VERTIGO Mark Jacob Dela Rosa, MD

1st year resident

CLINICAL PRACTICE OMMC ENT-HNS

AND EXAMINATION
 KEY TERMS
• Balance
• complex interaction between the vestibular, ocular, proprioceptive and central
nervous systems (CNS) to maintain head and body position in relation to the
environment
• Dizziness
• nonspecific term which includes sense of imbalance (disequilibrium), blacking
out (presyncope), lightheadedness, floating sensation or vertigo
• Vertigo
• hallucination of movement which is either rotatory or translational.
• It is a cardinal system of a disorder in the vestibular system either peripheral or
central
 KEY TERMS
• Oscillopsia
• Blurring of vision with head movement. Occurs with bilateral vestibular loss
• Peripheral Vestibular System
• vestibular apparatus which consists of the semicircular canals, utricle, saccule
and the vestibular nerve
• Central Vestibular
• vestibular nuclei and its central connections in the brainstem and cerebellum
 KEY TERMS
• Nystagmus
• An involuntary movement of the eyes due to a disturbance vestibulo-ocular reflex (VOR)
• Can be due to either a peripheral or central vestibular disorder
• Jerk Nystagmus
• The eye movement consists of a quick movement followed by a slow phase.
• The direction of nystagmus corresponds to the fast phase.
• Usually seen in peripheral vestibular disorders
• Pendular Nystagmus
• The eye movement consists of a quick movement followed by a slow phase.
• The direction of nystagmus corresponds to the fast phase.
• Usually seen in peripheral vestibular disorders
Dementia, Anxiety,
Depression
 VESTIBULAR SYSTEM
• Vestibular Apparatus
• Consists of
• Semi-Circular Canals
• Utricle, Saccule
• Vestibular Nerve
 VESTIBULAR SYSTEM
• Vestibular Apparatus
• Consists of
• The sensory neuroepithelium
• Crista in the ‘semicircular canals’
• Macula in the ‘otolithic organs
 VESTIBULAR SYSTEM
• Vestibular Apparatus
• Semi-Circular Canals
• 3 Semi-circular canals
• Anterior (Superior), Posterior, Lateral (Horizontal)
• Anterior and posterior forms a common crus
• Ducts terminate into the Ampulla
• Crista in Ampulla is called Cupula
 VESTIBULAR SYSTEM
• Vestibular Apparatus
• Semi-Circular Canals
• Detects angular Acceleration
• Anterior semicircular canal
• Detects nodding/pitch (anterior to posterior
movement)
• Posterior semicircular canal
• Detects head tilt/Roll
• Lateral semicircular canal
• Detects left to right head movement or Yaw (as if
saying “no”)
 VESTIBULAR SYSTEM
• Vestibular Apparatus
• The ‘otolithic organs’ consist of the utricle, which
is adjacent to the semicircular canals and the
‘saccule’ which is close to the cochlea
• They contain hair-cells coupled to calcium
carbonate crystals called otoconia or otoliths
 VESTIBULAR SYSTEM
• Vestibular Apparatus
• They sense gravity and linear accelerations
• Utricle
• detects accelerations in the horizontal plane
• Saccule
• detects accelerations in the vertical plane
 VESTIBULAR SYSTEM
• Functions
• Maintenance of balance (vestibulospinal
reflex)
• Maintenance of eye position during head
movement [vestibulo-ocular reflex (VOR)]
 VESTIBULAR SYSTEM
• Disorders in the VOR typically give rise to eye signs ‘nystagmus’.
• The characteristic of the eye signs will depend on the site of the lesion, whether it is peripheral
(labyrinth or VIII nerve) or central (brainstem or cerebellum)
• These eye signs may be spontaneous or induced.
• The vestibular tests
• Halmagyi/Head Impulse test, head shake, positional tests and VOR suppression
• assess the VOR pathways and positive tests are usually indicative of a peripheral vestibular
disorder.
• The oculomotor tests
• assess the central visual pathways and abnormal eye signs from these tests indicate a central
pathology and help to differentiate from a peripheral vestibular disorder
PERIPHERAL VESTIBULAR
DISORDERS
 ACUTE PERIPHERAL VESTIBULAR
DISORDERS
• Meniere’s Disease
• Initially one ear is affected but over time it extends
to involve the other ear
• It results in progressive sensorineural hearing loss
(SNHL) initially affecting low frequencies
• This progress to involve low and high frequency
with a central peak and finally a flat pattern around
50 dB
 ACUTE PERIPHERAL VESTIBULAR
DISORDERS
• Meniere’s Disease
• Is an idiopathic endolymphatic hydrops
• characterized by an episodic triad of
• vertigo, tinnitus and hearing loss
• It is often preceded by aural fullness and
associated with nausea and vomiting
• The symptoms usually last a few hours
• Initially one ear is affected but over time it extends to
involve the other ear. It results in progressive
sensorineural hearing loss (SNHL) initially affecting
low frequencies. This progress to involve low and high
frequency with a central peak and finally a flat pattern
around 50 dB
 ACUTE PERIPHERAL VESTIBULAR
DISORDERS
• Meniere’s Disease
• Meniere’s syndrome—endolymphatic hydrops with a
known cause, e.g. syphilis,
trauma, otosclerosis or infection (CSOM).

