1

Balance the imbalance

DIAGNOSIS & MANAGEMENT OF
VERTIGO - PRESENT
SENARIO
DIAGNOSIS & MANAGEMENT OF
VERTIGO - PRESENT
SENARIO
2
Dizziness Dizziness
!
4 varients of dizziness
-A definite rotational sensation or vertigo
-A sensation of faintness or i!ending loss of
"onsio#sness
-Dese$#ili%ri# or sense of i%alan"e
-An illdefined sense of dizziness or lig&t
&eadedness
!
4 varients of dizziness
-A definite rotational sensation or vertigo
-A sensation of faintness or i!ending loss of
"onsio#sness
-Dese$#ili%ri# or sense of i%alan"e
-An illdefined sense of dizziness or lig&t
&eadedness
3
VERTIGO VERTIGO
-A s#%'e"tive sensation of oveent
-Ma( feel eit&er t&at &i involving in s!a"e or
t&at o%'e"ts in t&e environent are oving
aro#nd &i)
-It also in"l#de feeling of s*a(ing oveent of
%od(
-A s#%'e"tive sensation of oveent
-Ma( feel eit&er t&at &i involving in s!a"e or
t&at o%'e"ts in t&e environent are oving
aro#nd &i)
-It also in"l#de feeling of s*a(ing oveent of
%od(
4
OT+ER T,-E OF DI..INESS OT+ER T,-E OF DI..INESS
!
Faintness- generall( indi"ates &eod(nai" fa"tors
"a#sing %rain is"&eia )
!
Dise$#ili%ri#- refers to a sense of #nsteadiness or
i%alan"e & o""#re d#ring a%#lation /es!e"iall( *&en
stressed li0e ra!id t#rning/ in t&e dar0 & s#ggests
"ere%ellar in"ordination/ #s"le *ea0ness & !eri!&eral
sensor( i!airent )
!
1ig&t &eadedness- is a fre$#entl( a ne#rologoi" "o!laints
& a( &ave no stereot(!ed "ondition for its !re!itation or
aggravation ot&er t&an eotional stress )
!
Faintness- generall( indi"ates &eod(nai" fa"tors
"a#sing %rain is"&eia )
!
Dise$#ili%ri#- refers to a sense of #nsteadiness or
i%alan"e & o""#re d#ring a%#lation /es!e"iall( *&en
stressed li0e ra!id t#rning/ in t&e dar0 & s#ggests
"ere%ellar in"ordination/ #s"le *ea0ness & !eri!&eral
sensor( i!airent )
!
1ig&t &eadedness- is a fre$#entl( a ne#rologoi" "o!laints
& a( &ave no stereot(!ed "ondition for its !re!itation or
aggravation ot&er t&an eotional stress )
5
ANATOM, AND
-+,SIO1OG,2
ANATOM, AND
-+,SIO1OG,2
2RE1ATED TO VERTIGO 2RE1ATED TO VERTIGO
6
7
Utricular
nerve
e
8
9
10
ry
ve
11
3entral !ro'e"tion of !eri!&eral
vesti%#lar s(ste
3entral !ro'e"tion of !eri!&eral
vesti%#lar s(ste
12
13
3A4SES OF
VERTIGO
3A4SES OF
VERTIGO
14
5&at "a#ses vertigo6 5&at "a#ses vertigo6
!
3ontradi"tor( inforation fro

T&e vesti%#lar s(ste 7ears8

9T&e vis#al s(ste 7e(es8

T&e -ro!rio"e!tive s(ste

7#s"les/ 'oints8
!
3ontradi"tor( inforation fro

T&e vesti%#lar s(ste 7ears8

9T&e vis#al s(ste 7e(es8

T&e -ro!rio"e!tive s(ste

7#s"les/ 'oints8
15
3a#ses of Vertigo 3a#ses of Vertigo

-ERI-+ERA1 : Meniere;s disease

1a%(rint&itis
Vesti%#lar ne#ro!at&(
<--V
Tra#a

3ENTRA1- referred to neoni" = VERTIGO>

V : vas"#lar "a#ses li0e Stro0e / Verte%ro%asilar
ins#ffi"ien"( / igraine / vas"#litis &
vas"#lar eleents li0e de"reased "ardia" o#t!#t /
ort&ostati" &(!otension/aneia/&(!o?ia/&(!ogl("eia

-ERI-+ERA1 : Meniere;s disease

1a%(rint&itis
Vesti%#lar ne#ro!at&(
<--V
Tra#a

3ENTRA1- referred to neoni" = VERTIGO>

V : vas"#lar "a#ses li0e Stro0e / Verte%ro%asilar
ins#ffi"ien"( / igraine / vas"#litis &
vas"#lar eleents li0e de"reased "ardia" o#t!#t /
ort&ostati" &(!otension/aneia/&(!o?ia/&(!ogl("eia
16
3A4SES OF 3ENTRA1 VERTIGO 3A4SES OF 3ENTRA1 VERTIGO
E : E!ile!s(7vertigino#s8
R : R? or dr#g related li0e
ANTIBIOTICS- aminoglycosides,
ANTIHYPERTENSIES
HYPNOTIC-SE!ATIE !R"#S- $henytoin, ba%bit&%ates,
' alcohol(
TRAN)"I**I+ERS ,Phenothia-ine,Ben-odia-e$ines
' T%icyclic antide$%essants
ASPIRIN
)"ININE


E : E!ile!s(7vertigino#s8
R : R? or dr#g related li0e
ANTIBIOTICS- aminoglycosides,
ANTIHYPERTENSIES
HYPNOTIC-SE!ATIE !R"#S- $henytoin, ba%bit&%ates,
' alcohol(
TRAN)"I**I+ERS ,Phenothia-ine,Ben-odia-e$ines
' T%icyclic antide$%essants
ASPIRIN
)"ININE


17
3A4SES OF 3ENTRA1 VERTIGO 3A4SES OF 3ENTRA1 VERTIGO
T : T4MO4R : -riar( li0e A"o#sti" ne#roa/ Glioa/
intraventri"#lar t#o#rs and se"ondar(
etastati" t#o#rs of %rain)
- TRA4MA
- T+,ROID- +(!ot&(roidis
I : INFE3TIONS : viral/ s(!&ilis/ vesti%#lar ne#ronitis)
G : G1IA1 DISEASE : M#lti!le s"lerosis
O : O41AR -AT+O1OG,- *ea0ness of e?tra o"#lar
#s"les )
T : T4MO4R : -riar( li0e A"o#sti" ne#roa/ Glioa/
intraventri"#lar t#o#rs and se"ondar(
etastati" t#o#rs of %rain)
- TRA4MA
- T+,ROID- +(!ot&(roidis
I : INFE3TIONS : viral/ s(!&ilis/ vesti%#lar ne#ronitis)
G : G1IA1 DISEASE : M#lti!le s"lerosis
O : O41AR -AT+O1OG,- *ea0ness of e?tra o"#lar
#s"les )
18
Vertigo@ Traditional 3lassifi"ation Vertigo@ Traditional 3lassifi"ation

-eri!&eral

7arises in vesti%#le8
Interediate

7arises in vesti%#lar nerve8

-eri!&eral

7arises in vesti%#le8
Interediate

7arises in vesti%#lar nerve8

3entral

7arises in vesti%#lar n#"lei8

3entral

7arises in vesti%#lar n#"lei8

Non-vesti%#lar

7arises o#tside t&e vesti%#lar s(ste8

Non-vesti%#lar

7arises o#tside t&e vesti%#lar s(ste8

!
Vertigo
!
Vertigo

Vesti%#lar

Vesti%#lar
19
Sites of Vertigo Sites of Vertigo
20
-&(siolog( of -eri!&eral Vertigo -&(siolog( of -eri!&eral Vertigo
!
Vesti%#lar a!!arat#s "onsist of : sei"ir"#lar "anal
- #tri"le
- sa""#le
All t&ese &ave sensor( &air "ells &aving stereo"ilia
arranged in as"ending fas&ion)
T&e longest sterio"ilia is 0Aa Bino"ilia)
Moveent of sterio"ilia to*ards 0ino"ilia- Sti#lation
Moveent of sterio"ilia o!!osite to 0ino"ilia- In&i%ition

