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Second level
● Third level

● Fourth level

● Fifth level

V ertig
o
Case Report Presentation

Cruz – Cusi – Dairo – Daz

De Grano – De Jesus – Dela Rosa – Young
Anatomy & Physiology

System of balance
Membranous and bony labyrinth
embedded in petrous bone
5 distinct end organs
3 semicircular canals:
● Superior
● Lateral
● Posterior
2 otolith organs:
● Utricle
● saccule
 Anatomy & Physiology

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• Semicircular Second level
● Third level
canals sense ● Fourth level

angular ● Fifth level

acceleration

• Otolithic organs
(utricle and
saccule) sense
linear acceleration
 Anatomy & Physiology
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Semicircular canals Second level
● Third level
are orthogonal to ● Fourth level

each other ● Fifth level

Lateral canal inclined

to 30 degrees
Superior/posterior
canals 45 degrees off
of sagittal plane
Anatomy & Physiology

Utricle is in horizontal
plane

Saccule is in vertical
plane
 Anatomy & Physiology
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Second level
There are five ● Third level

openings into ● Fourth level

● Fifth level

area of utricle
Saccule in
spherical recess
Utricle in elliptical
recess
 Anatomy & Physiology
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Second level 45% from AICA
● Third level

● Fourth level 24% superior

● Fifth level
cerebellar artery
16% basilar
Two divisions:
anterior vestibular
common cochlear artery
 Anatomy & Physiology
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Second level
● Third level

● Fourth level
Superior vestibular
● Fifth level
nerve: superior
canal, lateral canal,
utricle

Inferior vestibular
nerve: posterior
canal and saccule
 Anatomy & Physiology

Membranous labyrinth is surrounded

by perilymph
Endolymph fills the vestibular end
organs along with the cochlea
Perilymph
Similar to extracellular fluid
K+=10mEQ, Na+=140mEq/L
Unclear whether this is ultrafiltrate of
CSF or blood
 Anatomy & Physiology

Endolymph
Similar to intracellular fluid
K+=144mEq/L, Na+=5mEq/L
Produced by marginal cells in stria vascularis from
perilymph at the cochlea and from dark cells in the
cristae and maculae
Absorbed in endolymphatic sac which connected by
endolymphatic, utricular and saccular ducts
 Anatomy
Sensory & Physiology
structures

Ampulla of the
semicircular canals
Dilated end of canal
Contains sensory
neuroepithelium, cupula,
supporting cells

Crista ampullaris is
made up of sensory hair
cells and supporting
cells
 Anatomy & Physiology

Sensory cells are either Type

I or Type II

Type I cells are flask shaped

and have chalice shaped
calyx ending

One chalice may synapse

with 2-4 Type I cells

Type II cells – cylinder

 Anatomy & Physiology

Hair cells have 50-100 stereocilia and

a single kinocilium.

Stereocilia are not true cilia, they

are graded in height with tallest
nearest the kinocilium.
 Anatomy & Physiology

Kinocilium is located
on one end of cell
giving each cell a
polarity

Has 9+2
arrangement of
microtubule
doublets
Anatomy & Physiology

• Each afferent
neuron has a
baseline firing rate
• Deflection of
stereocilia toward
kinocilium results
in an increase in
the firing rate of
the afferent neuron
• Deflection away
causes a decrease
Anatomy & Physiology

• AMPULLOPETAL FLOW (toward the ampulla)

excitatory in lateral canals, inhibitory in
superior/posterior canals
Anatomy & Physiology
Saccule has hair cells
oriented away from
the striola

Utricle has hair cells

oriented towards
the striola

Striola is curved so
otolithic organs are
sensitive to linear
motion in multiple
trajectories
Anatomy & Physiology
 Anatomy & Physiology
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Second level Senses and controls
● Third level
motion
● Fourth level

● Fifth level

Information is
combined with that
from visual system and
proprioceptive system

Maintains balance and

compensates for effects
of head motion
 Anatomy & Physiology
Vestibulo-Ocular Reflex
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Membranous labyrinth moves with head Second level
motion ● Third level

● Fourth level

Endolymph does not causing relative ● Fifth level

motion

Cupula on right canal deflected towards

utricle causing increase in firing rate, left
deflects away causing a decrease in firing
rate.

