Evaluation of Vertigo

1. Evaluation of Vertigo Dr. Vishal Sharma

2. Definition of vertigo • A sensation of rotation or imbalance of one's self or of one's surroundings in any plane • rotation of one's self = subjective vertigo • rotation of one's surroundings = objective vertigo

4. Causes for vertigo A. Peripheral: lesions of vestibular end organs & vestibular nerve. Account for 85% of all cases of vertigo. B. Central:lesions of central nervous system. Account for 15% of all cases.

5. Central causes for vertigo Vascularcauses:see next slide Epilepsy:both disease & its treatment RoadTraffic Accident: Head trauma Tumor:of brainstem, 4th ventricle & cerebellum Infection: Meningitis, Encephalitis Glialdiseases:Multiple sclerosis Others: Parkinsonism, Psychogenic

6. Vascular Causes 1. Vertebro-Basilar Insufficiency 2. Wallenberg’s lateral medullary syndrome: PICA  Ipsilateral ataxia + vertigo + nystagmus + diplopia  loss of touch, pain & temperature: I/L face, C/L body  Dysphagia, hoarseness, decreased gag reflex  I/L Horner’s syndrome 3. Hypertension4. Basilar migraine

7. Peripheral causes  B.P.P.V. (commonest)  Temporal bone #  Meniere’s disease  Barotrauma  Vestibular neuronitis  Cholesteatoma  Labyrinthitis  Cochlear otosclerosis  Vestibulotoxic drugs  Autoimmune disease  Vestibular schwannoma  Presbystasis  Perilymph fistula  Paget’s disease

8. Miscellaneous causes Cervical Vertigo  Neurovascular  Neuromuscular  Mechanical vascular Ocular Vertigo  Error of refraction  Extra-ocular muscle palsy Iatrogenic  Surgical  Cholesteatoma  Stapedectomy Drug induced  Ototoxic drugs

9. Psychogenic vertigo Causes:anxiety, panic disorder, phobia Diagnostic features: • Absence of organic causes • Presence of vague & fleeting symptoms • Dramatic presentation & attention seeking behaviour • Relation b/w emotional stress & onset of vertigo

10. Vertigo-like symptoms Faintness light-headedness unsteadiness motion intolerance imbalance floating sensation

11. Causes of Vertigo-like symptoms

12. Hematological:anemia, polycythemia CardiovascularMetabolic  Orthostatic hypotension Diabetes mellitus  Cardiac failure Hypoglycemia  Obstructive cardiomyopathy Hypothyroidism  Cardiac dysrhythmias Chronic renal failure  Carotid sinus syndrome Alcohol intoxication  Hyperventilation

13. History Taking Can diagnose 80% cases

14. Important history questions • Confirmation of vertigo:rotatory sensation • Absence of syncope or light headedness • Onset:sudden or gradual • Episodic (isolated / recurrent) or continuous • Duration of each episode of vertigo • Associated symptoms • Provoking or aggravating factors • Systemic illness for vertigo

15. Associated symptoms • Decreased hearing: symmetric or asymmetric • Ear discharge • Tinnitus • Aural fullness • Nausea & vomiting • Imbalance

17. Provoking or aggravating factors

18. 1. Specific head position 2. Sudden standing up from sitting position 3. Sudden head & neck movement 4. Recent U.R.T.I. 5. Trauma to ear or head 6. Stress 7. Change in ear pressure 8. Headache 9. Drug intake 10. Diplopia

20. Drugs causing vertigo  Alcohol Analgesic (opiate)  Anti-histamine Anti-hypertensive  Anti-angina drug Anti-arrhythmic  Anti-coagulant Aminoglycoside  Isoniazide (INH) Rifampicin  Anti-malarial  Corticosteroid

21. Systemic illness for vertigo • Hypertension /Hypotension • Hypoglycemia • Epilepsy • Brain infection • Brain tumors • Parkinsonism • Multiple sclerosis

25. Routine ENT OPD tests for vertigo evaluation

26. Test for spontaneous & gaze-evoked nystagmus • Head shake test • Positional tests • Positioning tests (Dix-Hallpike & Roll tests) • Fistula test • Caloric tests • Tests for dysequilibrium • Tests for coordination • Cranial nerve examination

