Evaluation of

Vertigo
Dr. Vishal Sharma
 Physiology of equilibrium
Balance of body during static or dynamic

positions is maintained by 4 organs:

1. Cerebellum

2. Vestibular apparatus (inner ear)

3. Eye 4. Posterior column of spinal cord

Vestibulo-ocular reflex & vestibulo-spinal reflex

maintain eye & trunk position.
 Vestibular apparatus

Semicircular canals

Angular acceleration & deceleration

Utricle

Horizontal linear acceleration & deceleration

Saccule

Vertical linear acceleration & deceleration

Orientation of semicircular canals
Physiology of head movement
Head Movement Semicircular canal
stimulated
Yaw Lateral

Pitch Posterior + Superior

Roll Superior + Posterior

Nystagmus (fast component)
Semicircular canal Nystagmus Direction (fast phase)
stimulated

Right Lateral Right horizontal

Left Lateral Left horizontal

Right Superior Down beating, counter-clockwise

Left Superior Down beating, clockwise

Right Posterior Up beating, counter-clockwise

Left Posterior Up beating, clockwise

 Definition of vertigo
 A sensation of rotation or imbalance of one's self or

of one's surroundings in any plane

 rotation of one's self only = subjective vertigo

(seen commonly in central causes)

 rotation of one's surroundings = objective vertigo

(seen commonly in peripheral causes)

 Causes for vertigo

A. Peripheral: lesions of vestibular end organs &

vestibular nerve. Account for 85% of all cases of

vertigo.

B. Central: lesions of central nervous system.

Account for 15% of all cases.

 Peripheral causes
 B.P.P.V. (commonest)  Temporal bone #

 Meniere’s disease  Barotrauma

 Vestibular neuronitis  Cholesteatoma

 Labyrinthitis  Cochlear otosclerosis

 Vestibulotoxic drugs  Autoimmune disease

 Vestibular schwannoma  Presbystasis

 Perilymph fistula  Paget’s disease

 Central causes for vertigo
Vascular causes: see next slide

Epilepsy: both disease & its treatment

Road Traffic Accident: head trauma

Tumor: of brainstem, 4th ventricle & cerebellum

Infection: meningitis, encephalitis

Glial diseases: multiple sclerosis

Others: Parkinsonism, psychogenic

 Vascular Causes
1. Vertebro-Basilar Insufficiency

2. Wallenberg’s lateral medullary syndrome: PICA

 Ipsilateral ataxia + vertigo + nystagmus + diplopia

 loss of touch, pain & temperature: I/L face, C/L body

 Dysphagia, hoarseness, decreased gag reflex

 I/L Horner’s syndrome

3. Hypertension 4. Basilar migraine

 Miscellaneous causes
Cervical Vertigo Iatrogenic

 Neurovascular  SCC fenestration

 Neuromuscular
 Stapedectomy
 Mechanical vascular
Drug induced
Ocular Vertigo
 Vestibulotoxic drugs
 Error of refraction

 Extra-ocular muscle palsy

 Psychogenic vertigo
Causes: anxiety, panic disorder, phobia

Diagnostic features:

 Absence of organic causes

 Presence of vague & fleeting symptoms

 Dramatic presentation & attention seeking behaviour

 Relation b/w emotional stress & onset of vertigo

 Vertigo-like symptoms
 faintness

 light-headedness

 unsteadiness

 motion intolerance

 imbalance

 floating sensation
Causes of Vertigo-like
symptoms
Hematological: anemia, polycythemia

Cardiovascular Metabolic

 Orthostatic hypotension  Diabetes mellitus

 Cardiac failure  Hypoglycemia

 Obstructive cardiomyopathy  Hypothyroidism

 Cardiac dysrhythmias  Chronic renal failure

 Carotid sinus syndrome  Alcohol intoxication

 Hyperventilation
 History Taking

Can diagnose 80% cases

 Important history questions
 Confirmation of vertigo: rotatory sensation
 Absence of syncope or light headedness
 Onset: sudden or gradual
 Episodic (isolated / recurrent) or continuous
 Duration of each episode of vertigo
 Associated symptoms
 Provoking or aggravating factors
 Systemic illness causing vertigo
 Associated symptoms
 Decreased hearing: a. symmetric

b. asymmetric (CPA lesion)

