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