• Tumarkin-otolithic/utricular crises—brief sudden

falling attacks without loss
of consciousness caused by sudden activation of
vestibular reflexes.

• Lermoyez’s syndrome—tinnitus and loss of hearing

prior to an attack of vertigo,
after which hearing improves.
ACUTE PERIPHERAL VESTIBULAR
DISORDERS
 ACUTE PERIPHERAL VESTIBULAR
DISORDERS
• Meniere’s Disease
• Treatment
• Acute phase (symptomatic)—vestibular sedatives
and antiemetics [prochlorperazine, promethazine
(phenergan), cinnarizine, flunarizine and diazepam]
• Fluid and electrolyte management—fluid and salt
restriction; hydrochlorothiazide (loop diuretics can
damage stria vascularis)
 ACUTE PERIPHERAL VESTIBULAR
DISORDERS
• Meniere’s Disease
• Treatment
• Increasing inner ear blood supply—betahistine
dihydrochloride, nicotinic acid
• Intratympanic steroids or gentamicin—for failure
of conservative and medical
therapy.
 ACUTE PERIPHERAL VESTIBULAR
DISORDERS
• Vestibular Neuritis
• Viral infection of the vestibular nerve or vestibular
(Scarpa’s) ganglion
• Most commonly thought to be due to ‘Herpes
Simplex Type I’ viral infection
• Incidence is about 15% of all vertigo
 ACUTE PERIPHERAL VESTIBULAR
DISORDERS
• Vestibular Neuritis
• Characterized by an acute onset of severe vertigo
associated with nausea and vomiting
• Often preceded by a viral illness
• Symptoms persist and gradually subside in three
weeks
 ACUTE PERIPHERAL VESTIBULAR
DISORDERS
• Vestibular Neuritis
• Treatment
• Acute phase (symptomatic)—vestibular sedatives
and antiemetics
• Steroids—methylprednisolone 100 mg/day, reduced
in 20 mg stepwise every 3 day
• Vestibular rehabilitation—for faster recovery and
resumption of activities of daily living
 ACUTE PERIPHERAL VESTIBULAR
DISORDERS
• Labyrinthitis
• An infection of the entire labyrinth or the entire 8th
nerve (vestibulocochlear)
• Can be viral or bacterial in origin
• Clinical features are similar to vestibular neuritis
with the additional symptoms of hearing loss and
tinnitus
ACUTE PERIPHERAL VESTIBULAR
DISORDERS
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Benign Paroxysmal Positional Vertigo
• O ne of the most common types of
peripheral vertigo (20% of patients in vertigo
clinics)
• Due to dislodgement of calcium carbonate crystals
(otolith’s) from the utricle into the semicircular
canals
• Otolith’s can be free floating in the canal
“canalithiasis” or attached to the cupula
“cupulolithiasis”
• Posterior semicircular canal is affected in 80% of
cases
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Benign Paroxysmal Positional Vertigo
• Common complaints are dizziness when turning to
one side while in bed, looking up to take something
from the cupboard or bending down to pick
something up/praying
• Commonly occurs in patients above the age of 40
• In patients below 50, head trauma is a common
cause
There is a higher incidence in those with preexisting
Meniere’s disease and vestibular neuritis
• Benign Paroxysmal
Positional Vertigo
• Diagnosis: Dix-Hallpike
Maneuver (A&B)
• Treatment: Epley’s
Maneuver (A-E)
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Superior Semicircular Canal Dehiscence
• Absence of bony roof of the Superior semicircular
canal
• Dehiscence can be congenital, due to trauma,
surgery or cholesteatoma
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Superior Semicircular Canal Dehiscence