!
Vesti%#lar a!!arat#s "onsist of : sei"ir"#lar "anal
- #tri"le
- sa""#le
All t&ese &ave sensor( &air "ells &aving stereo"ilia
arranged in as"ending fas&ion)
T&e longest sterio"ilia is 0Aa Bino"ilia)
Moveent of sterio"ilia to*ards 0ino"ilia- Sti#lation
Moveent of sterio"ilia o!!osite to 0ino"ilia- In&i%ition

21
3onditions res#lting in sti#lation of onl( one la%(rint&
res#lts in #ne$#al i!#lses rea"&ing to %rain leading to
state of d(se$#ili%ri# & anifest as vertigo or dizziness)
3onditions res#lting in sti#lation of onl( one la%(rint&
res#lts in #ne$#al i!#lses rea"&ing to %rain leading to
state of d(se$#ili%ri# & anifest as vertigo or dizziness)
22
3a#ses of -eri!&eral Vertigo 3a#ses of -eri!&eral Vertigo
!
<enign -aro?(sal -ositional Vertigo
!
Meniere;s Disease
!
1a%(rint&itis
!
+ead In'#ries & S#rgi"al Tra#a
!
-ress#re Vertigo
!
<enign -aro?(sal -ositional Vertigo
!
Meniere;s Disease
!
1a%(rint&itis
!
+ead In'#ries & S#rgi"al Tra#a
!
-ress#re Vertigo
23
3a#ses of Interediate Vertigo 3a#ses of Interediate Vertigo
!
Vesti%#lar ne#ronitis
!
A"o#sti" ne#roa
!
Dr#gs :al"o&al/ ainogl("osides/
anti"onv#lsants/ antide!ressanta/
anti&(!ertensive/ %ar%it#rates/ "o"aine )
!
Vesti%#lar ne#ronitis
!
A"o#sti" ne#roa
!
Dr#gs :al"o&al/ ainogl("osides/
anti"onv#lsants/ antide!ressanta/
anti&(!ertensive/ %ar%it#rates/ "o"aine )
24
3a#ses of 3entral Vertigo 3a#ses of 3entral Vertigo
!
V<I 7Verte%ro%asilar Ins#ffi"ien"(8
!
Arterios"lerosis
!
3ervi"al S!ond(losis
!
5&i!las& in'#ries of Ne"0
!
<rain T#ors
!
V<I 7Verte%ro%asilar Ins#ffi"ien"(8
!
Arterios"lerosis
!
3ervi"al S!ond(losis
!
5&i!las& in'#ries of Ne"0
!
<rain T#ors
25
!
+ead in'#ries
!
E!ile!s(
!
M#lti!le s"lerosis
!
+(!ogl("eia
!
Migraine
Non-Vesti%#lar 3a#ses of Vertigo Non-Vesti%#lar 3a#ses of Vertigo
!
O"#lar vertigo
!
Aneia
!
3ardiovas"#lar
7ort&ostati" &(!otension8
!
3ere%rovas"#lar
disorders
!
-s("&ogeni"
!
<rain t#ors
!
O"#lar vertigo
!
Aneia
!
3ardiovas"#lar
7ort&ostati" &(!otension8
!
3ere%rovas"#lar
disorders
!
-s("&ogeni"
!
<rain t#ors
26
Anot&er "lassifi"ation of vertigo Anot&er "lassifi"ation of vertigo
!
-aro?(sal Vertigo - s#dden atta"0 "oes
on $#i"0l(/ lasts for a s&ort tie
!
T&e single atta"0 - s#dden intense atta"0
fading a*a( slo*l(
!
3&roni" vertigo - not severe
!
-ositional vertigo - o""#rs follo*ing s#dden
oveents of &ead in "ertain !ositions
!
Dizz( s!ells - lasting a fe* se"onds
o""#rring irreg#larl(
!
-aro?(sal Vertigo - s#dden atta"0 "oes
on $#i"0l(/ lasts for a s&ort tie
!
T&e single atta"0 - s#dden intense atta"0
fading a*a( slo*l(
!
3&roni" vertigo - not severe
!
-ositional vertigo - o""#rs follo*ing s#dden
oveents of &ead in "ertain !ositions
!
Dizz( s!ells - lasting a fe* se"onds
o""#rring irreg#larl(
27
28
DIAGNOSIS
OF VERTIGO
DIAGNOSIS
OF VERTIGO
29
30
Medi"al +istor( Medi"al +istor(
!
Des"ri!tion of s(!tos %( !atient
!
3lassifi"ation of vertigo atta"0s
75&i"& t(!e/ &o* de%ilitating/ fre$#en"(/ d#ration/
vegetative s(!tos8
!
Infl#en"ing "ir"#stan"es
7In'#ries/ dr#gs ta0en/ stress/ eating !attern/ Illnesses8
!
Se"ondar( s(!tos
Tinnit#s/ +earing loss/ +eada"&e/ na#seaA voiting
!
Des"ri!tion of s(!tos %( !atient
!
3lassifi"ation of vertigo atta"0s
75&i"& t(!e/ &o* de%ilitating/ fre$#en"(/ d#ration/
vegetative s(!tos8
!
Infl#en"ing "ir"#stan"es
7In'#ries/ dr#gs ta0en/ stress/ eating !attern/ Illnesses8
!
Se"ondar( s(!tos
Tinnit#s/ +earing loss/ +eada"&e/ na#seaA voiting
Bis.as A(, /Ne&%otological Histo%y Ta0ing1 IN An Int%od&ction to Ne&%otology, 2334, 4-22 Bis.as A(, /Ne&%otological Histo%y Ta0ing1 IN An Int%od&ction to Ne&%otology, 2334, 4-22
31
Ada$ted 5%om Bis.as A(,1Clinical tests in Ne&%otology1 IN An Int%od&ction to Ne&%otology, 2334, 26-78 Ada$ted 5%om Bis.as A(,1Clinical tests in Ne&%otology1 IN An Int%od&ction to Ne&%otology, 2334, 26-78
Vesti%#lar F#n"tion Tests Vesti%#lar F#n"tion Tests
!
Vesti%#lo s!inal refle?

Ro%erg test

4nter%erger test

Modified Si0atani test

<a%ins0i-*eill test

<aran( -ointing test

!
Vesti%#lo s!inal refle?

Ro%erg test

4nter%erger test

Modified Si0atani test

<a%ins0i-*eill test

<aran( -ointing test

32
Vesti%#lo o"#lar refle? Vesti%#lo o"#lar refle?
3old "alori" test 7Bo%ra0 test8
<it&eral test 7 Fitzgerald-+all!i0e test8
Air "alori" test
D#ndas Grant air "alori" test
Fist#la test
ENG
O!to0ineti" test
Rotation test
3old "alori" test 7Bo%ra0 test8
<it&eral test 7 Fitzgerald-+all!i0e test8
Air "alori" test
D#ndas Grant air "alori" test
Fist#la test
ENG
O!to0ineti" test
Rotation test
33
34

