• Vertigo Testing

  • Electro Nystagmo Graphy is the “Gold standard” test for analysis of patient’s with balance disorders.. It helps to confirm which inner ear (vestibule) is responsible for the vertigo (peripheral vertigo) and also confirms whether the brain, (central vertigo), cervical spine or certain eye disorders are responsible.

    Anatomy and Physiology of the ear

     



     

     

    The ear consists of 3 parts

     

    The outer ear consists of the ear canal which extends to the eardrum. It directs sound vibrations to the ear drum and sets it into vibrations.

    The middle earBehind the eardrum lies the middle ear. It is an air-filled space situated between the ear drum and inner ear. It has a chain of the body’s three smallest bones – the Hammer (Malleus), the Anvil (incus) and the Stirrup (stapes). The ear drum vibrations are conducted to the internal ear by this small chain of bones.

    For the ear drum to vibrate freely, there has to be air on both sides of the drum. Nature has made a clever provision for air on the inner aspect of the ear drum to come from the back of the nose through a tube (Eustachian tube) which is responsible for maintaining air in the middle ear and the inner aspect of the ear drum. Unfortunately, for this reason, all diseases of the nose have an effect on ventilation of the middle ear. Common colds, sinus infections, nasal tumours, adenoids can all affect the function of the Eustachian tube and cause a middle ear type of deafness (conductive deafness).

    The internal ear – Deeper inside is situated the inner ear with the organs of hearing and balance, which are filled with fluid and surrounded by fluid.

    The hearing portion is a coiled tube shaped like a snail shell (cochlea). From the tiny hair cells of the inner ear, the sound waves are converted into electrical impulses, which are transmitted to the brain’s hearing centre by the nerve of hearing.

    The balance portion has three semi circular canals and the vestibule.

    The semicircular canal systems of the two sides convey information of angular acceleration of the head to the brain in the three planes of space – horizontal, vertical and oblique.

    The vestibule consists of the Utricle and Saccule which inform the brain of head position head in space in the yaw and pitch planes.

    These impulses are transmitted by the nerve of balance as electrical impulses to be conveyed to the brain stem nucleii and finally to the cerebellum and other brain centres.

    The maintenance of equilibrium; mechanisms involved in the maintenance of balance

    The human balance system depends on the information that the brain receives from the eyes, muscles and joints of the body and most important, the balance organ situated in the inner ear. This information is integrated in the brain reflexly (immediately) and outputs are relayed

    1). to the eyes to maintain gaze fixation & stability,

    2).to the muscles of the body to maintain correct posture and fine movement (motor skill) and to

    3).the higher regions of the brain to make it aware of the position of the head and body and whether the body is stationary or in motion.

    If the inner ear is damaged by injury or disease, the brain receives incorrect and conflicting information. The result may be dizziness, balance problems or a sensation of spinning – vertigo. The inner ear has two parts – the hearing organ & the balance organ which are in continuity as one single entity. Therefore a hearing deficiency may be associated with a balance disorder. For this reason, a hearing check up (Audiogram & Impedance) is essential in addition to a balance function check up (CENG – Computerized Electro Nystagmography) to correctly diagnose the cause of a balance disorder.

    Getting a diagnosis, taking prescribed treatment, changes in activity and diet, and vestibular rehabilitation exercises will assist recovery and cure the condition. In some cases MRI scans of the brain may be required.


    Causes of Vertigo / Giddiness / Dysequilibrium / Dizziness

    Neuro-otological causes of vertigo/dizziness/imbalance

    Internal ear diseases

    Those affecting the hearing & balance organs and/or connections with brain (Hearing function affected)

    Meniere’s disease
    Septic and toxic labyrinthitis
    Tumour of the 8th cranial nerve
    Other Cerebello pontine angle lesions
    Audio Vestibular ischemia
    Cochlear otosclerosis
    Ramsay Hunt Syndrome
    Fistula of the labyrinth
    Paget’s Disease

     

     

    Those affecting the balance organ only and/or connections with brain (Hearing function normal)

    Benign paroxysmal positional vertigo (B.P.P.V)
    Vestibular neuritis
    Disseminated sclerosis
    Chronic alcoholism – Peripheral Neuropathy

     

     

     

    Central nervous system disorders

    Cerebrovascular disease due to atherosclerosis

    Vertebro-Basilar Artery Disease

    Lateral Medullary syndrome (Wallenburg’s syndrome)

    Pontine and Cerebellar haemorrhages

    Multiple Sclerosis

    Tumours and infections of Brain (Cerebrum, Cerebellum, Brain stem) & Meninges

    Epilepsy – Vertigo may be an aura

    Common of Causes of Vertigo

    20 % cases – Benign Paroxysmal Positional Vertigo (B.P.P.V.)

