Transcript 15- Vertigo.ppt

Vertigo
Dr. Abdulrahman Alsanosi
Associate professor
Otolaryngology consultant
Otologist , Neurotologist &Skull Base Surgeon
Head of Otology / Neurotology Unit
Director of cochlear implant program
King Abdulaziz University Hospital
Importance
• Can be a sign of serious diseases
• Can be seen in other specialties
• Hard to diagnose because it integrates several
organs and systems together and the
underlying cause is not clear.
• Very common, but hard to deal with.
INTRODUCTION
• Dizziness is a common symptom that accounted for more than 5.6
million clinic visits in the United States
• 15% to 30% of patients, most often women and the elderly, will
experience dizziness severe enough to seek medical attention at
some time in their life.
What are the components of balance system
?
• Inner ear (3 semicicular canals and otolith organ ): divided into 2 parts:
hearing (cochlea) and vestibular (semicircular canals , otolith organ)
• Cerebellum ; engine behind coordination , creating muscle movement and
keeping balance
• Vision (Vestibular Ocular Reflex): it is a reference between the eye and
the inner ear. it controls both eye movements and keeps them focused on
the same object. I.e If there is misalignment between one of the retinas on
a particular object it will lead to a sense of an “illusion” causing dizziness
• Proprioception: sensation in the sole of the foot. People need hard surfaces
to get the full effect of their proprioception or it will feel like they are walking
on sand “ shaky grounds”.
• 1 stimulus that leads to more than one response when it comes to
maintaining balance. Being pushed from behind will lead to all the previous
systems to work together to maintain balance.
How does balance system work ?
Physiology
Function of vestibular system:
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“Input” resulting from a stimulus that needs to be corrected through the vestibular
system such as falling down. An “output” results from responses of the vestibular
system to the input such as the eyes, cerebellum .. Etc.
The physical stimulus (input) will be transformed into a biological stimulas in the
brain stem which will in turn be sent afterwards to the corresponding areas in the
vestibular system.
Transform of the forces associate with head acceleration and gravity into a biological
signals that the brain can use to develop subjective awareness of head position in
space (orientation)
produce motor reflexes that will maintain posture and ocular stability to prevent the
feeling of dizziness.
If there is a defect in the input and output processes the patient will present with
vertigo, defects in the gait or ocular distortions.
It is not surprisingly that vestibular lesion cause:
• Imbalance
• posture and gait imbalance
• visual distortion (oscillopsia ).
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Patient with ocular distortions (oscillopsia) – if the head moves
the eyes will move along with it.
VOR system is not working.
What is vertigo?
VERTIGO
• The word "vertigo" comes from the Latin
"vertere", to turn + the suffix "-igo", a
condition = a condition of turning about).
• It is an allusion of being moving or the
world is moving too.
What are the questions to ask in history ?
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Onset (acute/chronic)
Frequency – how often
Duration
Associated auditory symptoms
Aggravating and relieving factors
Ear disease or ear surgery – tinnitus?
Trauma
Migraine
Ototoxic drug intake – (chemotherapy, aminoglycosides,
methotrexate)
• Family history
• Motion sickness
Differential diagnosis
A) peripheral vestibular loss – up to the vestibular
nerve.
B) central vestibular loss – above the level of the
vestibular nerve and towards the brain.
What are the causes of peripheral
vestibular loss ?
peripheral vestibular loss
• Vestibular neuritis
• Benign paroxysmal positional vertigo ( BPPV)
• Meneires disease (Endolymphatic hydrop )
Vestibular Neuritis
• Viral infection of vestibular organ
• Affect all ages but rare in children – mostly adults
• Affected patient presents acutely with spontaneous nystagmus ,vertigo and
nausea &vomiting stays for hours and sometimes days.
• Patient requires only symptomatic treatment
• It takes 3 weeks to recover from vestibular neuritis
• Diagnosis – no other tool other than history.
