Vertigo is a problem commonly encountered in daily clinical practice.So an uniform approach to a patient with Vertigo is essential to identify the underlying aetiology of Vertigo.

1. Approach to VertigoApproach to Vertigo
Dr. Subrata DeyDr. Subrata Dey
IMOIMO
Department of Medicine (Ward-13)Department of Medicine (Ward-13)
Chittagong Medical College HospitalChittagong Medical College Hospital

2. EpidemiologyEpidemiology
 Approximately 30% people – experienceApproximately 30% people – experience
moderate to severe dizziness at some pointmoderate to severe dizziness at some point
in their life.in their life.
 80% - seek medical care at some point.80% - seek medical care at some point.
 Though most people report non specificThough most people report non specific
forms of dizziness, nearly 25% of theseforms of dizziness, nearly 25% of these
people report true vertigo.people report true vertigo.
 Dizziness – Females>Males and olderDizziness – Females>Males and older
people.people.

3. DizzinessDizziness
 An ambiguous term that patients use toAn ambiguous term that patients use to
describe several entirely differentdescribe several entirely different
subjective states.subjective states.
 The complaint of dizziness generally canThe complaint of dizziness generally can
be divided into 1 of 4 categories-be divided into 1 of 4 categories-
1. Vertigo1. Vertigo
2. Syncope or presyncope2. Syncope or presyncope
33.. DisequilibriumDisequilibrium
44.. Ill-defined dizzinessIll-defined dizziness

4. Maintenance of balanceMaintenance of balance
Higher centersHigher centers ::
* Extra pyramidal system* Extra pyramidal system
* Cerebellum* Cerebellum
* Reticular formation* Reticular formation
Brain stem
integrating center
(Vestibular nuclei)
(Sensory systems)
Vision
Proprioception
Vestibular
labyrinths
( Effector pathways )
Oculomotor system
(Vestibulo-ocular reflex)
Antigravity muscles
controlling posture &
gait (Vestibulo spinal
reflex)
Perception of
orientation
(in Vestibular cortex)

5. VertigoVertigo
 An illusory or hallucinatory sense of movement of theAn illusory or hallucinatory sense of movement of the
body or environment.body or environment.
 May be described as – rotatory, spinning, tilting orMay be described as – rotatory, spinning, tilting or
swaying.swaying.

6. VertigoVertigo
 Causes :Causes :
 PeripheralPeripheral -Physiologic (motion sickness)-Physiologic (motion sickness)
- Benign paroxysmal positional vertigo- Benign paroxysmal positional vertigo
- Vestibular neuronitis- Vestibular neuronitis
- Meniere’s disease- Meniere’s disease
- Post-traumatic vertigo- Post-traumatic vertigo
- Labyrinthine imbalance- Labyrinthine imbalance
- Herpes zoster oticus- Herpes zoster oticus
-Aminoglycoside ototoxicity-Aminoglycoside ototoxicity
 CentralCentral - Brain-stem or Cerebellar stroke- Brain-stem or Cerebellar stroke
- Multiple sclerosis- Multiple sclerosis
- Post. Fossa tumour- Post. Fossa tumour
- Basilar migraine- Basilar migraine

7. Continued…Continued…
 Cervical spondylosisCervical spondylosis
 Orthostatic hypotensionOrthostatic hypotension
 AnemiaAnemia
 HypoglycemiaHypoglycemia
 PsychogenicPsychogenic

8. Benign Paroxysmal Positional Vertigo andBenign Paroxysmal Positional Vertigo and
Central Positional VertigoCentral Positional Vertigo
SignsSigns
BPPVBPPV CentralCentral
Latent periodLatent period 3 – 40 sec.3 – 40 sec. None, immediateNone, immediate
vertigo andvertigo and
nystagmusnystagmus
Duration ofDuration of
nystagmusnystagmus
< 30 sec.< 30 sec. > 30 sec.> 30 sec.
FatigabilityFatigability NystagmusNystagmus
disappears withdisappears with
repetitionrepetition
Nystagmus recursNystagmus recurs

11. AssessmentAssessment

12. Complete historyComplete history

14. Accompanying SymptomsAccompanying Symptoms
− Nausea, vomiting, diaphoresis, apprehensionNausea, vomiting, diaphoresis, apprehension
− DisequilibriumDisequilibrium
− Nystagmus (Visual Disturbance)Nystagmus (Visual Disturbance)

15.  A few minutes:A few minutes:
– Benign paroxysmal positional vertigoBenign paroxysmal positional vertigo
– Vestibular epilepsyVestibular epilepsy
 Several minutes to < 2 hours:Several minutes to < 2 hours:
– Benign recurrent vertigoBenign recurrent vertigo
– Vestibular aura of migraineVestibular aura of migraine
 2 hours to 24 hours2 hours to 24 hours
– Menieres diseaseMenieres disease
– Post. circulation TIA.Post. circulation TIA.
 > 24 hours> 24 hours
– Acute peripheral vestibular dysfunctionAcute peripheral vestibular dysfunction
– Multiple sclerosisMultiple sclerosis
– Bilateral vestibular failure.Bilateral vestibular failure.
Duration of dizzinessDuration of dizziness

