vestibular system anatomy and vertigo

[Link] ijla
ENT Consultant
Components of the vestibular system
• This comprises the 3 semicircular
canals and the saccule and utricle=
membranous labrynithin except
the cochlear duct.
• The semicircular canals are
concerned with the rotational
(angular) acceleration and the
saccule and utricle with gravitation
• Ampulla: pear-shaped expansion of
the membranous labyrinth located
at one end of each SSC near the
vestibular opening (where the
semicircular canal meets the
utricle)
• Within each ampulla there is the
sensory organ: the crista
ampullaris.
• Crista ampullaris has 2 types of hair
cells : Type I and Type II hair cells
• THE UTRICLE AND SACCULE:
• The utricle and saccule both
contain endolymph.
• Saccule is smaller than utricle &
lies in a depression below &
infront of utricle
• Within each structure is a
gravitational sense organ: the
macula (otolith organ).
• Utricle Horizontal acceleration,
Sacule Vertical accelation
detection.
Vertigo is defined as the illusion of movement of
the patient or the surroundings.
• chief complaint of patients with injury to the
vestibular system is usually dizziness not
vertigo.
• Never permanent, continuous symptom. Even
when the vestibular lesion is permanent, the
central nervous system adapts to the defect so
that vertigo subsides over days or weeks.
• Constant dizziness lasting months is not
vestibular.
• some patients describe it as constant due to
frequent episodic dizziness.
 The diagnosis depends mostly on history, much on examination and
little on investigation.

Neurological Sx: loss of

consciousness; weakness;
numbness; dysarthria;
diplopia; fitting.

Episodic with aural symptoms Constant with aural symptoms Solitary acute attack with aural
Menière’s disease (HOURS) Chronic otitis media with symptoms
Migraine (MINUTES) labyrinthine fistula (SECONDS) Head injury
Episodic without aural symptoms Ototoxicity Labyrinthine fistula (SECONDS)
Benign paroxysmal positional Acoustic neuroma Viral infection, [Link],herpes
vertigo (SECONDS) Constant without aural symptoms zoster
Migraine (MINUTES) Multiple sclerosis Vascular occlusion
Transient ischaemic attacks Posterior fossa tumour Round-window membrane rupture
(MINUTES) Cardiovascular disease Solitary acute attack without aural
Epilepsy Degenerative disorder of the symptoms
Cardiac arrhythmia vestibular labyrinth Vasovagal faint
Postural hypotension Hyperventilation Vestibular neuronitis (DAYS)
Cervical spondylosis Alcoholism Trauma
 Duration of vertigo. (orange color associated with
hearing loss)
1. Seconds
[Link] paroxysmal positional 5. Weeks
vertigo [Link] disorder
2. Minutes [Link] disease
[Link]-associated vertigo [Link] sclerosis
[Link] insufficiency [Link] neuroma
3. Hours [Link]
[Link]'s disease (endolymphatic 6. Variable duration
hydrops) a. Inner ear fistula
[Link] syphilis b. Labyrinthine concussion
4. Days c. Blast trauma or Barotrauma
[Link] neuritis e. Superior semicircular canal
[Link] dehiscence syndrome
Central vs. Peripheral Vertigo

Central Vertigo Peripheral Vertigo

Onset Gradual Usually Sudden
Tinnitus, hearing loss Absent Present
Neighbourhood signs Present Absent
(Diplopia, cortical
blindness, dysarthria,…)
Nystagmus Pure, vertical, suppress Mixed, horizontal,
with fixation, & suppress with fixation, &
multidirectional unidirectional
Diagnosis
History:
True vertigo, any sensation of motion
Any nausea, vomiting, sweating, and abnormal eye movements.
Occur when moving or changing positions
Duration
Constant or come and go
Any new medications
Recent head trauma
Other hearing symptoms (ringing or hearing loss).
Other neurological symptoms such as weakness, visual disturbances, altered level of
consciousness, difficulty walking, abnormal eye movements, or difficulty speaking
 Examination
Joint position sense (proprioception), carried in the dorsal columns of the spinal cord;
Vision; Vestibular apparatus
• Romberg's test is not a test of cerebellar function, it is a test of the proprioception
receptors and pathways function.
A positive Romberg's test has been shown to be 90% sensitive for lumbar spinal
stenosis.
• Unterberger test used to help assess whether a patient has a vestibular pathology.
It is not useful for detecting central disorders of balance.
If the patient rotates to one side they may have a labyrinthine lesion on that side (not
enough alone)
• Walking with eyes closed: repeat three times, if vestibular deficit is present pt gait is
deviated or unsteady towards the same side
• Turning test: close eyes, walk straight and turn quickly 180 stop at point pt tend to fall
toward the side of vestibular weakness (perilymph fistula)
Examination
• The head thrust test: an examination for chronic peripheral
vestibular loss, to diagnose a chronic as well as to identify the
side of the hypofunctioning labyrinth.
based on the doll’s eye phenomenon
• Show video