Reflex causes movement of eyes to the

left with saccades to right

Stabilizes visual image

 Anatomy & Physiology

If acceleration stops, and spin to right

is at constant velocity, sensation of
motion stops after 14-20 seconds as
does nystagmus

Cupula only takes 8-10 seconds to

return to equilibrium position

Vestibular integrator is the term for the

prolongation and is mediated by the
 Anatomy & Physiology
Vestibulospinal Reflex

Senses head movement and head

relative to gravity

Projects to antigravity muscles via 3

major pathways:
● Lateral vestibulospinal tract
● Medial vestibulospinal tract
● Reticulospinal tract
 Anatomy &
PhysiologyPhysiology

No single structure is solely

responsible for balance

Depends on the vestibular organs of

the inner ear and information from 3
different sources
● Eyes
● Muscles
● joints
 Anatomy &
PhysiologyPhysiology

At rest  baseline afferent vestibular

input is balanced in normal conditions
neural activity in the right and left sides
are equal

When head is rotated to the right 

excitation in the right side; inhibition in
the left
 Anatomy &
Reflexes Physiology

VESTIBULAR-OCULAR REFLEX
Will manifest as eye movement to the
contralateral side, and a fast movement to
the ipsilateral side

VESTIBULAR-SPINAL REFLEX
Will manifest as limb extension in the
ipsilateral side, limb flexion on the
contralateral side
 Anatomy & Physiology

Balance does not only depend on

vestibular, visual and proprioceptive
components

Cerebellar lesions and other systemic

diseases affecting the vascular supply
of the brain may also cause dizziness
and vertigo
Head Shake Te
 H e a d S h a ke Te s t
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Second level
● Third level

● Fourth level

● Fifth level

Action:
• Patient is seated
• Head is oscillated for 15-20 secs in a horizontal position.
• The head is abruptly immobilized in midposition and the induced
nystagmus is observed directly or through Frenzel’s glasses.
 H eHead
a d Shake
S h aTest
ke Test
Head Shake Nystagmus

Initial Nystagmus: the

direction of the fast phase
towards the pathologic or
normal side inpatients with
unilateral loss of vestibular
function

Time course of HSN:

Head Shake Test
• The nystagmus is associated with
the activation of a latent vestibular
imbalance.

• It states that, for high velocities of

head rotation, excitation is a more
effective stimulus than inhibition.

Vestibular afferents are silenced/driven

into inhibitory cut-off at a velocity of
head rotation that is lower than that
which leads to saturation during
excitation.
 H eHead
a d Shake
S h aTest
ke Test

• The effect of Ewald’s law is most apparent

when the head is positioned so that the
plane of the particular semicircular canal
being tested is parallel to the plane in
which the head is rotating.
Head Thrust/ Impulse Test
 Head Thrust/ Impulse
Test
Introduced by Halmagyi
and Curthoys in 1988

It aims to identify the

presence and lateralize the
side of a unilateral
vestibular weakness.
 Head Thrust/ Impulse
Test
Ask the patient to fixate on a target in front of the patient
 Head Thrust/ Impulse
Head Thrust or Impulse Test
Test

• The patient's head is gently grasped, and a small-amplitude (50-100) but

high-acceleration (3,000-4,0000/s) thrust is applied by the examiner.

• During the head turn, patient’s eyes are observed for corrective saccade
Head Thrust/ Impulse
Head Thrust or Impulse Test
Test

• Corrective saccade is
a rapid eye motion that
returns the eyes toward
the target.

• Normal: eyes stay fixed

on the target  no
corrective saccade
 Head Thrust/ Impulse
Test
• The presence of this movement is
due to contralateral horizontal
semicircular canal being stimulated
in an ampullofugal manner.

• Rapid head turns the discharge rate

of the vestibular afferents are driven
from about 90 spikes/s at rest to
zero, thus the compensatory
response is dependent on the
ipsilateral canal’s stimulation

• Impairment of the ipsilateral canal:

VOR does not function optimally and
compensatory movement is not
adequate to keep target fixated.
Fukuda Step Testi
 FUKUDA STEP TESTING

Method of obtaining objective evidence

of imbalance of labyrinthine function
which is expressed by functional
imbalance of the musculature of the
lower extremities during stepping.

Tadashi Fukuda. The Stepping Test Two Phases of the Labyrinthine

Reflex. Department of ORL Gifu Medical School
• Method:
1. The subject
stands upright in the
centre of the Fukuda
ring, blindfold, his
arms stretched out
horizontally in front of
him; he is invited to
step on the spot, 50
time, raising his knees
high. The manoeuvre F u k u d a
Step
is repeated, head at
Testing
• Method:
2. With his head
straight ahead, a
normal subject when he
marks time does not go
out of the hatched area.

3. But with his head

turned to the right he
deviates leftwards.

