DIZZINESS AND VERTIGO

Objectives:
You should be able to :
Describe dizziness and its manifestations
Enumerate and differentiate common causes of dizziness and their likely
system of origin
Discuss the anatomy of the vestibular system
Discuss the clinically relevant physiology of the vestibular system and the
basic mechanisms of balance control
Describe the symptoms, physical findings, diagnostic tests, and general
treatment of common diseases of the vestibular system
What is Dizziness ?
Any discomfort, other than pain, that involves the head
May be accompanied by other symptoms
Nausea and vomiting
Cold sweat
Diarrhea
How can dizziness be described ?
Like one is about to faint
Like one is floating - lightheaded
Like the world is spinning
Like a drunk unsteady when one walks
What is the cause of dizziness ?
FAINTING
Cardiac
Neurologic
LIGHTHEADED
Metabolic
Endocrinologic
Neurologic
Psychiatric
SPINNING
Vestibular
Neurologic
UNSTEADY
Neurologic
Cerebral
Cerebellar
Proprioceptive
Musculoskeletal

What are common diseases affecting the systems that manifest as dizziness ?
Ocular
muscle imbalance
errors of refraction
glaucoma
Proprioceptive
chronic alcoholism
anemia
pellagra
tabes dorsalis
diabetes mellitus
Cerebral Hypoxia (Cardiac or Neurologic)
arteriosclerosis, esp. vertebro-basilar artery sclerosis
hypertensive vascular disease
subclavian steal syndrome
cervical rib
chronic hypertension
anemia
cardiac arrhythmias (ex. heart block, carotid sinus syndrome)
valvular heart disease ( ex. aortic stenosis)
postural hypotension
Cerebral
Infections of the CNS
meningitis
encephalitis
brain abscess
tertiary syphilis
Trauma
Tumors
Multiple Sclerosis
Cervical Myofascial Dizziness
Endocrinologic / Metabolic
menstrual / pregnancy/ menopausal
hypothyroidism
hypoparathyroidism
hypoglycemia / hyperglycemia
Psychoneurosis

Vestibular
Benign paroxysmal positional vertigo
Menieres disease
Vestibular neuritis
Vestibular schwannoma
Recurrent vestibulopathy
Superior semicircular canal dehiscence syndrome

ANATOMY OF THE EAR

vertigo

Vestibular disease is the most common cause of

:
What is this???? Vertigo is a sensation of motion in which either the
patient or his environment is moving, often in a rotatory direction. For
many patients, a severe form of dizziness

Vestibular nystagmus is a key finding in patients with vertigo:

Nystagmus is a rhythmic, involuntary movement of the eyes
Vestibular nystagmus is a rhythmic beating of the eyes characterized by a
slow phase in one direction, followed by a fast (compensatory) phase in
the contralateral direction
In order to understand vertigo, we must understand vestibular anatomy and its
relevant clinical physiology.
SSC Structure and Fluid Dynamics
VESTIBULAR ANATOMY
The vestibular system is phylogenetically one of the oldest sensory organs
in the animal world
A key element of an integrated system that allows all mobile life forms to
move in their environment
Pars Superior: vestibular labyrinth
Semicircular canals
lateral (horizontal) SCC
posterior SCC
superior SCC
Utricle
Pars Inferior
Cochlea
Saccule
Endolymphatic duct and sac

VESTIBULAR ANATOMY

Otolith Organ Anatomy

Vestibular Nerve Supply

Otolith Organ Dynamics

VESTIBULAR NERVE

SUPERIOR, LATERAL, MEDIAL, & INFERIOR VESTIBULAR NUCLEI in MEDULLA

3 PATHWAYS:
VESTIBULO-OCULAR TRACTS (nuclei of III, IV, VI)
VESTIBULO-SPINAL TRACTS (skeletal system)
VESTIBULO-CEREBELLAR TRACTS (cerebellum)
Vestibular Causes of Dizziness
source is the ear or its nerve pathways
Vestibular Blood Supply

1.

2.

These are endarteries

(with no collateral branches)

3.
4.
5.