Fistula test: done when perilymph fistula is suspected by

pressing on tragus and checking for nystagmus and
symptoms
• Show video
Examination
• Nystagmus: Definition: Involuntary, rhythmical
oscillation of the eyes away from the direction of
gaze, followed by a return of the eyes to their
original position
• named after the fast component of the nystagmus
caloric test: (37 +-7)
• COWS:
• Cold: toward the opposite ear (makes the labyrinthine
hypoactive)
• warm: toward the same ear
• used to validate a diagnosis of asymmetric function in the
peripheral vestibular system.
• one of several tests which can be used to test for brain stem
death.
Investigation:
CT scan if a brain injury is suspected
Blood tests to check blood sugar levels.
ECG to look at heart rhythm may also be helpful.
 BENIGN PAROXYSMAL POSITIONAL VERTIGO
ESSENTIALS OF DIAGNOSIS
1. Sudden vertigo lasting seconds with certain head positions.
2. No associated hearing loss.
3. Characteristic nystagmus (latent, geotropic, fatigable) with Dix-Hallpike test.
Statistics:
• The posterior semicircular canal (PSC) was affected in the majority of cases of BPPV (93% of
cases), with 85% being unilateral, and 8% Bilateral.
• The horizontal semicircular canal (HSC) was affected in 5% of cases.
• Involvement of an anterior canal is rare.
• The average age of presentation is in the 5th decade
• no gender bias.
• The incidence may range from 10-100/100,000 per year.
• Nearly 20% of patients seen at vertigo clinics are given the diagnosis of BPPV.
• The rate of recurrence may be 10–15% per year.
 BPPV
• Arising as a result of mostly due to
Canalithiasis
• Predisposing factors of BPPV:
• Circumstances in which the head is placed
or maintained in an inverted orientation
(eg, dental procedures, visits to the
hairdresser).
• Age, Inactivity, Family history
• Trauma and vestibular neuritis.
• Other ear disease; Meniere’s syndrome.
• The triggering positions:
• rolling over in bed into a lateral position,
getting out of bed, looking up and back,
and bending over.
 Dix Hallpike test in diagnosing BPPV
MANUEVER INTERPRETATION
• A positive test is indicated by a latent period of 1-5 seconds
during which the patient is minimally symptomatic.
• followed by the acute onset of vertigo and rotatory
nystagmus with a rapid component toward the affected
side. A typical duration of symptoms and visible
nystagmus is 10-40 seconds.
• After it stops and the patient sits up, the nystagmus will
recur but in the opposite direction.
• repeated to the same side; with each repetition, the
intensity and duration of nystagmus will diminish.
 Dix Hallpike test in diagnosing BPPV
• DHP test Sensitivity =79%, specificity = 75 %
• Precautions
• patients that are suffering from back pain.
• patient with orthopnoea
• Absolute contraindications
• Neck Surgery
• Severe Rheumatoid arthritis
• Atlantoaxial and Occipitoatlantal instability
• Aplasia of Odontoid process
• Cervical Myelopathy
• Cervical Radiculopathy, disc prolapse
• Carotid Sinus syncope, Carotid artery stenosis
• Vascular dissection syndromes
 Treatment of PSC BPPV
Treatment with Repositioning:
First-line therapy for BPPV, use
gravity to move canalith debris out
of the affected semicircular canal
and into the vestibule.
• Epley maneuver, gravity is the
stimulus that moves the particles
within the canal.
• The maneuver is repeated until
no nystagmus is elicited. In this
way, the Epley maneuver is
effective in more than 90% of
cases in eliminating BPPV.
Show Video
Assistive devices
• Rotator devices
No author suggests that such a
device is required for treatment,
however, they may be useful in
patients who are difficult to
maneuver due to mobility
problems in the cervical spine,
and simultaneous treatment of
bilateral PSC BPPV may be
accomplished with a 360° heels
over head rotation.
endolymphatic hydrops
• In a normal inner ear, the endolymph is maintained at a constant
volume and with specific concentrations of sodium, potassium,
chloride, and other electrolytes. This fluid bathes the sensory cells of
the inner ear and allows them to function normally.
• In an inner ear affected by hydrops, these fluid-system controls are
believed to be lost or damaged. This may cause the volume and
concentration of the endolymph to fluctuate in response to changes
in the body’s circulatory fluids and electrolytes.
endolymphatic hydrops
• Primary idiopathic endolymphatic hydrops (known as Ménière’s
disease) is of unknown etiology
• Secondary endolymphatic hydrops : head trauma or ear surgery, and
it can occur with other inner ear disorders, allergies, or systemic
disorders (such as diabetes or autoimmune disorders).
MENIERE DISEASE