4.With his head

turned to the left, he
deviates rightwards.
Fukuda Step
Testing
Results

Head at rest, a normal subject does not go out of the 45

deg quadrant situated just in front of him, he deviates
to the left when his head is rotated to his right and vice
versa 

Deviation usually occurs to side of lesion

Fukuda Step
Testing
RESULTS: Normal or
abnormal?
1. Hardly no rotation of body
2. Right-handed persons show slight left rotation of the body
3. Left-handed persons show slight right deviation of the
body
4. Forward progression of the body up to 50-100 cm after 50-
100 steps
5. Angle of rotation within 30 ˚
6. Angle of rotation within 45 ˚
7. Otitis media purulenta acuta
8. Obstruction of the auditory canal

Tadashi Fukuda. The Stepping Test Two Phases of the Labyrinthine

Reflex. Department of ORL Gifu Medical School
 FUKUDA STEPPING TEST

• A vestibulospinal test known as the Fukuda stepping test (FST)

has been suggested to be a measure of asymmetrical
labyrinthine function. However, an extensive review of the
performance of this test to identify a peripheral vestibular
lesion has not been reported.

• These findings suggest that the FST with and without head
shake component is not a reliable screening tool for peripheral
vestibular asymmetry in chronic dizzy patients; however, future
research may hold promise for the FST as a tool for patients
with acute unilateral disorders.

Honaker JA, Boismier TE, Shepard NP, Shepard NT. Fukuda stepping
test: sensitivity and specificity. J Am Acad Audiol. 2009 May
Romberg’s
Primarily a test of somatosensation and
proprioception

Not a test of cerebellar function, as it is

commonly misconstrued.

Patients with cerebellar ataxia will,

generally, be unable to balance even with
the eyes open;

Test cannot proceed beyond the first step

and no patient with cerebellar ataxia can
correctly be described as Romberg's
positive.

Romberg’s Test
 Method

1. Have the patient

stand with feet close
together and arms at
the side with eyes
open and then eyes
closed.
Results:
Romberg's test is positive if the patient sways or falls
(+) equal sway with 1. Observe
eyes open for and
the closed =
proprioception problemsrelative amount of
(+) with eyes closed = vestibular weakness
Fukuda step testing &
Romberg’s test

(website for video demos)

http://www.vestibularseminars.com/officeexa
DIX-HALLPIKE MANEUVE
 DIX-HALLPIKE
MANEUVER
• A.K.A. Nylen-Barany test

• Diagnostic test used to identify

Benign Paroxysmal Positional
Vertigo

– The presence or absence of debris in

the posterior semicircular canal of the
inner ear

– If debris is present the test will induce

vertigo and nystagmus
DIX-HALLPIKE
MANEUVER
Dix-Hallpike test is
the gold standard
for posterior canal
BPPV

The test has been

shown to have a
sensitivity of 79-
82% and a
specificity of 71-
 DIX-HALLPIKE
MANEUVER

Patient sitting upright with the legs extended

Patient's head rotated by approximately 45 degrees
 DIX-HALLPIKE
MANEUVER

Clinician helps the patient to lie down backwards

quickly with the head held in approximately 20
degrees of extension
 DIX-HALLPIKE
HOWM A N E U V E R

The patient's eyes are then observed

for about 45 seconds as there is a
characteristic 5-10 second period of
latency prior to the onset of
nystagmus

To complete the test, the patient is

brought back to the seated position,
and the eyes are examined again to
see if reversal occurs.
POSTIVE TEST

If rotational nystagmus occurs then the

test is considered positive for benign
positional vertigo

NEGATIVE TEST
• If the test is negative, it makes
benign positional vertigo a less likely
diagnosis and CNS involvement
should be considered
 DIX-HALLPIKE
MANEUVER
During a positive test, the fast phase of the
rotatory nystagmus is toward the affected ear,
which is the ear closest to the ground

The direction of the fast phase is defined by

the rotation of the top of the eye, either
clockwise or counter-clockwise
 DIX-HALLPIKE
MANEUVER
There are several key characteristics of
a positive test:
Latency of onset (usually 5-10
seconds)
Torsional (rotational) nystagmus
● If no torsional nystagmus occurs but there is
upbeating or downbeating nystagmus, a CNS
dysfunction is indicated

Upbeating nystagmus indicates that

the vertigo is present in the posterior
 DIX-HALLPIKE
MANEUVER
There are several key characteristics of a
positive test:
Fatigable nystagmus
● Multiple repetition of the test will result in less and
less nystagmus
Reversal
● Upon sitting after a positive maneuver the direction
of nystagmus should reverse for a brief period of
time
FINGER-TO-
 Fi n ger to N o s e
Tes t
Ask the patient to
point to their nose,
and then reach out
to point to your
index finger
Ensure that they fully
extend their elbow
while doing this
Look for intention
CEREBELLAR EXAMINATION

The main role of the

cerebellum is to
coordinate voluntary
muscular contractions.

