13. A battery of tests
Many systems to be evaluated to assess structural and
functional integrity
NEUROTOLOGICAL
EVALUATION
14. For An ENT Specialist,
We look at the ears first.
In vertigo --> eyes are most important
15. Otoliths act as gravito-inertial force detectors
SVV is a psychophysical measure of the angle between perceptual
vertical and true/gravitational vertical
Also used to measure vestibular rehabilitation
Compensated utricular hypofunction may be detected on dynamic
SVV testing. The defect will be unmasked on eccentric rotation
because any otolith function asymmetry will be enhanced.
SVV
16. Pt is asked to adjust the orientation of a luminous bar until they
perceive it as vertical
SVV – saccule and its central pathways
SVH – utricle and its central pathways
Pinar et al reported changes in SVV and SVH in >25% pts of
chronic dizziness concluding that evaluation of the otolith system
is mandatory
SUBJECTIVE VISUAL
VERTICAL AND HORIZONTAL
17. SVV FINDING CONDITION
Normal range Upto 2° deviation
Ipsiversive tilt – >2o
peripheral vestibular disorder
pontomedullary lesion
thalamic lesion
Controversive Pontomesencephalic lesion parietoinsular
vest. lesion
Migraine Abnormal, little literature
18. CRANIOCORPOGRAPHY
Developed by Claussen [1968]
Assessment of vestibulospinal system
Photographic recording of head and body movement during
gait testing
Evaluation includes Romberg, Tandem walking and
Unterburger’s test
19. Done in dark room
Pt is blindfolded
Pt wears a helmet with LED lights
Path of the pt is recorded using an SLR camera
Result depends on vestibular system only as visuals cues cut off –
pt is blindfolded and by stepping in one place, the soles
intermittently lose contact with the floor thus reducing
somatosensory input
CCG : PROCEDURE
20. PARAMETER NORMAL RANGE-
LOWER BORDER
NORMAL RANGE-
UPPER BORDER
Longitudinal
displacement
30.03 cm 113.35 cm
Lateral sway 5.17 cm 16.15 cm
Angular deviation 55.13° (right) 48.37° (left)
Body spin 82.21° (right) 82.89° (left)
NORMAL PARAMETER OF
CCG
[CLAUSSEN]
25. Introduced by Halmagyi and Curthoy
Simple, fast, reliable
Tests scc function – can evaluate all 3 pairs
Measures high freq. vestibular response in 3 dimensions
HEAD IMPULSE TESTING
26. VHIT – using Video Frenzel glasses
Test for gaze stabilization during rapid translation of head
Assesses the peripheral utricular system and superior
vestibular N
A corrective saccade after VHIT indicates hypofunction of
same side
HEAD IMPULSE TEST
27. Subject seated upright with eyes focused on an fixed object
Unpredictable , low amplitude [10 – 20°] head rotation with
high acceleration
Angular VOR generates compensatory eye movements
equal in amplitude and opposite in direction to stabilize
gaze
HIT : PROCEDURE
32. Functional test of VOR
Comparison of visual acuity with
head still to VA with head moving
Reduction by 2 lines indicates
dysfunction of VOR as seen in
bilateral peripheral vestibulopathy
Improvement with rehab will
improve DVA
Early sign of vestibular toxicity
DYNAMIC VISUAL ACUITY
TEST
34. The ampulla contains the cupula – a gelatinous mass with the same
density as the endolymph.Cupula forms an impermeable barrier
across the lumen of the ampulla. Hence the particles in scc may only
exit via the end with no ampulla.
35.
36.
37. POSTERIOR CANAL BPPVPOSTERIOR CANAL BPPV
Most common– posterior canal is most gravity dependent in
upright and supine position
Once debris enter the post. canal ,the cupula at the shorter
most dependent arm trap the debris.
Debris can exit only through the longer arm through the crus
commune [non-ampullary]
45. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES
Used as a home program
Indications
o Posterior canal cupulolithiasis
o Persistant posterior canal canalithiasis
Mechanism
o Dislodge debris attached to cupula
o Habituation through central compensation
47. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES
Things to remember
o The exercises may dislodge more otoconia from the utricle
causing an increase in symptoms.
o May cause multiple canal involvement.
o Important to hold for 30 seconds in each position.