16. Dizziness : localizing featuresDizziness : localizing features

Inner earInner ear
– hearing losshearing loss
– tinnitustinnitus
– aural fullnessaural fullness
– otalgiaotalgia
– otorrhoeaotorrhoea
 VIIVIIthth
nervenerve
– facial weaknessfacial weakness
 C-P angleC-P angle
– impaired facial sensationimpaired facial sensation
– clumsinessclumsiness
– dysarthriadysarthria
– inco-orndinationinco-orndination
 Brain stemBrain stem
– loss of consciousnessloss of consciousness
– memory disturbancememory disturbance
– hemiplegia/ hemi paresis,hemiplegia/ hemi paresis,
hemi sensory losshemi sensory loss
– cranial nerve palsycranial nerve palsy
– dysarthria, dysphagiadysarthria, dysphagia
 CerebellumCerebellum
– inco-orndinationinco-orndination
– clumsinessclumsiness
– dysarthriadysarthria

17. ExaminationExamination
 General ExaminationGeneral Examination
PulsePulse
BP- lying and standingBP- lying and standing

18.  Neurological ExaminationNeurological Examination
Cranial NervesCranial Nerves
Signs of Cerebellar lesionSigns of Cerebellar lesion
GaitGait

19. InvestigationInvestigation
 General-General-
ECGECG
RBSRBS
X-ray CervicalX-ray Cervical
SpineSpine
 Specific-Specific-
Central-Central-
MRI ofMRI of
BrainBrain
Peripheral-Peripheral-
Neuro-Neuro-
otological Studiesotological Studies

20. Neuro – Otologic studiesNeuro – Otologic studies
 Electro nystagmographyElectro nystagmography
 PosturographyPosturography
 Audiologic batteryAudiologic battery
– Pure tone audiometryPure tone audiometry
– Speech discriminationSpeech discrimination
– RecruitmentRecruitment
– Stapedial reflexStapedial reflex
– Tone decayTone decay

21. Audiologic evaluation of cochlearAudiologic evaluation of cochlear
and retrocochlear disordersand retrocochlear disorders
TestTest Cochlear lesionCochlear lesion Retrocochlear lesionRetrocochlear lesion
Pure tonePure tone
audiometryaudiometry
S/N hearingS/N hearing
lossloss
S/N hearing lossS/N hearing loss
SpeechSpeech
discriminationdiscrimination
GoodGood PoorPoor
RecruitmentRecruitment YesYes NoNo
Stapedial reflexStapedial reflex NormalNormal ImpairedImpaired
Tone decayTone decay NoNo YesYes
ClinicalClinical
examplesexamples
Menieres synd.Menieres synd. Acoustic neuromaAcoustic neuroma
OtoscopyOtoscopy Middle earMiddle ear
pathologypathology
VIII nerveVIII nerve

22. TreatmentTreatment
 Acute attackAcute attack
– Bed restBed rest
– Vestibular sedatives.Vestibular sedatives.
 PreventionPrevention
– Low salt dietLow salt diet
– DiureticsDiuretics
– TranquillizersTranquillizers
– NeurolepticsNeuroleptics
– VasodilatorsVasodilators
 Betahistine has modest benefit inBetahistine has modest benefit in
preventionprevention
 Surgery – forSurgery – for
intractable casesintractable cases
None of these
superior to
placebo

23. Epley manoeuvreEpley manoeuvre
 Patient quickly laid on one side with the headPatient quickly laid on one side with the head
hanging over the edge of the bed with the affectedhanging over the edge of the bed with the affected
ear downwards.ear downwards.
 After the nystagmus and vertigo abate, the head isAfter the nystagmus and vertigo abate, the head is
kept hyper-extended and slowly rolled in thekept hyper-extended and slowly rolled in the
direction away from the affected ear until he/shedirection away from the affected ear until he/she
faces the opposite side.faces the opposite side.
 The head and trunk is slowly brought to sittingThe head and trunk is slowly brought to sitting
position.position.
 Patient is instructed not to move his/her headPatient is instructed not to move his/her head
vertically or lie down for 24 hours. A soft cervicalvertically or lie down for 24 hours. A soft cervical
collar can be used to restrict head movement andcollar can be used to restrict head movement and
the patient should sleep upright the night after thethe patient should sleep upright the night after the
manoeuvre.manoeuvre.

24. PharmacotherapyPharmacotherapy

34. Take Home MessageTake Home Message
 First decide between true vertigo and pseudoFirst decide between true vertigo and pseudo
vertigo.vertigo.
 Then differentiate between peripheral andThen differentiate between peripheral and
central vertigo.central vertigo.
 Peripheral causes are common.Peripheral causes are common.
 Vertical nystagmus is due to a centralVertical nystagmus is due to a central
neurological cause untill proved otherwise.neurological cause untill proved otherwise.

35.  Central causes are not too many but needCentral causes are not too many but need
urgent recognition as they have differenturgent recognition as they have different
treatment and prognosis.treatment and prognosis.
 BPPV occurs in 40% cases of peripheralBPPV occurs in 40% cases of peripheral
vertigo. It is treated by Epley`s method.vertigo. It is treated by Epley`s method.
 Adaptation exercise should be highlighted inAdaptation exercise should be highlighted in
clinical practice.clinical practice.