Data Flow
CORTEX
Via thalamus
Spinal cord
Vestibular nuclei Nuclei 3,4,6
Cerebellum Eyes
Visual Proprioception Vestibular sys
copulas maculae
ENT Embryology
The final vestibulo cochlear
apparatus
Membranous labyrinth
Macula and Cupula
TRUE VERTIGO
caused by a mismatch in the data to the brain stem
1.Illusion of self movement
2.OSCILLOPSIA (THE VISUAL ILLUSION THAT THE
ENVIRONMENT IS MOVING) must be induced
or exacerbated by head movement
3.PULSION OR A FEELING OF TILT (BEING
PULLED IN ONE DIRECTION)
Classification of vertigo
• Central (CNS)
• Peripheral (vestibular end organs)
history
• Ask the patient to describe the dizziness. Pulsion, oscillopsia, presyncope, anxiety.
• Severity
• Temporal pattern (continuous vs. episodic / short vs. prolonged)
• Head trauma in the past (post traumatic hydrops)
• If associated with turning the head, lying supine, or sitting upright.
• Flu like illness
• Associated with headache or visual symptoms.
• Brainstem symptoms (diplopoia, dysarthria, facial parenthesis, extremity numbness or
weakness.)
• Vestibular & cochlear symptoms (hearing loss either fluctuating or progressive,
tinnitus, ear pressure, nausea and vomiting)
• Degree of impairment during the attack.
• Presence or absence of positional vertigo
• Drug history (aminoglycosides, cisplatin, miocycline,) cause oscillopsia.
• Hx. of DM (causes visual, proprioceptive, vascular problems), HTN, cardiovascular
and cerebrovascular diseases, migraine, MS)
• Hx. Of prior ear surgery (labyrinthine fistula, perilymphatic fistula.)
Physical exam
may be normal in episodic cases
• Routine exams,
• Cardiovascular, BP (including orthostatic) in both arms, bruits in the neck,
valsalva, pulse,
• Neurologic, Cranial nerves, etc
• ENT, Tympanic membrane for retraction, perforation, cholesteatoma,
Assess hearing on both sides.
• SPECIFIC VESTIBULAR SYSTEM EXAM
• Gait (if the patient staggers or leans toward one side)
• Oculomotor exam, Search for nystagmus, INO
• Romberg test
• Fukuda test: stepping in place for 30 seconds and see the patient rotation.
• Dix- hallpike maneuver
• Head-shake test with +20 lens (1Hz for 10 sec, reveals latent nystagmus).
• Head thrust test / Position of eyes at rest and saccades and visual tracking.
• Oscillopsia test (read the smallest visible line on the eye chart before and
during head shake test)
• Fistula test with +20 lenses.
• Caloric testing (supine, 30’ elevation, +20 lens,
• Cerebellar tests
Laboratory examination of
vestibular system
• Electronystagmography with caloric testing
• Rotational chair testing
• Vestibular autorotation testing
• Computerized platform posturography
• Electrocochleography
• Auditory brain stem response
CNS causes of vertigo
• Migraine
• Vertebrobasilar insufficiency
• Posterior fossa CVA
• Cerebellar tumors
• Temporal lobe tumors
• Brain stem lesions
• CPA tumors
• MS
• Post traumatic
• Lyme neuroborreliosis
• Familial periodic ataxia syndrome.
• Psychogenic vertigo
Peripheral causes of vertigo
• BPPV
• Vestibular neuritis
• Labyrinthitis (viral, suppurative, serous)
• Meniere’s disease
• Meniere’s syndrome or Endolymph hydropse
(syphilis, RA, SLE, Thyroid disease,
• Ototoxocity
• Fistula
• Autoimmune
Central vs. peripheral nystagmus
• Central • Peripheral
• Spontaneous nystagmus that • Suppressed by fixation
can not be suppressed by • Doesn’t change direction with
fixation. gaze.
• Changes direction with gaze. • Horizontal, rotatory, or absent.
• Purely vertical, horizontal, or Never vertical.
torsional • Paroxysmal but fatigable in
• Saccade dysmetria Dix-hallpike test, has latency,
• Paroxysmal but Not fatigable lasts less than a minute,
in Dix-hallpike test, no latency, doesn't change direction with
Lasting longer than 60 sec. different head positions,
and often vertical, may change
direction with different head
positions.
