Migraine doctor and specialist in Jaipur

1. VERTIGO – MAKING IT SIMPLE DR.ANITA BHANDARI CONSULTANT NEUROTOLOGIST VERTIGO AND EAR CLINIC, JAIPUR 

5. ETIOLOGY

6. MATTER OF CONCERN More amenable to treatment -more sinister consequences

8.  Seconds – late ototoxicity  Minutes – BPPV, TIA  Hours – Meniere’s disease , Migraine related vertigo  Days – Vestibular neuritis  Months – years - Hysterical

10. EQUILIBRIUM  Spatial orientation  Ocular stabilization  Postural control

13. NEUROTOLOGICAL EVALUATION  A battery of tests  Many systems to be evaluated to assess structural and functional integrity

14. For An ENT Specialist,  We look at the ears first.  In vertigo --> eyes are most important

15. SVV  Otoliths act as gravito-inertial force detectors  SVV is a psychophysical measure of the angle between perceptual vertical and true/gravitational vertical  Also used to measure vestibular rehabilitation  Compensated utricular hypofunction may be detected on dynamic SVV testing. The defect will be unmasked on eccentric rotation because any otolith function asymmetry will be enhanced.

16. SUBJECTIVE VISUAL VERTICAL AND HORIZONTAL  Pt is asked to adjust the orientation of a luminous bar until they perceive it as vertical  SVV – saccule and its central pathways  SVH – utricle and its central pathways  Pinar et al reported changes in SVV and SVH in >25% pts of chronic dizziness concluding that evaluation of the otolith system is mandatory

17. SVV FINDING CONDITION Normal range Upto 2° deviation Ipsiversive tilt – >2o peripheral vestibular disorder pontomedullary lesion thalamic lesion Controversive Pontomesencephalic lesion parietoinsular vest. lesion Migraine Abnormal, little literature

18. CRANIOCORPOGRAPHY  Developed by Claussen [1968]  Assessment of vestibulospinal system  Photographic recording of head and body movement during gait testing  Evaluation includes Romberg, Tandem walking and Unterburger’s test

19. CCG : PROCEDURE  Done in dark room  Pt is blindfolded  Pt wears a helmet with LED lights  Path of the pt is recorded using an SLR camera  Result depends on vestibular system only as visuals cues cut off – pt is blindfolded and by stepping in one place, the soles intermittently lose contact with the floor thus reducing somatosensory input

20. NORMAL PARAMETER OF CCG [CLAUSSEN] PARAMETER NORMAL RANGE- LOWER BORDER NORMAL RANGE- UPPER BORDER Longitudinal displacement 30.03 cm 113.35 cm Lateral sway 5.17 cm 16.15 cm Angular deviation 55.13° (right) 48.37° (left) Body spin 82.21° (right) 82.89° (left)

21. INTERPRETATIONS OF CCG PATHOLOGY CCG FINDINGS Peripheral vestibular lesions Ipsilateral deviation Brainstem lesion, bilateral peripheral vestibulopathy Enlarged lateral sway, no angular deviation CPA tumors, PICA synd. Contralateral deviation, enlarged sway

22. INCREASED SWAY

23. ANGULAR DEVIATION TO LEFT

24. ANGULAR DEVIATION TO LEFT

25. HEAD IMPULSE TESTING  Introduced by Halmagyi and Curthoy  Simple, fast, reliable  Tests scc function – can evaluate all 3 pairs  Measures high freq. vestibular response in 3 dimensions

26. HEAD IMPULSE TEST  VHIT – using Video Frenzel glasses  Test for gaze stabilization during rapid translation of head  Assesses the peripheral utricular system and superior vestibular N  A corrective saccade after VHIT indicates hypofunction of same side

27. HIT : PROCEDURE  Subject seated upright with eyes focused on an fixed object  Unpredictable , low amplitude [10 – 20°] head rotation with high acceleration  Angular VOR generates compensatory eye movements equal in amplitude and opposite in direction to stabilize gaze

28. HEAD IMPULSE

29. HEAD SHAKING TEST  Nystagmus indicates an imbalance in vestibular tone between the 2 sides  Not seen in bilateral vestibular dysfunction

30. HEAD SHAKING TEST

31. HEAD SHAKING – DOWN BEATING NYSTAGMUS

32. DYNAMIC VISUAL ACUITY TEST Functional test of VOR  Comparison of visual acuity with head still to VA with head moving  Reduction by 2 lines indicates dysfunction of VOR as seen in bilateral peripheral vestibulopathy  Improvement with rehab will improve DVA  Early sign of vestibular toxicity 

33. BPPV AND PARTICLE REPOSITIONING MANEUVERS 

34.  The ampulla contains the cupula – a gelatinous mass with the same density as the endolymph.Cupula forms an impermeable barrier across the lumen of the ampulla. Hence the particles in scc may only exit via the end with no ampulla.

37. POSTERIOR CANAL BPPV POSTERIOR CANAL BPPV  Most common– posterior canal is most gravity dependent in upright and supine position  Once debris enter the post. canal ,the cupula at the shorter most dependent arm trap the debris.  Debris can exit only through the longer arm through the crus commune [non-ampullary]

38. DIX-HALLPIKE MANEUVRE

39. POSTERIOR BPPV

40. EPLEY EPLEY’ ’S MANEUVER S MANEUVER

41. EPLEY’S MANEUVRE

42. SEMONT SEMONT’ ’S MANEUVER S MANEUVER  Liberatory maneuver for pBPPV and cupulolithiasis  Used to overcome otoconia jam after Epley’s maneuver

43. SEMONT SEMONT’ ’S MANEUVRE S MANEUVRE

44. SEMONT’S MANEUVRE

45. BRANDT – DAROFF EXERCISES BRANDT – DAROFF EXERCISES  Used as a home program  Indications o Posterior canal cupulolithiasis o Persistant posterior canal canalithiasis  Mechanism o Dislodge debris attached to cupula o Habituation through central compensation

46. BRANDT-DAROFF EXERCISES

47. BRANDT – DAROFF EXERCISES BRANDT – DAROFF EXERCISES  Things to remember o The exercises may dislodge more otoconia from the utricle causing an increase in symptoms. o May cause multiple canal involvement. o Important to hold for 30 seconds in each position.

49. HORIZONTAL SCC BPPV HORIZONTAL SCC BPPV  Pagnini-McClure maneuvre  Geotropic nystagmus – debris are away from ampulla , side showing stronger nystagmus is the side involved  Apogeotropic nystagmus – indicates cupulolithiasis

50. McCLURE PAGNINI MANEUVER McCLURE PAGNINI MANEUVER SUPINE ROLL TEST SUPINE ROLL TEST