Rund AlJarrah
Dana Rida
Vertigo
is an illusion of
movement .
A sensation of whirling and
loss of balance,
ILO
• Normal Balance
• Vestibular sensation and maintenance of equilibrium –physiology
• Static and dynamic equilibrium
• BPPV
• Vestibular neuritis
• Labyrinthitis
• Meniere disease
• Perilymphatic fistula
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physiology
Normal Balance needs :
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Neuronal connections
Neck proprioceptors
It is important To receive input about
orientation of head in respect to rest of the
body from neck proprioceptors sent directly
to vestibular and reticular nuclei .
Visual information
Example :Head leaned or falling
Some people with
bilateral vestibular
appartus destruction
have almost normal Proprioceptive from body
equilibrium as long as
their eyes are open , Pressure sensation from footpads
and movement are tell one whether weight Is
slow distributed equally and whether
weight on feet is more foreword
or backward
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Corrective
movement of the
eye
Are specifically
concerned
with dynamic
equilibrium
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Vestibular sensation and
maintenance of equilibrium
The vestibular apparatus
It is encased in system of
is the SENSORY bony tubes and
organ for detecting chambers located in
sensation of petrous portion of
equilibrium temporal bone
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Bony labyrinth
Bony Tubes and chambers
Membranous labyrinth
Is the functional part of
vestibular apparatus
Composed mainly
Of the cochlea , three
semicircular canals ,
and two large chambers
, the utricle and saccule
.
the last two parts play
an integral parts of
equilibrium mechanism
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Maculae – sensory organ of utricle and
Saccule
Utricle Saccule
The Macula of The Macula of
utricle lies in the saccule lies in the
horizontal plane vertical plane
And plays an And signals Head
Important role in orientation when
determining person is lying
orientation of down
head when head
is upright
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Maculae – sensory organ of utricle and Saccule
Each macula is covered by
gelatinous layer in which
many small Ca carbonate
Crystals called statoconia
are embedded
Statoconia have specific
Gravity , its weight bends
the cilia in direction of
Gravitational pull
Also , there are thousands
of hair cells , that project
cilia up into gelatinous
layer.
The bases and sides of hair
cells synapse with sensory
endings of Vestibular nerve
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Directional sensitivity of Hair
Maculae – sensory organ of utricle and Saccule
cells– kinocilium
Hair cells have 50-60 small cilia
( sterocilia ) and one large
cilium ( kinocilium )
Filamentous attachments
connects each tip of sterocilium
to the next and finally
Kinocilium .
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Directional sensitivity of Hair
Maculae – sensory organ of utricle and Saccule
cells– kinocilium
Receptor membrane depolarization
When sterocilia and kinocilium binds
to direction of kinocilum , the
filamentous attachments tug in
sequence , pulling sterocilia away
from cell body , and this opens several
fluid channels
Receptor Hyperpolarization
When sterocilia and kinocilium binds
to opposite direction reduces the
tension on the attachments this closes
ion hannels
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Maculae – sensory organ of utricle and Saccule
The orientation of Head in space changes and weight of stataoconia bends cilia >> signals transmitted
In each macula , Hair cells are oriented in different direction , some are stimulated when bent backward ,
some when bends to one side , and so On .. Creating a pattern that appraise brain of the head’s orientation
in space
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Semicircular ducts
Three semicircular ducts arranged at
right angles to one another , so they
represent all 3 planes in space .
And ducts and ampulla are filled with
endolymph .
Ampulla
Enlargement at each duct end.
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Semicircular ducts
In Each ampulla a small Crist
called crista ampullaris , on
top pf this is a loose gelatinous
tissue mass , the capula .
When head moves in any direction
, fluid flow from form the duct and
through ampulla , bending the
capula to one side.
Into capula , are projected
hundreds of cilia from hair cells on
ampulla crest .
The kinocilia are all oriented in
same direction in capula
Bending to one side depolarization
, where as to opposite side causes
hyperpolarization .
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Static and dynamic
equilibrium
Function of utricle and saccule in
maintenance of static equilibrium
Hair cells oriented in
different directions in
the maculae
so with different positions
of head , different hair cells
become stimulated
in turn , the vestibular ,
cerebellar , and reticular motor
system of the brain excite
appropriate postural response
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Vestibular mechanism for stabilizing eye
When a person changes his direction rapidly , you
must have automatic control mechanism to
stabilize the direction of eyes gaze to maintain a
stable image
Mediated through Paramedian pontine reticular
formation (PPRF)
Each time head is suddenly rotated ,signals from
semicircular ducts causes the eyes to rotate in a
direction equal and opposite to the rotation of
head .
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Whenever we move our head to the right,
there is an increased firing to
the right vestibular nuclei
>> which will stimulate the contralateral PPRF
>> which in turn will stimulate the
contralateral abducent nerve nuclei causing
the contraction of the left lateral recti muscle
of left eye .