• Recent study studies show that giving steroids decreases the 3 week
recovery period.
Vestibualr neuritis
BPPV( benign paroxysmal
positional vertigo )
• Its provoked by certain positions.
• Pathophysiology:
• Calcium carbonate particles shear off and enter the canal leading to
brief episodes of vertigo.
BPPV
• The most common cause of vertigo in patient >
40 years
• Repeated attacks of vertigo usually of short
duration less than a minute .
• Provoked by certain positions (rolling in beds,
looking up ,and head rotations)
• Not associated with any hearing impairment
BPPV
Diagnosis
• History
• Dix-Halpike maneuver : putting the patient in a certain
position to stimulate the attack, and to look at the eye (causes
nystagmus) to see which canal is mostly affected by trying to
push the particles inside the canal and inducing the sense of
dizziness.
• Treatment: repositioning of the head to get particles out of the
canal (Epley or particle repositioning maneuver) . No medical
or surgical treatment needed.
• Epley’s maneuver could even be done at home.
Endolymphatic hydrop
(Meneire’s disease)
Pathophysiology :
• Unknown etiology
• ↑ ↓production of fluid within inner compartment
Endolymphatic hydrop
(Meneire’s disease)
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vertigo (minutes to hours )
Low frequency fluctuating SNHL
Tinnitus and fullness in the ear.
In 10 - 20% of cases the disease later
involves the opposite ear
Meniere's disease
• Diagnosis
-History
-PTA
Showing SNHL
Meneire’s disease
• Management
-low-salt diet
-Medical therapy
- Meniett device's
-Chemical perfusion
-Surgery
SUMMARY
Diagnosis
Duration of
attack
hearing
Course of
diseases
Treatment
Vestibular N
Days
normal
Self limited
Symptomatic
BPPV
Seconds
normal
Recurrent
Exercise
Meneire’s
diseaseM
Minutes to hours
Affected
Recurrent
Medical
&surgical
40
34
30
20
10
0
17
12
1
1 5
16
MEN
14
5
10
WOMEN
8
1
< 20 21-30
31-40 41-50
51-60 61-70
0
0
MEN
>70
Migraine associated vertigo (MAV): common in females between the ages of 20 to 35
Classical presentation , preceded by aura or without aura then headache followed by
couple of hours of dizziness.
Sometimes the patient could feel dizzy without the headache.
More frequently the patient might complain of nausea when smelling something in the
car or while driving around.
What are the causes of central ?
Central
• CVA (Cerebro vascular accident)- most
common
• Brain tumor ( acoustic neuroma )
• Multiple sclerosis
CVA
• Elderly patient with chronic disease
like (DM ,HTN) with sudden attack of
vertigo +neurological symptoms
Acoustic tumor
• Benign tumor
• Arise from vestibular division of VIII
Clinical presentation:
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Unilateral tinnitus
Hearing loss
Dizziness
The only way to differentiate between Meniere's
disease and the Acoustic tumor is by MRI.
Acoustic neuroma
Diagnosis :
• History
• PTA ( Unilateral SNHL )
• Radiology
diagnosis
History is the most important
key to diagnosis for a dizzy
patient .
Investiagtions
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PTA
Vestibular testing
CT SCAN
MRI
A dizzy patient may fit into one of the following
scenarios
Scenario # 1
The patient who is having a first ever
attack of acute spontaneous vertigo.
• Acute vestibular neuritis
• cerebellar infarction.
How to differentiate ?
- Clinically ( General appearance of patient /nystagmus/head
impulse test)
- Radiology
Scenario #2
The patient who has repeated attacks of vertigo,
but is seen while well
A- Recurrent spontaneous vertigo
• Menière’s disease
• Migraine induced vertigo
• perilymph fistula
B- Recurrent Positioning Vertigo
• BPPV
Scenario #3
The patient who is off balance
• Bilateral vestibulopathy – could be due to
streptomycin
• posterior fossa tumour
Take away message
Thank you