VERTIGO AND MENIERES

DISESASE
dr. Ida Ayu Sri Wijayanti, M.Biomed, Sp.S
Departement of Neurology
FMUNUD/Sanglah Hospital
Denpasar

DEFINITION
Vertigo is
derived from
the latin:

Vertere = to turn
Igo = a condition

A specific describing a false sense of motion,

usually spinning or rotatory, in the
surroundings or within oneself despite the
absence of physical movement.
Chang et al, 2008

Dizziness
Is a nonspecific term that describes a sensation
of altered spatial orientation
Any sensation of discomfort of head.
Dizziness has resulted in a classification
system with 4 different subtypes

Body Balance is Controlled by 3 Sensory

Systems:
Vestibular, Visual, Proprioseptif
Eye
(Visual)
Inner ear
(vestibular system)

Skin,Muscle and joint

(Proprioceptive)
Central Nervous system

Controls eye
movements

Postural control
via muscles

Balance
dyfunction

Imbalance /Dizziness
Goebel JA. Otolaryngol Clin North Am 2000;33:48393.
Shepard NT, Solomon D. Otolaryngol Clin North Am 2000;33:45569

Vestibular Labyrinth
Pathophysiology
Complex interaction of visual, vestibular
and proprioceptive inputs that the CNS
integrates as motion and spatial orientation

3 semicircular canals
rotational movement
cupula

2 otolithic organs
utricle & saccule
linear acceleration
Macula

Cause of Vertigo
An imblance of sensory input into the
two vestibular nuclei from
overactivity or underactivity of either
or both sides of labyrinth.
The brain interprets such input
differences as a sensation of
movement.

Cont..
However, any disturbances to the labyrinth,
visual-vestibular interaction centres in the
brainstem & cerebellum, and sensory pathway
to or from thalamus, can result VERTIGO

VERTIGO
Vertigo is an erroneous perception of motion
of either the subject or the environment.
1. VESTIBULAR VERTIGO
2. NONVESTIBULAR VERTIGO

Vestibular system
Visual, Somatosensory
systems

VERTIGO
Vestibular vs Nonvestibular
Vestibular

Nonvestibular

Feeling

Spinning

Swaying, rocking,
swimming, floating

Duration of attack

Episodic

Constant

Trigger

Movement of the
head or body

Stress, hyperventilation,
busy environment

Associated symptoms

Nausea, vomit, tinnitus, Pale, tachycardy,

deafness, oscillopsia
parresthesia, syncope

Physiological vertigo (motion stimulation) and pathological vertigo

(induced by lesion or stimuli) are characterised by similar signs and
symptoms that derive from the functions of the multisensory
vestibular system (Brandt and Daroff 1980)

Balance requires information of similar

intensity from both vestibular systems
Head movement

Activation of cells
in left
vestibular system

Activation of cells
in right vestibular
system
Central nuclei

10

10

Normally, the input from left and right vestibular

system is of similar intensity (e.g. of size 10)

Peripheral vestibular vertigo

Dysfunction of vestibular apparatus, vestibular nerve
Central nuclei

10

Central Vestibular Vertigo

dysfunction in central processing
Central nuclei

10

10

VESTIBULAR VERTIGO

1. Peripheral
2. Central

Decreasing frequency

Vertigo of Peripheral origin: causes

Condition

Details

Benign paroxysmal
positional vertigo
(BPPV)

Brief, position-provoked vertigo episodes caused by

abnormal presence of particles in semicircular canal

Menieres disease

An excess of endolymph, causing distension of

endolymphatic system

Vestibular neuronitis

Vestibular nerve inflammation, most likely due to virus

Acute labyrinthitis

Labyrinth inflammation due to viral or bacterial infection

Labyrinthine infarct

Compromises blood flow to the labyrinthine

Labyrinthine
concussion

Damage to the labyrinthine after head trauma

Perilymph fistula

Typically caused by labyrinth membrane damage

resulting in perilymph leakage into the middle ear

Autoimmune inner ear

disease

Inappropriate immunological response that attacks inner

ear cells

Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101. Parnes LS et al. CMAJ
2003;169:681 93. Puri V, Jones E. J Ky Med Assoc 2001;99:31621. Salvinelli F et al. Clin Ter 2003;154:3418.