Patient closes eyes and stretches

arms out in front

Walks on sot for a minute

Patients !ith "erti#o !ill start to

turn his a$is in articular direction

%he knees raised as hi#h

as ossi&le
35

Deviation to one side in

pointing occurs in
patients with vertigo
BARANYS
36
-atient *it& vertigo starts to *al0 in a star s&a!e -atient *it& vertigo starts to *al0 in a star s&a!e
<a%ins0(- 5eill Test <a%ins0(- 5eill Test
-atient "loses &is e(es and ta0es C ste!s for*ard
and C ste!s %a"0 for DE se"onds
-atient "loses &is e(es and ta0es C ste!s for*ard
and C ste!s %a"0 for DE se"onds
37
FIT.GERA1D- +A11-IBE A <IT+ERMA1
3A1ORI3 TEST
FIT.GERA1D- +A11-IBE A <IT+ERMA1
3A1ORI3 TEST
!
-atient in s#!ine !osition *it& &ead fle?ed at DE *it& &orizontal)
!
Ear is irrigated *it& *ater at 44 3 & DE 3 se!aratel( for !eriode of
4E Se" ea"& *it& t&e ga! of C in#te %et*een %ot& irrigations)
!
D#ration & "&ara"ter of n(stag#s is o%served )
!
Noral d#ration of n(stag#s is FE-G9E Se" *it& dire"tion for "old
*ater to*ards o!!osite ear & for *ar *ater for sae side) 7neoni"
: 3O5S8
!
If tie/d#ration & severit( de"reases on one side : 3ANA1 -ARESIS
!
If no rea"tion is o%served on one side : DEAD 1A<,RINT+
!
-atient in s#!ine !osition *it& &ead fle?ed at DE *it& &orizontal)
!
Ear is irrigated *it& *ater at 44 3 & DE 3 se!aratel( for !eriode of
4E Se" ea"& *it& t&e ga! of C in#te %et*een %ot& irrigations)
!
D#ration & "&ara"ter of n(stag#s is o%served )
!
Noral d#ration of n(stag#s is FE-G9E Se" *it& dire"tion for "old
*ater to*ards o!!osite ear & for *ar *ater for sae side) 7neoni"
: 3O5S8
!
If tie/d#ration & severit( de"reases on one side : 3ANA1 -ARESIS
!
If no rea"tion is o%served on one side : DEAD 1A<,RINT+
38
OT+ER 3A1ORI3 TESTS OT+ER 3A1ORI3 TESTS
!
BO<RAB;SA 3O1D 3A1ORI3 TEST- -osition siilar to
%it&eral test *it& irrigation *it& GE-GC"" of i"e "old *ater)
!
AIR 3A1ORI3 TEST- Air at different te!erat#re li0e
GH)C 3/4C)C 3 is !assed into ear & n#staf#s is noted)
!
D4NDAS GRANT AIR 3A1ORI3 TEST :Et&(le "&loride
is s!ra(ed on a "o!!er t#%e & t&en air fro t&e t#%e is
!assed into t&e ear ) Ntstag#s is noted )
!
BO<RAB;SA 3O1D 3A1ORI3 TEST- -osition siilar to
%it&eral test *it& irrigation *it& GE-GC"" of i"e "old *ater)
!
AIR 3A1ORI3 TEST- Air at different te!erat#re li0e
GH)C 3/4C)C 3 is !assed into ear & n#staf#s is noted)
!
D4NDAS GRANT AIR 3A1ORI3 TEST :Et&(le "&loride
is s!ra(ed on a "o!!er t#%e & t&en air fro t&e t#%e is
!assed into t&e ear ) Ntstag#s is noted )
39
40
FIST41A TEST FIST41A TEST
!
-ress#re is in"reased in EA3 *it& Siegle;s s!e"#l# or %(
a!!l(ing !ress#re over trag#s & o""#ran"e of an(
n(stag#s or vertigo is noted)
!
-OSITIVE FIST41A TEST- indi"ates fist#la in la%(rint&
es!e"iall( in 1S3 )
!
NEGATIVE FIST41A TEST-Noral la%(rint& or dead
la%(rint& )
!
FA1SE -OSITIVE TEST- Also BAa Hannebe%t1s Sign is seen
in Meniere;s disease and 3ongenital s(!&ilis)
!
FA1SE NEGATIVE TEST- Seen in "ases of dead la%(rint&
!
-ress#re is in"reased in EA3 *it& Siegle;s s!e"#l# or %(
a!!l(ing !ress#re over trag#s & o""#ran"e of an(
n(stag#s or vertigo is noted)
!
-OSITIVE FIST41A TEST- indi"ates fist#la in la%(rint&
es!e"iall( in 1S3 )
!
NEGATIVE FIST41A TEST-Noral la%(rint& or dead
la%(rint& )
!
FA1SE -OSITIVE TEST- Also BAa Hannebe%t1s Sign is seen
in Meniere;s disease and 3ongenital s(!&ilis)
!
FA1SE NEGATIVE TEST- Seen in "ases of dead la%(rint&
41
E1E3TRON,STAGMOGRA-+, E1E3TRON,STAGMOGRA-+,
!
ENG eas#res t&e f#n"tion of t&e vesti%#lar s(ste/
t&ro#g& t&e o""#lorotor !at&*a(s rat&er t&an t&e
a#ditor( !at&*a(s)
!
In ENG *e "o!are slo*I !&ase velo"it( and fast
!&ase velo"it( of t&e n(stag#s / of *&i"& slo*
!&ase velo"it( is ore i!ortant )
!
Standerd Deviation 7SD8 %et*een t*o ear s&o#ld not
%e ore t&an DE % for a normal person .
!
Practically without ENG we use a
costless procedure to count fast
componant in 10 ec. !f ma"imum
nystagmus periode which is #nown as a
cumulative velocity .
!
ENG eas#res t&e f#n"tion of t&e vesti%#lar s(ste/
t&ro#g& t&e o""#lorotor !at&*a(s rat&er t&an t&e
a#ditor( !at&*a(s)
!
In ENG *e "o!are slo*I !&ase velo"it( and fast
!&ase velo"it( of t&e n(stag#s / of *&i"& slo*
!&ase velo"it( is ore i!ortant )
!
Standerd Deviation 7SD8 %et*een t*o ear s&o#ld not
%e ore t&an DE % for a normal person .
!
Practically without ENG we use a
costless procedure to count fast
componant in 10 ec. !f ma"imum
nystagmus periode which is #nown as a
cumulative velocity .
42
E1E3TRON,STAGMOGRA-+, E1E3TRON,STAGMOGRA-+,

A %atter( of J tests are !erfored)

Sa""ade Test@ -atient loo0s %a"0 and fort& at a vis#al target on a

s"reen)

Gaze Test@ -atient gazes rig&t/ left/ #!/ do*n and "enter)

Tra"0ing Test@ -atient follo*s a vis#al target on an &orizontal !lane)

O!to0ineti" Test@ -atient follo*s a series of oving lig&ts on a

&orizontal !lane)

-osition Test@ -atient oves in vario#s !osition fo"#sing on one target)

3alori" Test@ -atient;s ears are sti#lated 9? ea"& *it& *ar and "ool
air or *ater

A %atter( of J tests are !erfored)

Sa""ade Test@ -atient loo0s %a"0 and fort& at a vis#al target on a

s"reen)

Gaze Test@ -atient gazes rig&t/ left/ #!/ do*n and "enter)

Tra"0ing Test@ -atient follo*s a vis#al target on an &orizontal !lane)

O!to0ineti" Test@ -atient follo*s a series of oving lig&ts on a

&orizontal !lane)

-osition Test@ -atient oves in vario#s !osition fo"#sing on one target)

3alori" Test@ -atient;s ears are sti#lated 9? ea"& *it& *ar and "ool
air or *ater
43
ROTATION TEST ROTATION TEST
!
%here are t!o kinds of comuteri'ed rotation tests( a#to &ead
rotation and rotar( "&air)
!
*n auto head rotation tests+ the erson &ein# tested is asked to
look at a fi$ed tar#et and mo"e his,her head &ack and forth or
u and do!n for short eriods of time)
!
-urin# rotary.chair tests+ the comuteri'ed chair mo"es for the
erson &ein# tested)
!
/ess usfull than caloric test &ecause it stimulates &oth the ear
simultaneously)
!
%here are t!o kinds of comuteri'ed rotation tests( a#to &ead
rotation and rotar( "&air)
!
*n auto head rotation tests+ the erson &ein# tested is asked to
look at a fi$ed tar#et and mo"e his,her head &ack and forth or
u and do!n for short eriods of time)
!
-urin# rotary.chair tests+ the comuteri'ed chair mo"es for the
erson &ein# tested)
!
/ess usfull than caloric test &ecause it stimulates &oth the ear
simultaneously)
44
O-TOBINETI3 TEST O-TOBINETI3 TEST
!
T&e !erson sits in front of a rotating dr# *it&
alternate *&ite and %la"0 verti"al stri!s )
!
No*da(s a "o!#terised &orizontal %ar *it& tra0ing
lig&t &as re!la"ed a rotator( dr# sti#lation
o!to0ineti" test )
!
T&e n(stag#s ind#"ed is re"orded
!
T&e !erson sits in front of a rotating dr# *it&
alternate *&ite and %la"0 verti"al stri!s )
!
No*da(s a "o!#terised &orizontal %ar *it& tra0ing
lig&t &as re!la"ed a rotator( dr# sti#lation
o!to0ineti" test )
!
T&e n(stag#s ind#"ed is re"orded
45
INVESTIGATIONS INVESTIGATIONS
+EMATO1OGI3 INVESTIGATIONS
- 3<3
- 3+EMI3A1 S3REENING 1IBE <4N/A1<4MIN
& G1O<41IN
- TD & TS+
- FTA : A<S
4RINE ANA1,SIS
RADIO1OGI3A1 ST4DIES
- MASTOID & INTERNA1 A3O4STI3 3ANA1 VIE5S
- 3T S3AN
- SB411 & 3ERVI3A1 S-INE RADIO1OG,

