Salute Vivamus 2023 | Central Philippine University | College of Medicine

Otolaryngology: S01L04

Anatomy and Physiology of the Vestibular System

Dr. Florence Yul N. Saquian | 9-24-2021 | F | 10:00 AM-12:00 PM

OUTLINE
I. The Vestibular System
A. Functions
B. Integrated Balance
System
C. Components
D. Anatomy
II. The Bony Labyrinth
III. The Membranous
Labyrinth IX. Dizziness and Vertigo
IV. Vestibular Blood
Supply
A. Basilar Artery
V. Semicircular Canals
VI. Hair cells
A. Hair cell Structure
B. Hair cll Function
C. Orientation of the
Macula
D. Structure of the
Macula
VII. Otoliths X. References
VIII. Neural Pathways of XI. Appendix
the Vestibular System
A. Vestibular Nerve
B. Vestibular Nerve
Fiber
B. INTEGRATED BALANCE SYSTEM
C. Vestibular Nuclei
D. Cerebellum: • A part of a large network of interconnected systems
Adaptive Processor → Right and left labyrinth: ear component
E. Brainstem: Neural
• Has a connection with your central vestibular pathways
Integrator
which is located in your midbrain
F. Vestibulo-ocular
• There is also a connection between your midbrain and
Reflex (VOR)
your vestibulo-ocular pathways which means it connects
G. Nystagmus
directly to your eyes and your spinal cord
• These connections will maintain a steady image of your
A. History Taking
vision as well as your position
B. Physical
Examination • Your posture is also being monitored by your central
Findings vestibular pathway
C. Dix-Hallpike • Balance system is an interconnected system of the different
Maneuvers organs of the body: your eyes, spinal column, skeletal
D. Other Tests muscles, and ears
Performed
E. Neurotologic Tests
F. Common Vestibular
Pathologies

I. THE VESTIBULAR SYSTEM

• Phylogenetically one of the oldest sensory organs in the animal
world
• A key element of an integrated system that allows all mobile
life form to move in their environment

NICE TO KNOW!
“Even the smallest organisms will have vestibular apparatus. They
know where they are located, where they are going, and where they
are oriented (spatial orientation)”.
-Doc Sqquian Figure 1. Integrated Balance System

A. FUNCTIONS • The picture above shows the different connections between the
balance system including labyrinth thin organs in the ears
• Provides accurate perceptions of the position of the body in the which is connected to the central vestibular pathways
environment and perceptions of direction and speed of • It also connects with eye muscles that control eye movements
movement as well as the skeletal muscles to control posture
→ Guides you to where you are located and what you are • All of these contribute to an integrated balance system so you
doing don’t fall into one side when you are moving
→ e.g., when you are in your car stuck in traffic, sometimes
you think you are moving but it is actually the car beside C. COMPONENTS
you that is moving
• Control eye movements to maintain a clear visual image of • Peripheral Sensory Apparatus
the external world while the individual, the environment or both → Bony labyrinth
are in motion → Membranous labyrinth
→ There is a connection between your eyes and vestibular → Hair cells
system so that you don’t get dizzy when you or somebody • Central Processor – integrates all the signal from your
else is in motion (example: driving) peripheral sensory apparatuses
→ Acts as a balance, makes you control your eye movements → Vestibular nuclear process complex
→ Cerebellum
• Mechanism for Motor Output
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 → Vestibulo-ocular reflex II. THE BONY LABYRINTH
→ Vestibulospinal reflex
*Reflex system- direct connection between one organ just • Composed of:
like your labyrinth as well as your eyes and then your → Three semicircular canals
ears as well as your spinal column. ▪ Has both a non ampullated end and ampullated end
which drains into your
▪ And it is embedded in your bony labyrinth
→ Vestibule and saccule
• Filled with perilymphatic fluid
→ Bathes the bony labyrinth
→ High Na:K ratio
• Connects or has a communication with subarachnoid space via
the cochlear aqueduct
• There is connection between your vestibule, bony labyrinth and
subarachnoid space
• Subarachnoid space contains the CSF, which has the same
composition with the perilymph, that is why they have a direct
communication

