Head of Otology / Neurotology Unit Vertigo Dr. Abdulrahman Alsanosi Associate professor Otolaryngology consultant Otologist , Neurotologist &Skull Base Surgeon Head of Otology / Neurotology Unit Director of cochlear implant program King Abdulaziz University Hospital

Importance Can be a sign of serious diseases Can be seen in other specialties Hard to diagnose because it integrates several organs and systems together and the underlying cause is not clear. Very common, but hard to deal with.

INTRODUCTION Dizziness is a common symptom that accounted for more than 5.6 million clinic visits in the United States 15% to 30% of patients, most often women and the elderly, will experience dizziness severe enough to seek medical attention at some time in their life.

What are the components of balance system ?

Inner ear (3 semicicular canals and otolith organ ): divided into 2 parts: hearing (cochlea) and vestibular (semicircular canals , otolith organ) Cerebellum ; engine behind coordination , creating muscle movement and keeping balance Vision (Vestibular Ocular Reflex): it is a reference between the eye and the inner ear. it controls both eye movements and keeps them focused on the same object. I.e If there is misalignment between one of the retinas on a particular object it will lead to a sense of an “illusion” causing dizziness Proprioception: sensation in the sole of the foot. People need hard surfaces to get the full effect of their proprioception or it will feel like they are walking on sand “ shaky grounds”. 1 stimulus that leads to more than one response when it comes to maintaining balance. Being pushed from behind will lead to all the previous systems to work together to maintain balance.

How does balance system work ?

Physiology Function of vestibular system: “Input” resulting from a stimulus that needs to be corrected through the vestibular system such as falling down. An “output” results from responses of the vestibular system to the input such as the eyes, cerebellum .. Etc. The physical stimulus (input) will be transformed into a biological stimulas in the brain stem which will in turn be sent afterwards to the corresponding areas in the vestibular system. Transform of the forces associate with head acceleration and gravity into a biological signals that the brain can use to develop subjective awareness of head position in space (orientation) produce motor reflexes that will maintain posture and ocular stability to prevent the feeling of dizziness. If there is a defect in the input and output processes the patient will present with vertigo, defects in the gait or ocular distortions.

It is not surprisingly that vestibular lesion cause: Imbalance posture and gait imbalance visual distortion (oscillopsia ).

oscillopsia Patient with ocular distortions (oscillopsia) – if the head moves the eyes will move along with it. VOR system is not working.

What is vertigo?

VERTIGO The word "vertigo" comes from the Latin "vertere", to turn + the suffix "-igo", a condition = a condition of turning about). It is an allusion of being moving or the world is moving too.

What are the questions to ask in history ? Onset (acute/chronic) Frequency – how often Duration Associated auditory symptoms Aggravating and relieving factors Ear disease or ear surgery – tinnitus? Trauma Migraine Ototoxic drug intake – (chemotherapy, aminoglycosides, methotrexate) Family history Motion sickness

Differential diagnosis A) peripheral vestibular loss – up to the vestibular nerve. B) central vestibular loss – above the level of the vestibular nerve and towards the brain.

What are the causes of peripheral vestibular loss ?

peripheral vestibular loss Vestibular neuritis Benign paroxysmal positional vertigo ( BPPV) Meneires disease (Endolymphatic hydrop )

Vestibular Neuritis Viral infection of vestibular organ Affect all ages but rare in children – mostly adults Affected patient presents acutely with spontaneous nystagmus ,vertigo and nausea &vomiting stays for hours and sometimes days. Patient requires only symptomatic treatment It takes 3 weeks to recover from vestibular neuritis Diagnosis – no other tool other than history. Recent study studies show that giving steroids decreases the 3 week recovery period.

Vestibualr neuritis

BPPV( benign paroxysmal positional vertigo ) Its provoked by certain positions. Pathophysiology: Calcium carbonate particles shear off and enter the canal leading to brief episodes of vertigo.