+EMATO1OGI3 INVESTIGATIONS
- 3<3
- 3+EMI3A1 S3REENING 1IBE <4N/A1<4MIN
& G1O<41IN
- TD & TS+
- FTA : A<S
4RINE ANA1,SIS
RADIO1OGI3A1 ST4DIES
- MASTOID & INTERNA1 A3O4STI3 3ANA1 VIE5S
- 3T S3AN
- SB411 & 3ERVI3A1 S-INE RADIO1OG,

46
INVESTIGATIONS INVESTIGATIONS
O-TIONA1 TESTS-
-five &o#r gl#"ose toleran"e test
- !ol("("li" toogras of t&e !etro#s %one
- E3G
- EEG
- -s("&oetri" testing
O-TIONA1 TESTS-
-five &o#r gl#"ose toleran"e test
- !ol("("li" toogras of t&e !etro#s %one
- E3G
- EEG
- -s("&oetri" testing
47
N(stag#s N(stag#s
S!ontaneo#s Ind#"ed S!ontaneo#s Ind#"ed
5&en 5&en 5&en 5&en 5&en 5&en 5&en
1oo0ing fo"#sing loo0ing follo*ing &ead "&anging t#rning
straig&t on fi?ed side*a(s oving is in !osition t&e &ead
a&ead s!ot o%'e"t !arti"#lar of &ead
!osition
5&en 5&en 5&en 5&en 5&en 5&en 5&en
1oo0ing fo"#sing loo0ing follo*ing &ead "&anging t#rning
straig&t on fi?ed side*a(s oving is in !osition t&e &ead
a&ead s!ot o%'e"t !arti"#lar of &ead
!osition
48
Ind&ced nystagm&s Ind&ced nystagm&s
!
-ositional n(stag#s
An( n(stag#s t&at o""#rs *&en t&e &ead is
in !osition ot&er t&an noral #!rig&t
!
-ositioning n(stag#s
o""#rs *&en "&ange of &ead !osition and
#sed to diagnose <--V
!
-ositional n(stag#s
An( n(stag#s t&at o""#rs *&en t&e &ead is
in !osition ot&er t&an noral #!rig&t
!
-ositioning n(stag#s
o""#rs *&en "&ange of &ead !osition and
#sed to diagnose <--V
49
Differentiation of -eri!&eral and 3entral Vertigo Differentiation of -eri!&eral and 3entral Vertigo
Sign A S(!tos -&eri!&eral 3entral Sign A S(!tos -&eri!&eral 3entral
1aten"( 9- GE se"ond none
D#ration Sto!es in DE Se" or less 3ontin#o#s for ore
t&an G in#te
Fatig#a%ilit( !resent a%sent
Ada!tation disa!!ears in CE Se" -ersist
1aten"( 9- GE se"ond none
D#ration Sto!es in DE Se" or less 3ontin#o#s for ore
t&an G in#te
Fatig#a%ilit( !resent a%sent
Ada!tation disa!!ears in CE Se" -ersist
50
Differentiation of -eri!&eral and 3entral Vertigo Differentiation of -eri!&eral and 3entral Vertigo
Sign A S(!to -eri!&eral 71a%(rint&8 3entral 7<rainste or
3ere%ell#8
Sign A S(!to -eri!&eral 71a%(rint&8 3entral 7<rainste or
3ere%ell#8
Vertigo Al*a(s !resent/ Severe Ma( %e ild or A%sent
Dire"tion of s!in To*ard fast !&ase Varied
Dire"tion of fall To*ard slo* !&ase Varia%le
D#ration of Finite 7in#tes/ da(s/ Ma( %e "&roni"
s(!tos *ee0s8 %#t re"#rrent
Tinnit#s and Aor Often !resent 4s#all( a%sent
deafness
Asso"iated "entral None E?treel( "oon
a%noralities
3oon "a#ses Infe"tion 7la%(rint&itis8/ Vas"#lar/ de(elinating/
MeniereKs/ ne#ronitis/ neo!las
is"&eia/ tra#a/ to?in
Vertigo Al*a(s !resent/ Severe Ma( %e ild or A%sent
Dire"tion of s!in To*ard fast !&ase Varied
Dire"tion of fall To*ard slo* !&ase Varia%le
D#ration of Finite 7in#tes/ da(s/ Ma( %e "&roni"
s(!tos *ee0s8 %#t re"#rrent
Tinnit#s and Aor Often !resent 4s#all( a%sent
deafness
Asso"iated "entral None E?treel( "oon
a%noralities
3oon "a#ses Infe"tion 7la%(rint&itis8/ Vas"#lar/ de(elinating/
MeniereKs/ ne#ronitis/ neo!las
is"&eia/ tra#a/ to?in
!a%o55 R( B(, /9aintness Synco$e, !i--iness and :e%tigo IN Ha%%isons P%inci$les o5 Inte%nal ;edicine, 2<th Edition, 2=8 !a%o55 R( B(, /9aintness Synco$e, !i--iness and :e%tigo IN Ha%%isons P%inci$les o5 Inte%nal ;edicine, 2<th Edition, 2=8
>Contd(? >Contd(?
51
MANEGMENT OF
-ERI-+ERA1
VERTIGO
MANEGMENT OF
-ERI-+ERA1
VERTIGO
52
If Mnire is due to a secondary cause (ie, Mnire
syndroe!, "riary first#line ana$eent is t%e
dia$nosis and treatent of t%e "riary disease
(e$, t%yroid disease!&
MEDI3A1 MANEGMENT-
!
'esti(ulosu""ressants (e$, ecli)ine!
!
*iuretics or diuretic#li+e edications (e$,
%ydroc%lorot%ia)ide!&
!
Steroids
If Mnire is due to a secondary cause (ie, Mnire
syndroe!, "riary first#line ana$eent is t%e
dia$nosis and treatent of t%e "riary disease
(e$, t%yroid disease!&
MEDI3A1 MANEGMENT-
!
'esti(ulosu""ressants (e$, ecli)ine!
!
*iuretics or diuretic#li+e edications (e$,
%ydroc%lorot%ia)ide!&
!
Steroids
MANEGMENT OF MENIRE;S DISEASE MANEGMENT OF MENIRE;S DISEASE
53
MANEGMENT OF MENIRE;S DISEASE MANEGMENT OF MENIRE;S DISEASE
!
In an acutely verti$inous "atient, ana$eent is
directed to,ard verti$o control&

Intravenous (I'! or intrauscular (IM! dia)e"a

"rovides e-cellent vesti(ular su""ression and
antinausea effects&

Steroids can (e $iven for anti#inflaatory effects in

t%e inner ear&

I' fluid su""ort can %el" "revent de%ydration and

re"laces electrolytes&
!
In an acutely verti$inous "atient, ana$eent is
directed to,ard verti$o control&

Intravenous (I'! or intrauscular (IM! dia)e"a

"rovides e-cellent vesti(ular su""ression and
antinausea effects&

Steroids can (e $iven for anti#inflaatory effects in

t%e inner ear&

I' fluid su""ort can %el" "revent de%ydration and

re"laces electrolytes&
54
MANEGMENT OF MENIRE;S
DISEASE
MANEGMENT OF MENIRE;S
DISEASE
S4RGI3A1 MANEGMENT-
3ONSERVATIVE S4RGER,- If servi"ea%le &earing
!resent)
I) ENDO1,M-+ATI3 SA3 DE3O-MRESSION
II) S+4NT -RO3ED4RE : <et*een sa" & astoid "avit( or
s#%ara"&noid s!a"e)
DESTR43TIVE S4RGER,-If &earing is not servi"ea%le)
I) 1A<,RINT+E3TOM,
II) VESTI<41AR NE4RE3TOM,
S4RGI3A1 MANEGMENT-
3ONSERVATIVE S4RGER,- If servi"ea%le &earing
!resent)
I) ENDO1,M-+ATI3 SA3 DE3O-MRESSION
II) S+4NT -RO3ED4RE : <et*een sa" & astoid "avit( or
s#%ara"&noid s!a"e)
DESTR43TIVE S4RGER,-If &earing is not servi"ea%le)
I) 1A<,RINT+E3TOM,
II) VESTI<41AR NE4RE3TOM,
55
!
T&e Di?-+all!i0e test/ along *it& t&e !atientKs &istor(/ aids in t&e
diagnosis of <-V)
!
T&e Di?-+all!i0e test/ along *it& t&e !atientKs &istor(/ aids in t&e
diagnosis of <-V)
MANEGMENT OF <--V MANEGMENT OF <--V
56
MANEGMENT OF <--V MANEGMENT OF <--V
!
TREATMENT-

