Vertigo

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Vertigo

• Dr A ABOU-HASSOUN
• (MD.FRCS.DLO)
• Consultant ENT

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Vertigo / Dizziness

• Sir Terence Cawthorne said
• Labyrinthine disturbance may make one feel
  like the end of the world has arrived.
• Doctor said
• dealing with dizzy patient make me dizzy

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Definitions

• Dizziness (vertigo)
• spinning or hallucination of movement.
• Imbalance
• unsteadiness.
• Light headedness
• orthostatic hypotension ,syncope.

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Ear anatomy
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BalanceAnatomy Physiology

• Vestibular sense organ consists of
• three semicircular canals?
• ( posterior ,horizontal, anterior). to
  detect
• angular acceleration.
• Utricle saccule ( have otoconia embedded
  in a gel overlying the cilia, to detect
• linear acceleration.

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BalanceAnatomy Physiology

• Inner ear ( cochlea vestibule vestibular
  nerve).
• Vestibular nuclei (brain stem).
• The two other inputs are
• Vision.
• Proprioception (skin, joints ,muscle
  receptors ,mainly neck ankles).
• The brain stem computerise these 3 inputs with
  the help of cerebellum to maintain balance (head
  balance).

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BalanceAnatomy Physiology
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Causes of Dizziness

• Otogenic (inner ear) 50 (of dizziness causes).
• Central (neurological) ( 5)
• Medical (5)
• Psychological ( 15)
• Unknown (25).

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Otogenic (50 of all dizziness)

• BPPV (50 of otogenic ) (begnin
  paroxysmal position vertigo) .
• Meniere ( 18 of otogenic).
• Vestibular neurinitis Labyrinthitis(14).
• Acoustic neuroma ( 10).
• Perilymph fistula (rare).
• Bilateral vestibular loss (rare).

10
Central or Neurological (5 of all dizziness)

• Migraine , stroke ( 50 of neurological).
• MS ( 5).
• Cerebrum degeneration / chiari(5).
• Head injury.
• Meningitis.
• Brain abscess.

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Medical (5 of all dizziness)

• Hypo/ hypertension.
• Cardiac arrhythmia.
• Drugs.

12
Psychological(15 of all dizziness)

• Anxiety.
• Panic.
• Phobia.
• Malingering.

13
Unknown(25 of all dizziness)

• Multi sensory disequilibrium (elderly).
• Post trauma.
• Psychogenic.

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How to diagnose?

• Confirm vertigo (spinning).
• Duration of vertigo
• For seconds lt minute (BPPV)
• For hrs lt 24hr (Meniere ,migraine ..).
• For days ( Labyrithitis , vestibular neurinitis,
  tumours).
• Otological signs (tinnitus, hearing loss, ear
  discharge, surgery,..)
• General health ,medication .

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Examination

• Otological exam ( mandatory).
• Neurological exam (mandatory- cranial nerves)
• Nystagmus.
• Vestibulo-ocular refluxes
• Hallpike (posterior canal)
• Caloric test (horizontal canal)
• Nystagmus
• ENG test
• Vestibulo-spinal refluxes
• Romberg
• Unterburger
• Gait

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Investigations

• Audiogram ,tempanometry, acoustic refluxes.
• Caloric test ,ENG (electronystagmography).
• MRI (acoustic neuroma).
• Blood tests (? medical ).

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Treatment

• Medical treatment
• to the causes.
• vestibular sedatives
• (prochlorperazine, stemitil..)
• vestibular vasodilatations
• (histamine analogues, betahistine.cinnerezin
  .).

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Treatment

• Surgery
• endolymphatic sac shunting
• (damage hearing).
• vestibular neurectomy
• (save hearing).
• Labyrinthectomy ( damage hearing)
• -surgical.
• -chemical / injection of gentamycin.

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Treatment

• Vestibular rehabilitation
• walking stick.
• spectacles.
• Eply manoeuvre (BPPV).
• cocksacy cawthorne exercises.

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Eply Brandt-Daroff
Manoeuvres
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Re-positioning otolith for
BPPV (Eply
Brandt-dorff manoeuvre)
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Thank you