48.
49. HORIZONTAL SCC BPPVHORIZONTAL SCC BPPV
Pagnini-McClure maneuvre
Geotropic nystagmus – debris are away from ampulla , side
showing stronger nystagmus is the side involved
Apogeotropic nystagmus – indicates cupulolithiasis
56. CUPULOLITHIASISCUPULOLITHIASIS
Coined by Schuknetch
Rare , more common in horizontal canal
Caused by otoliths attached to cupula of scc
When cupula is horizontal no vertigo
When non-horizontal constant input persistant
dizziness
Nystagmus : persistant non-fatiguable as long as patient is in
the same position
57. SUBJECTIVE BPPVSUBJECTIVE BPPV
No nystagmus is detected but patient feels dizzy on
provocative tests
PRP beneficial
Reasons
o Subtle nystagmus
o Fatigued nystagmus
o Inadequate neural signal to stimulate the VOR
60. NO COMMON TREATMENT FOR
ALL PATIENTS.
Therapeutic approach requires recognition of the
pathomechanism
Detailed history
Clinical examination
Neurotological tests
Imaging
61. Aim Of Vertigo Therapy
Elimination of Vertigo
Enhancement/non-compromise of “Vestibular compensation”
Reduction of Psychoaffective syndromes
Nausea and Vomiting
Anxiety
Thomas Brandt – Vertigo; A mutlisensory system disorder, 2nd
edition. Springer –Verlag- London 2002
62. Vestibular Suppressants
Rascol O et al, Drugs 1995; 50: 777-91
Lacour M. Curr Med Res Opion 2006; 22: 1651-9
Reduction in the
symptom of vertigo
comes at a price of
reduction in
vestibular function
63. Treatment with Vestibular Suppressants
Suppressants
reduce activity at
intact side and
thus hamper
recovery by VC
Not recommended
for long term use
They should be
discontinued as
soon as possible
Lacour M. Curr Med Res Opion 2006; 22: 1651-9
Vestibular
Nuclei
INTACT DAMAGED
64. Vestibular Suppressants
Useful for prevention of nausea and reduce
vomiting (generally to be used for not more
that 1-3 days) post an event
Should be discontinued as soon as possible
after event subsides
They are not to be used chronically or for
prophylaxis against subsequent attacks
Lacour M. Curr Med Res Opion 2006; 22: 1651-9
Goebel J. Otolaryngol Clin N Am 2000; 33: 483-93
Brandt T, Vertigo. Its Multisensory Syndromes, 2nd
Ed: Pg 49-61
66. ANTI- HISTAMINICS
Histamine is not a major neurotransmitter in the vestibular
pathway
It exerts effect by acting on H1 receptors antagonist
Structure of H1 receptors is similar to Muscaranic receptors
Drug which blocks H1 receptors will also have an anti-
cholinergic effect
68. BETAHISTINE
Historically seen that histamine relieved vertigo.
However had to be given IV and had serious
side effects.
Betahistine is a histamine analogue having the
advantages of histamine like action without its
side effects.
69.
70. DRUG COMBINATIONS
Anti-histaminics are H1 receptor antagonists
Betahistine is H1receptor agonist and H3 receptor antagonist
Hence these drugs should not be combined.
71. VESTIBULAR
REHABILITATION
VRT comprises of a series of maneuvers designed to
stimulate the vestibular system. These movements which in
the initial stages provoke vertigo, are combined with
exercises involving eye movements and postural changes
which encourage vestibular compensation.
73. Pts are asked to perform repeated head ,eye and body
movements which will help the brain recalibrate the relationship
between visual, vestibular and proprioceptive signals.
74. Bouncing on Swiss balls or mini-tramps may be advocated to build
up the otolith-ocular reflex as well as otolith-postural reflexes.
76. CENTRAL COMPENSATION
Adaptation – ability to regain spatial orientation
Substitution – as there is a derangement in function, using
different pathways to maintain equilibrium
Habituation – repeated maneuvres aimed at stimulating the
sensory mismatch and lead to desensitization.