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Dr. R. Srinivasa Raghavan Royal National Nose Throat and Ear Hospital London
dizziness vertigo balance problem light headed travel sickness panic attack disequilibrium dont like turning right quickly dont like supermarkets any more ?!?!?
Wanted:
A system that reacts promptly and accurately to head movements
Proprioception
Labyrinth
Visual input
Graviceptors
3D movement balance
semicircular canal
Transducers
Push-Pull Principle
6 ways to move
3 Rotations
Vestibular system
1) provide general orientation of the body with respect to gravity 2) enable balanced locomotion and body position 3) readjust autonomic functions after body reorientation and 4) ensure gaze stabilisation
saccades
(3500 - 6000/s) maintenance of visual target on fovea by either voluntary effort or involuntary reflex (i.e. fast phase of nystagmus) smooth pursuit (<600/s) maintains gaze on moving target
OKN
primitive smooth pursuit involving whole retina corrective saccades relocate gaze onto new targets coming into visual field
Vestibulo-ocular Reflex
VOR: Stabilises images on the retina during head movements, by moving the eyes in a direction opposite to that of head movement
Impairment of VOR
Unilateral vestibular damage results in two types of abnormality within VOR Static imbalance -difference in tonic discharge rate between vestibular nuclei on two sides spontaneous nystagmus
Saccades
check saccades i.e fast eye movements look back and forth between 2 targets and observe: reaction time (latency) accuracy velocity
Lesion of frontal cortex (ipsilateral gaze palsy) One and a half syndrome
Failure of conjugate gaze in one direction in INO and other
Vertical
Downward: low brainstem Upward: pre-tectal, basal ganglia Note: age, alcohol, psychotropic medication, anticonvulsants
BPPV Vestibular neuritis Herpes zoster oticus Meniere's disease Labyrinthine concussion Perilymphatic fistula Semicircular canal dehiscence syndrome Cogan's syndrome Recurrent vestibulopathy Vestibular schwannoma (acoustic neuroma) Aminoglycoside toxicity Otitis media CENTRAL ETIOLOGIES Migrainous vertigo Brainstem ischemia TIA Wallenberg's syndrome Cerebellar infarction and hemorrhage Chiari malformation
BPPV
The dizziness is brief usually seconds, rarely minutes when turning in bed or tilting the head nausea but rarely vomit predictably provoked and continue for weeks or months Episodes may recur. Diagnosis History Dix-Hallpike positive in only 50 to 80%
Vestibular Neuritis
Rapid onset severe, persistent vertigo (one or two days) Nausea, vomiting and gait instability
spontaneous vestibular nystagmus, a positive head thrust test, and gait instability without a loss of the ability to ambulate
Cerebellar haemorrhage or infarction may be similar
Meniere's disease
Peripheral vestibular disorder Excess endolymphatic fluid pressure episodic inner ear dysfunction spontaneous episodic vertigo minutes to hours unilateral tinnitus, hearing loss, and ear fullness the vertigo is often severe nausea and vomiting and disabling imbalance The disequilibrium may last for several days Horizontal-torsional nystagmus is typically seen on examination during an attack
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One study showed 20% of consecutive patients evaluated in a dizziness clinic had panic disorder (Clark et al 1994)
15% Stein et al 1994 16% Sullivan et al 1993 17.2% Persoona et al 2003 20% Yardley and Beech 2001 20.4% Clark and Leslie 1992 26% Honrubia et al 1996 27.8% Yardly and Masson 1992
Secondary (late/cognitive)
Fear (cognition) regarding future attacks of dizziness Its social consequences and disability Worries about illnesses such as tumours/ mental illness Begins when pt begins to worry about significance of symptoms
Jacob RG et al 2003
Balance-Anxiety Link
Parabrachial nucleus (PBN) network mediate visceral, vestibular and extra-vestibular information PBN network generate emotional, affective and physiological manifestations of fear and anxiety
1.
Prof. Floris Wuyts, Head of the Vestibular Function Lab & Research, University Antwerp (Research co- operation with NASA) Baloh and Honrubia, Clinical Neurophysiology of the Vestibular System, Oxford publication, third edition
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Clark, D. B., Hirsch, B. E., Smith, M., Furman, J. M. R., & Jacob, R. G. (1994). Panic in otolaryngology patients presenting with dizziness or hearing loss. American Journal of Psychiatry, 151(8), 1223-1225.
Prof. S. Wessely, BMJ. 2001 March 31; 322(7289): 767
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