Transcript Cold

Vertigo
&
Its Management
By
Dr.H.T.Lathadevi
M.S(ENT)
Shree B.M.Patil Medical College Hospital &
Research Centre Bijapur
What is Vertigo

Giddiness /dizziness

Light headedness.

Sensation of floating in space.

Unstable or uncertain gait.

Loss of balance

Ringing in the ears.
Vertigo

Vertigo is a hallucination of self
or
environmental movement , a feeling of spinning

Vertigo is a symptom and not a disease.
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
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
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
described
possible
causes
have
been
Vertigo- symptoms

Giddiness /dizziness

Light headedness.

Sensation of floating in space.

Unstable or uncertain gait.

Loss of balance

Ringing in the ears.
Vestibular System
Vestibular Function and
Anatomy
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
Semicircular canals are
orthogonal to each other
 Lateral canal inclined to
30 degrees
 Superior/postereor
canals 45 degrees off of
sagittal plane

Utricle is in horizontal
plane
 Saccule is in vertical
plane

Anatomy
There are five openings
into area of utricle
 Saccule in spherical
recess
 Utricle in elliptical recess

45% from AICA
 24% superior cerebellar
artery
 16% basilar
 Two divisions: anterior
vestibular and common
cochlear artery

Superior vestibular
nerve: superior canal,
lateral canal, utricle
 Inferior vestibular nerve:
posterior canal and
saccule

Membranous labyrinth is surrounded by
perilymph
 Endolymph fills the vestibular end organs along
with the cochlea


Perilymph
– Similar to extracellular fluid
– K+=10mEQ, Na+=140mEq/L
– Unclear whether this is ultrafiltrate of CSF or blood
– Drains via venules and middle ear mucosa

Endolymph
– Similar to intracellular fluid
– K+=144mEq/L, Na+=5mEq/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
Sensory structures
Ampulla of the semicircular canals
 Dilated end of canal
 Contains sensory neuroepithelium, cupula,
supporting cells

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





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
Hair cells have 50-100 stereocilia and a single kinocilium.
stereocilia are not true cilia, they are graded in height with tallest nearest
the kinocilium.
Kinocilium is located on one end of cell giving
each cell a polarity
 Has 9+2 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

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

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


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
Otolithic organs
Utricle and saccule sense linear acceleration
 Cilia from hair cells are embedded in gelatinous
layer
 Otoliths or otoconia are on upper surface

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

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

Central connections
Scarpa’s 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


Afferent fibers terminate in the vestibular nuclei
in floor of fourth ventricle
– Superior vestibular nucleus
– Lateral vestibular nucleus
– Medial vestibular nucleus
– Descending vestibular nucleus

Vestibular nuclei project to
– Cerebellum
– Extraocular nuclei
– Spinal cord
– Contralateral vestibular nuclei
Senses and controls
motion
 Information is combined
with that from visual
system and
proprioceptive system
 Maintains balance and
compensates for effects
of head motion


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
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
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



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)
Investigations for vertigo

Caloric Test

Audiometry

Electronystagmography (ENG)

Craniocorpography (CCG)

Brain -Stem Evoked Response
Audiometry (BERA)
Pendular
Or Phasic
Spontaneous Or Induced
Horizontal
Or Vertical
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
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
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
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)
Vertigo - Possible circulatory
causes

Increased vascular resistance

Increased blood viscosity due to  Reduced flexibility of RBCs
 Increased blood viscosity
 Reduced micro-circulation
Vertigo : Peripheral
Occurrence :
 Severity
:
 Axis
:
 Nyst. Type :






Latency
:
Direction
:
Duration
:
Fatigue
:
Hearing loss
/Tinitus
:
PERIPHERAL
Episodic
Proportionate
Horizontal
Slow & Fast
phases
10 to 20 sec.
Single
Brief
Yes
Possible
V/S
.
.
.
.
CENTRAL
May be constant
Disproportionate
Variable
Irregular
.
.
.
.
None
Changing
Long
No
.
No
Central
.
O
ANATOMY OF BALANCE AND
VERTIGO
Meniere’s 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.
Clinical Features
Deafness
 Tinnitus
 Episodic vertigo
 Autonomic –Nausea, vomiting, Diaphoresis
 Aural pressure

57
Managrment





Medical-Vestibular sedatives
Vascular-Increase blood supply-Betahistine
Carbogen
Alter electrolytic balance-Frusemide,Glycerol
Hydrochlorothiadize
Surgical-Endolymphatic sac decompression,
Vestibular neurectomy, Ultrasonic destruction
Reassurance
Vestibular rehabilitation exercises
58
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
DIX-HALL-PIKE’S TEST
EPLEY’S MANEUVER
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
Drug treatment

Labyrinthine suppressant/
Ca++ entry blocker
– Cinnarizine

Vasodilators
– Betahistine

Antihistaminics
– Meclizine, Promethazine
– Sedatives / tranquilizers
– Diazepam
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 RBC’s.
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
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
Vestibular Rehabilitation
Exercises

Co-ordinated head, body & eye movement helps to ameliorate the patient’s
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
Vestibular Rehabilitation Exercises (contd.)
Vestibular Rehabilitation Exercises (contd.)
THANK YOU !
ANATOMY OF BALANCE AND
VERTIGO