1. Vertigo
Dr. Saad Y. Sulaiman

2. There are 4 types of Dizziness:
Vertigo
Lightheadedness
Presyncope
Disequilibrium
Disorders of vestibular system cause vertigo.

3. Disorder of vestibular system cause
vertigo.
Vertigo
accounts for 54% of all dizziness
Vertere = Spin (Latin)
Vertigo is an illusion of movement of the patient’s body or patient’s environment. It should be restricted to sensation of rotation and linear motion(staggering to one side)

4. Aetiology
Peripheral which involve the vestibular end organs and their 1st order neuron (i.e. the vestibular nerve) 85% of all cases of vertigo.
Central ( non-otological) which involve the CNS after the entrance of the vestibular nerve in the brainstem e.g. intracranial tumors, multiple sclerosis, vestibulobasillar ischaemia, Temporal lobe epilepsy and migraine.

5. Nystagmus Involuntary, Rhythmic oscillation of the eyes
Types
Physiological; rotational & caloric test
Pathological
Occular
Vestibular
Central lesions

6. Occular nystagmus
Pendular/The two phases of oscillation are of the same speed
Vestibular Nystagmus
Horizontal
Named according to the direction of rapid component
Fatigable
Nystagmus associated with central lesions
Vertical ( 80%)
Non-fatigable.

7. Peripheral vestibular disorders

8. Meniere's disease ( Endolymphatic hydrops)
It is a disorder of the inner ear where the endolymphatic system is distended by endolymph.
It is characterized by
(1) Vertigo
(2) SNHL
(3) Tinnitus.

9. The Inner Ear The inner ear, or labyrinth, consists of:
Bony capsule (otic capsule)
Membranous labyrinth

10. Bony capsule (otic capsule)
Membranous labyrinth

11. There are two types of fluid in the inner ear;
Very similar to the ECF and CSF (has low k+ and high Na+ concentration).
Similar to the ICF (has high K+ and low Na+ concentration)

12. The Membranous Labyrinth
Membranous cochlear duct
(scala media)
Saccule and utricle
Membranous semicircular ducts 2 1 3

13. Pathology of Meniere’s disease
Dilatation of the endolymphatic compartment due to abnormality of endolymph formation or absorption or both.

15. Aetiology:
The exact cause of Meniere's disease is not yet known. Various theories have been postulated:
Defective absorption due to ischemia of sac.
Vasomotor disturbance.
Allergy.
Sodium and water retention.
Hypothyroidism.
Autoimmune and viral aetiology.

16. Clinical features Age: 35-60 years. Sex: no gender bias
Usually the disease starts unilateral but the other ear may be affected after a few years.

17. Cardinal symptoms of Meniere's disease are:
Episodic vertigo
Fluctuating hearing loss
Tinnitus
sense of fullness or pressure in the involved ear.
Remission is typical
The suddenness of the attack (characterestic)
Aura ( change in tinnitus or fullness sensation)

18. 1- Vertigo:
Sudden.
Last for few hours.
Associated with vomiting, nystagmus and bradycardia.
The patient may fall and injure himself, BUT he has normal level of consciousness.

19. 2- Hearing loss:
SNHL during or just after the attack.
In the early stages of the disease the hearing return to normal
as the attacks become more frequent complete loss of hearing results in the affected ear.

20. 3- Tinnitus:
Referred to the affected ear.
Precedes or accompany the vertigo.

21. Examination
Between the attacks, clinical examination may be completely normal.
During the attacks, the patient is :
disoriented, unable to stand and usually lie down with:
(1) Nystagmus
(2) Normal Otoscopy
(3) Tuning fork examination  SNHL.

22. Investigation: Audiological (PTA): SNHL.
Vestibular (Caloric test): canal paresis in the affected ear

23. Caloric test
The ears are irrigated in turn with water at 30 C then at 44 C (7 C above and below body temperature). This situation causes nystagmus with its quick component away from the ear on the cold testing and towards the ear on hot caloric testing (COWS). This nystagmus commonly lasted for about 2 minutes from the beginning of stimulation.

24. Canal paresis is present if the duration of nystagmus is reduced equally for both hot and cold tests. Canal paresis is suggestive of a lesion in the peripheral vestibular apparatus e.g. vestibule or vestibular nerve.

25. Treatment Medical During the acute attack Complete bed rest.
Antihistamine& labyrinthine sedatives: prochlorperazine (stemetil) and cinnarzine (stugeron).
Anxiolytics: IV diazepam.
Surgical:
Endolymphatic sac decompression or shunt.
Vestibular nerve section.

