vertigo, nystagmus, imbalance ,

1. Approach to a
vertiginous patient :
clinical evaluation
Dr Safika Zaman
RKMSP,VIMS
DEPT OF ENT & HNS

2. Anatomy

3. Anatomy  anatomy

5. Cupula

6. Sensory
system

7. Vestibular
nerve
 Vestibular nerve is made
up of about 25,000
neurons.
 These neurons are
bipolar, with cell bodies
located in the vestibular
nerve near the brain
stem in Scarpa's
ganglion

8. Vestibular
nucleus

9. Vestibular
system

10. PLANESOF
MOTION
 Right anterior (RA) canal
is parallel with the left
posterior (LP) canal and
both lie in a plane
denoted as the RALP
plane.
 Together with the right
posterior (RP) canal the
left anterior (LA)
constitutes the LARP
plane.
 Both horizontal canals are
also parallel with each
other in the lateral plane.

11. Spatial
orientation
 The vestibular system
 The visual system (retina to occipital cortex)
 The somatosensory system

12. FUNCTIONOF
VESTIBULAR
SYSTEM
 Gaze stabilization
 Balanced locomotion and body position
 General orientation of the body with respect to gravity .
 Readjust autonomic functions after body reorientation

15. MOTION
DECOMPOSITION
 Every motion in space
can be broken down
into three rotational
degrees of freedom
(yaw, pitch and roll)
and three
translational degrees
of freedom (left–right,
up–down, fore–aft).

16. OTOLITH
ORGANS
 Saccule and utricle are relatively
orthogonally oriented to each other.
 Horizontal plane triggers predominantly
the utricle.
 Vertical movements trigger mainly the
saccule.

17. Line of polarity
reversal

18.  The implantation of the hair cells
is opposite for both right and left
canals as a mirror image, the
deflection on the ‘leading’ right
side induces a movement of the
stereocilia towards the
kinocilium, whereas on the
opposite ‘following’ ear the
movement of the stereocilia is
away from the kinocilium.

19. Cont..
 Each horizontal canal is maximally excited by a rotation toward
the side of the canal and inhibited by a rotation in the opposite
direction.
 This results in an excitatory Slow phase movement toward the
side opposite the canal and a resetting saccade towrard the canal.

20. Cont..
 The superior canal is excited by a rotation downward and to the
side, in the plane of the canal.
 This results in a vertical-torsional nystagmus, with the slow phase
of the vertical component upward and the resetting saccade
downward.
 The posterior canal is excited by an upward rotation and to the
side, in the plane of the canal, so that the slow phase is downward
and the resetting phase upward.

23. Velocity
storage
 Process that maintains the sense of rotation even after the
rotation has stopped.
 In patients with peripheral vestibular dysfunction, the velocity
storage mechanism may cease to function.
 This causes rotation-induced nystagmus.

24. Neural
integrator
 Process that provides the signal to hold the eyes away from
"primary position" facing straight ahead. when looking away from
primary position.
 Extraocular muscles require a burst of activity to move the eyes to
their eccentric position and then a sustained level of discharge
that signals the muscles to hold the eye in an eccentric position.
 In patients with vestibular loss, this process may become
dysfunctional and the eyes may drift inappropriately toward
primary position.

25. Vestibulo-
ocular reflex
Resting discharge rate of 90 spikes per second. > Head
rotation is to the right.
Endolymph moves left within each SCC due to inertia
The cupula bends to the left in each canal.> In the
(leading) right SCC the stereocilia bend toward the
kinocilium.> In the (following) left SCC the stereocilia
bend away from the kinocilium.
The discharge rate increases in the leading right ear
The discharge rate decreases in the following left ear
>The vestibular nuclei interpret the difference in
discharge rates between left and right SCCs as move
and therefore trigger the oculomotor nuclei to drive
the eyes to the left to maintain gaze stabilization

27. History
 History is often sufficient to identify a likely cause of his or her
symptoms.
 History of a patient with a complaint related to dizziness should
begin in an open-ended fashion.

29. Vertigo – a clinical approachMan Mohan Mehndiratta,Rohit Kumar, New Delhi

30. Peripheral
vs
central vertigo

31. Causes of
vertigo
Vertigo among elderly people: Current opinion
Santosh Kumar Swain1, Nishtha Anand1, Satyajit Mishra2

32. Drugs
Vertigo: Helping Patients Identify and Manage It
March 17, 2015
Yvette C. Terrie, BSPharm, RPh

33. BPPV

34. Vestibular
neuritis

35. Menieres
disease

36. Examination  Much of the examination of peripheral labyrinthine function is
dedicated to evaluating semicircular canal function,

37. Nystagmus
 It is a rhythmic, involuntary, rapid, oscillatory movement of the
eyes. It may have a slow, fast, or a combination of both. It can be
continuous, paroxysmal, with positional or gaze or head
positioning triggers.

38. Inspection for
Spontaneous
Nystagmus
 Vestibular evoked nystagmus is termed "jerk nystagmus" and
comprises a drifting slow phase followed by a rapid resetting
motion.
 The direction of this type of nystagmus is typically named
according to its fast phase.
 The amplitude of nystagmus is often reduced if a patient is able to
fixate on a target.
 Examination for nystagmus should therefore take place with the
patient wearing Frenzel goggles.

39. Positional
Testing
 The Dix-Hallpike maneuver- BPPV: Posterior canal BPPV results in
a vertical-torsional nystagmus with the slow phase components of
the nystagmus directed downward and toward the uppermost ear.

40. Post
headshaking
nystagmus
 Post head shaking nystagmus occurs in patients with imbalance in
dynamic vestibular function.
 Unilateral loss of labyrinthine function, however, there is usually a
vigorous nystagmus with slow-phase components initially
directed toward the lesioned side.

41. Dynamic visual
acuity
 The patient reads a Snellen chart with the head stationary and
visual acuity is recorded.
 Normal vestibular function typically show no more than a one-line
decline during head movement but thoseWith vestibular
hypofunction (particularly bilateral hypofunction) may show up to
a five-line decline in acuity.

42. Caloric test

43. CochlearVIII
nerve function
 Rinne test
 Weber test

44. Kerber KA, Baloh RH. Dizziness, vertigo, and hearing loss. In: Bradley
WG, Daroff RB, Fenichel GM, Jankovic J. eds. Neurology in clinical practice

45. Thank you