Services for Vertigo Center
Diagnosis and Management
Dizziness is a complaint wherein the patient tries to describe the subjective disturbance in his or her orientation in space. Dizziness may signify one or more of the following sensations to the patient.
- A sensation of rotation.
- A sensation of faintness & impending unconsciousness.
- Light-headedness & weakness.
- Uneasiness, insecurity & confusion.
This large & confusing list of symptoms is due to the fact that subjective orientation in space is controlled by multiple complex systems and presented in very different manners from person to person.hence its thorough evaluation is important for effective treatment.
Balance System and Brief overview
Human beings enjoy the advantage of erect posture,and has also learned the method to maintain the body posture i.e. the position of body with respect surroundings and position of the head with respect the rest of the body.this is achieved by the well evolved balance systems in humans.It consists of :
1) Peripheral sensory apparatus that informs brain about the surroundings :
- A. Bilateral Vestibular apparatus
- B. Both Eyes
- C. The proprioceptive system
2) Integrating System - The data collectedly the peripheral systems processed by :
- A. VIII cranial nerve
- B. Bilateral vestibular nuclei
- C. Vestibulospinal, Vestiblocerebellar, Vestibulocerebellar tract
- D. Medial longitudinal fasciculus
3) Higher centres - Overall balance is coordinated by higher centres like :
- A. Cerebellum
- B. Cerebrum
- C. Cognitive apparatus
A DISTURBANCE IN ANY OF THE ABOVE LEVELS CAN GIVE RISE TO SYMPTOMS OF VERTIGO
Diagnosis Of Vertigo
Diagnosis Of Vertigo
When a patient with vertigo is presented to a physician the aim of evaluation are Whether it is TRUE VERTIGO or PSEUDO VERTIGO.
If it is true vertigo :
- What is the site i.e. which level of balance system is affected.
- If it is unilateral or bilateral.
- The underlying cause
The main steps in evaluation are :
1. Detailed history taking
Physicians has to evaluate patients thoroughly by detailed history of the disease,duration of the disease,drugs etc.
2. Detailed Physical Examination :
Apart from the routine examination like Pulse,BP,RR Vertigo can be evaluated by :
- A. Romberg Test
- B. Unterbergs test
- C. Nystagmus Evaluation
- D. Dix-hallpike test
- E. Head Shaking test
Sometimes, vertigo can be a symptom of a brain tumor or reduced blood circulation in the brain. when this is suspected, MRI is useful.
3. Balance testing :
The organs of balance are tested by the VNG (video-nystagmography). In our sophisticated VESTIBULAR LAB, we offer the GOLD STANDARD of testing the organs of balance. This involves multiple tests:
Detailed evaluation of -
- VHIT to test the Vestibulo-ocular reflex.
- VNG to test the caloric response as well as the vestibulo-ocular reflex.
- CCG to test the Vestibulo-spinal reflex It is also useful as a screening test as well as a test to determine the progress of the patient.
- VEMP to test the Vestibulo-collic reflex.
These are simple and easy tests done in the clinic, which represent the gold standard in the evaluation of peripheral vestibular disorders.
THE TREATMENT OF VERTIGO
The treatment is dependent upon the cause of the vertigo.
MEDICAL TREATMENT IS INITIALLY RECOMMENDED.
The treatment of various central nervous & psychogenic disorders is beyond the scope of this discussion.
The Treatment of vertigo due to peripheral causes.
- 1. Vasodilators. Xanthine nicotinate derivatives.
- 2. Anti-vasoconstrictors. Cinnarizine & Flunarizine are known to act both centrally & peripherally.
- 3. Anti-histaminics. Promethazine theoclate or dimenhydrinate are commonly used.
- 4. Steroids.
- 5. Vestibular suppressants.
- 6. Sedatives.
- 7. Beta-blockers.
- 8. Adjuvant therapy. Low-salt diet, propantheline bromide, Vitamins & bioflavonoid compounds.
SURGICAL TREATMENT IS VERY EFFECTIVE WHEN MEDICAL TREATMENT FAILS. Surgery for vertigo will be discussed in the next section.
VESTIBULAR REHABILITATION EXERCISES ARE FOUND TO BE USEFUL.
These are the most important aspect in the management of vertigo, because we need to strengthen the organ of balance. Generally, most doctors prescribe exercises arbitrarily, but this is wrong. However, there are many exercises, and they are prescribed according to the results of the VNG.
WE HAVE ESTABLISHED THE BALANCE GYM, WHERE THE EXERCISES WILL BE GUIDED BY TRAINED THERAPISTS & DOCTORS
Three types of peripheral vertigo are extremely common :
Vestibular neronitis :
This is an extremely common form of vertigo. This is postulated to be the consequence of a viral infection. This is characterised by intense vertigo, generally associated with an upper respiratory viral infection. after the first attack, lasting for minutes to hours, the patient feels better, but again vertigo attacks occur with varying frequency. The hallmark of this form of vertigo is that the first attack is the worst attack. The patient is completely well between episodes. The treatment for this is symptomatic medication, with extensive vestibular rehabilitation (balance exercises).
Barany in 1921 first proposed this disorder & felt that it was related to the otolithic organ. Dix & Hallpike coined the term B.P.P.V. Schuknecht reported temporal bone sections showing amorphous basophilic debris on the posterior canal cupula, & thought it to be degenerated otoconia. He referred to this as cupulolithiasis.
- 1. Idiopathic: 60%
- 2. Post-traumatic: 60%
- 3. Otitis media & post-otologic surgery: 25%
- 4. VBI.
- 5. Excessive alcohol consumption.
- 6. Localized head and neck infection.
All of the above dislodge the otoconia from the macula utriculae, & these gravitate to the most dependant part of the labyrinth, the ampulla of the posterior semi-circular canal.
The classic clinical appearance is of intense rotatory vertigo of variable intensity, a few seconds to few minutes in duration, increasing on change of position, which is fatiguable, with a tendency to relapse.
There are no neurologic signs, the gait is normal & the caloric test is ambiguous.
The nystagmus is not spontaneous, it is fatiguable, & is directed towards the lowermost ear.
- Vestibular suppressants.
- Cawthorne-Cooksey rehabilitation exercises
- Atropine analogues
- Gacek's nerve section. (very rarely performed )
Meniere's disease :
It is a disease of the membranous labyrinth characterised by episodic vertigo, fluctuant hearing loss & roaring tinnitus, which has as its pathologic correlate the hydropic distension of the endolymph space.
It is usually associated with vagal symptoms, fullness of the ears & the sufferer is usually normal in between attacks.
- 1. Overproduction of the endolymph.
- 2. Vasospastic theory: Autonomic imbalance in the arterioles of the stria vascularis.
- 3. Herniation/rupture of the membranous labyrinth.
- 4. Metabolic disturbances, either local or systemic.
- 5. Allergy.
- 6. Thyroid disorders.
This is to be differentiated from Meniere's syndrome, wherein a known etiology exists, & Meniere-like syndrome, wherein there is no fluctuation of hearing or episodic vertigo. A predominantly cochlear type & a predominantly vestibular type of Meniere's exists. Lermoyez' syndrome is another variant, characterised by progressively increasing hearing loss & vertigo, followed by vomiting, & then complete recovery.
The initial treatment of Meniere's disease is medical. If medical treatment fails, surgery is indicated.