Figure 2. Components of the Vestibular System

• Sensory cells in ampulla of SSC and macula of utricle and

saccule
• The afferent nerve fibers from the semicircular canals and the
otolith organs merge to form the vestibular nerve
• Vestibular nerve fibers
→ Bipolar neurons with their cell bodies in Scarpa’s ganglion
→ Their peripheral synapses on the hair cells
→ Their central synapses on the central vestibular structures.
• Scarpa’s ganglion consists of:
→ Superior portion: receives fibers from the horizontal and
Figure 4. Bony Labyrinth
superior SSC and the utricular maculae, as well as a branch
of the saccular nerve
→ Inferior portion: comprises fibers from the crista of the III. THE MEMBRANOUS LABYRINTH
posterior canal and the saccular macula

D. ANATOMY

Figure 5. Membranous Labyrinth

• Contains 5 sensory organs

Figure 3. Anatomy of the Vestibular System
→ Membranous portions of three semicircular canals
o Composed of:
• Bony labyrinth (blue)
▪ Anterior/Superior SCC
• Membranous labyrinth (orange)
▪ Posterior SCC
▪ Horizontal SCC
→ Found inside the bony labyrinth
o Crista ampullaris- sensory organ of ampulla
• Semicricular canals and otolytic organs are involved in
maintaining balance → Membranous portions of 2 otolith organs: utricle and
• Cochlea is for hearing
saccule
o Utricle- oriented horizontally
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 o Saccule- oriented vertically
o Macula: sensory organ
• Filled with Endolymphatic fluid
→ High K:Na ratio

Figure 7. Vestibular Blood Supply

V. SEMICIRCULAR CANALS
Figure 5. Endolymphatic duct (red arrow) has no communication with subarachnoid space
• Superior semicircular canal
IV. VESTIBULAR BLOOD SUPPLY → Ampullated end contains the sensory organ
o Crista ampullaris
o Has a direct connection to your vestibular nerve
A. BASILAR ARTERY o The other part of your vestibular nerve is innervated by
your utricle and saccule
• Where vestibular blood supply comes from
• Horizontal Canal
• Supplies the anterior inferior cerebellar artery (AICA)
• Posterior semicircular canal
• This bifurcates to form labyrinthine artery
→ Non ampullated and ampullated end
→ Subdivides in anterior vestibular artery and common
cochlear artery
NICE TO KNOW!
• Anterior vestibular artery
“Your vestibular apparatus is imbedded in your mastoid bone. It is
→ Supplies the ampullated end of the semicircular canals directly behind your ossicles (your hearing). There is a big correlation
→ will give nutrients to the otolithic organs and some parts of between hearing loss and dizziness whenever there is an infection in
semicircular canal your middle and inner ear.”
• Common cochlear artery -Doc Saquian
→ Supplies the cochlea
→ It also branches off to the posterior vestibular artery ANATOMIC ORIENTATION OF SSCS
o Which supplies otolithic organs and semicircular canals • Semicircular canals are organized in three nearly orthogonal
• Therefore, vestibular apparatus has two blood supply (mutually perpendicular) planes
→ Anterior vestibular artery • Right and left vestibular organ is the mirror image of each other
→ Posterior vestibular artery → Meaning, your right and left SCC are mirror images of each
→ Significance: other
o Whenever an individual has problem with balance, we • Horizontal SCC is not coplanar with the horizontal axis
have to take in consideration which part of the vessel → It elevates 30 degrees above the horizontal plane
has been compromised • Anterior and Posterior SCC forms 45 degrees angulation with
o Vestibular organs are supplied by two vessels so respect to horizontal plane
whenever there is an obstruction in one vessel, the • (Book)The three canals are approximately perpendicular to
functions of the organs are not fully compromised each other, and each canal of one ear is coplanar with a canal
from other ear
NICE TO KNOW! • Each semicircular canal is synergistically paired with a canal in
“If somebody has an atherosclerosis of the basilar artery, the the opposite ear such that they reside in approximately parallel
symptoms would be dizziness or vertigo because it doesn’t have blood planes
supply to your sensory organs.” • The three pairs are:
-Doc Saquian
→ Two horizontal canals
→ Right anterior and left posterior canals
→ Right posterior and left anterior canals