• ESSENTIALS OF DIAGNOSIS
• Episodic vertigo lasting hours.
• Fluctuating hearing loss.
• Tinnitus.
• Aural pressure. (fullness)

Usually starts Unilateral, but in 25% Bilateral

Show video
Management

Stabilizing the body’s fluid and electrolyte levels

• A hydrops diet regimen (HDR): minimizing the use of solutes (salts and sugars); Adequate fluid intake
6-8 glasses/day; Caffeine and alcohol have strong diuretic properties and may need to be restricted.
• Physicians may prescribe diuretics as part of treatment—not to cause fluid loss, but rather to “push”
the kidneys to excrete a constant amount of urine throughout the day,
IDENTIFYING AND TREATING THE UNDERLYING CONDITION
Creating a safe physical environment
Managing persistent symptoms and changes
• Aminoglycoside therapy: intratympanic gentamicin therapy. generally 10% risk of worsening the
hearing loss
• SURGICAL MEASURES Endolymphatic sac decompression; Vestibular neurectomy; Labyrinthectomy
leads to unsteadiness in up to 30% of patients, and should only be performed in the unilateral case
and when the hearing is already severely impaired.
VESTIBULAR NEURITIS
• ESSENTIALS OF DIAGNOSIS
• Vertigo lasting days after an upper respiratory infection.
• No hearing loss.
• No other neurologic signs or symptoms.

• The proposed etiologies for vestibular neuritis include viral infection,

vascular occlusion, and immunologic mechanisms
• The patient may have postural instability toward the injured ear but is
still able to walk without falling.
Labyrinthitis
• characteristically is viral-induced endolabyrinthitis and is not
potentially fatal.
• However, labyrinthitis secondary to middle ear infection can be fatal if
suppurative labyrinthitis and, subsequently, meningitis occur.
• Suppurative labyrinthitis= Vertigo + SNHL permanent.
• Therefore, each call from the emergency department to see a patient
in whom severe vertigo and hearing loss occur simultaneously
requires the clinician to determine whether the middle ear is normal.
Labyrinthitis
• Route of spread into the labyrinth:
In AOM:
• Weakened oval window membrane: post stapes surgery
• Dehiscent oval window membrane: as occurs in congenital labyrinthine deformities
COM:
• Direct bacterial invasion of the labyrinth through a cholesteatomatous Lateral SCC
fistula

• Diffuse Suppurative Labyrinthitis:

• Cause: suppurative otitis media
• Pathogens: S. pneumoniae (most common), H. influenzae, and Neisseria
meningitides
• Management: admission, IV antibiotic ( to prevent further bacterial invasion
intracranially, not to reverse SNHL or vestibular damage)
SUPERIOR SEMICIRCULAR CANAL DEHISCENCE

• ESSENTIALS OF DIAGNOSIS
• Vertigo induced by loud sounds or pressure
changes in the middle ear.
• Conductive or mixed hearing loss with
presence of acoustic reflexes.
• Nystagmus align with the plane of the
dehiscent superior semicircular canal.
others
Herpes zoster oticus — Ramsay Hunt syndrome, this syndrome is believed to
represent activation of latent herpes zoster infection of the geniculate
ganglion.
In addition to acute vertigo and/or hearing loss, ipsilateral facial paralysis,
ear pain, and vesicles in the auditory canal and auricle are typical features

Acoustic neuroma
 A type of tumor of the nerve tissue.
 Symptoms include:
a. Vertigo.
b. One-sided ringing.
c. Hearing loss.
Vertigo Medications
 For acute phase relieve, should be tapered as soon as possible so not to delay
central adaptation to the vestibular insult.

 Anticholinergic (Meclizine hydrochloride)

 Antihistamine (Diphenhydramine)
 Scopolamine transdermal (Anticholinergics/Antispasmodics)
 Promethazine hydrochloride (Antihistamine)
 Diazepam