Medi"ations-Antieeti"
- Anti&istaini"
-Anti"&olinergi"

T&e 3analit& Re!ositioning -ro"ed#re 73R-8

S#rger(
!
TREATMENT-

Medi"ations-Antieeti"
- Anti&istaini"
-Anti"&olinergi"

T&e 3analit& Re!ositioning -ro"ed#re 73R-8

S#rger(
57
3analit& Re!ositioning -ro"ed#re 7 3R- 8 3analit& Re!ositioning -ro"ed#re 7 3R- 8
!
T&e treatent of "&oi"e for <--V)
!
Also 0no*n as t&e E!le( ane#ver)
!
T&e !atient is !ositioned in a series of ste!s so as to slo*l( ove t&e
oto"onia !arti"les fro t&e !osterior sei"ir"#lar "anal %a"0 into t&e
#tri"le)
!
Ta0es a!!ro?iatel( C in#tes)
!
T&e !atient is instr#"ted to *ear a ne"0 %ra"e for 94 &o#rs and to not
%end do*n or la( flat for 94 &o#rs after t&e !ro"ed#re)
One *ee0 after t&e 3R-/ t&e Di?-+all!i0e test is re!eated)
!
If t&e !atient does e?!erien"e vertigo and n(stag#s/ t&en t&e 3R- is
re!eated *it& a vi%rator !la"ed on t&e s0#ll in order to %etter dislodge
t&e oto"onia)
!
T&e treatent of "&oi"e for <--V)
!
Also 0no*n as t&e E!le( ane#ver)
!
T&e !atient is !ositioned in a series of ste!s so as to slo*l( ove t&e
oto"onia !arti"les fro t&e !osterior sei"ir"#lar "anal %a"0 into t&e
#tri"le)
!
Ta0es a!!ro?iatel( C in#tes)
!
T&e !atient is instr#"ted to *ear a ne"0 %ra"e for 94 &o#rs and to not
%end do*n or la( flat for 94 &o#rs after t&e !ro"ed#re)
One *ee0 after t&e 3R-/ t&e Di?-+all!i0e test is re!eated)
!
If t&e !atient does e?!erien"e vertigo and n(stag#s/ t&en t&e 3R- is
re!eated *it& a vi%rator !la"ed on t&e s0#ll in order to %etter dislodge
t&e oto"onia)
58
3analit& Re!ositioning -ro"ed#re 7 3R- 8 3analit& Re!ositioning -ro"ed#re 7 3R- 8
59
!
%01 %,% 23 4PP5 *6 78P 9:;1<5186 :6 -1678*41- 4=
6192;% :;- 1P*/1= 328 P26%18*28 7:;:/ :;- 0:9*-
:;- /19P18% 328 028*>2;%:/ 7:;:/ ) 6192;%
9:;1<518 *6 13317%*51 *; %81:%*;? P7
7<P2/*%0*:6*6+ 1P*/1= 328 P7 7:;:/*%0*:6*6+ /19P18%
328 07 7:;:/*%0*:6*6 @ 0:9*- 328 07
7<P</2/*%0*:6*6) /19P18% :;- 0:9*- 9:;1<5186
*; 6291 71;%81 A;2W; :6 4:84*B<1 P8271-<816
!
%01 %,% 23 4PP5 *6 78P 9:;1<5186 :6 -1678*41- 4=
6192;% :;- 1P*/1= 328 P26%18*28 7:;:/ :;- 0:9*-
:;- /19P18% 328 028*>2;%:/ 7:;:/ ) 6192;%
9:;1<518 *6 13317%*51 *; %81:%*;? P7
7<P2/*%0*:6*6+ 1P*/1= 328 P7 7:;:/*%0*:6*6+ /19P18%
328 07 7:;:/*%0*:6*6 @ 0:9*- 328 07
7<P</2/*%0*:6*6) /19P18% :;- 0:9*- 9:;1<5186
*; 6291 71;%81 A;2W; :6 4:84*B<1 P8271-<816
60
61
62
63
!
S,NDROME 3+ARA3TERI.ED <, SO4ND OR
-RESS4RE IND43ED VERTIGO
!
DEFINITIVE TREATMENT ISRES4RFA3ING OR
-14GGING T+E <ON, DEFE3T VIA MIDD1E
FOSSA OR TRANSMASTOID A--ROA3+
!
-RESS4RE EL4A1I.ING 7-E8 T4<E /DIAMOM
AND TO-AMAM TO 3ONTRO1 S,M-TOMS
!
S,NDROME 3+ARA3TERI.ED <, SO4ND OR
-RESS4RE IND43ED VERTIGO
!
DEFINITIVE TREATMENT ISRES4RFA3ING OR
-14GGING T+E <ON, DEFE3T VIA MIDD1E
FOSSA OR TRANSMASTOID A--ROA3+
!
-RESS4RE EL4A1I.ING 7-E8 T4<E /DIAMOM
AND TO-AMAM TO 3ONTRO1 S,M-TOMS
DE+IS3EN3E OF S4-ERIOR
SEMI3IR341AR 3ANA1 S,NDROME
DE+IS3EN3E OF S4-ERIOR
SEMI3IR341AR 3ANA1 S,NDROME
64
1ARGE VESTI<41AR AL4ED43T
S,NDROME
1ARGE VESTI<41AR AL4ED43T
S,NDROME
!
DEVE1O-MENTA1 ANOMA1, OF INNER EAR
-RESENT 5IT+ S4DDEN SENORINE4RA1 OR
F143T4ATING +EARING 1OSS IN
3+I1D+OOD
!
DEFINITIVE TAT IS 3O3+1EAR IM-1ANTS
!
S,M-TOMS STA<I1.ED 5IT+ 1O5 SA1T
DIET/ +,DRO3+1OROT+IA.IDE AND
VESTI<41AR S4--RESSANTS
!
DEVE1O-MENTA1 ANOMA1, OF INNER EAR
-RESENT 5IT+ S4DDEN SENORINE4RA1 OR
F143T4ATING +EARING 1OSS IN
3+I1D+OOD
!
DEFINITIVE TAT IS 3O3+1EAR IM-1ANTS
!
S,M-TOMS STA<I1.ED 5IT+ 1O5 SA1T
DIET/ +,DRO3+1OROT+IA.IDE AND
VESTI<41AR S4--RESSANTS
65
1ARGE 3O3+1EAR AL4ED43T
S,NDROMES
1ARGE 3O3+1EAR AL4ED43T
S,NDROMES
!
31INI3A1/A4DIO1OGI3 AND VESTI<41AR
FINDING IN -ATIENTS 3ONSISTENT 5IT+
=+,DRO-S>/ ON T+E SIDE IDENTIFIED <, 3T
!
RES-OND TO TAT 5IT+ DIAMOM ANDAOR
TO-AMAM
!
31INI3A1/A4DIO1OGI3 AND VESTI<41AR
FINDING IN -ATIENTS 3ONSISTENT 5IT+
=+,DRO-S>/ ON T+E SIDE IDENTIFIED <, 3T
!
RES-OND TO TAT 5IT+ DIAMOM ANDAOR
TO-AMAM
66
67
<randt-Daroff E?er"ises <randt-Daroff E?er"ises
!
et&od of treating <--V/ #s#all( #sed *&en t&e
offi"e treatent fails)
!
T&ese e?er"ises s&o#ld %e !erfored

for t*o *ee0s/ t&ree ties !er da(

for t&ree *ee0s/ t*i"e !er da()

!
In ea"& tie/ one !erfors t&e ane#ver as s&o*n
five ties)
!
G re!etition N ane#ver done to ea"& side in t#rn
7ta0es 9 in#tes8
!
et&od of treating <--V/ #s#all( #sed *&en t&e
offi"e treatent fails)
!
T&ese e?er"ises s&o#ld %e !erfored

for t*o *ee0s/ t&ree ties !er da(

for t&ree *ee0s/ t*i"e !er da()