    15 % cases – Vestibular Neuritis. Central –Vestibular vertigo

    10 % cases – Meniere’s disease. Vestibular Migraine Phobic Postural vertigo

    5 % cases – Bilateral vestibulopathy Vestibular paroxysma Psychogenic vertigo

    Miscellaneous

    Cervical Vertigo

    Anatomy

    Pathophysiology And Diagnosis

    CVNCS (Cochleo Vestibular Nerve Compressions Syndrome)

    SSCDS (Superior Semi Circular Dehiscence Syndrome )

    BTM (Basilar Type Migraine)

    Drop attacks and frequent falls

    Management of the Dizzy Elderly Patient

    Ocular causes

    Clinical Neuro otological and Neuro ophthalmogical Examination for Balance disorders

    Evaluation of Vestibulo-Ocular system & Central Connections from observation of characteristics of Spontaneous and Provoked Nystagmus.

    Without Optic Fixation with Frenzel’s glasses


    Evaluation of Vestibu¬lo-Spinal system from examination of stance and gait

    Evaluation of the function of Otolith organs by Hallpike Maneuvre for B.P.P.V.

    1.  Head Down Right & Sitting Head Right


    2. Head Down Midline & Sitting Head Midline

    3. Head Down Left & Sitting Head Left

    Evaluation of Cranial Nerve Function

    Evaluation of Cerebellar Function

    Vertigo History

    VERTIGO HISTORY (Importance of differentiating PERIPH & CENTRAL VERTIGO)

    Dizziness and vertigo, after headache, are the second most common complaint of patients. In a recent survey in more than 30,000 patients, the incidence of dizziness and vertigo was around 20%, rising to 40% in those over 80 years of age.

    With a correct diagnosis it is possible to manage almost all the cases very successfully..

    History of patient complaints should be on the following four lines:

    The the form of vertigo, its duration, possible triggers, and possible accompanying symptoms.

    Form of vertigo: rotatory vertigo, i.e. spinning around sensation, versus a postural vertigo or dizziness.

    Duration of vertigo: How long the vertigo lasts.- attacks of vertigo which may last only for few seconds and occur up to 30 times a day, as typically found in some forms of vestibular paroxysmia, a disorder analogous to trigeminal neuralgia, or does the patient suffer from a persistent vertigo which may last days, weeks or even years?

    Possible triggers bringing on the vertigo: The patient should be asked whether the attacks occur

    (1) spontaneously, for example while sitting and having breakfast

    (2) only when the patient changes his or her position of the head, sneezes or coughs (typical for perilymph fistula), or

    (3) in certain situations such as exposure to malls or department stores (typical for phobic postural vertigo, the second most common cause of vertigo).

    Accompanying symptoms: which may indicate whether they originate (from the inner ear (e.g. hypoacusis in one ear or tinnitus) or the brain stem (e. g. double vision, perioral parasthesia, facial palsy, dysarthria, problems with swallowing, or trunk or limb ataxia). If the patient suffers from vertigo plus any of the symptoms arising from the brain stem, the underlying cause may be very serious (e.g. the beginning of basilar thrombosis) and he or she should be instantaneously transferred to a clinic for further investigations.

    Differentiate between peripheral and central vertigo

    On basis of patient’s history and clinical examination, one can often differentiate between peripheral vertigo versus central vertigo. Peripheral vestibular lesions may arise from the vestibular nerve, the semicircular canal or the otolith organs, namely, the utricle or the sacculus, while the central vestibular forms most often originate from disease conditions of the brain stem, the cerebellum or the connecting pathways between the cerebellum and the brain stem. – the lower part of the brain – Infratentorial. (Supratentorial lesions very rarely cause vertigo.)

    Among the non-vestibular disorders the most common form .s psychogenic somatoform vertigo or the so-calted phobic postuural vertigo. It is the most frequent cause of vertigo in patients between 20 and 60 years of age. Visual vertigo is a rare form of non-vestibular vertigo which may occur due to the side effects of certain drugs such as anti-convulsants or drugs to treat Parkinson’s syndrome. Non ¬vestibular causes also include orthostatic problems and cardiac arrhythmias.

    Frequency of Vertigo Syndromes

    The most common vertigo syndrome seen is benign paroxysmal positioning vertigo, accounting for almost 20% of patients, followed by phobic postural vertigo, the most common form in younger patients.

    The central forms of vertigo most often originating from stroke (within the brain stem or cerebellum) and multiple sclerosis and, rarely, from brain stem tumors. Central vestibular vertigo is also seen in patients with neuro-degenerative disorders, especially degenerative disorders of the cerebellum. such as spinal cerebellar ataxia.