The cerebellum adjusts

the rate, regularity, and
force of willed
movements and
regulates muscle tone.

Coordination of
CEREBELLAR EXAMINATION

From this information the cerebellum

coordinates the range, velocity and
strength of contractions to produce
steady volitional movements and
steady volitional postures.

Incoordination (ataxia) is the main

feature of cerebellar dysfunction.
 WRIST
SLAPPING
 Wri s t Sl ap p in g
Rapid alternating movements test for
dysdiadochokinesia

Rapid alternating movements, such as

wiping one palm alternately with the
palm and dorsum of the other hand.
 OVERSHOOTING

Clinical examination for postural or

position “overshooting”
Test for overshoot by having the
patient raise both arms suddenly from
their lap to the level of your hand.
In addition, you can apply pressure to
the patient's outstretched arms and
then suddenly release it.
 Wri s t Sl ap p in g
Normal performance of these motor tasks
depends on the integrated functioning of
multiple sensory and motor subsystems.

These include position sense pathways, lower

motor neurons, upper motor neurons, the
basal ganglia, and the cerebellum.

Thus, in order to convincingly demonstrate

that abnormalities are due to a cerebellar
lesion, one must first test for normal joint
position sense, strength, and reflexes and
confirm the absence of involuntary
movements caused by basal ganglia lesions.
 Common Disorders

COMMON DISORDERS
Meniere’s Disease
• Idiopathic
endolymphatic
hydrops
• distortion of the
membranous
labyrinth due to
overaccumulation
of endolymph
• clinical triad of
vertigo, tinnitus
and hearing loss
Benign Paroxysmal Positional
Vertigo

Dislodgement of
calcium crystals
(otoconia) from the
utricle with migration
to the semicircular
canals (most
commonly the
posterior canal)
Benign Paroxysmal Positional
Vertigo

When the head is reoriented relative to

gravity, the gravity-dependent movement
of the heavier otoconial debris within the
affected semicircular canal causes
abnormal fluid endolymph displacement
and a resultant sensation of vertigo
 Dix Hallpike Test:
Nystagmus
The nystagmus associated with BPPV has several important characteristics
which differentiate it from other types of nystagmus.
Positional: the nystagmus occurs only in certain positions
Latency of onsent: there is a 5-10 second delay prior to onset of nystagmus
Nystagmus lasts for 5–120 seconds
Visual fixation does not suppress nystagmus due to BPPV
Rotatory/Torsional component is present or (in the case of lateral canal
involvement)the nystagmus beats in either a geotropic (towards the
ground)or ageotropic (away from the ground) fashion
Repeated stimulation, including via Dix-Hallpike maneuvers, cause the
nystagmus to fatigue or disappear temporarily
Management
Watchful waiting
Canalith repositioning procedure
Employs gravity to move the calcium buildup
Vestibulosuppressant medication
Surgical management
– Semicircular canal occlusion
VESTIBULAR
NEURITIS
acute, sustained dysfunction of
the peripheral vestibular
system with secondary nausea,
vomiting, and vertigo

sudden disruption of afferent

neuronal input from 1 of the 2
vestibular apparatuses
VESTIBULAR
NEURITIS
abrupt onset of severe, debilitating
vertigo with associated
unsteadiness, nausea, and vomiting.

They often describe their vertigo as

a sense that either they or their
surroundings are spinning.
Vertigo increases with head
movement.
Labyrinthitis

inflammatory disorder of the inner ear or

labyrinth caused most commonly by
 Labyrinthitis
Viral
characterized by a sudden, unilateral loss of
vestibular function and hearing
The acute onset of severe, often incapacitating,
vertigo, frequently associated with nausea and
vomiting
Vertigo eventually resolves after several days to
weeks; however, unsteadiness and positional
vertigo may persist for several months
Bacterial Labyrinthitis
potential consequence of meningitis and otitis
media and may occur by either direct bacterial
invasion (suppurative labyrinthitis) or through the
passage of bacterial toxins and other inflammatory
mediators into the inner ear (serous labyrinthitis).
Profound hearing loss, severe vertigo, ataxia, and
nausea and vomiting

Management
Treat underlying infection
Antiemetic medications
Steroids for recovery of peripheral vestibular
function
Thank You!