Management of Vertigo Literature

Literature Reading
MANAGEMENT OF
VERTIGO
Roland Lallo Mangontan
Pembimbing Utama :
Dr. Wijana, dr., Sp.THT-KL(K).,FICS
Department of Otorhinolaryngology-Head and Neck Surgery
Faculty of Medicine Padjadjaran University
Hasan Sadikin General Hospital
Bandung
2016
Introduction
Balance disorders are common and
can occur in patients of all ages

Balance disorders may result from
abnormalities in a variety of organ
systems
Balance disorder can be debilitating
and lead to catasthropic outcome
that limitate daily activities
Bailey BJ (Ed) Head and Neck Surgery Otolaryngology.5 th Ed. Volume 2. Philadelphia. JB.
Lippincott Company. 2014: 2673-2698
System Connections Of The Vestibular

System
Roeser, Valente, and Hosford-Dunn, Audiology: Diagnosis. Thieme Medical

publishers, Inc., New York, 2010
System Connections Of The Vestibular

System
Roeser, Valente, and Hosford-Dunn, Audiology: Diagnosis. Thieme Medical

publishers, Inc., New York, 2010
John PC, Charles CDS. Principles of Applied Vestibular Physiology in Cummings Otolaryngology Head & Neck
Surgery. Fifth Edition. Mosby Elsevier. Philadelphia. 2010. p.2276-2304
Inner Ear
Obrist, Dominik. Fluid Mechanics of the Inner Ear. Zurich: Institute of

Fluid Dynamics. 2011
ANATOMY - PERIPHERAL VESTIBULAR SYSTEM
Types of hair cell bodies: type I (chalice) & type II (cylindrical)

Type I & type II are not evenly distributed throughout the neuroepithelium
of either the semicircular canal ampullae/the utricular maculae
John PC, Charles CDS. Principles of Applied Vestibular Physiology in Cummings Otolaryngology
7
Head & Neck Surgery. Fifth Edition. Mosby Elsevier. Philadelphia. 2010. p.2276-2304
Hair cell
Barin K, Clinical Neurophysiology of the vestibuler system. Handbook of clinical

audiology 6th.2009. 431-63
Utricle
Linear
Horizontal
Saccule
Linear Vertical
Roeser, Valente, Hosford-Dunn. Audiology : Diagnosis. Thieme Medical publishers, Inc., New
York. 2010
Normal position
Rotation
Vertigo
In
latin vertere , the meaning is

rotate
Vertigo can be a symptom alone
without any other symptoms, but can
also be a collection of symptoms
( syndrome)
Vertigo syndrome usually consist of
symptoms of vertigo, nausea, vomiting,
nystagmus, and unsteadiness
Bailey, Byron et al: Head & Neck Surgery - Otolaryngology, 5th Edition, Lippincott
Williams & Wilkins.2014
Classification
Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical Practice Guidelines: Benign

paroxysmal positional vertigo. Otolaryngology. 2008 ; 139: S47-S81
Peripheral VS Central
Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical Practice Guidelines: Benign

paroxysmal positional vertigo. Otolaryngology. 2008 ; 139: S47-S81
16
Decreasing frequency
Etiology of Peripheral Vertigo

Condition
Details
Benign paroxysmal
positional vertigo
(BPPV)
Brief, position-provoked vertigo episodes caused by

abnormal presence of particles in semicircular canal
Menieres disease
An excess of endolymph, causing distension of

endolymphatic system
Vestibular neuronitis
Vestibular nerve inflammation, most likely due to virus
Acute labyrinthitis
Labyrinth inflammation due to viral or bacterial infection
Labyrinthine infarct
Compromises blood flow to the labyrinthine
Labyrinthine
concussion
Damage to the labyrinthine after head trauma
Perilymph fistula
Typically caused by labyrinth membrane damage

resulting in perilymph leakage into the middle ear
Autoimmune inner ear

disease
Inappropriate immunological response that attacks inner

ear cells
17
Decreasing frequency
Etiology of Central Vertigo

Condition
Details
Migraine
Vertigo may precede migraines or occur concurrently
Vascular disease
Ischaemia or haemorrhage in vertebrobasilar system

can affect brainstem or cerebellum function
Multiple sclerosis
Demylination disrupts nerve impulses which can result

in vertigo
Vestibular
epilepsy
Vertigo resulting from focal epileptic discharges in the

temporal or parietal association cortex
Cerebellopontine
tumours
Benign tumours in the internal auditory meatus
PATIENT EVALUATION
Patient History
Symptoms Taking a patient history
should include determining the

patients symptoms, including
balance, hearing, vision,
somatosensation, and motor function
Physical Examination
X.ray, CT Scan, MRI
Bulent Satar,MD.Anil K. Lalwani. Vestibular Testing. Current Diagnosis and Treatment
Otolaryngology-Head and Neck Surgery.3th 2012: 626-643
Testing & Evaluation
A. Oculomotor Function Tests:

1. Nystagmus testing Spontaneous
nystagmus, Gaze
nystagmus,
Head-shaking nystagmus
2. Nonlinearity testing
3. Fistula testing

B. Positional Tests : Positional tests can be

described as either dynamic or static
Dix-Hall-pike maneuver
C. Visual Acuity Testing
D. Postural Control Tests
1. Romberg test
2. Pastpointing test
3. Tandem gait test
4. Fukuda stepping test
E. Cranial Nerve Evaluation

Nystagmus testing
Headshake
Head Thrust Test
Positional Tests
Dix-Hall-pike
maneuver :
Testing for Benign
Paroxysmal Position
Vertigo

Supine Roll Test

Semicircular
Direction of
canal
nystagmus
Anterior Canal
Downbeating and
Posterior canal
torsional
Up beating and
Horizontal canal
torsional
Horizontal or
rotatory linear
Hyun-Nguyen Anh. Evidence-Based Practice : Management Vertigo.