NICE TO KNOW!
Semicircular canals are mirror images of the contralateral
side which means your right lateral, or horizontal SCC are
mirror image of your left horizontal SCC
Right posterior SCC: Left posterior SCC

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 o Embedded in gel-like substance otolithic membrane
o Otolithic membrane has the same content as your
cupula but the otolithic membrane has otoconia
o Otoconia: calcium crystals on top of otolithic
membrane; not found on top of cupula
o Otoconia are benign, but there is trouble when otoconia
are displaced and they go into your semicircular canals

Figure 8. Anatomic Orientation of SSCS

VI. HAIR CELLS

Figure 10. Hair Cell Structure

B. HAIR CELL FUNCTION

Figure 9. Hair Cells
• Excite or inhibit
• Depolarize or hyperpolarize with respect to kinocilium
• Main sensory organ of vestibular apparatus
• Excitation: when stereocilia moves toward kinocilium
• Specialized cell that transduces hydromechanical energy to
neural activities → There is a depolarization causing the nerve to be
stimulated
• Contain approximately 70 short hairs called stereocilia and a
• Inhibition: when stereocilia moves away from kinocilium
single, thicker longer hair called a kinocilium
→ Hyperpolarization
→ When they move sideways, there is a release of
neurotransmitters that travels into your efferent and afferent • Kinocilium is the reference used to note the the movement of
nerve endings going to your vestibular nerve stereocilia
• Found in two locations • Change in the firing rate of the afferent neuron is proportional
to the displacement of the stereocilia
→ Utricle and saccule (Otolithic organs)
o Called Maculae • However, there is an inherent asymmetry between the
→ Ampullated end of semicircular canal excitatory and inhibitory responses
o Called the crista ampullaris • Firing rate of neurons can increase to approximately 400 spikes
per second during the excitatory phase
A. HAIR CELL STRUCTURE • Inhibitory response is limited to cessation of neural activity and
therefore cannot exceed the spontaneous firing rate
• Hair cells transduce mechanical energy to neural activity
• Neurotransmitter release changes firing rate of vestibular
neurons
• Microscopic displacement of the hair cells subsequent to the
applied forces causes the chemical reaction that releases
neurotransmitter substance and changes the neural firing rate
of the primary vestibular neurons
• 70 stereocilia
• Single kinocilium
• Vestibular Hair Cells
→ Ampullae
o Hair cells rest on the crista ampullaris
o Overlied by gelatin substance called cupula
o Detect angular or rotatory motion
→ Maculae
o Located on medial wall of saccule
o Located on floor of utricle
o Figure 11. Hair Cell Function
o Excited when bent toward kinocilium
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 NICE TO KNOW!
“The movement of your stereocilia towards your kinocilium is the same
as your kinocilium moving away from your stereocilia. This movement
is called excitation.
Movement of the kinocilium towards your stereocilia is called inhibitory
polarization.”
-Doc Saquian
C. ORIENTATION OF THE MACULA
• Otolithic organs: vestibular receptors are also found in the
macula of the saccule and of the utricle
• Utricular macula: oriented roughly parallel to that of the lateral
semicircular canals
• Saccular macula: parallel to the sagittal plane
• Hair cells of the maculae have different patterns of polarization
• In the utricle, the hair cells are oriented such that their kinocilium
are towards the striola (which is a stripe that runs through the
middle of the otolithic membranes)
• Reverse in the saccular macula
• Because the otolithic organs are curved and non-planar, the
patterns of hair cell activation are complex
Figure 12. Orientation of the Macula
D. STRUCTURE OF THE MACULA
• Cilia of the macular hair cells likewise project into the otolithic
membrane
• Otolithic membrane is topped by deposits of calcium carbonate
called otoconia or otoliths, and this increases the specific gravity
of the otolithic membrane to three times that of the endolymph
• Mechanism of stimulation for the otolith organs: any force that
displaces the otolith membrane with respect to the macula