 Ear discharge

 Tinnitus & aural fullness

 Focal neurological deficit

 Nausea & vomiting

 Imbalance
 Associated Causes
symptoms

Deafness + tinnitus Meniere’s disease

+ aural fullness

Imbalance Vestibular neuronitis, Acoustic

neuroma

Headache Migraine, Acoustic neuroma

Focal neurological Acoustic neuroma, Central vascular

findings causes

Ear discharge Labyrinthitis, perilymph fistula

 Provoking or
aggravating factors
1. Specific head position
2. Sudden standing up from sitting position
3. Sudden head & neck movement
4. Recent U.R.T.I.
5. Trauma to ear or head
6. Stress
7. Change in ear pressure
8. Headache
9. Drug intake
10. Diplopia
 Provoking factor Causes

Change in head position B.P.P.V., labyrinthitis

Sudden standing up from Orthostatic hypotension

sitting position

Sudden neck movement Cervical spondylosis, VBI

Recent URTI Vestibular neuronitis

Stress Psychogenic, migraine

Change in ear pressure Perilymph fistula

 Drugs causing vertigo
 Alcohol  Analgesic (opiate)

 Anti-histamine  Anti-hypertensive

 Anti-angina drug  Anti-arrhythmic

 Anti-coagulant  Aminoglycoside

 Isoniazide (INH)  Rifampicin

 Anti-malarial  Corticosteroid
Systemic illness causing vertigo
 Hypertension / Hypotension

 Hypoglycemia

 Epilepsy

 Brain infection

 Brain tumors

 Parkinsonism

 Multiple sclerosis
Episode Causes
duration
Deafness absent Deafness present

Seconds BPPV Perilymph fistula

Minutes Central vascular causes Perilymph fistula

Hours Vestibulopathy, Meniere’s disease,

Head trauma Perilymph fistula

Days Vestibular neuronitis, Labyrinthitis,

Multiple sclerosis Vestibular schwannoma

Weeks Multiple sclerosis, Vestibular schwannoma

Psychogenic
Routine ENT OPD
tests for vertigo
evaluation
 Test for spontaneous & gaze-evoked nystagmus
 Head shake test & head thrust test
 Positional tests
 Positioning tests (Dix-Hallpike & Roll tests)
 Fistula test
 Caloric tests
 Tests for dys-equilibrium
 Tests for co-ordination
 Cranial nerve examination
 Nystagmus
 Involuntary, rhythmical oscillatory movement of eye

 Vestibular or jerk nystagmus have slow & fast

phases. Pendular nystagmuses don’t have 2 phases.

 Direction of nystagmus given by its fast phase

 Vestibular nystagmus gets enhanced by looking in

direction of faster phase & diminished by looking

away from it (Alexander’s law)

 Features Peripheral Central
1. Nystagmus character

a. Direction Fixed Changes

b. Duration Short (days) Long (weeks)
c. Effect of optic fixation Inhibited Unchanged
d. Latency Present Absent
e. Fatigability (asthenia) Present Absent
2. Nausea & vomiting Severe Variable
3. Deafness & tinnitus Common Rare
4. Imbalance Mild Severe
5. Neurological deficit Rare Common
 Alexander’s Classification
Intensity grading of vestibular nystagmus:

1°  only present while looking towards fast phase

2°  present while looking towards fast phase &

also while looking straight

3°  present while looking towards fast phase,

looking straight & looking towards slow phase

 Peripheral Nystagmus
 Vestibular lesion nystagmus gets suppressed

by optic fixation & gets enhanced with removal

of optic fixation (with Frenzel glasses or in dark)

 Irritative vestibular labyrinthine lesion:

Ipsilateral nystagmus

 Paralytic vestibular labyrinthine lesion:

Contralateral nystagmus
Test for spontaneous nystagmus
Patient’s eyes examined with: pt’s looking straight
ahead with fixed head; no visual or vestibular
stimulus; no optic fixation