>> The nuclei which supply the lateral recti
muscle will stimulate the MLF on the contra
lateral side causing the stimulation
of the nuclei to the medial recti through the
oculomotor nerve.
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What is Vertigo
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Pathologies
BPPV
Benign paroxysmal positional vertigo —
most common.
• It is most commonly attributed to calcium
debris within the posterior semicircular
canal, known as canalithiasis.
BPPV
Symptoms
Classically, patients
describe a brief spinning
sensation brought on when
turning in bed or tilting the
head backward to look up. .
Patients may experience
nausea but rarely vomit.
Ear pain, hearing loss, and
tinnitus are absent.
BPPV
Rarely, patients presenting with positional
vertigo have central nervous system
abnormalities with a less favorable
prognosis Usually, the symptoms are
somewhat more prolonged. Patients with
atypical positional vertigo or nystagmus who
do not respond to treatment should
undergo(MRI) of the brain to rule out a
posterior fossa abnormality.
BPPV
Diagnosis
Recurrent
Brief (<1 minute) episodes of vertigo
Provoked by specific types of head movements
Confirmed by observing nystagmus during a provoking maneuver
BPPV
Treatment
Particle repositioning maneuvers
Office-based
●The Epley maneuver
●The Semont maneuver
The treatment maneuvers encourage the debris to migrate toward the common
crus of the anterior and posterior canals and exit into the utricular cavity
Vestibular neuritis
Also known as vestibular neuronitis and labyrinthitis, is believed to be
a viral or postviral inflammatory disorder, affecting the vestibular
portion of the eighth cranial nerve.
Symptoms
• Vestibular neuritis is characterized by the rapid onset of severe,
persistent vertigo(>24h), nausea, vomiting, and gait instability
• The clinical features of cerebellar hemorrhage or infarction may be
similar to vestibular neuritis, and brain imaging is therefore often
required to rule this out
• Patients with vestibular neuritis generally suffer from severe
vestibular symptoms for a few to several days, followed by a gradual
diminution of symptoms and a return of equilibrium.
• Recovery may be improved with corticosteroid therapy
• Here what happens is that there is an inflammation of the vestibular
nerve causing decreased firing from the affected side( in contrary to
the BPPV and Ménière’s disease in which there is an increased firing
from the affected side )which causes nytsgamus AWAY from the
affected side
Labyrinthitis
It may be further classified as suppurative or serous
Suppurative (bacterial)labyrinthitis follows direct microbial invasion of
the inner ear and usually presents with severe to profound hearing loss
and vertigo.
Serous (viral) labyrinthitis results from inflammation of the labyrinth
only and usually presents with less severe hearing loss and vertigo than
suppurative labyrinthitis, and the hearing loss often recovers.
Meniere disease
Peripheral vestibular disorder
attributed to excess endolymphatic
fluid pressure, which causes episodic
inner ear dysfunction
Symptoms
Attacks of dizziness may come on suddenly or after a short period of
tinnitus or muffled hearing.
• Some people with Ménière’s disease have
vertigo so extreme that they lose their balance
and fall. These episodes are called “drop
attacks.”
• Attacks occur in clusters with periods of
remission, during which balance is normal.
Each lasts for several hours, rarely less than 10
minutes or more than 12 hours
• Horizontal – torsional nystagmus
When the particles are in the horizontal canal, the nystagmus triggered
by head movement is a horizontal nystagmus rather than the vertical-
torsional nystagmus seenwith BPPV of the posterior canal.
The diagnosis of Meniere disease is suggested by the history. A low-
frequency sensorineural hearing loss on audiometry and a unilateral
reduced vestibular response on electronystagmography help confirm
the diagnosis.
Treatment
Medical treatment
●Includes histamine agonists
vasodilator drugs
diuretics combined with a sodium-restricted diet and corticosteroids.
●Operative treatment
Conservative surgical procedures aim to protect hearing and include decompression of the endolymphatic sac
(with or without drainage) and selective division of the vestibular branch of the vestibulocochlear nerve
(vestibular neurectomy).
Labyrinthectomy, with total destruction of the membranous labyrinth, almost guarantees relief from the
vertigo but at the expense of total loss of hearing in that ear
Perilymphatic fistula
This is an infrequent complication of head injury, barotrauma, or heavy
lifting in which a fistula develops at the otic capsule, permitting a
transfer of pressure changes to the macular and cupular receptors.
So-called Tullio phenomenon, occurs
because sound-induced pressure waves
are abnormally distributed through the
inner ear
• Establishing a diagnosis is difficult, as clinical tests are insensitive .
Computed tomography (CT) scanning may show fluid in the region of
the round window recess
• Treatment with bed rest, head elevation, and avoidance of straining is
the first step; failure to resolve after several weeks of conservative
therapy is an indication to consider a surgical patch
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