Vertigo Evaluation & its Management

INTRODUCTION
 Vertigo, defined as an unpleasant illusion of one’s own body
movement, is one of the most complicated morbid
symptoms.

 It is difficult to identify, practically impossible to measure and

not easy to treat.

 The symptom may result from a disease due to various causes

(with both the peripheral or central vestibular or retro
vestibular etiology), differing in severity (from minor to very
severe) and prevalence.
INTRODUCTION
 While its early diagnosis can be of immense importance for
further fate of the affected person 1,2

 Vertigo most commonly reflect functional disorders .

.. without underlying somatic/structural change.

 Hence, a great need for precise and effective diagnostics is

undoubted and urgent.
 INTRODUCTION
 Fortunately, the subjective feeling of
vertigo may be objectively verified by
measurement of nystagmus3.
 Nystagmus , i.e., spontaneous or
induced (e.g., by caloric or rotatory
stimuli) is two-phase slow movement of
the eyes to one direction followed by
rapid recoil to the other direction,
which enables the qualitative and
quantitative assessment of vestibular
system lesion4.
INTRODUCTION
 This nystagmus can be objectively recorded by
Electronystagmography (ENG )
which tests the integrity of Vestibulo-ocular reflex [VOR]).

 ENG testing is widely used :

Because of its simplicity, reliability, its ability to lateralize the
side of a vestibular lesion and central lesions,
which are difficult to localize by various vestibular function
tests and in absence of any structural central lesion (where
CT/MRI Scans can detect them easily, if present.)
INTRODUCTION
 Early diagnosis also helps us to manage effectively, reducing
the morbidity & recovery of the patient.

 So, this study was taken to have an overview of vertigo and

its management.
AIMS AND OBJECTIVES:

 To evaluate the role of various clinical tests, investigations in

vertigo.

 To know the peripheral, central and other causes of vertigo.

 To know the overall management of vertigo.

MATERIALS AND METHODS:

 Study design: Prospective study.

 Sample Size: 50 cases.

 Study period: January 2016 to May 2017

 Study place :Department of Otorhinolaryngology, Head and

Neck Surgery, M. R. Medical College, Gulbarga.

 Ethical clearance was granted from institutional ethical committee

Clinical Cerebellar tests

HEAD-IMPULSE TEST.
FISTULA TEST.
Clinical Cerebellar tests

DYSDIADOKENSIA UNTENBERGER TEST

Clinical Cerebellar tests

ROMBERG’S TEST FINGER NOSE TEST

Electronystagmography tests.

Spontaneous nystagmus-GAZE CENTER

Spontaneous nystagmus

GAZE UP GAZE LEFT

Positional test

HEAD LEFT LATERAL LEFT

Dix-Hallpike test

HEAD RIGHT
PENDULUM TEST

PENDULUM
BI-THERMAL CALORIC TEST

CALORIC TEST
ENG TRACINGS

NYSTAGMUS TRACING PENDULAR TRACING

CLAUSSEN’S BUTTERFLY CHART

CODE “0000”
Other investigations
 CT / MRI Scan of Brain : If ENG is suggestive of central
lesion. (to rule out
 Routine blood investigation.
 Specific investigations if required.
 RESULTS (Age & Sex distribution)
AGE
14 Sex Distribution
12
10
Female
8
44%
13
6 11 AGE Male
10 56%
4
6 6
2 4
0

Most of the patients belonged to 3rd & 4th decade i.e. 31 – 50 years.

Most common among Males > Females.

 RESULTS ( Presenting Complaints)
Presenting complaints Associated symptoms

Faintness 2 Nausea
Imbalance 23 Vomiting
Spinning 27 Headache
Earache
Light Headedness 2
Hearing loss
Unsteadiness 4 Aural fullness
Swaying 16 Tinnitus

0 10 20 30

Most common presentation was Spinning sensation > Imbalance.

Most common associated symptom was Nausea > Vomiting.