Best examined in dark room with infra-red video

goggles over open eyes or during electro-
nystagmography with eyes closed

Spontaneous nystagmus seen in unilateral

peripheral vestibular lesion or central lesions.
Test for gaze-evoked nystagmus
 Finger kept centrally 30 cm from pt's eyes &

moved in horizontal & vertical planes

 Pt is asked to follow it with his / her eyes

 Keep displacement from midline to maximum of

30° (avoids physiological end-point nystagmus)

 Bidirectional nystagmus seen in CNS lesions

Test for gaze-evoked nystagmus
 Head shake test
 Patient’s head grasped by physician & rapidly (2

Hz) shaken from side to side for 20 times. Repeat

in vertical plane for 20 times.

 Presence of > 3 horizontal nystagmus indicates

opposite vestibular disorder (left lesion  right

nystagmus). Vertical nystagmus indicates

brainstem or cerebellar lesion.

 Head thrust test
 Starting from neutral position (A), rapid head thrust to

Rt in horizontal plane  compensatory eye movement

to left  pt's eyes remain stable on examiner (B)

 On similar head movement to left (C), I/L hypoactive

labyrinth results in delayed catch up saccade (D) to

maintain gaze. Arrow shows direction of saccade

Head thrust test
 Fistula test
 Transmission of increased air pressure in

E.A.C., via middle ear, into inner ear through a

labyrinthine fistula causes vertigo + nystagmus

towards affected ear

 E.A.C. pressure is increased by intermittent

tragal pressure or Siegelization

Fistula Test
 Sites of labyrinthine fistula
1. Horizontal semicircular canal

 Cholesteatoma destruction

 Fenestration operation

2. Oval window

 Post-stapedectomy

3. Round window membrane rupture

 Hennebert’s sign
False positive fistula sign in absence of labyrinthine
fistula. Seen in:

1. Meniere's disease: fibrosis b/w stapes footplate &

utricle

2. Hyper mobile stapes footplate

 Congenital syphilis

 Idiopathic
 False negative fistula sign
Negative fistula sign in presence of labyrinthine

fistula. Seen in:

1. Cholesteatoma matrix / granulation covering

labyrinthine fistula

2. Dead Labyrinth

3. Total E.A.C. obstruction (impacted wax)

 Positional Nystagmus
 Placing pt’s head slowly in different positions,

detects response to changes in direction of

gravitational force

 11 specific head position:

a. Sitting position: 5 head positions

b. Supine position: 6 head positions

 Each position to be maintained for 30 sec

 Head positions
Sitting position Supine position

 Head upright  Head straight

 Right side down

 Right side down
 Left side down
 Left side down
 Head hanging straight
 Head extended
 Head hanging with right turn
 Head flexed
 Head hanging with left turn
 Positioning Nystagmus

 Helps to detect anomalies in otolith system

 Provoked by placing head rapidly in different

positions

Tests

 Dix-Hallpike Test

 Roll Test
 Dix – Hallpike
maneuver
(Nylen – Barany
maneuver)
Step 1
Step 2
Step 3
Step 4
Steps 1 to 3
Step 3 to 4
 Dix-Hallpike Manoeuvre
1. Pt in sitting position on a couch looking ahead

2. Pt’s head turned 45° towards diseased ear

3. Pt moved rapidly into supine position with

head hanging 30° below couch. Pt’s eyes

observed for nystagmus for 1 minute

4. Pt moved rapidly back into sitting position

5. Manoeuvre repeated for opposite ear

Intermission
Caloric testing
Fitzgerald-Hallpike Bithermal
Caloric Test
Contraindications:

1. E.A.C. obstruction

2. Ear infection

3. T.M. perforation

4. Bradyarrythmias

5. Labyrinthine sedatives (for 24 hrs)

 Bithermal Caloric Test
 Pt supine + 30° head elevation. Each ear

irrigated in turn for 40 sec with warm water at

44°C & then cold water at 30°C.