Migraine
• In 18% of women and 6% of men have migraine.
• Episodic vertigo occurs in 30% of all migraine
patients.
• Acute onset, from mild to severe, short to long.
• May precede (part of aura), follow, or be
simultaneous
• Basilar migraine (accompanied by visual deficits,
diplopia, dysarthria, hearing loss, ataxia,
decreased consciousness)
• History is present
• Physical exam is normal.
VBI, VBATD (ATHEROTHROMBOTIC)
• Age, HTN, DM, COPD, HLP.
• ¼ of all TIAs and CVAs.
• Shorter than carotid TIAs. 8 min vs.14 min.
• vertigo alone in 1/3.
• Vertigo is the hallmark symptom.
• Non violent, as swimming or swaying.
• Different but overlapping clinical syndromes.
• Symptoms are determined by the particular branch, collaterals, degree of
occlusion.
• Weakness, numbness, incoordination, dysarthria, diplopia, field defects,
tinnitus, hearing loss, etc…
• No residual signs or symptoms in VBI
• Related syndromes: wallenberg, cerebellar infarction, basilar artery
syndrome,
• MRI, MRA, Doppler, transcranial Doppler.
• Treatment: ASA (minimal), anticoagulant, thrombolysis.
Cerebellar tumors
• Primary in children, secondary in adults.
• Features dependent on tumor location,
size, growth rate.
• Positional vertigo
• Headaches
• Gait disturbance
Temporal lobe tumors
• Recurrent brief attacks of vertigo lasting
minutes followed by transient
disorientation, amnesia, dysphasia.
Brain stem lesions
• Neoplastic
• Traumatic
• Vascular
• BRIEF OR PROLONGED,
• MILD TO SEVERE
CPA tumors
• Mostly vestibular schwanoma, followed by
meningiomas, lipomas, cholesteatomas, and
metastatic.
• Also cause unilateral hearing loss and
nystagmus.
• Nystagmus may be inhibited by visual fixation.
• Mild, causes disequilibrium rather than vertigo
unless a sudden change in tumor size with
hemorrhage or disruption of regional blood flow
to the labyrinth occurs.
MS
• Vertigo is the presenting symptom in 5%.
• May last several days to weeks, may be
positional, often associated with facial
numbness, diplopia.
Post traumatic
• Both peripheral and central
• Usually follows a mild head injury.
• BPPV, perilymphatic fistula, labyrinthine
concussion, cerebral concussion.
Familial periodic ataxia syndromes
• Rare
• Family history of recurrent spells of vertigo
• Nausea, vomiting, diplopia, dysarthria,
progressive truncal ataxia.
• Precipitated by physical and emotional
stress.
Psychogenic vertigo
• Vertigo is a manifestation of panic or
anxiety disorder.
• Have the patient hyperventilate.
BENIGN PAROXYSMAL POSITIONAL VERTIGO
• The most common,
• complaints of acute vertigo lasting less than 1 minute that occurs
when lying supine, sitting, rolling over in bed, or tilting the head
backward.
• A latency period of 1-4 seconds usually occurs before the onset of
vertigo and torsional nystagmus. This latency period also applies to
a reversal of nystagmus when the patient returns to the upright
position.
• BPPV often is related to head trauma; however, it frequently is
found in older patients without a history of head trauma.
• Particles (probably dislodged otoconia) that become trapped in the
posterior semicircular canal cause BPPV.
• the posterior semicircular canal is the most common site.
• may resolve spontaneously. Medications usually are not helpful.
• The most effective treatment is canalith repositioning.
Vestibular neuritis
• Intense.
• begins acutely after a flu-like illness.
• Middle age.
• Hearing not affected.
• Severe vertigo, nausea, vomiting.
• lasts 24-48 hours and gradually subsides.
• Unidirectional, horizontal nystagmus which may be apparent only
when gazing toward the healthy ear or during hallpike. May be
suppressed by fixation.
• Fall towards the affected side during Romberg.
• After the vertigo resolves, patients may complain of unsteadiness
for weeks as the vestibular system gradually accommodates.
• Drugs such as meclizine, promethazine, or prochlorperazine are
useful in suppressing vertigo and nausea and vomiting.
labyrinthitis
• Viral
• Bacterial
• Serous
Viral labyrinthitis
• Bacteria by routes, viruses also by blood.