Inner Ear
Benign Paroxysmal Positional Vertigo
a. Described as a very brief episode of vertigo lasting for a few
seconds brought about by changes in head position
b. Short lag with fatigable response on Dix Hallpike testing.
c. Often benign and self-limited
d. Due to high density bodies in the endolymph
e. Of the posterior semi-circular canal.
f. Canaliths can be repositioned into the utricle (Epley maneuver).
Labyrinthitis
a. localized (as in surgical procedures)
b. diffuse
c. serous
d. suppurative
Round window membrane rupture
Reissners membrane rupture
Vascular episodes
ex. Wallenberg syndrome

6.
7.
8.
9.
10.

Trauma
Allergy
Motion Sickness
Syphilis
Drug-Induced
ex. anti-neoplastics, alcohol, aminoglycosides
11. Menieres Disease
or Endolymphatic Hydrops vs necrosis along the stria vascularis
other possible etiologies:hormonal, vascular, poor drainage of
endolymph, hypersecretion of endolymph
Menieres Disease triad of:
a. tinnitus
b. low frequency hearing loss
c. vertigo
TREATMENT OF MENIERES DISEASE
salt and water limitation
diuretics
labyrinthine sedatives:
anti-histamines
diazepam
cinnarizine
vasodilator drugs: ex. Betahistine
surgical treatment
endolymphatic sac decompression
vestibular nerve section
destruction of the labyrinth
a. surgery
b. ultrasound
c. radiofrequency ablation
streptomycin treatment (medical labyrinthectomy)

1.
2.
3.

Eight Cranial Nerve

Infection
Trauma
Neoplasm
a. acoustic neuroma (hearing loss initially, followed by tinnitus,
then dizziness)
b. cerebellopontine angle (CPA) tumor
c. tumors of the temporal bone

MISCELLANEOUS CAUSES OF DIZZINESS

External Ear
1. impacted cerumen
2. foreign bodies

1.
2.
3.
4.

Middle Ear
retracted tympanic membrane
serous otitis media (osmotic diffusion)
Trauma to the middle ear
Chronic middle ear disease sequelae:
a. cholesteatoma erosion into the lateral semicircular canal ( fistula
formation )
b. labyrinthitis

HOW TO ARRIVE AT THE PROPER DIAGNOSIS?

Do a careful history with emphasis on:
a. exact type of dizziness or vertigo, direction of vertigo, any
trigger factors.
b. any hearing loss or tinnitus or fullness of ears.
c. related to other symptoms like difficulty in speaking while
exercising, walking or other activities.
d. frequency of the dizziness, duration, any maneuvers which
improve the dizziness.
Family history of Hypertension, Diabetes mellitus, otospongiosis,
neurofibromatosis, etc...
History of surgery, trauma, drugs taken, or other recent illness
The DIZZY MATRIX

Do a careful physical examination, including:

Vital signs
Otoscopy and tuning fork tests
Cranial nerve examination
Do not discount the rest of the body! Pay attention to the heart, lungs, and
the peripheral circulation.
Dix Hallpike test, caloric testing of ears

LABORATORY TEST
Blood test
Hgb, CBC, VDRL
EKG
Pertinent Radiologic studies
MRI or CT Scan as needed
Audiologic evaluation:
a. Pure Tone Audiometry (PTA)
b. Speech Discrimination Score (SDS)
c. Speech Reception Threshold (SRT)
d. Auditory Brainstem Response (ABR)
Electronystagmography (ENG)
FACIAL NERVE
ANATOMY
Course of the facial nerve is divided into:
Intracranial segment
Meatal segment
Labyrinthine segment
Tympanic segment
Mastoid segment
Extratemporal segment
FUNCTIONS
Innervates muscle of facial expression
Taste to anterior 2/3 of tongue
Lacrimation
Salivation
Impedance regulation of middle ear
Sensation of pain, touch, taste and temperature

DIAGNOSTIC TESTING
Audiologic test
Tear test
Taste test
Salivation test
Nerve function test
DIFFERENTIAL DIAGNOSIS OF FACIAL NERVE PARALYSIS
Congenital
Mobius syndrome
Childbirth trauma
Infections
Middle ear infections
Trauma
Temporal bone fracture
Vascular
Aneurysms or thrombosis
Neoplasms
Acoustic neuroma
Meningioma
Idiopathic
Bells palsy
BELLS PALSY
Most common
Unilateral weakness or paralysis
Unknown cause
Recovers within 6 months

belle ens 09