 Duration of nystagmus is from start of irrigation

to end point of nystagmus. Normal = 90–140 sec

 Direction of fast component:

Cold → Opposite ear; Warm → Same ear

Effect of 30 head elevation
0
Fitzgerald-Hallpike Bithermal
Caloric Test
Mechanism of caloric
stimulation
Convection current formation in endolymph due to

temperature gradient → ampullo-petal flow for

warm water  activation of Vestibulo-Ocular Reflex

OR ampullo-fugal flow for cold water  inhibition

of Vestibulo-Ocular Reflex  vertigo + horizontal

nystagmus (slow phase away from side of VOR

activation & toward side of VOR inhibition)

Normal Calorigram
 Canal Paresis

Duration of nystagmus with both 44°C &

30°C irrigations in one ear is 30 % less

than opposite ear. Seen in same sided

peripheral vestibular lesion.

C. P. (%) = (R30 + R44) – (L30 + L44) X 100

R30 + R44 + L30 + L44

Right Canal Paresis
Left Canal Paresis
 Directional Preponderance
Duration of nystagmus in one direction is 30 %

more than opposite direction. Seen in same

sided central lesion or opposite sided

recovering peripheral vestibular lesion.

D.P. (%) = (L30 + R44) – (R30 + L44) X 100

R30 + R44 + L30 + L44

Right Directional Preponderance
Left Directional Preponderance
 Caloric test in comatose patient
 With brainstem intact: Only slow phase movements to

cool or warm irrigation. Fast corrective phase absent.

 With B/L MLF damage (internuclear ophthalmoplegia)

in Multiple Sclerosis: only lateral movement of one eye

possible as B/L medial rectus muscles are denervated

 With B/L low brainstem lesion at vestibular nuclei: no

nystagmus in either warm or cool water irrigation

 Modified Kobrak's Test
E.A.C. irrigated for 60 sec with ice cold water in

increasing quantity (5, 10, 20 & 40 ml) till

nystagmus is noticed

If nystagmus noticed with:

 5 ml = Normal vestibular labyrinth

 10 / 20 / 40 ml = Hypoactive labyrinth

 No nystagmus (40 ml) = Dead labyrinth

Dundas Grant Cold Air Caloric
Test
 Done in T.M. perforation as water syringing is

contraindicated

 Air in coiled copper tube is cooled by pouring

ethyl chloride in it

 Effluent cool air is blown into E.A.C. to

produce vertigo + nystagmus

 Tests for dys-equilibrium

1. Standing test

2. Tandem gait test

3. Romberg test

4. Modified Romberg test

5. Unterberger / Fukuda stepping test

6. Babinski Weill test

 Standing Test
Task: patient stands normally, with eyes closed

In peripheral vestibular lesion, pt assumes Discus

Thrower’s position:
 Head turned towards side of lesion
 Trunk twisted to side of lesion
 Raising of hand on healthy side & lowering on
side of lesion
 Falling to side of lesion
Discus thrower position
 Tandem gait test
 Patient made to walk with eyes open in a straight

line in tandem position (toes of one feet right

behind heel of other feet). Stopped suddenly &

asked to walk back.

 Test repeated with eyes closed

 Falling towards side of peripheral vestibular lesion

Tandem gait test
Romberg
test
 Subject stands with feet together, eyes open & hands
by the sides for 1 minute. Observe for swaying.
 Subject closes eyes in same position for 1 minute.
Observe for swaying.
 Romberg test sharpened by tandem position of feet.
 Positive Romberg = swaying towards side of lesion,
only when eyes are closed. Seen in sensory ataxia
(loss of proprioception).
 Negative Romberg = swaying even when eyes are
open. Seen in cerebellar ataxia (non-specific).
Sharpened Romberg test
 Unterberger test
 Patient blindfolded, standing erect, arms extended

 Asked to step on same spot 90 times in 1 minute

 Peripheral vestibular lesion: pt deviates / rotates

to side of lesion by > 30 degrees

 Deviation if <30 degrees on either side is

considered normal
Unterberger
test
 Babinski Weill test

 Patient asked to walk with eyes closed 5 pace

forwards & 5 pace backwards 6 times in 30 sec

 U/L vestibular lesion: patient walks in star shaped

trajectory
 Tests for coordination

1. Past pointing

2. Fukuda writing test

3. Tests for cerebellar function

– Finger nose test

– Heel knee test

– Rapid alternating task test

 Past pointing test
 Pt. made to sit with hands up & index finger
extended
 Examiner raises his index finger in front of pt
 Pt asked to touch examiners finger with eyes open
& then with eyes closed
 If pt cannot perform task smoothly  past
pointing
Past pointing test
 Fukuda writing test