• 15% of all vertigo cases
• Prenatal hearing loss: Rubella and CMV
• Post natal hearing loss: measles, mumps.
• Also influenza, Para influenza, RSV, Adeno, coxackie, HSV1
• 30-60 years, rare in children.
• Viral: sudden reversible unilateral loss of vestibular function and hearing.
• Hearing loss is often mild with high freq.
• Severe vertigo, nausea and vomiting for days or weeks with some residual positional
vertigo for months.
• Spontaneous nystagmus to the unaffected side.
• diminished caloric responses in the affected side.
• Flu prodrome in 50%.
• Rarely recurrent. if so, confused with meniere
• Confused with vestibular neuritis if the hearing loss is minimal.
• Ramsay-hunt syndrome, a distinct entity with any combination of vertigo, hearing loss
and bell’s palsy. May leave cochlear and vestibular sequele.
• Treatment: hydration, rest, anti viral (in herpes), corticosteroids, symptomatic.
Serous labyrinthitis
• Rather benign
• One of the most common complications of otits media
• Pediatric disease.
• Acute or chronic middle ear disease.
• Vestibular symptoms are less common
• SNHL or Mixed if middle ear effusion is present
• Inflammatory mediators, bacterial toxins cross the round
window
• Treatment: clear the middle ear by AB, drainage, etc
• Complications: transient hearing loss.
Bacterial labyrinthitis
• Less common
• More grave
• Secondary to meningitis (by way of int. aud. Canal or cochlear aqueduct or congenital
and acquired defects in bony labyrinth)
• Meningogenic in very young children, Otogenic( acute otitis media and
cholesteatoma) at any age.
• Streptococcus pneumoniae, Neisseria meningitidis.
• 20% of children with meningitis.
• 35% of all cases of acquired hearing loss.
• Usually bilateral
• Secondary to otitis media( by way of a dehiscent horizontal canal due to
cholesteatoma)
• Usually unilateral
• Symptoms are the same as viral
• Treatment: AB, myringotomy, middle ear and mastoid surgery for mastoiditis and
cholesteatoma, corticosteroids (controversial), symptomatic
• Complications: labyrinthitis ossificans, progressive fibrosis and hearing loss, menier’s
Ménière disease
• Ménière disease (or syndrome)
• typically manifests as a combination of 4 symptoms, namely, hearing that fluctuates in one ear
(although Ménière disease can be bilateral), tinnitus that fluctuates in one ear, aural fullness, and
attacks of vertigo that last for hours.
• Ménière disease often presents with just 1 or 2 symptoms of the tetrad months to years before
manifesting the entire tetrad.
• Low-frequency hearing loss is a typical manifestation in Ménière disease.
• A relative overproduction or under absorption of endolymph is thought to cause Ménière disease.
The underlying etiology is unknown.
• Attack is brought about by the rupture of membranes and resultant receptor block.
• Evaluate for tertiary syphilis,. A fluorescein treponema antibody (FTA) test can be used.
• initially treated with sodium restriction and possibly a diuretic.
• A combination of a diuretic and a vestibular suppressant controls attacks of vertigo in 60-80% of
patients.
• Patients whose symptoms fail to respond to conservative treatment and who continue to suffer
from attacks of vertigo may benefit from a variety of treatments, including the following:
• Transtympanic gentamicin.
• An endolymphatic sac decompression can be performed.
• Performing a posterior or middle fossa craniotomy, through which the vestibular nerve is
sectioned.
• Labyrinthectomy can be performed in patients with unilateral symptoms who have poor hearing
that cannot be improved by a hearing aid.
Drug induced ototoxicity
• Cause OSCILLOPSIA
• Aminglycosides
• Vancomycin
• Chloroquine
• chloramphenicol
• Aspirin (dose dependent, reversible)
• Furesmide (dose dependent, reversible)
• Ethacrynic acid (dose dependent, reversible)
• Quinidine
• Quinine
• Mincycline
• Cisplatin, Mustin
• Hg, Au, Pb, As
Para clinic
Peripheral: Central
• Complete Audiogram • MRI
• EEG in children • MRA
• ENG • Doppler
• Transcranial Doppler