Decreasing frequency

Vertigo of Central origin: causes

Condition

Details

Migraine

Vertigo may precede migraines or occur concurrently

Vascular disease

Ischaemia or haemorrhage in vertebrobasilar system

can affect brainstem or cerebellum function

Multiple sclerosis

Demylination disrupts nerve impulses which can

result in vertigo

Vestibular
epilepsy

Vertigo resulting from focal epileptic discharges in

the temporal or parietal association cortex

Cerebellopontine
tumours

Benign tumours in the internal auditory meatus

Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101. Salvinelli F et al. Clin Ter 2003;154:
3418. Solomon D. Otolaryngol Clin North Am 2000;33:579601. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:1120.

Vertigo-Characteristics
Peripheral
Onset
Sudden
Severity of Vertigo
Intense
Pattern
Paroxysmal
Exac. by movement Yes
Autonomic
Frequent
Laterality
Unilateral
Nystagmus
Horizontorotary
Fatigable/Fixation
Yes
Auditory symptoms Yes
CNS symptoms
Absent

Central
Usually slow
Usually mild
Constant
Variable
Variable
Uni or bilat
Any
No
No
Present

Approach to Patients with Vertigo

COMPLAINT
Mabuk, pusing

Dizziness / Imbalance?
Ilusion of motion (+)

Not Dizziness ?
Ilusion of motion (-)

- Headache
- Stress

Ask the patient to describe the symptom ! !

DIZZINESS / IMBALANCE
no
VERTIGO ?
yes
Vertigo type

Etiology

Diagnosis

Therapy

DYSEQUILIBRIUM, PRESYNCOPE

Vestibular or Nonvestibular ?

- Peripheral ?
or
- Central ?

- Visual ?
or
- Somatosensory ?

Symptoms Accompanying
Peripheral Disease
Hearing

loss

Tinnitus
Aural fullness
Position

changes exacerbate the

dizziness
Lying still lessens the symptoms
Sem in Neurol. 2001;21(4)

Symptoms Accompanying Central

Nervous System Disease
The

sensation may be described in a

variety of ways: spinning, tilting,
pushed to one side, lightheadedness,
clumsiness, or even blacking out.
Signs of neural dysfunction, that is,
dysarthria, dysphagia, diplopia,
hemiparesis, severe localized
cephalgia, seizures, and memory
loss
Sem in Neurol. 2001;21(4)

Symptoms Accompanying
Auditory Complaints
Unilateral

otologic complaint: aural

fullness, tinnitus, hearing loss, or
distortion.

Frequent

causes of unilateral
auditory disease with dizziness
include:
Endolymphatic hydrops
Perilymphatic fistula
Labyrinthitis

General Physical &

Emotional Health
Hypertension,

hypotension,
atherosclerotic disease, endocrine
imbalances, anxiety
common causes of lightheadedness,

near syncope, instability

rarely produce a sense of true vertigo
Medication

side effects and

excessive caffeine, nicotine, and
alcohol intake should be investigated

Routine Full Head & Neck

Examination
Important for 2 reasons:
Dizzy

patients frequently have other

ear, nose, throat pathology

Structural

problems of the ear, nose,

throat at times cause dizziness or
indicate a more widespread process
Sem in Neurol. 2001;21(4)

NEURO-OTOLOGIC
EXAMINATION

VESTIBULOOCCULER REFLEX
EXAMINATION
NYSTAGMUS
involuntary, ritmic, continuous, to and fro or shuttle
movement of eyeballs. Shuttle with different speed
(Jerky) or same speed (Pendulum), whereas its
direction can be horizontal, vertical or mixed.
Nystagmus can be seen by naked eyes or Frenzel
glasses

Nystagmus Forms
1. Spontaneous Nystagmus :
Happen by normal eye position without head
alternation
Characteristic of spontaneous nystagmus :
- No change after fixation possible caused by
central vestibular abnormality
- Spontaneous nystagmus with vertical, see saw,
rotatory direction caused by central vestibular
abnormality

2. Gaze Nystagmus :
happen when eye glance a side at 30
degree from neutral position. Simple
examination by asked the patient to
follow movement of fingers examiner
- Nystagmus happen bilateral very
possible central vestibular lesion.
- Nystagmus happen unilateral
central or peripheral lesion

Dix-Hallpike Maneuver
Action
Turn the patient's
head 45 degrees to
one side while seated
and rapidly but
carefully have the
patient recline
Observe the eyes for
nystagmus and, if
present, note the
following 5
characteristics:
Latency, direction,
fatigue, habituation