 Patient asked 8-10 capital letter vertically in a

straight line first with eyes open then with eyes

closed

 In U/L vestibular lesion: Letter deviates >20 deg

towards involved side but are legible

 In cerebellar lesion: Letters are illegible

 Finger nose test

Pt asked to touch her nose & then touch examiner’s

index finger with her index finger.
Cerebellar lesion pt cannot do it.
Heel shin test
 Pt asked to move heel of one leg over shin of other leg

in a straight line. Cerebellar lesion pt cannot do it.

Rapid alternating task test

 Patient asked to alternately perform supination &

pronation of one palm over other palm at rapid rate.

Cerebellar lesion pt cannot do it (adiadochokinesia) or

has difficulty doing it (dysdiadochokinesia).

Heel shin test
Rapid alternating task test
Other Specific
Investigations
1. Electro-nystagmography

2. Computerized dynamic posturography

3. Cranio-corpography

4. Galvanic test (obsolete)

5. Vestibular rotation tests

6. Vestibular evoked potential

7. Brain Electrical Activity Mapping (BEAM)

8. Dynamic visual acuity

 Electro-
nystagmography
 Principle
 Retina is negative charged

compared to positive cornea

resulting in corneo-retinal

potential

 Movement of eyeball causes

movement of electrical field

currents & detected by

electrodes around eye

 Electrode positioning

Lateral to outer canthus both sides:

 horizontal movement

Above & below eye one side:

 vertical movement

Glabella:

 ground electrode
Electrode placement
 Electro-nystagmograph

Y axis: 1 cm = 5 degree ocular movement

X axis: 1 cm = 1 sec
 Identification of movement
 Horizontal movement of eye:

– Right movement = upward deflection

– Left movement = downward deflection

 Vertical movement of eye:

– Upward movement = upward deflection

– Downward movement = downward deflection

 Nystagmus Identification
 Nystagmus beat should be triangular in shape

 Upward & downward deflection should have

different slopes

 Gradual slope = slow component

 Steep slope = fast component

 Both slopes equal = pendular nystagmus

 E.N.G. procedures
Vestibular tests

 Spontaneous nystagmus

 Gaze nystagmus

 Positional nystagmus

 Positioning nystagmus

 Fistula test

 Bi-thermal caloric tests

 Culmination Frequency
 No. of nystagmus beats in 30 seconds of most

prolific phase of nystagmus duration in ENG

Caloric test values:

 Right warm = 22 - 59 beats / 30 seconds

 Right cold = 24 - 67 beats / 30 seconds

 Left warm = 23 - 63 beats / 30 seconds

 Left cold = 27 - 68 beats / 30 seconds

Response graded as:

0 = normal response

1 = hypoactive response

2 = hyperactive response

Result given as code of 4 digits in order of:

Right warm, Right cold, Left warm, Left cold

Graphical presentation of this data called

Claussen’s Butterfly chart

Claussen’s

Butterfly

chart
0000 (normal butterfly) = normal balance function
1111 (minor butterfly) = B/L vestibular or brain stem lesion
2222 (major butterfly) = B/L brain stem or cerebellar lesion
1010 & 0101 = B/L vestibular lesion
1100 (Rt canal paresis) = Rt vestibular lesion
0011 (Lt canal paresis) = Lt vestibular lesion
0220 (Lt directional preponderance) ├ peripheral / central
2002 (Rt directional preponderance) ├ lesion
0022 (Lt nystagmus dysinhibition) = Rt cerebellar lesion
2200 (Rt nystagmus dysinhibition) = Lt cerebellar lesion
0110 (Lt directional inhibition) = Lt brain stem lesion
1001 (Rt directional inhibition) = Rt brain stem lesion
 Computerized dynamic
posturography
 Consists of computer-controlled platform & visual

booth used to evaluate both sensory + motor

components of balance

 Has 2 parts: a. Sensory organization test

b. Motor coordination / Motor control test

 Posturography not a substitute for careful gait

examination & is more valuable in rehabilitation

 Sensory organization test
 Detects defect in subject’s ability to use vestibular,

somatosensory & visual inputs to maintain balance

 These 3 systems are singly or collectively manipulated

to test subject’s ability to maintain balance under

these stressful conditions. Analyzed by computer.