• The maculae are responsive to linear acceleration, such as the
force of gravity
Figure 13. Structure of the Macula
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NICE TO KNOW!
“It is the otolithic membrane or the gelatinous layer that moves
whenever you move your head, and it goes with the displacement of
your hair cells.”
-Doc
VII. OTOLITHS
• Responds to the linear head motion and static tilt with
respect to gravitational axis
→ Otolith will depolarize whenever there is linear motion
→ Forward, backward, side to side, up and down
• Saccule is vertically oriented structure
• Utricle is horizontally oriented structure
NICE TO KNOW!
“If you move your head up and down, the saccule is responsible for the
movement”
-Doc
VIII. NEURAL PATHWAYS OF THE
VESTIBULAR SYSTEM
A. VESTIBULAR NERVE
• Afferent nerve projections from bipolar neurons of the vestibular
ganglion
• Enters the brainstem at the pontomedullary junction
• The ampullated end of the posterior semicircular canal contains
the crista ampullaris which contains the hair cells
• While the otolithic organ contains the macula, which is the
sensory structure. It has the otoconia, the otolithic membrane,
as well as the hair cells.
• Once the hair cell detects the signal it depolarizes, and it goes
into your nerve fibers and then your vestibular ganglion which
then goes into the vestibular nerve. Together with the facial and
cochlear nerve it enters the internal auditory meatus
NICE TO KNOW!
“When going into the midbrain, there is a very fine connection between
your facial nerve (which is a motor nerve) and your cochlear nerve
(hearing). If something blocks (e.g., mass, or infection that causes
inflammation of your vestibular nerve), it causes symptoms such as
paralysis, Bell’s palsy, hearing loss, dizziness, etc. so that’s why we
need to know the interconnection of the internal auditory meatus.”
B. VESTIBULAR NERVE FIBER
• Innervate vestibular nuclei located in the pons and medulla
primarily
• Some innervate the cerebellum directly (Sub-connection)
C. VESTIBULAR NUCLEI
• Receive afferent innervation from numerous sources
→ Cerebellum
→ Reticular formation
→ Spinal cord and cervical areas
→ Interconnection from contralateral nuclei
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Figure 13. Neural Pathway of the Vestibular System
• The vestibular nerve is projecting into the vestibular nuclei
located in the brainstem connecting to the cerebellum and to the
contralateral vestibular nuclei
• From the peripheral apparatus it goes into the vestibular nuclei,
send nerves into the cerebellum and to the contralateral
vestibular nuclei, goes up and it decussates and goes into the
vestibulo-thalamic tracts, eventually reaching the vestibular area
of the cerebral cortex. The vestibular apparatus has connections
with CN III nucleus (Oculomotor nerve nucleus) and CN IV
nucleus (Trochlear nerve)
NICE TO KNOW!
“The vestibular area of the cerebral cortex is the one that programs
your response to whatever stimulus is given to it from the peripheral
organs. It will now tell all your organs, your eyes, cerebellum, spinal
cord, as well as your ears, what to do in case you fall or suddenly have
imbalances.”
D. CEREBELLUM: ADAPTIVE PROCESSOR
• NA major recipient of outflow from/source of inhibitory input to
the vestibular nucleus
• Flocculus: adjusts and maintains the gain of the Vestibulo-ocular
reflex (VOR)
• Nodulus: adjusts the duration of the VOR responses and
involved with processing of otolith input
• Anterior-superior vermis: Vestibulospinal Reflex
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NICE TO KNOW!
“For ballerinas and figure skaters, they don’t feel dizzy and fall to their
sides when they do pirouettes and turns many times because their
cerebellum and labyrinths have already adapted to the movements of
their body in relation to their environment.”
E. BRAINSTEM: NEURAL INTEGRATOR
• For the oculomotor system:
→ Nucleus prepositus hypoglossi
→ Just below the medial vestibular nucleus
• For the vestibulospinal system:
→ Presently unknown
F. VESTIBULO-OCULAR REFLEX (VOR)
• The mechanism by which the vestibular system participates in
the task of providing clear vision during head movement
