Vertigo
Prof. Dr. Jihad K. Albaba
Definitions Of Vertigo.
 Illusion of motion.
 Hallucination of motion.
Patient feels as if he is turning in stationary environment or objects
around him moving.
Dizziness
(Loss Of Balance)
 Is a group of sensations as feeling of :
Light headedness.
Unsteadiness.
Confusion.
Faintness.
All are of vascular origin or psychoneurotic.
Human balance system
 Vestibular system.
 Proprioceptive receptors:
Light touch in skin.
Stretch receptors of muscle spindle.
 Eye.
The three systems are intermingled in the CNS.
Vestibular labyrinth
Causes of Vertigo
 Non-labyrinthine

Non-labyrinthine:
 Cardiovascular causes




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Metabolic causes
Vascular insufficiency
Intracranial tumours
Intracranial haemorrhage
Multiple sclerosis
CAUSES of CENTRAL Labyrinthine
VERTIGO
 Cerebellopontine angle tumors (majority are acoustic
neuromas)
 Vertebral-basilar circulation vascular events
 Vestibular nuclei area TIA or stroke
 Cerebellar infarction or hemorrhage
 Lateral medullary infarct (Wallenberg’s
syndrome)



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Multiple sclerosis
Complex partial seizures (temporal lobe epilepsy)
Migraine with vertiginous symptoms
Post traumatic brainstem injury
(Postconcussive syndrome)
 Infections (meningitis, encephalitis
Causes of Peripheral Vertigo
(Labyrinthine Vertigo)
1.BPPV
2. Meniere’s Disease
3. Vestibular Neuronitis (viral labyrinthitis)
4. Otitis Media
5. Vestibular migraine
6. ‘Senile’ vestibulopathy
Rare Causes
• Acoustic neuroma
• Vertebro-basilar insufficiency
• Otosclerosis
• Perilymph fistula
• Ototoxic drugs
• Temporal bone fracture
• Syphilis
• Others
Causes of Peripheral Vertigo
 Toxic chemicals
 Qunidine
 Alcohol
 Cisplatin
 Aminoglycosides
 Aspirin
 Chloramphenicol
 Phenytoin
 Minocycline
 Furosemide
 Quinine
 Ethacrynic acid
BPPV
• Common
• Easily diagnosed
• Easily treated
• Patients can be Cured of
their condition
• Precipitated by head
position
• Vertigo lasts for seconds
• Multiple brief attacks typical
• Spontaneous remission, but
may recur
Short – lived episodic rotatory
vertigo
 Benign proxysmal positional vertigo.
 Labyrithine fistula.
 Caloric effect.
 Alternobaric vertigo.
 Post- concussional syndrome.
 Vertebrobasilar insufficiency.
 Cervical vertigo.
Comparison between peripheral &
central
Vertigo:
BPPV
CNS
Latent period
A few seconds
Nil
Distress
Present:may be severe with patient
clutching at couch or examiner
Nil
Direction of nystagmus
This is usually rotatory and is
anticlockwise with the right ear
down and clockwise with the left ear
down.(when the nystagmus is
horizontal it is towards the
undermost ear)
Variable
Duration of nystagmus
Less than 30 second
Persists while position maintained
On sitting up again
Similar events with nystagmus in
opposite direction.
Nystagmus stops
fatiguability
Nystagmus and dizziness stop with
repeated testing.
Nystagmus persists with repeated
testing
Characteristics of Peripheral and
Central Vertigo
Peripheral
Central
Intensity
Moderate to Intense
Mild to Moderate
Temporal Pattern
Brief, episodic
Chronic, continuous
Onset
Abrupt
Gradual
Nystagmus
Rotatory / Horizontal
Any kind including bizarre /
vertical.
Nausea / Vomiting
Common
Uncommon
Hearing loss
Possible
Unlikely
Neurological Deficits
Otherwise none
Often present
Nystagmus:
Defined as involuntary, rhythmical, oscillatory
movements of the eye. And its always due to
abnormal maintenance of eye posture.

Physiological Nystagmus.

Pathological Nystagmus.
Pathological Nystagmus.
 Ocular
 Vestibular
 Brainstem
 Cerebellar
 Toxic
•Rotatory
•Horizontal
•Bi-directional
• Rebound
•Convergent
Physiological Nystagmus.
Seen in normal person when focusing on a series
of fast-moving objects at a sufficiently close
distance, as in ‘railway nystagmus’.
Vestibular Nystagmus
 Horizontorotatory.
 Has slow component (Labyrinthine).
 Rapid component.
 Suppressed by optic fixation.
Examination of patient
 History – Trauma, Drugs
 Ears Examination- hearing
,DM ,BP, Renal, Infection.
 Neurology – Gait,
Memory , Voice, Cranial
Nerves, Hearing , Muscle
Tone, Cerebellum.
, Infection , trauma,
Surgery.
 Cardio Vascular SystemBP Standing & laying –
Pulse Regularity &
Bilateral equality.
Meniere’s Disease
• Pathology: ‘endolymphatic hydrops’
• Need 4 symptoms for classical meniere’s:
 Aural fullness
 Vertigo lasting minutes to hours
 Tinnitus
 Hearing loss
• Symptoms remit and recur
• 85% unilateral
• Complete remission in 60%
To Make Diagnosis of Meniere’s
• Typical history
• Examination: may be spontaneous
nystagmus, Hallpike test negative
• Investigations:
1. Audiogram- low frequency SNHL
2. ECog- endolymphatic hydrops
3. Caloric testing- hypoactive labyrinth
4. MRI – to exclude acoustic neuroma
Treatment of Meniere’s Disease
• Medical:

Low salt diet
2. Vestibular
Suppressants
3. Vasodilators
4. Diuretics
1.
1.
Surgical:
Intratympanic
gentamicin
2. Endolymphatic sac
procedure
3. VNS
4. Labyrinthectomy
Meniere’s Variants
• Cochlear MD
• Vestibular MD
• Lermoyez Syndrome
Have aural fullness as common denominator
Vestibular Neuronitis
• ‘Viral labyrinthitis’
• Prodrome- non-specific viral illness
• Vertigo with nausea and vomiting
• Vertigo lasts days to weeks
• No hearing loss
• Diagnosis made on typical history
• Treatment with vestibular suppressants
Otitis Media
• Serous or suppurative OM
• Serous OM restricts RW membrane, or there may be
serous labyrinthitis
• Improvement with drainage
• Suppurative OM – reversible serous labyrinthitis or
irreversible suppurative labyrinthitis
Vertigo with Migraine
• Vestibular migraine, or vertebro-basilar
migraine
• Impairment of circulation to vestibular nuclei.
• Vasoconstriction causes- vertigo, dysarthria,
ataxia, paraesthesia, visual.
• Vasodilation causes headache, which may not
always be present.
• Treatment with migraine prophylactics
‘Senile Vestibulopathy’
• Diagnosis of exclusion
• Old patient with ‘dizziness’
• Combination of cervical spondylosis, V-B insufficiency,
vestibular degeneration, poor vision, deteriorating
mobility
• Exclude BPPV
Vertigo investigations
 Blood.
 X-ray.
 Audiology.
 ENG.
 EEG.
Prof. Dr. Jihad K. Albaba
Treatment of vertigo
 Treatment of Acute Case (e.g. bed rest, fluids,
drugs).
 Treatment of Possible Cause (e.g. Rehabilitation) .
 Rehabilitation & Follow up.
 Surgical Treatment.
Prof. Dr. Jihad K. Albaba
Thank You