A concise presentation about BPPV and Ménière's disease and other causes of vertigo, the difference between central and peripheral vertigo, symptoms and etiology and approach to physical examination and treatment.

2. What is vertigo?
• Illusion of spinning sensation of self or surroundings, usually due to
disturbance of vestibular system.
• Caused by contradictory information from vestibular, visual and
proprioceptive systems.

3. Prevalence of vertigo
• 5% of patients visiting the GP
• 10% of patients visiting the otorhinolaryngologists
• 3rd most common symptom symptom.

4. Anatomy of the inner ear:
- The inner ear or the labyrinth
is an important organ of
hearing and balance.
- It consists of a bony and a
membranous labyrinth.

5. Inner ear has three parts:
1- Cochlea : the auditory portion of the ear ,concerned with hearing
It is a snail-shaped chamber that houses the organ of Corti. It translates
mechanical vibrations into electrical impulses and sends them to the
brain through the cochlear nerve.
2- Vestibular portion : concerned with balance
The vestibular system consists of a large chamber (the vestibule) from
which 3 semicircular canals protrude. Within the vestibule, there are 2
sensors (the utricle and the saccule), detect linear acceleration, and the
semicircular canals detect rotational movements in the 3 planes of
rotation.

6. • The semicircular canals contain fluids
and sensory cells that have
neuro epithelium "macula and crista"
that responses to head movements to
indicate the body status.

7. • All the information sensed by macula and crista goes to vestibular
nerve then to vestibular ganglion then cochlear nerve joins and
together they form vestibulocochlear nerve. The vestibular part will
go to the brainstem to the superior ,inferior, medial and lateral
vestibular nuclei.
• After the nuclei receive the information it's time to send information
to the
• 1- eyes : through the vestibulo-ocular reflex (VOR).
• 2- spine: though the vestibulo spinal tract

9. Peripheral vs. Central vertigo
Peripheral Central
Any problem in the utricle, saccule,
semicircular canals ,vestibular
ganglion, up to the vestibular nerve.
Any problem in the vestibular nuclei,
or with the central neural connections
in the brainstem.
nystagmus will be vertical or
horizontal.
nystagmus will be rotated, associated
with vomiting , headache, sweating,
palor..etc

10. Benign paroxysmal positional vertigo
• Trauma
• Otoliths in endolymph: The macula has calcium carbonate
crystals known as otoliths or otoconia , they will be displaced
into the semicircular canals (especially the posterior
semicircular canal)
• specific head movements
- How to diagnose BPPV?
• History: the patient has no other problems, they have only one
complaint, no hearing loss at all.
- To confirm your diagnosis:
• Dix-Hallpike manoeuvre.

11. - The patient's head is turned in 45 then head is taken into 30 below
horizontal in a hanging position .
- you will see the nystagmus usually after 20 seconds.

13. Epley's manoeuvre

15. Ménière's disease
• Aka idiopathic endolymphatic hydrops
• It's a disorder of the inner ear where the endolymphatic system
is distended with endolymph.
• It's characterized by:
1- vertigo:
It comes in attacks, sudden onset, lasts for more than 20
minutes, can go on for hours.. usually there's nausea and
vomiting.
2- sensorineural hearing loss
3- tinnitus
4- aural fullness.

16. The exact pathophysiology of Ménière disease is controversial. The underlying
mechanism is believed to be distortion of the membranous labyrinth resulting
from overaccumulation of endolymph. Some authors have questioned whether
endolymphatic hydrops is actually a marker of disease rather than a cause.

17. Clinical examination
• Otoscopy : no abnormality is seen in the tympanic membrane.
• Nystagmus: it's seen only during an acute attack. The quick
component of nystagmus is towards the unaffected ear.
• Tuning fork tests indicate sensorineural hearing loss, Rinne's test is
positive (because both bone and air conduction are reduced equally)
Absolute bone conduction is reduced in the affected ear, Weber is
lateralized to the better ear.

18. Treatment
• treatment of Ménière’s disease is aimed at symptomatic relief.
1- General measurements:
• Smoking should be completely stopped (nicotine causes vasospasm)
• Low salut diet
• minimize coffee, tea and alcohol
• Avoid stress

19. 2- Management of acute attacks:
• Intravenous (IV) or intramuscular (IM) diazepam provides excellent
vestibular suppression and antinausea effects.
3- For chronic management, we can give vestibular sedatives
(prochlorperazine 10mg thrice a day ,orally for 2 months then reduced
to 5mg thrice a day for another month.)
• Surgical therapy for Ménière disease is reserved for medical

20. Other causes of vertigo
• Vestibular neuritis
• Vestibulotoxic drugs: (Aminoglycoside antibiotics especially
streptomycin, gentamicin, kanamycin)
• Perilymph fistula: In this condition, perilymph leaks into the middle
ear through the oval or round window.
• Syphilis of inner ear: both acquired and congenital, causes dizziness in
addition to sensorineural hearing loss.
• Ocular vertigo: may occur in case of acute extraocular muscle paresis
or high errors of refraction
• Psychogenic vertigo.

21. References
• Diseases of ENT by Dhingra 5th Edition
• Medscape.com