• It maintains a steady retinal image by generating compensatory
eye movements in response to head motion
• Generates eye movements that enable clear vision while the
head is in motion
• Example, right head rotation:
→ Activation of right (ipsilateral) medial rectus and left
(contralateral) lateral rectus
→ Inhibitory impulses to antagonists
→ Result: compensatory eye movements toward the left
NICE TO KNOW!
“Your balance system, ears, and eyes have a direct connection that
makes it possible for you to have a steady and clear image of what is
in your line of sight even though you are moving your head. ”
• Vestibulo-occular reflex (VOR) pathways make two distinct
connections between the vestibular nuclei and the oculomotor
neurons
→ Direct: using the nerve fibers in the medial longitudinal
fasciculus
→ Indirect: mediated through the reticular formation
• Signals from the vestibular nuclei project to the oculomotor
nuclear complex
• Excitatory responses from one side are usually coupled with
inhibitory responses from the opposite side to generate
conjugate eye movements
• There is a connection between the vestibular nuclei and CN VI
and CN III so that whenever the lateral rectus of the right eye is
excited, the medial rectus of the left eye is also excited while the
corresponding medial rectus of the right eye and lateral rectus of
the left eye is inhibited so that the eye would move on the same
direction creating a uniform movement.
Figure 14. Vestibulo-Ocular Reflex
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 NICE TO KNOW!
“When you say a reflex, it doesn’t have central connections. It goes
directly from the nuclei of the vestibular apparatus to the other motor
nerves. As shown in Figure 14, it goes to CN VI & III and goes directly
to the medial rectus and lateral rectus, which means when you move
your head to one side, there is a compensatory contralateral
movement of your eyes. Since it is a reflex, you do not notice yourself
doing it at all.”
Figure 15. Neural Pathway of the Vestibular System
G. NYSTAGMUS
• A rhythmic to-and-fro eye movement typically identified by a
slow drift of the eyes in one direction followed by a fast reset in
the opposite direction
• Physiologic nystagmus
→ When you look on a side for a prolonged period of time,
there is a slight movement of your eye
VIII. DIZZINESS AND VERTIGO
• Dizzy” (“hilo”, “iyo”), (“linging ulo”)
• Used to describe various sensations with different causes
• Important to distinguish dizziness from true vertigo:
differential diagnosis and management are totally different
• Dizziness: light-headed (“daw ga lutaw”), syncopal, “passing
out” sensation (as in standing abruptly); replicated by
hyperventilating
• Vertigo: sensation of spinning (“daw gatiyog”), whirling or falling,
either of self (“I’m spinning) or of the environment (“the room is
spinning); replicated by spinning like a top
→ Symptom rather than a disease
→ Can have various causes
→ Can occur suddenly and be accompanied by nausea,
vomiting, and disequilibrium (if it’s their first-time
experiencing vertigo)
→ Mild episodes: a rocking sensation or mere
lightheadedness; often confused with dizziness
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→ Patients usually are able to describe symptoms (what was
actually felt in their own words)
→ Patients cannot tolerate even slight head movements
A. HISTORY TAKING
• Very important especially in diagnosing vertigo: 80-90% comes
from History alone
• Pattern of vertigo: onset, duration, relation to position,
triggering & alleviating factors
• Accompanying symptoms of hearing loss, tinnitus, ear fullness
(otologic)
• Drug (including alcohol!) ingestion & trauma
• Other systemic, neurologic, neck, ophthalmologic & psychiatric
problems
*SEE APPENDIX FOR SNNOOP QUESTIONS DURING
HISTORY TAKING
B. PHYSICAL EXAMINATION FINDINGS
• May provide information leading to diagnosis
• May be normal (unless patient is vertiginous at the time of
examination): corroborated by nystagmus
• Blood pressure recorded in supine, sitting, and standing
positions
→ Rule out orthostatic hypotension
C. OTOLOGIC EXAMINATION
• Bedside hearing evaluation (tuning forks)
• Pneumatic otoscopy and fistula test (vertigo and observed