!
In ea"& tie/ one !erfors t&e ane#ver as s&o*n
five ties)
!
G re!etition N ane#ver done to ea"& side in t#rn
7ta0es 9 in#tes8
68
<randt-Daroff E?er"ises <randt-Daroff E?er"ises
69
S4RGI3A1 MANEGMENT OF
<--V
S4RGI3A1 MANEGMENT OF
<--V
!
Sing#lar ne#re"to(
!
Vesti%#lar Ne#re"to(
!
-osterior 3anal -l#gging -ro"ed#re
!
Sing#lar ne#re"to(
!
Vesti%#lar Ne#re"to(
!
-osterior 3anal -l#gging -ro"ed#re
70
-osterior 3anal -l#gging -ro"ed#re -osterior 3anal -l#gging -ro"ed#re
Re"entl( develo!ed !ro"ed#re
!
Re!la"ed t&e sing#lar ne#re"to()
!
A astoide"to( is !erfored t&ro#g& an in"ision ade
%e&ind t&e ear)
!
T&e %alan"e "enter is t&en #n"overed )
!
T&e !osterior sei"ir"#lar "anal is o!ened/ e?!osing t&e
deli"ate e%rano#s "&annel in *&i"& t&e "r(stalline
de%ris is floating)
!
T&e "anal is t&en gentl(/ %#t firl( !a"0ed off *it& tiss#e so
t&e de%ris "an no longer ove *it&in t&e "anal and stri0e
against t&e nerve endings)
!
T&e "anal is t&en sealed and t&e in"ision "losed)
Re"entl( develo!ed !ro"ed#re
!
Re!la"ed t&e sing#lar ne#re"to()
!
A astoide"to( is !erfored t&ro#g& an in"ision ade
%e&ind t&e ear)
!
T&e %alan"e "enter is t&en #n"overed )
!
T&e !osterior sei"ir"#lar "anal is o!ened/ e?!osing t&e
deli"ate e%rano#s "&annel in *&i"& t&e "r(stalline
de%ris is floating)
!
T&e "anal is t&en gentl(/ %#t firl( !a"0ed off *it& tiss#e so
t&e de%ris "an no longer ove *it&in t&e "anal and stri0e
against t&e nerve endings)
!
T&e "anal is t&en sealed and t&e in"ision "losed)
71
MANEGMENT OF 1A<,RINT+ITIS MANEGMENT OF 1A<,RINT+ITIS
!
<ed rest & aintanan"e of &(dration
!
Antieeti" & antivertigo)
!
<enzodiaze!enes in "ase of sever voiting & vertigo)
!
Steroids
!
Anti%ioti"s in "ase of %a"terial la%(rint&itis
!
Antiviral dr#gs- role is not *ell do"#ented)
!
S#rgi"al- if it is se"ondar( to iddle ear disease re$#iring
s#rgi"al treatent)
!
Antio?idents
!
Vesti%#lar re&a%ilitation e?er"ises)
!
<ed rest & aintanan"e of &(dration
!
Antieeti" & antivertigo)
!
<enzodiaze!enes in "ase of sever voiting & vertigo)
!
Steroids
!
Anti%ioti"s in "ase of %a"terial la%(rint&itis
!
Antiviral dr#gs- role is not *ell do"#ented)
!
S#rgi"al- if it is se"ondar( to iddle ear disease re$#iring
s#rgi"al treatent)
!
Antio?idents
!
Vesti%#lar re&a%ilitation e?er"ises)
72
MANEGMENT OF VESTI<41AR
NE4RO-AT+,
MANEGMENT OF VESTI<41AR
NE4RO-AT+,
!
S(!toati"
!
Steroids
!
Anti%ioti"s in "ase of a"tive iddle ear disease)
!
Vesti%#lar re&a%ilitation e?er"ises
!
S(!toati"
!
Steroids
!
Anti%ioti"s in "ase of a"tive iddle ear disease)
!
Vesti%#lar re&a%ilitation e?er"ises
73
E@ERCISES IN
ESTIB"*AR
HABIT"ATION THERAPY
E@ERCISES IN
ESTIB"*AR
HABIT"ATION THERAPY
74
EMER3ISES IN <ED @ E,E MOVEMENTS EMER3ISES IN <ED @ E,E MOVEMENTS
1oo0ing #! and t&en do*n 1oo0ing #! and t&en do*n
75
1oo0ing alternatel( left and rig&t 1oo0ing alternatel( left and rig&t
76
3onvergen"e e?er"ise 3onvergen"e e?er"ise
77
EMER3ISES IN <ED @ +EAD MOVEMENTS EMER3ISES IN <ED @ +EAD MOVEMENTS
<ending alternatel( for*ard and %a"0*ard
78
EMER3ISES IN <ED @ +EAD MOVEMENTS EMER3ISES IN <ED @ +EAD MOVEMENTS
T#rning alternativel( to t&e left and t&en rig&t
79
EMER3ISES IN SITTING -OSITION EMER3ISES IN SITTING -OSITION
S&r#gging and rotating s&o#lders
80
EMER3ISES IN SITTING -OSITION EMER3ISES IN SITTING -OSITION
<ending for*ard and !i"0ing #! o%'e"ts fro t&e
floor
81
EMER3ISES IN SITTING -OSITION EMER3ISES IN SITTING -OSITION
T#rning &ead and tr#n0 alternatel( to t&e left and t&e rig&t
82
EMER3ISES IN STANDING -OSITION EMER3ISES IN STANDING -OSITION
3&anging fro sitting to standing/ initiall( *it&
e(es o!en and t&en *it& t&e e(es "losed
83
EMER3ISES IN STANDING -OSITION EMER3ISES IN STANDING -OSITION
T&ro*ing a sall 7!ing !ong8 %all in/ an ar" fro
&and to &and and follo*ing it *it& t&e e(es
84
EMER3ISES IN STANDING -OSITION EMER3ISES IN STANDING -OSITION
T&ro*ing a sall %all fro &and to &and #nder t&e 0nee
85
EMER3ISES 5+I1E 5A1BING EMER3ISES 5+I1E 5A1BING
T&ro*ing and "at"&ing t&e %all *&ile *al0ing
86
EMER3ISES 5+I1E 5A1BING EMER3ISES 5+I1E 5A1BING
5al0ing aro#nd in t&e roo *it& e(es o!en and "losed
87
EMER3ISES 5+I1E 5A1BING EMER3ISES 5+I1E 5A1BING
5al0ing #! and do*n a flig&t of stairs
88
EMER3ISES 5+I1E 5A1BING EMER3ISES 5+I1E 5A1BING
-la(ing an( gae involving %ending/
stret"&ing and aiing *it& t&e %all
89
-&ara"ot&era!(
7Antivertigo dr#gs8
-&ara"ot&era!(
7Antivertigo dr#gs8
!
Vasodilators
!
Antieeti"s
!
1a%(rint&ine sedatives
!
An?iol(ti"s
!
Di#reti"s
!
Vasodilators
!
Antieeti"s
!
1a%(rint&ine sedatives
!
An?iol(ti"s
!
Di#reti"s
90
Anti- eeti"s Anti- eeti"s
Anti&istaines Anti -&enot&iazines Mis"ellaneo#s
3&olinergi"s
Anti&istaines Anti -&enot&iazines Mis"ellaneo#s
3&olinergi"s
1arge overla! %et*een t&e effe"ts !rod#"ed %(
anti&istaines/ anti"&olinergi"s and !&enot&iazines)
91
-&enot&iazines
7-ro"&lor!erazine/ T&iet&(l!erazine8
-&enot&iazines
7-ro"&lor!erazine/ T&iet&(l!erazine8
!
-ro"&lor!erazine is less sedating t&an soe ot&er
!&enot&iazines %#t dro*siness still o""#rs
!
Also "a#ses &(!otension/ -ar0insonian side effe"ts
--Betts T et al, B%it( A( Clin( Pha%mac, 2332, 67, <88-4,
--C&%ley ABA, E N T Ao&%nal, 234<, C8, 888-8C=
!
=T&e dr#g *&i"& ost "oonl( "a#ses
!ar0insonis in general !ra"ti"e is -ro"&lor!erazine>
--Cha$lin S, #e%iat%ic ;edicine, 2343, 9eb, 26-2<
!
-ro"&lor!erazine is less sedating t&an soe ot&er
!&enot&iazines %#t dro*siness still o""#rs
!
Also "a#ses &(!otension/ -ar0insonian side effe"ts
--Betts T et al, B%it( A( Clin( Pha%mac, 2332, 67, <88-4,
--C&%ley ABA, E N T Ao&%nal, 234<, C8, 888-8C=
!
=T&e dr#g *&i"& ost "oonl( "a#ses
!ar0insonis in general !ra"ti"e is -ro"&lor!erazine>
--Cha$lin S, #e%iat%ic ;edicine, 2343, 9eb, 26-2<
92
An?iol(ti"s 7Tran$#ilizers8
7<enzodiaze!ines s#"& as diaze!a/ 1oraze!a8
An?iol(ti"s 7Tran$#ilizers8
7<enzodiaze!ines s#"& as diaze!a/ 1oraze!a8
!
No effe"t on t&e #nderl(ing vertigo
!
+el!s !atient end#re t&e s(!tos %( alla(ing an?iet(
!
Man( side effe"ts dro*siness and sedation/ de!enden"e and
addi"tion a%#se !otential/ !s("&ootor i!airent/
eor( loss/ intera"tions *it& al"o&ol
!
No effe"t on t&e #nderl(ing vertigo
!
+el!s !atient end#re t&e s(!tos %( alla(ing an?iet(
!
Man( side effe"ts dro*siness and sedation/ de!enden"e and
addi"tion a%#se !otential/ !s("&ootor i!airent/
eor( loss/ intera"tions *it& al"o&ol
Ha%%is T, Ea% Nose Th%oat A, 234<, C8, 882-8
93
Di#reti"s
7e)g) F#roseide/ +(dro"&lort&iazide8
Di#reti"s
7e)g) F#roseide/ +(dro"&lort&iazide8
!
4sed in vertigo and eniere;s disease
!
Red#"e t&e vol#e of endol(!& %( !rooting #rine
flo* and red#"ing fl#id retention)
!
4se ainl( asso"iated *it& ele"trol(te i%alan"e
!
4sed in vertigo and eniere;s disease
!
Red#"e t&e vol#e of endol(!& %( !rooting #rine
flo* and red#"ing fl#id retention)
!
4se ainl( asso"iated *it& ele"trol(te i%alan"e
*&dman H, B%it( ;ed( A(, 2342, 747, <8<-<8D, Ha%%is T, Ea% Nose Th%oat A, 234<, C8, 882-8 *&dman H, B%it( ;ed( A(, 2342, 747, <8<-<8D, Ha%%is T, Ea% Nose Th%oat A, 234<, C8, 882-8
94
Cinna%i-ine, Collin !olle%y The%a$e&tic !%&gs, C7<=-6, #od5%aind T et al, !%&gs o5 Today, 2347, @III>2?, 7D-<7,
en0ata%aman S, Ne&%osciences Today, 233D, ol( I, 6'<, 7=8-C, No%%e ; E, C%it Re:( Phy( Rehab( ;ed(, 233=, 7,7,2=2-7=
1a%(rint&ine Sedative 5it&
Anti&istaini" a"tion
1a%(rint&ine Sedative 5it&
Anti&istaini" a"tion
Cinna%i-ine, 9l&na%i-ine, Cycli-ine
!
Dro*siness and %l#rred vision 7Diffi"#lt for !atients *&o
drive or o!erate a"&iner(8
!
Dela( noral vesti%#lar "o!ensation !ro"ess
!
3innarizine and Fl#narizine a"t via "al"i# antagonis/
#ns!e"ifi" a"tion a( "a#se side effe"ts

