Dizziness and

Vertigo
Dr Budhi Suwarma SpS
FK UNJANI
Dizziness and Vertigo
The most frequent complaints among OPD
Dizziness-imbalance,headache,back pain,
fatique
Mostly benign
Analyse correctly the nature of disturbance and
anatomic location
A feeling of rotation,whirling,non-rotatory
swaying,weakness,faintness,unsteadiness
Dizziness and Vertigo
Dizziness may mean giddiness,light head-
edness,unsteadiness,swimminess,vertigo

The specific qualities of vertigo : all subject

ive and objective illusion of motion/position

Pseudo vertigo : non-rotatory giddiness

Vestibular ganglion (Scarpa)
(in the internal auditory canal)
Bipolar
Peripheral terminate in hair cells crista ampu llaris
SCC & macula acusticae Saccule-Utricle
Central via internal auditory meatus+cochlear +
7th, terminate in the vestibular nuclei (sup-
Bechterew, lat-Deiters, med-Schwalbe, inf). Some
fibre from SCC project directly to the
flocculonodular lobe+ adjacent vermian cortex
cerebellum via the juxtarestiform body
Vestibular ganglion (Scarpa)(cont.)
SCC horizontal is inclined upwards 30 from the
horizontal plane, detect turning
The utricle is a gravity-operated receptor which
responds to tilting (out of position R)
The saccule responds to acceleration
The utricle-saccule system provides inform
ation leading to correct vertical postures when
sits,stands and walks
Vestibular ganglion (Scarpa)(cont.)
Efferent fiber from cerebellum to i.l. vestibular
and fastigial nucleus
Efferent fiber from fastigial ncl to c.l. vestibular
nuclei via juxtarestiform body
Lateral and medial nuclei have important
connection with the spinal cord via the uncrossed
lateral vestibulospinal tract (limb muscles) and
via the crossed and uncrossed medial
vestibulospinal tract (axial muscles)
Vestibular ganglion (Scarpa)(cont.)
Superior and medial nuclei influence 3rd 4th 6th CN

Allvestibular nuclei have afferent and efferent

connections with pontin RF subserve
Vestibulo Ocular (clear vision) and Vestibulo
Spinal reflex (stable posture)
There are projection from the vestibular nuclei to
Cerebral Cortex (intra parietal sulcus and
superior Sylvian gyrus)
Maintenance of a balanced posture and
awareness of the position of the body in relation
to its sorrounding (Physiology)
Afferent visual impulses (retina) and
proprioceptive impulses (ocular muscles)

Afferent impulses from the labyrinths

Afferent impulses from the propriceptors of

the joint and muscles
Psychophysiology
Early in life
Coordinate parts of our body in relation to one
another
Perceive that portion of space occupied by our bodies

Body and environmental schema

We can see stationary objects while we are moving
and moving objects while we are either moving or
stationary (# corollary)
Aging vs equilibrium
Old people often lose their balance on extending
the neck

Their peripheral sensory afferents are often

impaired

Destructive lesion of one or both labyrinths

permanent imbalanced
Clinical charateristics of Vertigo and
Giddiness
DD : true vertigo / dizziness of the anxious
patient / pseudovertigo
Objects in the environment spin-around /
move in one direction (objective vertigo) or he
had a sensation of the head and body whirling
(subjective vertigo)
Accompanying symptoms : nausea,vomit-
ting,pallor,prespiration,nystagmus,tensi.
Clinical charateristics of Vertigo and
Giddiness (cont.)
Other feeling : to-fro, up-down movement of
the head/body, pitch-roll of a ship, floor / wall
tilt-sink-rise up, walk unsteady, veered to one
side, sensation of leaning / pulled to the
ground etc
Provocation test: halt after a rapid rotation,
caloric test, stoop for a minute and straight
en up, HV 3 min
Giddiness and other types of
pseudovertigo
Feeling of swaying, lightheadedness, swim ming
sensation, walking on air, faintness
Anxiety neurosis, hysteria, depression
Reproduced by HV
Accompanying : apprehension, palpitation,
breathlessness, trembling, sweating
Pseudovertigo : anemia, AS, emphysema,
hypertension, postural, hypoglycemia,drug
Neurologic and Otologic causes of
vertigo
Aura of an epileptic seizure (vertiginous E) Many
complain of dizziness, but few true vertigo
Electric stimulation posterolateral temporal lobe
or inferior parietal lobe adjacent to the Sylvian
fissure intense vertigo
Diplopia of abrupt onset brief vertigo
First adjusting to bifocal glasses or looking down
from a height
Neurologic and Otologic causes of
vertigo (cont.)
Cerebellar lesion involving the territory of medial
branch of PICA intense vertigo
Cervical vertigo (asymmetrical spinovesti bular
stimulation) : C. muscle spasm, C- trauma, C
sensory roots irritation, VB- insufficiency
Commonly vertigo indicates a disorder of the
vestibular end organ, vestibular nerve,
vestibular ncl and their connections
Specific Cause of Dizziness
Vestibular disorders 38%
Hyperventilation syndrome 23%
Multi sensory disorders 13%
Psychiatric disorders 9%
Brainstem lesion 5%
Other neurologic disorders 4%
Cardiovascular disorders 4%
Tests of Labyrinth function
Caloric test / Oculovestibular test / OV test
Horizontal SCC should be vertical ! Irrigation
each EAC / simultaneous both EAC with
water at 30C and then 44C. Directional
preponderance,COWS,CUWD Do not tell the
signs/symptoms ;just warn!

Barany chair
Benign Positional Vertigo (BPV)
More often then Meniere
Positioning / positional ~ only by rapid changes
in head position
Occur only in certain critical positions of the
head (lying down, rolling over in bed, bending
over, straightening up, tilting the head
backward)
Last for less than a min.,recur periodically
BPV cont.
Test Dix & Hallpike. With repetition of the
maneuvre, vertigo become less apparent
(fatique)
Neuronitis Vestibular
Paroxysmal and usually a single attack of
vertigo (absence of tinnitus and deafness)
Severe vertigo,nausea,vomiting,immobile
Young middle age
Vestibular process on one side (viral), ante
cedent URTI nonspecific type
Subside in several days
Meniere Disease
(Endolymphatic hydrops)
Recurrent attacks of rotational vertigo ass
ociated with fluctuating low pitch tinnitus,
sensory neural deafness and ear fullness
Preferentially lie with faulty ear uppermost
Onset most frequently in the 5 th decade, last
several min-hr, sporadic
Recur several times weekly for many week
Remission may several yr/completely deaf
Vertigo e.c.vestibular nerve
Less severe, less frequently paroxysmal
than labyrinthine vertigo
The most common cause is an acoustic
neurinoma
Deafness high tone
Followed some mo/yr later by chronic vertigo
and impaired caloric test
Additional 7th 5th 10th palsy, ataxia i.l., headache
Vertigo of Brainstem origin
Vestibular ncl and their connections
Auditory function is nearly always spared
Vertigo and accompanying symptoms are
generally more protracted than with laby- rinthine
lesion ( some exception!)
Marked nystagmus without the slightest degree
of vertigo (uni/bidirectional,purely
horizontal,vertical/rotatory worsened by
attempted visual fixation
Vertigo of Brainstem origin(cont)
Signs of involvement of other structure within the
brainstem to localize the lesion
Causative disease is determined by the mode of
onset,duration and other features
Vertigo as the sole manifestation of brain- stem
disease is rare
Basilar migraine:vertigo +suboc headache
Cerebellar lesion : limb ataxia, dysarthria