• Symptoms:
• Unsteadiness with activity and relieved with rest
• Conductive deafness
• Valsalva induced dizziness—worsening of symptoms
with coughing, sneezing and blowing of nose
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Superior Semicircular Canal Dehiscence
• Symptoms:
• Tullio’s phenomenon—dizziness induced by loud
sounds (either patient’s own voice or from an
external source).
• May also occur in Meniere’s disease and perilymph
fistulas
• Autophony—the patients find that their voice sounds
louder than normal
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Superior Semicircular Canal Dehiscence
• Diagnosis:
• Valsalva test:
• Positive pressure—valsalva against pinched
nostrils; downbeating torsional nystagmus
• Negative pressure—Valsalva against closed
glottis; upbeating torsional nystagmus
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Superior Semicircular Canal Dehiscence
• Diagnosis:
• Fistula test: Pressure is applied to each ear and eyes
are observed for nystagmus (also used for perilymph
fistula detection).
• A negative test does not exclude the condition as the
test is not sensitive.
• False-negative tests can occur with a dead ear or a
cholesteatoma covered fistula.
• High resolution CT scans of the temporal bone, < 0.6
mm cuts with direct coronal views.
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Superior Semicircular Canal Dehiscence
• Treatment
• Conservative—lifestyle modification with avoidance
of aggravating factors
• Surgery—plugging of the superior semicircular canal
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Perilymph Fistula
• condition where rupture of the inner ear membranes
occurs, leading to leakage of perilymph into the
middle ear usually through the oval window or
round window
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Perilymph Fistula
• Causes:
• Head trauma:
• The most common cause.
• Due to a fracture involving the otic capsule or
through stapes subluxation into the oval
window.
• Spontaneous nystagmus after a head injury
results after an acute injury to the labyrinth.
• The injury is usually paralytic, with nystagmus
beating away from the affected
side
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Perilymph Fistula
• Causes:
• Barotrauma—diving, rapid descent in an airplane,
explosion, straining during
childbirth, straining at stool and sneezing
• Cholesteatoma—cholesteatoma can erode into the
lateral canal or cochlea
• Congenital—patients with stapes footplate or
temporal bone anomalies
• Iatrogenic—following stapedectomy or lateral canal
injury during a
mastoidectomy
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Perilymph Fistula
• Signs and Symptoms:
• Fluctuating hearing loss and episodic vertigo
• Symptoms worse with sneezing, coughing or
straining
• Tullio phenomenon—vertigo with exposure to loud
sounds
• Fistula test—nonspecific and may be positive in only
50% of patients
 MECHANICAL DISTURBANCE OF
SEMICIRCULAR CANALS
• Perilymph Fistula
• Management
• Conservative—aim is to reduce cerebrospinal fluid
(CSF) pressure with bed
rest, head elevated and stool softeners
• Surgical exploration—the middle ear is explored via
a transcanal approach
and the defect sealed with fascia, fat or muscle
CENTRAL VESTIBULAR DISORDER