26. Benign Paroxysmal Positional Vertigo ( BPPV)
Recurrent Paroxysmal short lived attacks of vertigo initiated by certain critical positions of the head. There are no other aural symptoms

27. Aetiology
Idiopathic.
Head injury.
Viral infection.
Aging process.
Pathology
The disease is thought to be due to displacement of otoliths (calcium carbonate particles) from the utricle and saccule to the capula of the semicircular canal.

28. Cupula

29. Clinical picture
Brief attacks of vertigo when the patient put his head in the critical position.
Absence of aural symptoms: hearing is normal and there is no tinnitus.

30. Examination
1- Positional nystagmus which is elicited by performing Hallpike maneuvers .The classical features of BPPV are:
A latent period of 5-10 sec. followed by rotatory nystagmus lasting up to 30 seconds.
The fast component of the nystagmus is directed towards the undermost ear.
The nystagmus fatigue rapidly.
2- Normal Otoscopy and audiometry.
Investigation: Caloric test: Normal.

31. Treatment of BPPV Medical:
Reassurance and avoidance of the provocating position.
Antivertigo drugs: prochlorperazine (stemetil), Cinnarzine (stugeron) and Betahistine (Serc).
Surgical:
Posterior semicircular canal denervation

32. Prognosis
There is normal tendency for spontaneous cure, which may be delayed for several months.

33. Vestibular Neuronitis
This condition is characterized by
a SEVERE vertigo of
Sudden onset
Without deafness or tinnitus
and with NO sign of neurological involvement.
Causes: Viral ( URTI)

34. Clinical picture Examination
Hx. of URTI (1 w.- 10 days).
Vertigo which can last several days before a gradual recovery begins.
Nausea and vomiting.
Absence of aural symptoms: Hearing is normal and there is no tinnitus.
Examination
Spontaneous nystagmus of the vestibular type.
Investigations: Caloric test: canal paresis on the affected side.

35. Other causes of vestibular disorder ( vertigo)
Labyrinthitis
Vestibulotoxic drugs: e.g. Aminoglycosides
Head trauma
Perilymph fistula:
Causes: complication of ear surgery (stapedectomy), barotrauma, raised intracranial pressure.

36. Vestibular Schwannoma (Acoustic neuroma)
Nerve sheath tumors which arise from Schwann cells covering the superior and inferior vestibular nerve . Rarely they originate from the cochlear nerve.
8% of all intracranial tumors
80% of cerebellopontine angle tumors.
Slowly growing tumors &do not infiltrate local tissues or metastasize BUT compress the adjacent tissues.

37. Aetiology
The cause is unknown although neurofibromatosis type 1 (NF1) and NF2 are associated with Vestibular schwannoma.
Bilateral Vestibular schwannoma are common in NF2.

38. Clinical picture Sex: M=F Age: 30-60yr I.Otological symptoms
Progressive unilateral SNHL+ Unilateral tinnitus ± Vertigo
II. Facial and trigeminal nerve dysfunction
III. Further expansion leads to brainstem and cerebellar compression and increase intracranial pressure.

39. Investigation Audiological: PTA: asymmetrical SNHL, Imaging:
MRI with gadolinium contrast is the gold standard for the diagnosis.
CT scan may detect large tumors
Caloric test: canal paresis in the affected side.

40. Treatment
Observation if the life expectancy of the patient is shorter than the growth time required for the vestibular schwannoma to cause neurological symptoms
Surgical removal.
Stereotatic radiation using cobalt-60 gamma knife system.

41. How to differentiate between central and peripheral type of vertigo?

42. 4- History of medications, toxins, DM, hypertension.
1- Timing and duration
The longer the symptoms last  central
Sudden onset  peripheral
Early morning vertigo peripheral
2- Provoking Factors:
Positional changes
Recent viral illness
Trauma, excessive straining (perilymphatic fistula)
3- Associated symptoms
4- History of medications, toxins, DM, hypertension.
5-Family history: Migraine, CVA risk.

43. Examination 1- Otological: 2- Cardiovascular TM: Vesicles
Cholesteatoma (CSOM).
Hennebert’s sign &Valsalva maneuver
2- Cardiovascular
Orthostatic changes (drop of BP by 20 mmHg)
arrhythmias, carotid bruits or other signs of atherosclerosis.

44. 3- Neurological:
Cranial nerves palsies & SNHL
Nystagmus
Vertical– 80% sensitive for vestibular nuclear or cerebellar lesions
Horizontal– suggests peripheral cause
Gait and balance
If peripheral, pt will be able to walk
Central –pt usually will be severely impaired in walking
Hallpike maneuvers