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2. Objectives
• Vertigo
Defintion, Types, Causes
• Central & Peripheral Vertigo
• Clinical Tests
• Laboratory Tests
• BPPV
• Vestibular Neuronitis
• Dizziness and Vertigo
• Quiz
What will
I Learn
Today ?

3. FAQ’s in RGUHS Examination
• Fistula Test
• Caloric Test
• BPPV
• Vestibular Neuronitis
• Aural causes of Vertigo
• Evaluation Of Vertigo

4. Vertigo- Definition
• Not a disease, But a
symptom.
A feeling in which the
external world seems to
revolve around the
individual or in which the
individual itself seems to
revolve in space.

5. Types
Rotation
Rotatory
Non-rotatory
Patient’s
perception
Subjective
Objective
Stimulus
involved
Spontaneous
Induced

6. Physiological Vertigo
• Balance between 3 stabilising sensory systems
is lost.
• Non-adaptation of vestibular system to
unfamiliar head movements.
• Unusual head & neck positions

7. Pathological Vertigo
Pathological
Vestibular
Peripheral Intermediate Central
Non-
vestibular
Occular Other

8. Peripheral & Central Vertigo
Peripheral: Lesions of vestibular
end organs
( 85% of all cases of vertigo)
Intermediate: Lesions in
vestibular nerve
Central: Lesions of central
nervous system(vestibular nuclei)
( 15% of all cases)

9. Peripheral & Central Vertigo

10. Central Vertigo
Vascular causes: Hypertension, Basilar artery insufficiency
Epilepsy: both disease & its treatment
Road Traffic Accident: Head trauma
Tumor: of brainstem, 4th ventricle & cerebellum
Infection: Meningitis, Encephalitis
Glial diseases: Multiple sclerosis
Others: Parkinsonism, Psychogenic

11. Peripheral Causes for Vertigo
• BPPV
• Vestibular Neuronitis
• Meniere’s disease
• Labrynthitis
• Vestibulotoxic Drugs
• Perilymph Fistula
• Head injuries & Surgical trauma
• Syphillis
• Acoustic Neuroma

12. Evaluation of Vertigo
Tests for
assessment of
Vestibular functions
Clinical tests Laboratory tests

13. Clinical Tests of Vestibular Function
1. Spontaneous Nystagmus
2. Fistula test
3. Romberg Test
4. Gait
5. Past-Pointing & Falling
6. Dix Hallpike Maneuver
7. Test of Cerebellar Dysfunction

14. Nystagmus
• Involuntary rhythmical oscillatory movement of the eyes.
• Triggered by inner ear stimulation.
• Slow pursuit movement initially, fast rapid resetting phase .
• Nystagmus is always named after direction of the fast phase
Nystagmus
Based on
Direction
Rotatory/
Tortional
Horizontal
Vertical

15. Nystagmus
Nystagmus
Peripheral
Lesion of
Labyrinth/8Th nerve
Supressed by Optic
fixation
Enhanced in
darkness
Central
Lesion in Vestibular
nuclei, Brainstem,
Cerebellum

16. Nystagmus

17. Nystagmus- Types
Nystagmus
Spontaneous
Looking straight
ahead, sides &
focusing
Not induced by
any stimulus
Presence always
indicates an
ORGANIC LESION
Induced
Caloric
Positional(Head)
Rotational
Optokinetic

18. Rt gaze Lt gaze
Degrees of Nystagmus
(Alexander’s Law)
Grade I
Grade III
Grade II
Primary position

19. Fistula Test
• Principle: To induce nystagmus by producing pressure
changes in the EAC which are transmitted to the labyrinth.
Stimulation of Labyrinth causes nystagmus & vertigo.
• E.A.C. pressure is increased by intermittent tragal pressure or
Siegelization
• Normally : Negative
Fistula present Fistula sign + Cholesteatoma True Positive
Fistula absent Fistula sign + Congenital
syphillis
False positive
Fistula present Fistula sign - Dead ear False negative

20. Fistula Test

21. Laboratory Tests
1. Caloric Test
2. Electronystagmography
3. Optokinetics
4. Rotational Test
5. Galvanic Test
6. Posturography

22. Caloric test
• Principle:
To induce nystagmus by thermal stimulation of the vestibular
system
• Advantages:
o Each labryinth can be tested separately
o Also checks for labrynthine origin of vertigo