BPPV The most common cause of vertigo in patient > 40 years Repeated attacks of vertigo usually of short duration less than a minute . Provoked by certain positions (rolling in beds, looking up ,and head rotations) Not associated with any hearing impairment

BPPV Diagnosis History Dix-Halpike maneuver : putting the patient in a certain position to stimulate the attack, and to look at the eye (causes nystagmus) to see which canal is mostly affected by trying to push the particles inside the canal and inducing the sense of dizziness. Treatment: repositioning of the head to get particles out of the canal (Epley or particle repositioning maneuver) . No medical or surgical treatment needed. Epley’s maneuver could even be done at home.

Endolymphatic hydrop (Meneire’s disease) Pathophysiology : Unknown etiology ↑ ↓production of fluid within inner compartment

Endolymphatic hydrop (Meneire’s disease) vertigo (minutes to hours ) Low frequency fluctuating SNHL Tinnitus and fullness in the ear. In 10 - 20% of cases the disease later involves the opposite ear

Meniere's disease Diagnosis -History -PTA Showing SNHL

Meneire’s disease Management -low-salt diet -Medical therapy - Meniett device's -Chemical perfusion -Surgery

SUMMARY Treatment Course of diseases hearing Duration of attack Diagnosis Symptomatic Self limited normal Days Vestibular N Exercise Recurrent Seconds BPPV Medical &surgical Affected Minutes to hours Meneire’s diseaseM

Migraine associated vertigo (MAV): common in females between the ages of 20 to 35 Classical presentation , preceded by aura or without aura then headache followed by couple of hours of dizziness. Sometimes the patient could feel dizzy without the headache. More frequently the patient might complain of nausea when smelling something in the car or while driving around.

What are the causes of central ?

Central CVA (Cerebro vascular accident)- most common Brain tumor ( acoustic neuroma ) Multiple sclerosis

CVA Elderly patient with chronic disease like (DM ,HTN) with sudden attack of vertigo +neurological symptoms

Acoustic tumor Benign tumor Arise from vestibular division of VIII Clinical presentation: Unilateral tinnitus Hearing loss Dizziness The only way to differentiate between Meniere's disease and the Acoustic tumor is by MRI.

Acoustic neuroma Diagnosis : History PTA ( Unilateral SNHL ) Radiology

History is the most important key to diagnosis for a dizzy patient .

Investiagtions PTA Vestibular testing CT SCAN MRI

A dizzy patient may fit into one of the following scenarios

Scenario # 1 The patient who is having a first ever attack of acute spontaneous vertigo. Acute vestibular neuritis cerebellar infarction. How to differentiate ? - Clinically ( General appearance of patient /nystagmus/head impulse test) - Radiology There is a horizontal-torsional spontaneous nystagmus with the slow phases towards the affected ear - that is, quick phases towards the unaffected ear. The head impulse test (Figure 3) is invariably positive and shows impaired lateral semicircular canal function on the affected side The patient, although unsteady, can stand without support with the eyes open but rotates toward the side of the lesion when trying to march on the spot with the eyes closed - a positive Fukuda or Unterberger test if the head impulse test is positive then the patient has acute vestibular neuritis and if the head impulse test is negative, then the patient does not have acute vestibular neuritis With a cerebellar infarct the nystagmus might be bilateral, might be vertical, and will not be well suppressed by visual fixation, that is, it will be obvious even without Frenzel glasses. A patient with a cerebellar infarct usually cannot stand without support even with the eyes open, whereas the patient with acute vestibular neuritis usually can. Acute cerebellar infarcts are obvious on MR but might not be on CT

Scenario #2 The patient who has repeated attacks of vertigo, but is seen while well A- Recurrent spontaneous vertigo Menière’s disease Migraine induced vertigo perilymph fistula B- Recurrent Positioning Vertigo BPPV

Scenario #3 The patient who is off balance Bilateral vestibulopathy – could be due to streptomycin posterior fossa tumour

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