2012 ; 45(5) : 925-940
Dynamic Visual Acuity
Postural Control Tests

Fukuda stepping test:
The patient is asked to march in place with

eyes closed. After 50 steps, a rotation >30
toward one side is considered abnormal.
Romberg test
Pastpointing test
Management
According to etiology
Counselling (time consuming, exercise)
Drug of choice
Multi-disciplinary approach
I. Anti Vertigo
Vestibular Suppressant
1. Ca antagonist : Flunarizin
2. Vasodilator
: Betahistine mesilate
3. Tranquilizer : Diazepam, haloperidol,
sulpiride
4. Antihistamin : Difenhidramine, meclizine
5. CNS stimulant: Ephedrin, amphetamin
II. Antiemetic
1. Anticholinergic
: atropine, scopolamine
2. Antidopaminergic : prochlorperazine,
metoclopramide
Posterior canal
Epley Maneuver (Canalith Repositioning
Procedure)
Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical Practice Guidelines: Benign paroxysmal
positional vertigo. Otolaryngology-HNS 2008 ; 139: S47-S81
Posterior canal
Manuver Terapi
Semont Maneuver (Liberatory Maneuver)
positional vertigo. Otolaryngology-HNS 2008; 139: S47-S81
Posterior canal
Brandt Daroff Excercise
Hain T, Benign Paroxysmal Positional Vertigo (BPPV). American Hearing Research

Foundation. 2012
Lateral canal
Lempert Roll Maneuver
positional vertigo. Otolaryngology-HNS 2008; 139: S47-S81
Lateral canal
Gufoni Maneuver
positional vertigo. Otolaryngology-HNS 2008 ; 139: S47-S81
Surgery
Singular Neurectomy
Posterior ampular nerve
Success rate 94 %
Complication hearing loss
Posterior Semi Circular Canal
Occlusion
Highlight
Vertigo are common and can occur in
patients of all ages and can lead to limitate

daily activities
Vertigo can be a symptom alone without
any other symptoms, but can also be a
collection of symptoms ( syndrome)
Vertigo can be central or peripheral
Highlight
Together with physical therapy and
lifestyle changes, the pharmacological

approach is one of the three pillars for
vestibular disorder treatment.
The use of medication in each case comes
from a proper assessment of symptoms,
severity of disease and side effects.
Thank You

Management of Vertigo Literature

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Literature Reading

can occur in patients of all ages

System Connections Of The Vestibular

Roeser, Valente, and Hosford-Dunn, Audiology: Diagnosis. Thieme Medical

System Connections Of The Vestibular

Roeser, Valente, and Hosford-Dunn, Audiology: Diagnosis. Thieme Medical

Obrist, Dominik. Fluid Mechanics of the Inner Ear. Zurich: Institute of

ANATOMY - PERIPHERAL VESTIBULAR SYSTEM

Types of hair cell bodies: type I (chalice) & type II (cylindrical)

Barin K, Clinical Neurophysiology of the vestibuler system. Handbook of clinical

latin vertere , the meaning is

Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical Practice Guidelines: Benign

Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical Practice Guidelines: Benign

Etiology of Peripheral Vertigo

Brief, position-provoked vertigo episodes caused by

An excess of endolymph, causing distension of

Vestibular nerve inflammation, most likely due to virus

Labyrinth inflammation due to viral or bacterial infection

Compromises blood flow to the labyrinthine

Damage to the labyrinthine after head trauma

Typically caused by labyrinth membrane damage

Autoimmune inner ear

Inappropriate immunological response that attacks inner

Etiology of Central Vertigo

Vertigo may precede migraines or occur concurrently

Ischaemia or haemorrhage in vertebrobasilar system

Demylination disrupts nerve impulses which can result

Vertigo resulting from focal epileptic discharges in the

Benign tumours in the internal auditory meatus

should include determining the

Testing & Evaluation

A. Oculomotor Function Tests:

Bulent Satar,MD.Anil K. Lalwani. Vestibular Testing. Current Diagnosis and Treatment

B. Positional Tests : Positional tests can be

Bulent Satar,MD.Anil K. Lalwani. Vestibular Testing. Current Diagnosis and Treatment

Head Thrust Test

Bulent Satar,MD.Anil K. Lalwani. Vestibular Testing. Current Diagnosis and Treatment

Supine Roll Test

Bulent Satar,MD.Anil K. Lalwani. Vestibular Testing. Current Diagnosis and Treatment

Hyun-Nguyen Anh. Evidence-Based Practice : Management Vertigo.

Dynamic Visual Acuity

Postural Control Tests

The patient is asked to march in place with

Hain T, Benign Paroxysmal Positional Vertigo (BPPV). American Hearing Research

patients of all ages and can lead to limitate

lifestyle changes, the pharmacological

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