1. Vertigo
Dr. MTD lakshan
MBBS, MS(ORL), DOHNS(Eng), FEB ORL HNS, FRCS ORL-HNS(Edin)
Consultant ENT and Head and Neck Surgeon
DGH Hambantota
Ruhunu Clinical Society Annual Sessions 2012
1

2. Objectives
1.Define Vertigo
2.Essential Clinical Evaluation of patients
3.Common Vertiginous Syndromes
4.Common Management strategies

3. Definition
• Illusion of Movement (Rotatory & Postural)
• Differentiate from
• Light headedness,
• Imbalance,
• Visual phenomenon,
• faintish-ness

4. Basic Sciences
• Systems involved :
• Vestibular
• Ocular
• Proprioception
• Central Nervous System

5. Basic Sciences

6. Anatomy

7. Schematic drawing of the
vestibular epithelium showing
the two cell types and the nerve
connections made on each.

8. The position of the crista ampularis and cupula within a cross section
of the ampulla of one semicircular canal. Also shown is the movement
of the cupula and its embedded cilia during rotation first in one
direction and then in the opposite direction.

9. Shearing force in vestibular organs. Upper diagram shows arrangement of cilia on a hair
cell as seen from above; position of kinocilium indicated by larger dot. Dashed line
indicates direction of effective shearing forces; forces at right angles are ineffective.
Lower diagram shows section through hair cell along dashed line (upper diagram) with
cilia at rest (center) and tilted right and left. Tilt toward kinocilium excites, tilt away
deceases excitation.

10. Brainstem
pathways for
control of eye
movements by
the left
horizontal
semicircular
canal.

11. Clinical Evaluation

12. Aetiology
• BPPV
• Phobic Postural Vertigo
• Central Vertigo
• Vestibular Migraine
• Meniere’s disease
• Vestibular Neuronitis
• B/L Vestibulopathy
• PLF
• Superior Semicircular Canal Dehiscence

13. History
• Key Question: True Vertigo or Not

14. Type
• Rotatory : “Merry go round’
• Postural : “Boat ride” - B/L vetibulopathy
• Lightheaded ness

15. Episode Duration
• Episodic / Continuous
• Episode duration - Seconds, Minutes/Hours,
Days

16. Precipitations
• At rest without any precipitation
• Walking
• Coughing, loud sounds
• Turning in the bed
• Turning head to a side
• Certain social / environmental conditions

17. Accompanying
• Inner Ear Symptoms
• Diplopia Sensory symptoms, dysphagia,
dysarthria
• Headache - Migraine

18. Other-History
• Recent Respiratory Infection
• RTA
• PMHx
• Disability
• Previous treatments and success

19. Examination
Neuro-otological
• Complete Ear Examination
• Nystagmus
• VII
• Other Cranial Nerves
• Romberg’s

20. Examination
Neuro-otological
Neuro-otological
• Tandem gait
• Stepping test
• Head thrust test

21. VOR
• Video

23. Investigations
• Directed
• Inner Ear Test Battery : FBC, ESR, TSH,
VDRL, Lipids, FBS
• Calorics ENG - video
• Electrocochleography, ABR,VEMP
• MRI

24. Four CD of Vertigo
Management
• Correct Diagnosis
• Correct Drugs
• Correct Dosage
• Correct Duration

25. Pharmacotherapy
7 A’s
• Anti Emetics - Dimenhydronate
• Anti Inflammatory - Steroids
• Anti - Migraine - Beta-blockers, topiramate
• Anti Meniere's - Betaserc
• Anti Depressants - SSRI
• Anti Convulsants - Carbamezepine
• Amino Pyridines - for cerebellar gait
disorders

26. BPPV
• canalolithiasis theory
• Dix Hallpike test +
• Epley Manoeuvre

27. Dix Hallpike Test

28. Epley Manoeuvre

29. Meniere’s Disease
• Saccin Theory / Dark Cell theory
• Aural fullness vertigo tinnitus hearing loss
fluctuating
• Diagnosis of exclusion
• treatment : salt restriction, diuretics,
betahistine, Intratympanic gentamicin,
Grommet, Meniett, ELS Surgery, Vestibular
nerve section, labirynthectomy

30. Vestibular Neuronitis
• Medical Management
• self improving

31. Summary
• True Vertigo or Not
• Central vs Peripheral
• Clinical Evaluation and Judicious Investigations
• Medications and Physical treatment modalities
• Satisfying to properly assess and treat a vertigo
patient

33. Questions?
• Thank You!
• email questions to:
• lakshent@gmail.com