Cold

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Vertigo Its Management By Dr.H.T.Lathadevi

M.S(ENT) Shree B.M.Patil Medical College
Hospital Research Centre Bijapur
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What is Vertigo

• Giddiness /dizziness
• Light headedness.
• Sensation of floating in space.
• Unstable or uncertain gait.
• Loss of balance
• Ringing in the ears.

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Vertigo

• Vertigo is a hallucination of self or
  environmental movement , a feeling of spinning
• Vertigo is a symptom and not a disease.

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Body Balance System

• Maintenance of balance is a function of nervous
  system
• Balance is achieved by integrating information
  from 3 sources
• Vestibular labyrinth
• Eyes
• Proprioceptors located in muscles and joint
• Harmonious integration of these inputs in the
  brain is essential for maintenance of balance

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Disorder of Balance System

• Disorder may occur in one or more organs of the
  balance system
• Commonest site is labyrinth
• Labyrinth is susceptible to damage by numerous
  factors -
• Medicines ( e.g.gentamycin,streptomycin )
• Infections
• Degenerative changes of aging
• Head trauma

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Vertigo - Prevalence

• Present in about 5 of all patients consulting
  general practitioners
• Seen in 10-15 of patients seen by ENT
  specialist or neurologist
• The reasons for high prevalence
• -Vertigo is a symptoms which accompanies
  large number of diseases
• -More than 80 possible causes have
  been described

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Vertigo- symptoms

• Giddiness /dizziness
• Light headedness.
• Sensation of floating in space.
• Unstable or uncertain gait.
• Loss of balance
• Ringing in the ears.

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Vestibular System
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Vestibular Function and Anatomy
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• System of balance
• Membranous and bony labyrinth embedded in petrous
  bone
• 5 distinct end organs
• 3 semicircular canals superior, lateral,
  posterior
• 2 otolith organs utricle and saccule

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• Semicircular canals are orthogonal to each other
• Lateral canal inclined to 30 degrees
• Superior/postereor canals 45 degrees off of
  sagittal plane

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• Utricle is in horizontal plane
• Saccule is in vertical plane

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Anatomy
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• There are five openings into area of utricle
• Saccule in spherical recess
• Utricle in elliptical recess

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• 45 from AICA
• 24 superior cerebellar artery
• 16 basilar
• Two divisions anterior vestibular and common
  cochlear artery

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• Superior vestibular nerve superior canal,
  lateral canal, utricle
• Inferior vestibular nerve posterior canal and
  saccule

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• Membranous labyrinth is surrounded by perilymph
• Endolymph fills the vestibular end organs along
  with the cochlea

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• Perilymph
• Similar to extracellular fluid
• K10mEQ, Na140mEq/L
• Unclear whether this is ultrafiltrate of CSF or
  blood
• Drains via venules and middle ear mucosa

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• Endolymph
• Similar to intracellular fluid
• K144mEq/L, Na5mEq/L
• Produced by marginal cells in stria vascularis
  from perilymph at the cochlea and from dark cells
  in the cristae and maculae
• Absorbed in endolymphatic sac which connected by
  endolymphatic, utricular and saccular ducts

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Sensory structures

• Ampulla of the semicircular canals
• Dilated end of canal
• Contains sensory neuroepithelium, cupula,
  supporting cells

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• Cupula is gelatinous mass extending across at
  right angle
• Extends completely across, not responsive to
  gravity
• Crista ampullaris is made up of sensory hair
  cells and supporting cells

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• Sensory cells are either Type I or Type II
• Type I cells are flask shaped and have chalice
  shaped calyx ending
• One chalice may synapse with 2-4 Type I cells
• Type II cells cylinder shaped, multiple
  efferent and afferent boutons

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Hair cells have 50-100 stereocilia and a single
kinocilium.
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stereocilia are not true cilia, they are graded
in height with tallest nearest the kinocilium.
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• Kinocilium is located on one end of cell giving
  each cell a polarity
• Has 92 arrangement of microtubule doublets
• Lacks inner dynein arms, and central portion of
  microtubules not present near ends may mean
  they are immobile or weakly mobile

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• Each afferent neuron has a baseline firing rate
• Deflection of stereocilia toward kinocilium
  results in an increase in the firing rate of the
  afferent neuron
• Deflection away causes a decrease in the firing
  rate