    Vestibular migraine accounts for more than I 0~6 of the patients. Its diagnosis was often difficult because only two-thirds of the patients with a proven vestibular migraine also have headache during or after the attacks of vertigo. Meniere’s disease was diagnosed in about 7% of the patients. It was. the second most common cause of peripheral vertigo. Vestibular neuritis, which is an inflammation ofthe vestibular nerve, was detected in about 6%, while bilateral vestibulopathy, a failure of both labyrinths, occurred in about 4% of the patients.

    Vestibular paroxysmia, which is analogous to trigeminal neuralgia and characterized by recurrent attacks of vertigo, and psychogenic vertigo (other than phobic postural vertigo) were diagnosed in 3-4% each. Perilymph fistula was rarely seen. Only 5% of the patients had no diagnosis.

    VERTIGO HISTORY  (Importance of differentiating  PERIPH & CENTRAL VERTIGO)

    Dizziness and vertigo, after headache, are the second most common complaint of patients. In a recent survey in more than 30,000 patients, the incidence of dizziness and vertigo was around 20%, rising to 40% in those over 80 years of age.

    With a correct diagnosis it is possible to manage almost all the cases very successfully..

    History of patient complaints should be on the following four lines:

    The the form of vertigo, its duration, possible triggers, and possible accompanying symptoms.

    Form of vertigo: rotatory vertigo, i.e. spinning around sensation, versus a postural vertigo or dizziness.

    Duration of vertigo: How long the vertigo lasts.- attacks of vertigo which may last only for few seconds and occur up to 30 times a day, as typically found in some forms of vestibular paroxysmia, a disorder analogous to trigeminal neuralgia, or does the patient suffer from a persistent vertigo which may last days, weeks or even years?

    Possible triggers bringing on the vertigo: The patient should be asked whether the attacks occur

    (1) spontaneously, for example while sitting and having breakfast

    (2) only when the patient changes his or her position of the head, sneezes or coughs (typical for perilymph fistula), or

    (3) in certain situations such as exposure to malls or department stores (typical for phobic postural vertigo, the second

    most common cause of vertigo).

    Accompanying symptoms: which may indicate whether they originate (from the inner ear (e.g. hypoacusis in one ear or tinnitus) or the brain stem (e. g. double vision,  perioral parasthesia, facial palsy, dysarthria, problems with swallowing, or trunk or limb ataxia). If the patient suffers from vertigo plus any of the symptoms arising from the brain stem, the underlying cause may be very serious (e.g. the beginning of basilar thrombosis) and he or she should be instantaneously transferred to a clinic for further investigations.

    Differentiate between peripheral and central vertigo (See diagram)

    On basis of patient’s history and clinical examination, one can often differentiate between peripheral vertigo versus central vertigo. Peripheral vestibular lesions may arise from the vestibular nerve, the semicircular canal or the otolith organs, namely, the utricle or the sacculus, while the central vestibular forms most often originate from disease conditions of the brain stem, the cerebellum or the connecting pathways between the cerebellum and the brain stem. – the lower part of the brain – Infratentorial. (Supratentorial lesions very rarely cause vertigo.)

    Among the non-vestibular disorders the most common form .s psychogenic somatoform vertigo or the so-calted phobic postuural vertigo. It is the most frequent cause of vertigo in patients between 20 and 60 years of age. Visual vertigo is a rare form of non-vestibular vertigo which may occur due to the side effects of certain drugs such as anti-convulsants or drugs to treat Parkinson’s syndrome. Non ­vestibular causes also include orthostatic problems and cardiac arrhythmias.

    Frequency of Vertigo Syndromes

    The most common vertigo syndrome seen is benign paroxysmal positioning vertigo, accounting for almost 20% of patients, followed by phobic postural vertigo, the most common form in younger patients.

    The central forms of vertigo most often originating from stroke (within the brain stem or cerebellum) and multiple sclerosis and, rarely, from brain stem tumors. Central vestibular vertigo is also seen in patients with neuro-degenerative disorders, especially degenerative disorders of the cerebellum. such as spinal cerebellar ataxia.

    Vestibular migraine accounts for more than I 0~6 of the patients. Its diagnosis was often difficult because only two-thirds of the patients with a proven vestibular migraine also have headache during or after the attacks of vertigo. Meniere’s disease was diagnosed in about 7% of the patients. It was. the second most common cause of peripheral vertigo. Vestibular neuritis, which is an inflammation ofthe vestibular nerve, was detected in about 6%, while bilateral vestibulopathy, a failure of both labyrinths, occurred in about 4% of the patients.