Interpretation
A positive maneuver is
diagnostic for benign position
vertigo (posterior semicircular
canal).
Classical positioning nystagmus:
geotropic torsional direction
brief latency (5 to 20 seconds)
decline with repeated
positioning
30 seconds or less duration
reversal upon arising

Tests of stance and gait

Romberg test
Action:
Have the patient stand with feet close
together and arms at the side with eyes
open and then eyes closed

Observe for the relative amount of sway

with vision present versus absent

Interpretation
Patients with compensated bilateral
vestibular loss stand normally in
both eyes-open and eyes-closed
Romberg position because of
adequate proprioception from the
stable support surface.
Increase sensitivity with:
tandem stance
3-inch foam

 Gait

test

Walk 5 m, firstly with the eyes open and

then with the eyes closed

Tandem

gait test

Start with feet in the tandem position

and arms folded against the chest and to

make 10 steps
Eyes open test of cerebellar function
Eyes closed test of vestibular
function

Treatment of Vertigo
1. Pharmacotheraphy:
a. Symptomatic
b. Causal
2. Rehabilitation

The goals of Pharmacotherapy

for Vertigo
Elimination Vertigo
Enhance Vestibular Compensation
Decreasing the Neurovegetative Symptoms
Decreasing Psychoaffective Symptoms

Immediately

Symptomatic
I. ANTI VERTIGO
1.Vestibular Suppressant
a. Ca antagonist : Flunarizin
b. Vasodilator
: Betahistine
c. Tranquilizer : Diazepam, haloperidol,
sulpiride, clonazepam
d. Antihistamin

: Difenhidramine,

meclizine untuk mengobati motion sickness

2. CNS stimulant
Ephedrin, amphetamin

Cont
II. ANTI EMETIC
1. Anticholinergic : atropine,
scopolamin
2. Antidopaminergic :
Prochlorperazine,
metoclopramide.

Drug/ Medicine
Multiple Drug Action

Antihistamine

Histamine:

Anticholinergic Activity
Orally
Duration of Action: 4 - 12 hours
Side Effect: Sedation

Tx. Vertigo: Vascular?

i.v, s,c., sub lingual
Increase capillary & Venous volume
Regulator of Microcirculation

Betahistine

Anti
Cholinergic

L-histidine, orally Meniere Disease

H1 post synaptic agonist & H3 presynaptic antagonist
Increase Inner Ear Blood flow & Central Effect
Adverse effect: Headache, Nausea
Contra indication: Pheochromocytoma & Gastric
Ulcer

The Oldest Agent to control Vertigo

Atrophine
Scopolamine/ Hyoscine Transdermal Patch
Decrease side effect
The effect last for 4 days
Homatrophin

Calcium Entry Blocker

Flunarizine

Used in Eurrope, Not Yet Approved in US

Long Half Life
Steady State 2 months
Adverse Effect: Sedation, Weight Gain,
Depression, Parkinsonism
Used 1 month in Elderly

+ Anti Histamine (Cinnarizine/ + Dimenhydrinate Same

Effect

Rehabilitation
Brandt-Daroff Exercises
method of treating BPPV, usually used when the
office treatment fails.
These exercises should be performed
for two weeks, three times per day
for three weeks, twice per day.
In each time, one performs the maneuver as
shown five times.
1 repetition = maneuver done to each side in
turn (takes 2 minutes)

Brandt-Daroff
Exercises

MENIERES DISEASE

Mnire Disease
First described in 1861
Triad of vertigo, tinnitus and hearing
loss
Due to cochlea-hydrops
Unknown etiology
Possibly autoimmune

Abrupt, episodic, recurrent episodes with

severe rotational vertigo
Usually last for several hours

 2 phases early (almost always unilateral

and symptoms episodic) and late
(symptoms present more or less all the
time with episodes of exacerbation
consisting of an increased severity of
symptoms).

Mnire Disease
Often patients have eaten a salty meal
prior to attacks
May occur in clusters and have long
episode-free remissions
Usually low pitched tinnitus
Symptoms subside quickly after attack
No CNS symptoms or positional vertigo
are present

Management
Severe Mnire disease may require chemical
ablation with gentamicin
Attempt Epley maneuver for BPPV
Mainstay of peripheral vertigo management are
antihistamines that possess anticholinergic
properties
-Meclizine
-Diphenhydramine
-Promethazine
-Droperidol
-Scopolamine

MATUR SUKSMA