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• kinocilia are located closest to utricle in
  lateral canals and are on canalicular side in
  other canals
• Ampullopetal flow (toward the ampulla) excitatory
  in lateral canals, inhibitory in
  superior/posterior canals
• Ampullofugal flow (away from the ampulla) has
  opposite effect

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• Semicircular canals are paired
• Horizontal canals
• Right superior/left posterior
• Left superior/right posterior
• Allow redundant reception of movement
• Explains compensation after unilateral vestibular
  loss

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Otolithic organs

• Utricle and saccule sense linear acceleration
• Cilia from hair cells are embedded in gelatinous
  layer
• Otoliths or otoconia are on upper surface

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• Calcium carbonate or calcite
• 0.5-30um
• Specific gravity of otolithic membrane is
  2.71-2.94
• Central region of otolithic membrane is called
  the striola

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• Saccule has hair cells oriented away from the
  striola
• Utricle has hair cells oriented towards the
  striola
• Striola is curved so otolithic organs are
  sensitive to linear motion in multiple
  trajectories

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Central connections

• Scarpas ganglion is in the internal auditory
  canal
• Contains bipolar ganglion cells of first order
  neurons
• Superior and inferior divisions form common
  bundle which enters brainstem
• No primary vestibular afferents cross the midline

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• Afferent fibers terminate in the vestibular
  nuclei in floor of fourth ventricle
• Superior vestibular nucleus
• Lateral vestibular nucleus
• Medial vestibular nucleus
• Descending vestibular nucleus

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• Vestibular nuclei project to
• Cerebellum
• Extraocular nuclei
• Spinal cord
• Contralateral vestibular nuclei

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• Senses and controls motion
• Information is combined with that from visual
  system and proprioceptive system
• Maintains balance and compensates for effects of
  head motion

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• Vestibulo-ocular reflex
• Membranous labyrinth moves with head motion to
  right
• Endolymph moves utriculopetally
• Cupula on right canal deflected towards utricle
  causing increase in firing rate, left deflects
  away causing a decrease in firing rate.
• Reflex causes movement of eyes to the left with
  saccades to right
• Stabilizes visual image

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• If acceleration stops, and spin to right is at
  constant velocity, sensation of motion stops
  after 14-20 seconds as does nystagmus
• Cupula only takes 8-10 seconds to return to
  equilibrium position
• Vestibular integrator is the term for the
  prolongation and is mediated by the vestibular
  nuclei and cerebellum

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Vestibulospinal Reflex

• Senses head movement and head relative to gravity
• Projects to antigravity muscles via 3 major
  pathways
• Lateral vestibulospinal tract
• Medial vestibulospinal tract
• Reticulospinal tract

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How do calorics work?

• Patient is lying down with horizontal canals
  oriented vertically (ampulla up)
• Cold water irrigation causes endolymph in lateral
  portion to become dense and fall causing
  deflection of cupula away from utricle with a
  decrease in the firing rate
• This causes nystagmus with fast phase (beat) away
  from the stimulus

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• With warm water irrigation column of endolymph
  becomes less dense, rises and causes deflection
  of cupula toward the utricle
• Results in increase firing rate and nystagmus
  which beats towards the stimulation
• COWS (cold opposite, warm same)

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Investigations for vertigo

• Caloric Test
• Audiometry
• Electronystagmography (ENG)
• Craniocorpography (CCG)
• Brain -Stem Evoked Response Audiometry (BERA)

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NYSTAGMUS
Pendular Or Phasic Spontaneous Or Induced Horizont
al Or Vertical
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Electronystagmography (ENG)

• Basic test for balance system
• Assesses the integrity of
• - vestibular labyrinth its connections with
  the eyes and certain parts of the brain which
  are concerned with the maintenance of balance
• Gives an idea of functional integrity of
  vestibulo-ocular reflex system
• It comprises tests like test for spontaneous
  nystagmus, the gaze nystagmus, pendulum tracking
  test caloric test

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Caloric Test

• Caloric test involves instillation of hot or cold
  water into ear canal
• When labyrinth is stimulated, either by heat or
  cold, caloric nystagmus generally results
• Nystagmus produced by left right eyes are
  assessed

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Brain Stem Evoked Response Audiometry (BERA)

• A method of plotting electrical activities in
  response auditory or vestibular stimuli
• Electrical activities are measured by keeping the
  electrode on the scalp
• In BERA wave-form obtained from one particular
  site on the scalp (vertex), over specified
  duration of time of 10 milliseconds