27. Nystagmus • Involuntary, rhythmical oscillatory movement of eye • Vestibular disorders cause jerk nystagmus with slow & fast phases • Direction of nystagmus given by its fast phase • Vestibular nystagmus gets enhanced by looking in direction of faster phase & diminished by looking away from it (Alexander’s law)

28. Alexander’s Classification Intensity grading of vestibular nystagmus: 1°  only present while looking towards fast phase 2°  present while looking towards fast phase & also while looking straight 3°  present while looking towards fast phase, looking straight & looking towards slow phase

29. Nystagmus • Vestibular lesion nystagmus gets suppressed by optic fixation & gets enhanced with removal of optic fixation (with Frenzel glasses or in dark) • Irritative vestibular labyrinthine lesion:Ipsilateral nystagmus • Paralytic vestibular labyrinthine lesion:Contralateral nystagmus

31. Nystagmus (slow component)

32. Nystagmus (fast component)

34. Other eyeball movements • Opsoclonus:non-rhythmic, bizarre eye movements. Seen in brain stem & cerebellar pathology. • Ocular Flutter:mild form of opsoclonus lasting for few seconds • Ocular Myoclonus:pendular movement of eyeball with rhythmic movement of soft palate & tongue • Ocular Bobbing:irregular, abrupt downward jerks seen in CNS lesions

35. Test for spontaneous nystagmus Patient’s eyes examined with: pt’s looking straight ahead with fixed head; no visual or vestibular stimulus; no optic fixation Best examined in dark room with infra-red video goggles over open eyes or during electro-nystagmography with eyes closed Spontaneous nystagmus seen in unilateral peripheral vestibular lesion

36. Infra-red video goggles

37. Test for gaze-evoked nystagmus

38. Test for gaze-evoked nystagmus • Finger kept centrally30 cmfrom pt's eyes & moved in horizontal & vertical planes • Pt is asked to follow it with his / her eyes • Keep displacement from midline to maximum of30°(avoids physiological end-point nystagmus) • Bidirectional vertigo seen in CNS lesions

39. Head Shake Test Patient’s head grasped by physician & rapidly shaken from side to side for 20 times. Repeat in vertical plane for 20 times. Presence of horizontal nystagmus indicates peripheral vestibular disorder. Lt lesion  Rt nystagmus. Vertical nystagmus indicates brainstem or cerebellar lesion.

40. Head Shake Test • Starting from neutral position (A), rapid head thrust to Rt in horizontal plane  compensatory eye movement to left  pt's eyes remain stable on examiner (B) • On similar head movement to left (C), I/L hypoactive labyrinth results in delayed catch up saccade (D) to maintain gaze. Arrow shows direction of saccade

41. Positional Nystagmus Placing pt’s head slowly in different positions, detects response to changes in direction of gravitational force 11 specific head position: a. Sitting position: 5 head positions b. Supine position: 6 head positions Each position to be maintained for 30 sec

42. Head positions Sitting position Head upright Right side down Left side down Head extended Head flexed Supine position Head straight Right side down Left side down Head hanging Head hanging with right turn Head hanging with left turn

43. Positioning Nystagmus Helps to detect anomalies in otolith system Provoked by placing headrapidlyin different positions Tests Dix-Hallpike Test Roll Test

44. Fistula test • Transmission of increased air pressure in E.A.C., via middle ear, into inner ear through a labyrinthine fistula causes vertigo + nystagmus towards affected ear • E.A.C. pressure is increased by intermittent tragal pressure or Siegelization

45. Fistula Test

46. Sites of labyrinthine fistula 1. Horizontal semicircular canal  Cholesteatoma destruction  Fenestration operation 2. Oval window  Post-stapedectomy 3. Round window membrane rupture

47. Hennebert’s sign False positive fistula sign in absence of labyrinthine fistula. Seen in: 1. Meniere's disease: fibrosis b/w stapes footplate & utricle 2. Hyper mobile stapes footplate  Congenital syphilis  Idiopathic

48. False negative fistula sign Negative fistula sign in presence of labyrinthine fistula. Seen in: 1. Cholesteatoma matrix / granulation covering labyrinthine fistula 2. Dead Labyrinth 3. Total E.A.C. obstruction (impacted wax)

49. Dix – Hallpike maneuver(Nylen – Barany maneuver)

50. Step 1