nystagmus from alternating positive and negative ear canal
pressure)
• Dix-Hallpike maneuvers (for positioning vertigos)
→ Check for presence of BPPV
Figure 16. Otologic Examination
NICE TO KNOW!
“Some patients may feel dizziness or vertigo when tube is inserted
and air is introduced to ear; it might be due to a fistula.”
D. DIX-HALLPIKE MANEUVERS
• Sit patient upright in bed or table with enough space for head to
dangle over edge
• Standing at the side facing the patient, explain the procedure,
including the possibility that dizziness or vertigo may result
→ Patient is instructed to immediately report any vertigo
experienced
→ The patient will feel dizzy whenever there is otoconia
(calcium crystals) in crista ampullaris
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 o Calcium crystals (usually only present in utricle and
saccule) in crista ampullaris for whatever reason will
cause a sense of rotatory dizziness
• To detect the presence of right posterior canal BPPV, the
patient’s head is turned 45 degrees and 30 degrees down with
chin tucked toward the right shoulder.
• Holding the head firmly, the patient is brought into a supine right
head hanging position (30 degrees over edge) and observed for
nystagmus.
• The position is maintained for at least 30 seconds before
returning to the original upright position.
• After returning to the original position, again look for any
nystagmus.
• Repeat the procedure with the head toward the other side.
• Very specific for Benign Positional Vertigo
Figure 17. Dix-Hallpike Maneuver
NICE TO KNOW!
“A 45-degree angle is important in Dix-Hallpike Manuever so that it
could create a 90-degree angle with your lateral semicircular canals
(45-degree angle also.
30-degree angulation is needed so that its horizontal orientation
could align with the horizontal plane of semicircular canals
These angulations are important so that it could be coplanar with
your sagittal and horizontal axis.”
E. NEUROTOLOGIC TESTS
• Oculomotor evaluation for various forms of nystagmus,
oscillopsia, and vestibule-ocular-reflex cancellation
• Caloric testing (bithermal or ice)
• Postural tests such as
→ Romberg’s: standard and sharpened, with Jendrassik’s
maneuver
→ Jendrassik’s manuever
→ Unterberger or Fukuda (marching)
→ Babinski-Weill (walking) test
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HEAD SHAKE NYSTAGMUS
• Oscillopsis and Vestibulo-ocular reflex cancellation
• Use of special lenses called Frenzel lenses
→ High magnification lenses
→ To prevent patient from seeing examiner; examiner
however sees patient
→ Thick lenses magnify patient’s eyes to allow examiner to
see subtle nystagmus
• Hold head of patient, then shake vigorously to induce dizziness
and vertigo
• When shaking stops, movement will be seen if there is
nystagmus
Figure 18. Head Shake Nystagmus
NICE TO KNOW!
“Because of the thickness of the lens, the patient cannot see.
Thus, no external stimuli. But the doctor can see the eyes of the
patient, the very fine nystagmus in the patient. For patients who
are vertiginous, sometimes you can see the nystagmus even
without the Frenzel lens.”
ROMBERG’S TEST
• To rule out central causes of vertigo
• Let patient stand with his feet close together
• Let them clasp their hand on their stomach and close their eyes
• Jendrassik’s Maneuver
→ It is just Romberg but what you tell your patient is to pull
their hands to the side
• If there is central pathology patient will fall on one side
• If Romberg’s (or Jendrassik’s) test is negative, vertigo is
peripheral
Figure 19. Romberg's Test
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UNTERBERGER’S STEPPING TEST (FUKUDA) Perilymphatic Fistula Basilar Migraine
• Let the patient raise hand in front Labyrinthine Insufficiency Temporal Lobe Epilepsy
• Have the patient march in place for around 15-20 times Trauma Temporal Bone Fracture
• If patient rotates to either side (45 or 90 degrees either side) it Ototoxicity Drugs
means that there is a central pathology of the vertigo Ramsay-Hunt Syndrome Multiple Sclerosis
• Peripheral vertigo: normal Unterberger Stepping Test *Vestibular Neuronitis Tumor
Table 1. Common causes of Vertigo
*Most common

