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
+ 7
th
, 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 3
rd
4
th
6
th

CN
All vestibular 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 7
th
5
th
10
th
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