1. The Dizzy Patient 4x4 Method
Dr Ahmad Alamadi FRCS
Consultant, HOD
Al Baraha Hospital

2. Vestibular Physiology
Orientation of our body in space is the primary function of the vestibular system. This is achieved by integration of signals from vestibular, visual and proprioceptive receptors at the level of brain stem.
Information regarding the movement of the head relative to the body is largely provided by paired vestibular sensory endorgans

3. Vestibular Sensory Endorgans

4. Cristae & Otolithic organ

5. Information Relay Vestibulo-Ocular reflex (VOR)
Peripheral Vestibular System
EYES
Proprioceptive Receptors
Central Vestibular Nuclei
Vestibulocerebellar tracts (VCT)
Vestibulospinal
(VST)
Vestibulo-Ocular reflex
(VOR)

6. VOR Keeps a stable retinal image during head movement
As the head moves in one direction there should be an equal and opposite conjugate movement of the eyes (sometime known as the doll’s eye maneuver)

7. VOR Defect
Bilateral Defect : (for example from systemic aminoglycoside toxicity) the patient will complain of imbalance and a blurring of vision with head movement better known as oscillopsia
Unilateral defect : the equilibrium of the push-pull forces between the inner ears is altered. This result in a drift of the eyes away from side of lesion followed by a quick central nervous system (CNS) mediated saccade in a repetitive to and fro fashion better known as nystagmus.
Nystagmus is the cardinal sign of a central or
peripheral vestibular disorder

8. History Steps Organic Vs Psychogenic Vestibular Vs Non vestibular
Peripheral Vs Central
Which Peripheral Vestibular Disorder

9. Organic Vs Psychogenic
Features
Organic vestibular
Psychogenic
Duration
Usually well defined i.e. seconds, minutes or hours
(never a “flash”)
Variable from a “flash” to days
Not well defined
Frequency
Except for benign paroxysmal positional vertigo (BPPV), rarely more than once a day
Constant or many times a day
Head Movement
Intensifies symptoms
Symptoms usually unaffected
Ataxia during spell
Usually prominent
Insignificant
Effect of Hyperventilation
Not like the attack
Often reproduces symptoms accurately

10. Vestibular Vs Non vestibular
True Vertigo (hallucination of movement relative to self) Vs Non specific Dizziness
Note patient with non specific dizziness need to be investigated for cardiac and neurological causes.
Patients with true vertigo have a vestibular disease which can be central or peripheral

11. Peripheral Vs Central
Ask for associated symptoms i.e. discharge, tinnitus, aural fullness and hearing loss
Ask for focal neurological complaints i.e. diplopia, dysphagia, dysarthria, paresis, parasthesia or incontinence and LOC.
Inner ear disorders should never be associated
with a loss of consciousness

12. Which Peripheral Vestibular Disorder
Benign paroxysmal positional vertigo (BPPV)
seconds; several attacks /day; positional
Meniere's disease
minutes to hours; tinnitus; fluctuating hearing loss; aural fullness
Recurrent Vestibulopathy
minutes to hours
Vestibular Neuronitis (acute viral labyrinthitis)
Hours to days

13. Examination Steps Otological examination Neurological examination
Special clinical vestibular tests
Important Diagnostic Tests

14. Otological examination
Otoscopy
Hearing assessment (Weber and Rinne tests)
Fistula Test

15. Neurological examination
Cranial Nerves
Cerebellar Tests
Oculomotor Tests
Smooth pursuit, saccades, visual fixation and vergence
Balance Tests
proprioception, Romberg’s and tandem gait tests (both eyes open and closed).
When Smooth Pursuit is Normal it would be
unlikely for a central disorder to be present

16. Special clinical vestibular tests
The Halmagyi maneuver
The head shake test
The oscillopsia test
VOR suppression test

17. Important Diagnostic Tests
Dix-Hallpike Positional Test
Hyperventilation Test

18. Conclusion
4 steps in History
x = 99% Diagnosis
4 steps in Examination

19. Soon on DVD and Internet Interactive Multimedia Textbook of Otology www.otologytextbook.com
Thank You