• Can be grouped into peripheral or central causes

• Many peripheral causes of vertigo are not life threatening
(though debilitating)
→ Less urgent
→ Just reassure your patient
→ Peripheral causes of vertigo may also cause severe
discomfort, nausea, vomiting & merit admission for
supportive therapy
• Many central causes of vertigo merit urgent admission and
evaluation
→ Refer to neurologist right away
• Presence or absence of spontaneous nystagmus can be
observed with eyes open or shut
Figure 20. Unterberger's Test
→ Peripheral
o (-) nystagmus with eyes open
o (+) nystagmus with eyes shut (easily observed
BABINSKI-WEILL TEST (VIVA) beneath closed eyelids)
→ Central
o Spontaneous nystagmus with eyes open
o Disappears when eyes are shut
→ Nystagmus is present whether eyes are open or closed,
vertigo may be peripheral or central

BENIGN PAROXYSMAL POSITIONING VERTIGO

(BPPV)
• Sudden onset, brief episodes (secs - mins) vertigo associated
with certain head positions, particularly when involved ear
positioned dependently
• (+) Dix-Hallpike maneuvers
→ Crescendo-decrescendo nystagmus pattern following 10-
15 sec latency after affected ear positioned dependently
→ Geotropic (horizontal or rotatory) nystagmus about 30 secs
→ Increasingly difficult to replicate (fatigability)
Figure 21. Babinski-weill Test
• Pure tone audiometry & caloric testing are normal
• Caused by free-floating calcium carbonate crystals in the
F. COMMON VESTIBULAR PATHOLOGIES posterior semicircular canal, may be a one-off in many people
• Treatment:
→ Special canalith repositioning techniques (Epley
COMMON CAUSES OF VERTIGO maneuver): can relieve symptoms when recurrent and not
self-limiting
PERIPHERAL CENTRAL o Try to move calcium crystals from ampulla back to their
EAC Foreign Body Acoustic Neuroma original position in the utricle and saccule
o Treatment of choice
→ Vestibular suppressants: should be administered
Otitis Media: Effusion, Meningitis, Encephalitis,
selectively only for severe attacks as they may prevent
Acute, Chronic, and and Brain Abscess
habituation
Cholesteatoma
→ Surgery: when severe BPPV-related vertigo does not
Otitis Media: Effusion, Meningitis, Encephalitis,
respond to the canalith repositioning procedure, as
Acute, Chronic, and and Brain Abscess
vestibular suppressants can only lessen symptoms in the
Cholesteatoma
short-term
*Acute Labyrinthitis Brainstem/Cerebellar Infarct
or Hemorrhage
*Meniere’s Disease Subclavian/Steal Syndrome
*Benign Paroxysmal Vertebrobasilar
Positioning Vertigo Insufficiency

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WHAT HAPPENS DURING EPLEY MANEUVER

Figure 22. Natural placement of calcium crystals when the patient is positioned at 45 degrees.

Figure 25. Next, rotate the head of the patient and rotate it again to the other side. This is to allow
the rotation of the calcium crystals too. The calcium crystals will now travel towards the non-
ampullated end of the semicircular canal.

Figure 23. The calcium crystals are displaced into the ampulla when you turn the patient.
Figure 26. Turn the patient’s whole body to one side. Note how the otoconia travels into the non-
ampullated end.

Figure 24. Position the patient as seen in the picture above to allow the calcium crystals to travel Figure 27. Bring the patient back to their original position. The calcium crystals from the
back into the semicircular canal ampullated end, it goes all the way to the semicircular canal and back to the non-ampullated end. It
can now rest on the otolithic organs.

