Sasan Dabiri, MD, Assistant Professor

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1 Sasan Dabiri, MD, Assistant Professor Department of Otorhinolaryngology Head & Neck Surgery Amir A lam hospital Tehran University of Medical Sciences October 2015

2 Outlines Anatomy of Vestibular System Principles of Vestibular Function Clinical Evaluation of Vertigo Paraclinics in Vertigo Differential Diagnoses of Vertigo Benign Positional Peripheral Vertigo Meniere s Disease Vestibular Neuritis Bilateral Vestibulopathy Vestibular Migraine

3 Circadian Rhythm Gaze stabilization Orientation & Navigation Balanced Locomotion Autonomic Function

4 Circadian Rhythm Gaze stabilization Orientation & Navigation Balanced Locomotion Autonomic Function

5 Circadian Rhythm Gaze stabilization Orientation & Navigation Balanced Locomotion Autonomic Function

6 Reticular formation - Cerebellum Visual information Vestibular information Proprioceptive information

7 Anatomy Vestibular System Peripheral Part (inner ear and vestibular nerve) Semicircular canals Superior (anterior) Posterior Lateral (horizontal) Otolith organs Saccule Utricle

8 Anatomy Vestibular System Peripheral Part (inner ear and vestibular nerve) Semicircular canals Superior (anterior) Posterior Lateral (horizontal) Otolith organs Saccule Utricle

9 Anatomy Vestibular System Peripheral Part (inner ear and vestibular nerve) Semicircular canals Superior (anterior) Posterior Lateral (horizontal) Otolith organs Saccule Utricle Central Part (CNS)

10 Physiologic Points - Vestibular System The main functions of Vestibular system Orientation respect to gravity Balanced Locomotion (and related adjustments) Stabilized environment in vision

11 Physiologic Points - Vestibular System Normal Vestibular Function: Continuous Bilateral input to central vestibular system with Activation of each vestibule body & eyes are pushed away from Cerebellum usually compensates vestibular injury In fluctuating states, it can not compensates In slowly progressive states, occurs near complete

12 Definition - Vertigo sensation of motion when no motion is occurring relative to earth s gravity (vertere means turning in latin)

13 Clinical Evaluation - Vertigo History taking The most important point in approach to vertigo: differentiation from other similar symptoms such as dizziness True vertigo or Pseudo vertigo Other history points (such as Otologic symptoms, Past Medical Hx, Drug Hx)

14 Clinical Evaluation - Vertigo History taking (confirming true vertigo) Physical Examination Otologic Examination Otoscopy Attention to Nystagmus (direction, fixation) Dix-Hallpike test Head thrust test Neurologic Examination Peripheral Lesion Rule out central causes (with Romberg test or other similar tests)

15 Audiovestibular Test Battery Audiologic Tests Paraclinics - Vertigo Audiometry (PTA SRT WRS Tympanometry AR) Electrocochleography (ECoG)

16 Audiovestibular Test Battery Audiologic Tests Vestibular Tests Paraclinics - Vertigo Video Nystagmography (VNG) Vestibular Evoked Myogenic Potential Test (VEMP) o Cervical vs Ocular Rotatory Chair Test Posturography

17 Audiovestibular Test Battery Audiologic Tests Vestibular Tests Imaging Paraclinics - Vertigo Computed Tomography Scan (Temporal CT) Magnetic Resonance Imaging (Brain MR ± Gd)

18 Differential Diagnosis - Vertigo Peripheral Causes (inner ear and vestibular nerve) Benign Positional Peripheral Vertigo (BPPV) Meniere s Disease Vestibular Neuritis Perilymphatic fistula Superior Semicircular Canal Dehiscence Syndrome Otitis Media Acoustic Neuroma Central Causes (CNS) Vestibular Migraine Intracranial mass Cerebrovascular diseases Multiple Sclerosis

19 Differential Diagnosis - Vertigo Duration without Hearing Loss with Hearing loss Seconds to minutes BPPV Perilymphatic fistula Minutes to hours Vestibulopathy Meniere s disease Hours to days Vestibular neuritis Migraine Days to weeks CNS disorders Acoustic neuroma

20

21 Benign Positional Peripheral Vertigo Description Prevalence: 5 th decade Male = Female Pathology: Debris in semicircular canals (Mostly: Posterior Canal) Clinical Findings Sudden onset vertigo Attack: seconds Not spontaneous nystagmus Normal Hearing Triggers (Rollover in bed, Look up & back, Bending over) Dix-Hallpike Test Management Medical Antivertiginous drugs Maneuvers (Epley) Surgical Canal occlusion Singular neurectomy

22 Ménière s Disease Description Clinical Findings Management Prevalence: 5 th decade Male = Female Pathology: Endolymphatic hydrops Drain defect/over product Autoimmune / Allergy Endocrine - Metabolic Vertigo: minutes to hours Fluctuating SNHL Tinnitus Aural Fullness Audiometry Low freq. / tent ECoG / VEMP Medical Prophylactic Diet / Diuretic Symptomatic Surgical Antivertiginous Drugs Aminoglycoside

23 Vestibular Neuritis Description Clinical Findings Management Prevalence: middle age Male = Female Pathology: Viral infection Vascular occlusion Immunologic reaction Vertigo: a few days Sudden onset with nausea / vomit Normal hearing Characteristic Nystagmus Imaging for R/O stroke Medical Rest in dark room Antivertiginous Drugs Antiemetic Drugs

24 Bilateral Vestibulopathy Description Prevalence: Old age the most common cause of aa imbalance in elderly Pathology: Idiopathic Ototoxic drugs Meniere s Disease Meningitis & Clinical Findings Dizzy with Movement Blurred vision in motion (Oscillopsia) Spatial Memory Loss Dx: Head Impulse Test + Paraclinics + History points Management Prevention (ototoxic) Recovery (steroid?) Physical Therapy Substitution Education

25 Vestibular Migraine Description Clinical Findings Management Prevalence: middle age Female >>> Male Pathology: Migraine etiology Trigemino-vascular system Serotonin / Calcitonin GRP Vertigo: minutes to days Migraine (current or Hx) Overlap of both Photo & Phono phobia Dx with Criteria Prophylaxis Metoprolol Valproate Attacks Antiemetic + Analgesic not sole use Triptan?

26 Summary Vestibular Suppressant Medications : the shortest duration as possible Ototoxic Drugs : the last indication as possible

27 Thanks for Your Attention

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