5eig&t gain & de!ression 7serotonergi" effe"ts8

E?tra!(raidal s(!tos 7do!ainergi" effe"ts8

G)I) #!set
Cinna%i-ine, 9l&na%i-ine, Cycli-ine
!
Dro*siness and %l#rred vision 7Diffi"#lt for !atients *&o
drive or o!erate a"&iner(8
!
Dela( noral vesti%#lar "o!ensation !ro"ess
!
3innarizine and Fl#narizine a"t via "al"i# antagonis/
#ns!e"ifi" a"tion a( "a#se side effe"ts

5eig&t gain & de!ression 7serotonergi" effe"ts8

E?tra!(raidal s(!tos 7do!ainergi" effe"ts8

G)I) #!set
95
Data on file
<eta&istine <eta&istine
T%&sted the%a$y 5o% mo%e than
<2 million
e%tigo $atients .o%ld.ide
T%&sted the%a$y 5o% mo%e than
<2 million
e%tigo $atients .o%ld.ide
96
<eta&istine - 3&eistr( <eta&istine - 3&eistr(
+istaine <eta&istine +istaine <eta&istine
N N
N N
+ +
3+
9
3+
9
N+
9
3+
9
3+
9
N+
9
N N
3+
9
3+
9
N+3+
D
3+
9
3+
9
N+3+
D
+istaine analog#e/ "an %e given orall(
*it& no &istaine li0e side effe"ts
+istaine analog#e/ "an %e given orall(
*it& no &istaine li0e side effe"ts
an Ca&.enbe%ge P B, et al, Acta Otola%yngol, 233D, s&$$l( 87C, <6-C,
en0ata%aman S, Ne&%osciences Today, 2334, II, 2 ' 7, 8C-4
an Ca&.enbe%ge P B, et al, Acta Otola%yngol, 233D, s&$$l( 87C, <6-C,
en0ata%aman S, Ne&%osciences Today, 2334, II, 2 ' 7, 8C-4
97
<eta&istine @ -&ara"o0ineti"s <eta&istine @ -&ara"o0ineti"s
!
Oral adinistration
!
Ra!id and "o!lete a%sor!tion
!
Mean !lasa &alf life @- D-4 +rs)
!
3o!lete e?"retion via #rine in 94 &o#rs
!
Ver( lo* !lasa !rotein %inding
!
One eta%olite 79-ainoet&(l !(ridine8 is fo#nd
to %e a"tive
!
Oral adinistration
!
Ra!id and "o!lete a%sor!tion
!
Mean !lasa &alf life @- D-4 +rs)
!
3o!lete e?"retion via #rine in 94 &o#rs
!
Ver( lo* !lasa !rotein %inding
!
One eta%olite 79-ainoet&(l !(ridine8 is fo#nd
to %e a"tive
98
<eta&istine @ Mode of A"tion <eta&istine @ Mode of A"tion
Vas"#lar Effe"ts Ne#rologi"al Effe"ts
7in inner ear & %rain8 7in %rain8
Vas"#lar Effe"ts Ne#rologi"al Effe"ts
7in inner ear & %rain8 7in %rain8
99
+D-A4TORE3E-TORS O 3ONTRO11ING T+E
RE1EASE OF +ISTAMINE
Ada$ted an Ca&.enebe%ge PB, Acta Otola%yngol, 233D, s&$$l( 87C, <6-C,
en0ata%aman S, Ne&%osciences Today, 2334, II, 2 ' 7, 8C-4
Ada$ted an Ca&.enebe%ge PB, Acta Otola%yngol, 233D, s&$$l( 87C, <6-C,
en0ata%aman S, Ne&%osciences Today, 2334, II, 2 ' 7, 8C-4
01 02
+
D