MENIERE’S DISEASE
• Increased production or decreased reabsorption of endolymph
→ Increased pressure or endolymphatic hydrops
→ Too much pressure in the membranous labyrinth causing
rupture of endolymph and perilymph
o Once ruptured, there is already an admixture of
perilymph and endolymph causing the triad
• Subjective sensation of aural fullness or pressure
• Diagnostic triad:
→ Progressive sensorineural hearing loss
→ Tinnitus
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 → Vertigo • Treatment
• Vertigo builds in intensity over 30 mins to < 24 hrs → Supportive therapy
→ may be accompanied by nausea and vomiting → Initially vestibular suppressants (central compensation
→ to differentiate from BPPV delayed by prolonged administration)
→ Waxing and waning type of vertigo → Vestibular rehabilitation as early as possible to improve
o When endolymph cause too much pressure, there is balance function
a rupture of membranous labyrinth causing the
admixture. X. REFERENCES
o In the next few hours, it will heal. There will be no more
admixture or perilymph and endolymph. Goes back to
• Doc Saquian’s PowerPoint Presentation
normal
• ViVa Trans
o In the next days, there will be a build up of pressure
again causing the vertigo • Boies Fundamentals of Otolaryngology p39-45
• Symptom free intervals may last several days to months
• Physical examination findings may be normal
• Pure tone audiometry may reveal Iow frequency sensorineural
hearing loss early on progressive course until hearing loss
becomes total, vertigo begins to wane till it disappears
• Treatment:
→ Supportive therapy: reducing pressure through dietary
sodium restriction and diuresis (“maize tea”)
→ Severe attacks: vestibular suppressants such as
dimenhydrinate or diazepam
→ Betahistine HCI,16 mg BID for 2- 3 months may reduce
frequency and severity of vertiginous attacks
→ Surgery: intractable cases unresponsive to medications
(usually cutting of the vestibular nerve)

ENDOLYMPHATIC HYDROPS

Figure 28. Endolymphatic hydrops

• Membranous labyrinth contains endolymph due to increased

pressure
• Sensorineural hearing loss because of admixture of perilymph
and endolymph in the cochlea
• Overproduction of endolymph causes labyrinth to rupture
• When it ruptures, there is an admixture of endolymph and
perilymph
→ Causes the diagnostic triad

VESTIBULAR NEURONITIS AND VIRAL LABYRINTHS

• In the history, patient usually have common cold
• Sudden onset severe vertigo and imbalance, nausea and
vomiting, usually following non-specific viral illness
• Vertigo persists days to weeks; preferentially lie still in dark,
quiet room
→ Needs to be admitted
• Spontaneous nystagmus to contralateral (unaffected) ear
• Pure tone
• Audiometry is normal
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XI. APPENDIX

SNNOOP PHYSICAL EXAMINATION WHAT TO LOOK FOR

SYSTEMIC • Vital signs Hypo/hypertension or postural hypertension
Chest and Heart Findings Arrhythmia

NEUROLOGIC • Cranial Nerve Exam Neurologic deficits that might point out a
• Motor/Sensory Exam cerebrovascular accident (CVA) e.g. Unilateral
• Cerebellar Exam weakness, paresthesias
Cerebellar dysfunction

NECK • Auscultation for bruits Neck positions that might induce dizziness
• Range of motion Carotid bruits

OPHTHALMOLOGIC • Visual acuity/refraction Errors of refraction

• Extraocular muscles (EOMs) Limitation of EOMs
• Fundoscopy Papilledema: Retinal Abnormalities

OTOLOGIC • Otoscopy Otologic diseases e.g., AOM, CSOM. Nystagmus

• Pneumatic otoscopy Hearing deficits
• Tuning fork tests Vestibular dysfunction
• Vestibular function tests
• Dix-Hallpike
• Head Shaking Nystagmus
• Head Thrust Test
• Unterberg/Fundus Marching Test

PSYCHIATRIC • Mental Status Exam Abnormalities in memory, concentration,

aphasias

Table 2. SNNOOP Questionnaire

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