Disorders Of Balance

1
Disorders Of Balance Otological Causes (Vertigo)

• Wong Pik Wa Carrie
• Wong On Kit
• Wong Sze Nga
• Yeung Yat Sing Kevin
• 22nd December 2006

2
Definition

• Hallucination of movement

3
Causes

• Peripheral (lesion in vestibular system)
• Benign paroxysmal positional vertigo (BPPV)
• Ménières disease
• Vestibular neuronitis

• Central (lesion in brainstem vestibular nerve
  nuclei)
• Migraine
• Cerebral vascular accident
• Multiple sclerosis
• Tumour
• Ototoxic drug
• Infection
• Hyperventilation
• Acoustic neuroma

4
Approach

• History
• Onset
• Duration
• Headache
• Vertigo
• Tinnitus
• Hearing loss
• Ear fullness, pressure
• Nausea vomiting

• Physical Examination
• Extraocular movement, nystamus
• CN VII, VIII
• Otological exam
• Dix Hallpike maneuver
• Investigations
• CBC, RBG, UE
• MRI IAM
• ENG

5
BPPV

• Cupulolithiasis theory
• Canalithiasis theory
• Particles in the semicircular canal slow and even
  reverse the movement of the cupula switch and
  create signals that are incongruous with the
  actual head movements
• Mismatch of sensory information results in
  sensation of vertigo
• Average age of onset 51 yo
• Treatment
• Epley maneuver
• Vestibular sedatives

6
Scenario

• Mrs. Lee, 55/F
• C/O
• Dizziness for 3 months
• HPI
• Sudden onset
• Rotatory in nature
• Episodic, last up to 1 min
• a/w head movement
• Nausea vomiting ve
• No symptoms between episodes
• 2 episodes of URTI recently
• ? Subjective hearing loss

7

• PMH
• HT on adalat for 5 years
• Poorly controlled DM on insulin
• NKDA
• Social history
• Retired factory worker
• NSND
• O/E
• TM intact
• No focal neurological deficit

8
1. What is your top ddx?

1. Benign paroxysmal positional vertigo
2. Ménières disease
3. Vestibular neuronitis
4. Hypoglycemia
5. Acoustic neuroma

9
2. Which one is not a feature of BPPV?

1. Lasts for seconds
2. No acoustic symptoms
3. Associates with nausea vomiting
4. Asymptomatic between attacks
5. Provoked by head movements

10
3. What one is associated with BPPV?

1. Sinusitis
2. Cervical spondylosis
3. Use of aminoglycosides
4. Whiplash injury
5. CSOM

11
4. Which one is not a feature of A ve Dix
Hallpike maneuver?

1. Geotropic nystagmus
2. Diplopia
3. Fatiguability
4. Latency
5. Coherence

12
5. What is the most appropriate management?

1. Vestibular neurectomy
2. Urgent MRI IAM
3. Observation
4. Transtympanic aminoglycoside application
5. Epley maneuver