23. Caloric Test- Types
1. Modified Kobrak Test: 60°, 60 s, Ice water
2. Fitzgerald-Hallpike Test/Bithermal Caloric Test:
• Supine position
• Water at 30° & 44°
• Head tilt: 30° forward
• 5 mins gap b/w 2 ears
• Direction of Nystagmus:COWS
Cold- Same
Warm- Opposite
3. Cold air caloric test: Done in TM perforation

24. Caloric Test

25. Electronystagmography
• Detects both Spontaneous and Induced nystagmus.
• Depends on presence of Corneo-retinal potentials

26. Other tests
Optokinetic Test
Useful to diagnose a
Central lesion
Rotation Test
Barany’s Revolving chair,
30° forward head tilt

27. Other tests
Galvanic test
• Only test which helps in
differentiating end
organ lesion from that
of nerve lesion.
Posturography

28. Treatment of Vertigo
1. Reassurance/Psychological Support
2. Pharmacotherapy
3. Adaptation exercises
4. Intratympanic antibiotic injections
5. Surgery
• Conservative
• Destructive

29. Benign Paroxysmal Positional Vertigo
• Most common cause.
• Described by Barany
• Definition: Abnormal sensation of motion that is
elicited by certain provocative positions.
• These provocative positions usually trigger specific
eye movements i.e. Nystagmus
Rotational Geotropic
Latency: 1-
5 s
Duration:
20-30 s
Fatiguable
Associated
with
Vertigo
Reversible

30. BPPV
Canalithiasis:
(Canal stones)
• Otoconial debris are
floating freely in the
canal portion of the SCC
• Free floating
• Most common
• Posterior SCC m/c
involved.
Cupulolithiasis:
(cupula stones)
• Otoconial debris are
adhered to the cupula
of the crista ampullaris.
• Not free floating
• Not common

31. Benign Paroxysmal Positional Vertigo
• Sex: F>M
• Age: Old age (6th decade)
• Predisposing factors: MAC
• Causes: TIM
• Associations: Cervical diseases, Ear diseases,
Vertibrobasilar insufficiency , CNS Disease
• Differential Diagnosis:

32. Signs & Symptoms
Symptoms
• Sudden Onset
• Have few asymptomatic
periods in between
• Dizziness triggered by head
movements
• Classic BPPV: erect to
supine, 45°
• During attacks, Rolling spin
• Symptoms dissipate within
20-30 s after a violent start.
Signs
• Neurological examination:
Normal
• Dix-Hallpike maneuver:
• Caloric Test: Normal or
Hypofunctional

33. Investigations
• Electronystagmography(ENG)
• Caloric Test
• Audiometry
• Posturography

34. Treatment
Medical
1. WAIT & WATCH
2. Vestibulo-suppressant
medication
3. Vestibular Rehabilitation:
Cawthorne exercises
4. Canalith repositioning
(CRP):
• Epley Maneuver
• Semont maneuver
Surgical
(failure of CRP)
1. Labyrinthectomy
2. Posterior canal Occlusion
3. Singular neurectomy
4. Vestibular nerve section
5. Transtympanic
Aminoglycoside application

35. Vestibular Neuronitis
• Sudden onset of vertigo, nausea, vomiting w/o tinnitus and
deafness.
• Etiology: Labrynthine Stimulation by:
Virus, Idiopathic
Age(>adolescents)
Sex(M=F)
• Pathophysiology: Inflammatory process in vestibular nerve,
self-limiting

36. Vestibular Neuronitis
• Clinical Features:1. Vertigo
2. Nausea and Vomiting
3. Normal Hearing
4. Nystagmus
• Investigations: PTA, Caloric Test, ENG
Treatment:
1. Bed Rest and Reassurance
2. Drugs

37. Vertigo-like symptoms
 Faintness
 Light-headedness
 Unsteadiness
 Motion intolerance
 Imbalance
 Floating sensation

38. Vertigo & Dizziness
Vertigo
Specific term
Includes only
Vertigo
More common in
elderly
Dizziness
Broad term
Includes vertigo,
syncope,
unsteadiness
All age groups

40. Question 1
• Nystagmus pattern in peripheral Vertigo

41. Question 2
• Other name of Bithermal Caloric Test

42. Question 3
• Treatment of Choice in BPPV?

43. Question 4
• Vestibular disease in which patient presents
with vertigo & normal hearing?

44. Question 5
• Vestibulotoxic Drugs