a#tore"e!tor
+istainergi" Ne#ron
100
en0ata%aman S, Ne&%osciences Today, 2334, II >2 ' 7?, 8C-4 en0ata%aman S, Ne&%osciences Today, 2334, II >2 ' 7?, 8C-4
EFFE3TS OF <ETA+ISTINE
101
<eta&istine - Vas"#lar Effe"ts <eta&istine - Vas"#lar Effe"ts
+D a#tore"e!tors antagonist +G agonist
In&i%its a#toreg#lation of
&istaine release
+D a#tore"e!tors antagonist +G agonist
In&i%its a#toreg#lation of
&istaine release
en0ata%aman S, Ne&%osciences Today, 2334, II >2 ' 7?, 8C-4 en0ata%aman S, Ne&%osciences Today, 2334, II >2 ' 7?, 8C-4
I!roves "o"&lear i"ro"ir"#lation
I!roves "ere%ral A verte%ro%asilar %lood flo*
I!roves "o"&lear i"ro"ir"#lation
I!roves "ere%ral A verte%ro%asilar %lood flo*
102
<lo"0s +D &eterore"e!tors
In"reases release of ot&er
ne#rotransitters e)g) serotonin
Reg#lates firing a"tivit( of
vesti%#lar n#"lei
<lo"0s +D &eterore"e!tors
In"reases release of ot&er
ne#rotransitters e)g) serotonin
Reg#lates firing a"tivit( of
vesti%#lar n#"lei
en0ata%aman S, Ne&%osciences Today, 2334, II >2 ' 7?, 8C-4,
Bis.as A, Ind( A( Otola%yngol H N S, 233D, <3>7?, 2D3-42
en0ata%aman S, Ne&%osciences Today, 2334, II >2 ' 7?, 8C-4,
Bis.as A, Ind( A( Otola%yngol H N S, 233D, <3>7?, 2D3-42
<eta&istine - Ne#rologi"al Effe"ts <eta&istine - Ne#rologi"al Effe"ts
103
<eta&istine @ Mode of a"tion <eta&istine @ Mode of a"tion
<lo"0s <lo"0s
+D &eterore"e!tors +D &eterore"e!tors +D a#tore"e!tors +D a#tore"e!tors
sti#lates release of ot&er
ne#rotransitter e)g) serotonin
sti#lates release of ot&er
ne#rotransitter e)g) serotonin
Sti#lates release of
&istaine
Sti#lates release of
&istaine
Reg#lator( effe"t on
vesti%#lar n#"lei
Reg#lator( effe"t on
vesti%#lar n#"lei
+G re"e!tor +G re"e!tor
S(!toati" relief of
vertigo
S(!toati" relief of
vertigo
-ro!&(la"ti" effe"t of
vertigo
-ro!&(la"ti" effe"t of
vertigo
i!roveent of "o"&lear
& "ere%ral %lood flo*
i!roveent of "o"&lear
& "ere%ral %lood flo*
dire"t sti#lator( effe"t dire"t sti#lator( effe"t
104
<ETA+ISTINE <ETA+ISTINE
T&era!e#ti" Indi"ations
!
Vertigo
!
Meniere;s S(ndroe
Dosage Re"oendations
!
94-4P g Ada(
T&era!e#ti" Indi"ations
!
Vertigo
!
Meniere;s S(ndroe
Dosage Re"oendations
!
94-4P g Ada(
105
<eta&istine -Toleran"e <eta&istine -Toleran"e
!
No sedation
!
No gastri" side effe"ts
!
No anti"&olinergi" effe"ts
!
No e?tra!(raidal side effe"ts
!
No sedation
!
No gastri" side effe"ts
!
No anti"&olinergi" effe"ts
!
No e?tra!(raidal side effe"ts
B%adoo RA et al, Ind( A( Otola%yngol HNS, 7===, 87>7?, 282-4,
Bis.as A, Ind( A( Otola%yngol H N S, 233D, <3>7?, 2D3-42
B%adoo RA et al, Ind( A( Otola%yngol HNS, 7===, 87>7?, 282-4,
Bis.as A, Ind( A( Otola%yngol H N S, 233D, <3>7?, 2D3-42
106
<eta&istine@ No affinit( for
+9 re"e!tors
<eta&istine@ No affinit( for
+9 re"e!tors
!
+9 re"e!tors !redoinate in stoa"& and
"ontrol gastri" se"retion
!
<eta&istine &as no effe"t on +9 re"e!tors)
!
<eta&istine is generall( free of gastri" side
effe"ts
!
+9 re"e!tors !redoinate in stoa"& and
"ontrol gastri" se"retion
!
<eta&istine &as no effe"t on +9 re"e!tors)
!
<eta&istine is generall( free of gastri" side
effe"ts
Betahistine, Collin !olle%y The%a$e&tic !%&gs, B C7-8
an Ca&.enbe%ge PB, Acta Otola%yngol, 233D, S&$$l( 87C, <6-C
Betahistine, Collin !olle%y The%a$e&tic !%&gs, B C7-8
an Ca&.enbe%ge PB, Acta Otola%yngol, 233D, S&$$l( 87C, <6-C
107
<eta&istine <eta&istine
!
3ontraindi"ations - Not 0no*n
!
-re"a#tion A 3a#tion for #se
<eta&istine/ %eing a &istaine analog#e/ s&o#ld
%e #sed *it& "a#tion in !atients *it&
!&eo"&roo"(toa/ !e!ti" #l"er/ %ron"&ial
ast&a/ "on"#rrent #se of anti&istaines
!
3ontraindi"ations - Not 0no*n
!
-re"a#tion A 3a#tion for #se
<eta&istine/ %eing a &istaine analog#e/ s&o#ld
%e #sed *it& "a#tion in !atients *it&
!&eo"&roo"(toa/ !e!ti" #l"er/ %ron"&ial
ast&a/ "on"#rrent #se of anti&istaines
B%adoo RA et al, Ind( A( Otola%yngol HNS, 7===, 87>7?, 282-4 B%adoo RA et al, Ind( A( Otola%yngol HNS, 7===, 87>7?, 282-4
108
<eta&istine <eta&istine
!
3ontraindi"ations - Not 0no*n
!
-re"a#tion A 3a#tion for #se
<eta&istine/ %eing a &istaine analog#e/ s&o#ld
%e #sed *it& "a#tion in !atients *it&
!&eo"&roo"(toa/ !e!ti" #l"er/ %ron"&ial
ast&a/ "on"#rrent #se of anti&istaines
!
3ontraindi"ations - Not 0no*n
!
-re"a#tion A 3a#tion for #se
<eta&istine/ %eing a &istaine analog#e/ s&o#ld
%e #sed *it& "a#tion in !atients *it&
!&eo"&roo"(toa/ !e!ti" #l"er/ %ron"&ial
ast&a/ "on"#rrent #se of anti&istaines
B%adoo RA et al, Ind( A( Otola%yngol HNS, 7===, 87>7?, 282-4 B%adoo RA et al, Ind( A( Otola%yngol HNS, 7===, 87>7?, 282-4
109
<eta&istine No antagonisti" effe"t on
+G re"e!tors
<eta&istine No antagonisti" effe"t on
+G re"e!tors
!
Anti&istaines %lo"0 +G re"e!tors in %rain/ "a#sing
sedation or dro*siness
!
<eta&istine/ sti#lates +G re"e!tors
!
<eta&istine/ does not slo* do*n vesti%#lar
"o!ensation/ #nli0e anti&istaines) +en"e is s#ita%le
for #se *it& vesti%#lar &a%it#ation t&era!()
!
Anti&istaines %lo"0 +G re"e!tors in %rain/ "a#sing
sedation or dro*siness
!
<eta&istine/ sti#lates +G re"e!tors
!
<eta&istine/ does not slo* do*n vesti%#lar
"o!ensation/ #nli0e anti&istaines) +en"e is s#ita%le
for #se *it& vesti%#lar &a%it#ation t&era!()
Ei%tane ;, Ind( A( Otola%yngol HNS, 2333, 82>7?,7D-6C Ei%tane ;, Ind( A( Otola%yngol HNS, 2333, 82>7?,7D-6C
110
<eta&istine - S#ar( <eta&istine - S#ar(
!
-&ara"o0ineti"s@ Ra!id and "o!lete a%sor!tion after
oral ro#te
!
-&ara"olog(@ It is a +G agonist and +D re"e!tor
antagonist) It in"reases "o"&lear and "ere%ral %lood flo*
and reg#lates firing a"tivit( of vesti%#lar n#"lei)
!
Dose@ 94-4P g Ada(
!
Indi"ation@ vertigo/ eniere;s s(ndroe
!
3ontraindi"ations@ not 0no*n
!
-re"a#tion for #se@ !&eo"&roo"(toa/ !e!ti" #l"er/
%ron"&ial ast&a
!
-&ara"o0ineti"s@ Ra!id and "o!lete a%sor!tion after
oral ro#te
!
-&ara"olog(@ It is a +G agonist and +D re"e!tor
antagonist) It in"reases "o"&lear and "ere%ral %lood flo*
and reg#lates firing a"tivit( of vesti%#lar n#"lei)
!
Dose@ 94-4P g Ada(
!
Indi"ation@ vertigo/ eniere;s s(ndroe
!
3ontraindi"ations@ not 0no*n
!
-re"a#tion for #se@ !&eo"&roo"(toa/ !e!ti" #l"er/
%ron"&ial ast&a
111