 Sensory test useful in peripheral lesions, vestibular

rehabilitation & medico legal cases

 Eye Visual Base Equilibrium Inputs

1 Open Steady Steady Vestibular + Visual + Somatosensory

2 Close Absent Steady Vestibular + Somatosensory

Vestibular + Somatosensory +
3 Open Sway Steady
Visual (altered)

Vestibular + Visual +
4 Open Steady Sway
Somatosensory (altered)

5 Close Absent Sway Vestibular + Somatosensory (altered)

Vestibular + Visual (altered) +

6 Open Sway Sway
Somatosensory (altered)
Dysfunction Pattern Abnormal Test Condition

Vestibular ------------------------------------- 5, 6

Visual + vestibular ------------------------ 4, 5, 6

Visual preference --------------------------- 3, 6

Visual preference + vestibular -------- 3, 5, 6

Somatosensory + vestibular --------- 2, 3, 5, 6

Severe dysfunction --------------------- 1, 2, 3, 4

 Motor coordination test
Evaluation of efferent motor pathway of balance

Support surface of CDP machine suddenly moved:

1. forward & backward

2. upward & downward

Lower limb muscle responds by movement of ankle

& hip joints. Motor output assessed by CDP

Motor coordination test
 Cranio-corpography
 Pt wears helmet with light bulbs

 Photographic representation of pt's movement

patterns on performing Romberg & Unterberger tests

 Wide angular deviation (> 700 away from sagittal axis)

indicates peripheral dysfunction on side of deviation

 Lateral sway > 20 cm suggests central pathology

Cranio-corpography
Left angular deviation
Broad lateral sway
Barany’s chair rotation test
 Findings in rotation tests

 Rt rotation (clockwise)  Rt beating nystagmus

 Lt rotation (anti-clockwise)  Lt beating nystagmus

 Intensity of nystagmus same for both rotations

 Asymmetrical intensity  vestibular pathology

 Intensity not ed on optic fixation  central lesion

 Vestibular evoked potentials
 Vb.E.P study is like BERA with vestibular stimulus

(head movement) instead of auditory stimulus

 Response recorded by electrode placed on pt’s vertex

 Short latency response: recorded from first 10 msec

 Middle latency response: 10 – 100 msec

 Long latency response: 100 - 1000 msec (also known

as Long latency rotational evoked potential)

Vestibular (auditory)
Evoked Myogenic
Potentials
(VEMP)
 VEMP = Electromyography response of I/L sterno-

cleidomastoid muscle to loud click. Afferent reflex limb

from saccule via inferior vestibular nerve & efferent limb

via medial vestibulo-spinal tract.

 Normal audio threshold for VEMP is > 75 dB. Low

thresholds (60 dB) or Tullio effect seen in Meniere’s

disease, superior SCC dehiscence, multiple sclerosis,

acoustic neuromas & vestibular neuronitis.

Electrode placement in VEMP
VEMP with threshold of 85 dB
Referral to other departments
 Internal Medicine: cardiovascular & metabolic causes

 Neurology: central nervous system causes

 Ophthalmology: ocular pathology

 Orthopedics: cervical spine problems

 Psychiatry: psychogenic vertigo

 Pediatric: in pediatric migraine

 Radiology: X-ray cervical spine, CT scan / MRI brain

Imaging indications in vertigo
 Unilateral or asymmetric hearing loss
 Vertical nystagmus, nystagmus not suppressed with
fixation, inability to stand unassisted
 Direction-changing spontaneous nystagmus
 Presence of cerebellar signs
 New-onset severe headache
 Stroke risk (DM, HTN, smoking, h/o myocardial infarct)
 Acute vertigo with neck pain
Thank You