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Investigations - for structural integrity

• Tests to asses structural integrity of the system
• X rays
• CT scan
• MRI
• Newer imaging ethnologies - for visualization of
  functional or metabolic activity occurring in
  brain
• Positron emission tomography (PET)
• Single photon emission computed tomography (SPECT)

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Vertigo - Possible circulatory causes

• Increased vascular resistance
• Increased blood viscosity due to -
• Reduced flexibility of RBCs
• Increased blood viscosity
• Reduced micro-circulation

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Vertigo Peripheral V/S Central

• PERIPHERAL
  CENTRAL
• Occurrence Episodic . May
  be constant
• Severity Proportionate .
  Disproportionate .
• Axis Horizontal .
  Variable O
• Nyst. Type Slow Fast .
  Irregular phases
  
• Latency 10 to 20 sec. . None
• Direction Single .
  Changing
• Duration Brief .
  Long
• Fatigue Yes .
  No
• Hearing loss
• /Tinitus Possible .
  No

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ANATOMY OF BALANCE AND VERTIGO
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Menieres syndrome

• Sudden onset recurring episodes of vertigo
• Tinnitus
• Progressive deafness.
• Ischaemia of the inner ear.
• The cause is unknown - may be associated with
  dilation of the endolymphatic system due to
  increase in the amount of endolymph.

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Meniere's Disease
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Clinical Features

• Deafness
• Tinnitus
• Episodic vertigo
• Autonomic Nausea, vomiting, Diaphoresis
• Aural pressure

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Managrment

• Medical-Vestibular sedatives
• Vascular-Increase blood
  supply-Betahistine
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  Carbogen
• Alter electrolytic
  balance-Frusemide,Glycerol
• 
  Hydrochlorothiadize
• Surgical-Endolymphatic sac decompression,
• Vestibular neurectomy, Ultrasonic destruction
• Reassurance
• Vestibular rehabilitation exercises

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Benign Paroxysmal Positional Vertigo

• BPPV results from freely moving crystals of
  calcium carbonate (Otoconia) usually within the
  semicircular canals
• BPPV develop with change in position
• This type of vertigo can be sequelae of head
  trauma or vestibular neuritis
• Most common in age group of 60-70 years

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BPPV
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DIX-HALL-PIKES TEST
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EPLEYS MANEUVER
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General management of vertigo

• Management of patients suffering from vertigo or
  vertiginous syndrome should consist of.
• Elimination of the underlying cause
• Symptomatic relief.
• Methods
• Drug treatment
• Vestibular rehabilitation exercises
• Surgical

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Drug treatment

• Labyrinthine suppressant/ Ca entry blocker
• Cinnarizine
• Vasodilators
• Betahistine
• Antihistaminics
• Meclizine, Promethazine
• Sedatives / tranquilizers
• Diazepam

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Cinnarizine

• Selective Antivasoconstrictant, Ca entry
  blocker
• Antivertiginous activity due to
• Suppressant action on vestibular labyrinth.
• Anti-vasoconstrictant activity.
• Lowering of blood viscosity by improving the
  flexibility of the RBCs.

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Cinnarizine

• Presentation Tablet of 25 mg / 75 mg
• Dosage
• 1-2 tablets of 25 mg two to three times a day or
  as directed by the physician.
• Children (5 - 12 yr.) 1/2 tablet three times a
  day

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Betahistine

• Histamine analogue.
• Vasodilator-increases blood flow
• Indicated for vertigo.
• Side effects headache, rash, g.i. disturbances.
• Steal effect
• Contraindicated in asthma, peptic ulcer
• Dose 8 to16 mg. tid

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Vestibular Rehabilitation Exercises

• Co-ordinated head, body eye movement helps to
  ameliorate the patients symptoms
• Exercises should be performed 5 - 10 minutes
  twice or thrice daily.
• Exercises of eye movement
• Exercises in sitting position like
• Shrugging rotating shoulders
• Bending forward picking up the objects from the
  floor
• Exercises in standing position like
• Changing from sitting to standing initially with
  eyes open then with eyes shut repeatedly for 15
  times

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Vestibular Rehabilitation Exercises (contd.)
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Vestibular Rehabilitation Exercises (contd.)
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ANATOMY OF BALANCE AND VERTIGO