More than 50% of patient had associated ear symptoms Suggestive of Peripheral cause.
 RESULTS (Other Co-morbidities)
Other Ailments
25
20 20
15
12
10 9
7 8
5
0

Most common associated Co-morbidity was Hypertension > diabetes mellitus> H & N
Trauma.
 RESULTS ( Clinical Findings)
CLINICAL TESTS POSITIVE IN NO. OF PATIENTS

FISTULA TEST 0

HEAD-IMPULSE TEST 8

DIX-HALLPIKE TEST 20

UNTERBERGER TEST 16

ROMBERGS TEST 3

STRAIGHT LINE WALKING TEST 2

DYSDIADOCHOKINESIA 1

Dix-Hallpike test + in 20 casesBPPV (20) Romberg test + in 20 cases

Straight line test + in 8 cases Central
Head-Impulse test + in 8 cases Peripheral Dysdiadochokinesia + in 16cases Cause(6)
Unterberger test + in 16cases Cause (24)
 RESULTS (Clinical ENG findings & ENG Caloric findings)
ENG FINDINGS POSITIVE IN NO. CALORIC TEST POSITIVE IN NO.
OF PATIENTS FINDINGS OF PATIENTS
SPONTANEOUS 10
NYSTAGMUS
NORMAL 10
POSISTIONAL 14 RESPONSE
TEST
HYPOACTIVE 34
DIX-HALLPIKE 20
RESPONSE
TEST
PENDULUM TEST 6 HYPERACTIVE 6
RESPONSE

Dix-hallpike +in 20 cases BPPV(20) Hypoactive Response +in 34 cases Peripheral

Test Cause(34)

Spontaneous + in 10 cases Peripheral Hyperactive Response +in 06 cases Central

Nystagmus Cause (24) Cause (06)
Posistional + in 14cases Normal response + in 10 cases
Test BPPV- 6 cases
Cervicogenic vertigo-2 cases
Pendulum + in 06 cases Central Psychogenic vertigo-1 case
Test Cause(06) Migranous vertigo- 1 case
 RESULTS (Various causes of vertigo)
Peripheral causes No of Central causes No of cases Others No of cases
cases (6) (6)
(38)

Acute Labyrinthitis 8 Cerebellar 2 Cervicogenic 2

lesion vertigo
Vestibular neuronitis 6 Brain stem lesion 2 Psychogenic 1
vertigo
BPPV 20 Vascular causes 1 Migranous 1
vertigo
Meniere’s disease 2 Vertebrobasillar 1 Metabolic 2
insufficiency causes

labyrinthine Trauma 1
dysfunction
Chronic 1
Management
 BPPV in 20 cases, were managed by
 Epley’s maneuver.
 Repeat Epley’s was done in two cases with relapse.
 Two Cases of Meniere's disease were managed by
 Medical therapy
 Vestibular rehabilitation exercises
 Salt restricted diet.
 Peripheral labyrinthine dysfunction( 16 cases) were treated with:
 Labyrinthine sedatives
 Cawthrone Cooksey's exercises.
 Cases with central lesions were
 Evaluated with CT/MRI Scans.
 Referred to neurologist for further management.
EPLEY’S MANEUVER(Posterior canal)
CONCLUSION
 Hence, thorough evaluation of patients with:
 Meticulous history,
 ENT examination,
 Tests for balance,
 Clinical cerebellar test,
 Vestibulo-ocular test with Electronystagmography

 Helps establish a diagnosis and consider appropriate

treatments in most cases avoiding expensive and
inappropriate investigations to patients
REFERENCES
1. Józefowicz-Korczyńska M, Łukomski M, Pajor A.
Electronystagmographic evaluation of the vestibular organ condition
in patients with tinnitus and cervical spine degeneration.
Otolaryngol Pol 2004;58(2):349–53 [in Polish].
2. Olszewski J, Repetowski M. Clinical analysis of cervical vertigo
patients in the own material. Otolaryngol Pol 2008;62(3): 283–7
[in Polish].
3. Milojevic, B.: Electronystagmography, Laryngoscope
75:243-258 (Feb) 1965.
4. Farkashidy, J.: Electronystagmography: It's Clinical
Application, Canad Med Assoc J 94:368-372 (Feb) 1966.