Shabih H. Zaidi Arun Sinha. Vertigo. A Clinical Guide

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2 Shabih H. Zaidi Arun Sinha Vertigo A Clinical Guide 123

3 Vertigo

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5 Shabih H. Zaidi Arun Sinha Vertigo A Clinical Guide

6 Shabih H. Zaidi Department of ENT and Audiology City Hospital Birmingham UK Arun Sinha Department of ENT and Audiology City Hospital Birmingham UK ISBN ISBN (ebook) DOI / Springer Heidelberg New York Dordrecht London Library of Congress Control Number: Springer-Verlag Berlin Heidelberg 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied speci fi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (

7 Lovingly dedicated to our parents and our families

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9 Foreword The care provided to patients with disorders of balance has in recent years undergone a welcome and long overdue renaissance. Many factors have had a role in this enhanced delivery of healthcare to these individuals. There has been the recognition of new disorders and the re-evaluation of the investigation and treatment of those of which we are more familiar. Improved understanding of the interpretation of the results of investigations of the balance pathway has aided the diagnostic process. Our colleagues in radiology have more accurately de fi ned conditions of the inner ear and central pathways to further aid in diagnosis. We now better understand the roles of rehabilitation and surgery, and improved quality of reporting of the outcomes of our interventions places us in a position whereby patient counseling is now a more accurate science. Despite these innovations and the application of new technology perhaps the greatest contributor to improved outcomes has been the changes in the way we deliver our balance services and the development of the team approach. With an ageing population the demand for balance services will continue to grow exponentially, and it falls largely to clinicians to develop ef fi cient and cost-effective approaches to provide this. The balance patient is, in my view, best managed by multidisciplinary teams, working in dedicated balance clinics that have specialist knowledge and expertise. This expertise can only be obtained by a combination of high quality training in the clinical arena combined with a thorough understanding of the knowledge base. Within the pages of this book the attentive reader will fi nd all that is required to equip themselves with this necessary knowledge and understanding. I hope this will inspire some to develop high quality services for their local populations and maybe also stimulate a thirst for further research in this highly rewarding and extremely important subject. Richard M. Irving, MD, FRCS Consultant Neuro-otologist, Skull Base Surgeon, Queen Elizabeth, University Hospital, Birmingham, UK vii

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11 Preface Medicine is a lifetime profession, and we the lifelong learners. Not a day goes by when we do not learn something new. We have spent several decades in Otolaryngology, learning, sharing and teaching. Otology has dominated our lives for many long years, and we have seen sea changes in this speciality. We continue to serve our patients with the latest knowledge and matching skills. We have gained much through our long association with various universities and teaching hospitals in many parts of the world. The NHS, UK, is our nursery, to which we owe much and continue to bene fi t with its rich and invaluable resources. We see a large number of patients at the various hospitals of our trust, af fi liated to the University of Birmingham and the West Midlands Deanery. For many years, we have been engaged in research on the subject of vertigo. It is a fascinating and mind-boggling subject indeed. Numerous textbooks are available for an avid reader to bene fi t from. Besides, in today s age of communication, particularly due to the electronic media, one can never starve of the lack of information on any subject. Vertigo is no exception. We have attempted to look at its many facets from a clinician s view point. There is much to learn as there are huge gaps in our knowledge base. We fully comprehend our shortcomings. We simply wish to share our experience with our colleagues. We would also certify that observing the principle of con fi dentiality all clinical data is duly anonymised. An audio-vestibular service is an absolute necessity for the investigation of vertigo. We are blessed with an excellent lab. Dr. Suki Dhillon and her team, particularly Phil, Phil Y.S, Parmajeet, Mark, Helen, Sameer, Rashcida, Jag and Carl, helped us immensely. We are grateful to them all. We would particularly like to thank Claire Danks who helped us with the VNGs and vestibular investigations. Her contribution is immeasurable. Karen Harris deserves special thanks for helping us out with the interpretations of some VNGs. Kathy, Tammy and Tracy also deserve to be acknowledged. No medical documentation is possible without an excellent library and referencing service. We want to acknowledge the support given us by the librarians of the City and Sandwell hospitals, particularly Sally, Nicola, Angela, Cheryl and Stacey. We must duly acknowledge the support of our nursing colleagues, Marion, Santosh, Martin, Connie, Ann, Diane, Sam, Lorraine, Michelle and Dawn. We also wish to ix

12 x Preface thank the medical director and the executive authority of Sandwell and West Birmingham NHS trust for allowing the use of the services. And last but not least, a note of gratitude to our editor Sylvana Freyberg, and Springer, for publishing our humble work. Birmingham, UK Shabih H. Zaidi Arun Sinha

13 Contents Part I Fundamentals 1 Nomenclature and Epidemiology References Basic Sciences, Clinical Evaluation and Investigations Posture and Balance Neurotransmitters Vestibulo-Ocular Reflex Translational VOR Past Pointing Dysdiadokinesia Dysarthria Intention Tremor Cerebellar Nystagmus Hypotonia History and Clinical Examination Questionnaire Basic Clinical Examination Head Impulse Test Fukuda and Unterberger s Test Romberg s Test Past Pointing Dix Hallpike Test Oscillopsia Nijmegen Scoring Nijmegen Questionnaire Cerebellar Tests Haematological Tests Other Lab Investigations Radiology Vestibular Investigations VNG in the Investigation of Vertigo VEMP xi

14 xii Contents 2.18 Video Head Impulse Test (vhit) Audiometry Objective Audiological Assessment (Otoacoustic Emissions) Auditory Brain Response (ABR) Behavioural Tests Visual Response Audiometry (VR) Pure Tone Audiometry Speech Discrimination Audiometry References Part II Clinical Conditions 3 Meniere s Disease Lermoyez s Syndrome References Benign Paroxysmal Positional Vertigo (BPPV) Epley s Manoeuvre: How I Do It Semont s Manoeuvre: How I Do It References Vestibular Migraine References Cervical Vertigo/Labyrinthitis/Ototoxicity Vestibular Neuronitis Viral Labyrinthitis Vestibular Compensation Motion Sickness/Travel Sickness Perilymph Fistula Ototoxicity References Chronic Suppurative Otitis Media (CSOM) Reference Central Causes Acoustic Neuroma Multiple Sclerosis References General Causes Cardiovascular Diseases Vertebrobasilar Insufficiency Noise

15 Contents xiii 9.4 Miscellaneous Causes of Vertigo References Paediatric Clinical Conditions Vertigo in Children References Part III Rehabilitation and Ethical Issues 11 Rehabilitation References Vertigo in the Elderly: Quality of Life and Some Ethical Issues Epilogue References Index