular stimuli
Electrical activities are measured by keeping the electrode on the scalp
In BERA wave-form obtained from one particular site on the scalp (vertex), over specified duration of time of 10 milliseconds
Investigations - for structural integrityInvestigations - for structural integrity
Tests to asses structural integrity of the system– X rays– CT scan– MRI
Newer imaging ethnologies - for visualization of functional or metabolic activity occurring in brain
– Positron emission tomography (PET)– Single photon emission computed tomography
(SPECT)
Vertigo - Possible circulatory Vertigo - Possible circulatory causescauses
Increased vascular resistance
Increased blood viscosity due to -
Reduced flexibility of RBCs
Increased blood viscosity
Reduced micro-circulation
Vertigo : Peripheral Vertigo : Peripheral V/SV/S Central Central
PERIPHERAL CENTRALPERIPHERAL CENTRAL Occurrence Occurrence : Episodic . May be constant: Episodic . May be constant Severity Severity : Proportionate . Disproportionate : Proportionate . Disproportionate
.. Axis Axis : Horizontal . Variable : Horizontal . Variable
O O Nyst. TypeNyst. Type : Slow & Fast . Irregular : Slow & Fast . Irregular
phases phases LatencyLatency : 10 to 20 sec. . None : 10 to 20 sec. . None DirectionDirection : Single . Changing : Single . Changing DurationDuration : Brief . Long : Brief . Long FatigueFatigue : Yes . No : Yes . No Hearing lossHearing loss
//TinitusTinitus : Possible . No : Possible . No
ANATOMY OF BALANCE AND ANATOMY OF BALANCE AND VERTIGOVERTIGO
Meniere’s syndrome
Sudden onset & recurring episodes of vertigo
Tinnitus
Progressive deafness.
Ischaemia of the inner ear.
The cause is unknown - may be associated with dilation of the endolymphatic system due to increase in the amount of endolymph.
Clinical FeaturesClinical Features
DeafnessDeafness TinnitusTinnitus Episodic vertigoEpisodic vertigo Autonomic –Nausea, vomiting, Autonomic –Nausea, vomiting,
DiaphoresisDiaphoresis Aural pressureAural pressure
5757
ManagrmentManagrment Medical-Vestibular sedativesMedical-Vestibular sedatives
Vascular-Increase blood supply-BetahistineVascular-Increase blood supply-Betahistine
CarbogenCarbogen
Alter electrolytic balance-Frusemide,GlycerolAlter electrolytic balance-Frusemide,Glycerol
HydrochlorothiadizeHydrochlorothiadize Surgical-Endolymphatic sac decompression, Surgical-Endolymphatic sac decompression, Vestibular neurectomy, Ultrasonic destructionVestibular neurectomy, Ultrasonic destruction ReassuranceReassurance Vestibular rehabilitation exercisesVestibular rehabilitation exercises
5858
Benign Paroxysmal Positional VertigoBenign Paroxysmal Positional Vertigo
BPPV results from freely moving crystals of calcium carbonate (Otoconia) usually within the semicircular canals
BPPV develop with change in position
This type of vertigo can be sequelae of head trauma or vestibular neuritis
Most common in age group of 60-70 years
DIX-HALL-PIKE’S TESTDIX-HALL-PIKE’S TEST
EPLEY’S MANEUVEREPLEY’S MANEUVER
General management of General management of vertigovertigo
Management of patients suffering from vertigo or vertiginous syndrome should consist of….
Elimination of the underlying cause
Symptomatic relief.
Methods:
Drug treatment
Vestibular rehabilitation exercises
Surgical
Labyrinthine suppressant/ Ca++ entry blocker
– Cinnarizine
Vasodilators
– Betahistine
Antihistaminics
– Meclizine, Promethazine
– Sedatives / tranquilizers
– Diazepam
Drug treatmentDrug treatment
Selective Antivasoconstrictant, Ca ++ entry blocker
Antivertiginous activity due to
– Suppressant action on vestibular labyrinth.
– Anti-vasoconstrictant activity.
– Lowering of blood viscosity by improving the flexibility of the RBC’s.
Cinnarizine
Cinnarizine
Presentation: Tablet of 25 mg / 75 mg
Dosage :
1-2 tablets of 25 mg two to three times a day or as directed by the physician.
Children (5 - 12 yr.) : 1/2 tablet three times a day
Betahistine Histamine analogue.
Vasodilator-increases blood flow
Indicated for vertigo.
Side effects : headache, rash, g.i. disturbances.
Steal effect
Contraindicated in asthma, peptic ulcer
Dose : 8 to16 mg. tid
Vestibular Rehabilitation Exercises
Co-ordinated head, body & eye movement helps to ameliorate the patient’s symptoms
Exercises should be performed 5 - 10 minutes twice or thrice daily.
– Exercises of eye movement
– Exercises in sitting position like Shrugging & rotating shoulders Bending forward & picking up the objects from the floor
– Exercises in standing position like Changing from sitting to standing initially with eyes open & then with
eyes shut repeatedly for 15 times
Vestibular Rehabilitation Exercises (contd.)Vestibular Rehabilitation Exercises (contd.)
Vestibular Rehabilitation Exercises Vestibular Rehabilitation Exercises (contd.)(contd.)
THANK YOU !
ANATOMY OF BALANCE AND ANATOMY OF BALANCE AND VERTIGOVERTIGO