    Vestibular paroxysmia, which is analogous to trigeminal neuralgia and characterized by recurrent attacks of vertigo, and psychogenic vertigo (other than phobic postural vertigo) were diagnosed in 3-4% each. Perilymph fistula was rarely seen. Only 5% of the patients had no diagnosis.

    Treatment of Vestibular Disorders Basically there are four options on how to treat patients with vestibular disorders:

    Physiotherapy is applied as (1) vestibular exercises in patients with unilateral or bilateral vestibular deficit or central vestibular lesions to improve the central compensation or substitution, or (2) liberatory maneuvers to treat benign paroxysmal positioning vertigo.

    Medical treatment:

    A growing number of agents are available for the medical treatment of vestibular disorders. However, before initiating treatment, it is importal1t to make the diagnosi:; and then to specifically treat the form of vertigo.

    Surgery:

    The role of surgery has diminished over the past years.

    Psychological, psychiatric or behavioral therapy:

    This is useful in patients who suffer from phobic postural vertigo.

    Vertigo testing by Computerized Electronystagmography (CENG)

    Equipment and set up for CENG testing

    The inner ear is the main organ which maintains the body’s balance.

    It is situated deep within the skull (within th temporal bone).

    Any organ of the human body can nowadays be visualised by radio imaging (C.T. scans for bony abnormalities and M.R. Scan or Sonography for soft tissues, basically without “intervention” entry into the body).

    Any organ of the human body canalso have its function assessed by measuring the electrical impulses emitted by electrodes placed on the surface of the body. To give an example, an electro cardiogram records electrical impulses from the heart from the surface of the body by means of electrodes. An X-Ray of the chest shows heart size to be normal but the ECG may be significantly normal.

    Similarly, the CENG is a test of the function of the inner ear. The CENG test is the gold-standard for diagnosis of balance disorders. It is a recording of the electrical activity of the balance organ and its connections with the balance centers at the base of the brain, brain stem and cerebellum, all of which contribute to the maintenance of the body’s balance.

    2 groups of tests are available – The Oculomotor tests and the Vestibular tests

    Tests employed for balance disorders

    Patient wired up for Computerised Electronystagmography

    Oculomotor Tests (Tests integrity of nerve connections between eyes and inner ear balance organ)

    • Spontaneous nystagmus test

    Whenever there is disease anywhere in the balance organs or their connections with the central nervous system, eyes or cervical spine, triangular beats – quick short beat and long beat known as nystagmus are obtained. These can be recorded on CENG even with eyes closed.

    • Calibration and Saccade test – To and fro movement of eyes on following 2 fixed points

    • Gaze nystagmus test – Records abnormal eye movement on gazing left, right, up or down.

    • Optokinetic tracking test – Recordings of eye movement on following a moving target.

    An Optokinetic stimulator. Patient’s gaze follows moving LEDs and recordings are obtained.

    Recording of Saccades                                                     Recording of Optokinetic target tracking

    Vestibular tests

     

    1. Positional tests determine whether dizziness originates from different positions of the head.

    Positional testing is to detect positional nystagmus in cases of vertigo which comes on with change of  position of head and body in specific positions (Hallpike positions). If there is positional nystagmus, to determine if it is due to the ear (usually BPPV), brain (central positional nystagmus), or neck (cervicogenic vertigo).

    2. Caloric test

     

    Whether spontaneous nystagmus is present or not, recordings are also obtained by stimulating the inner ear balance organs. The patient lies on a couch. Water at 7 degrees above and 7 degrees below body temperature (30 and 44 degrees centigrade) is irrigated into the ear on one side at a time, for 40 seconds  The water stimulates the inner ear fluids setting up convection currents.

    Right ear stimulus and Left ear stimulus give nystagmus responses in opposite directions. The recordings are analysed by a computer and nystagmus parameters of velocity, frequency and amplitude are analysed and graphs obtained.

    This is the most important test for analysis of the function of the inner ear and its connections.

    Recordings of the Caloric test

    Right ear warm stimulus

    Right ear cold Stimulus

    Left Ear warm Stimulus

    Left ear cold Stimulus

    Recording of right and left ear caloric responses for frequency calculation

     

    Treatment of Vestibular Disorders

    Basically there are four options on how to treat patients with vestibular disorders:

    Physiotherapy is applied as (1) vestibular exercises in patients with unilateral or bilateral vestibular deficit or central vestibular lesions to improve the central compensation or substitution, or (2) liberatory maneuvers to treat benign paroxysmal positioning vertigo.

    Medical treatment:

    A growing number of agents are available for the medical treatment of vestibular disorders. However, before initiating treatment, it is importal1t to make the diagnosi:; and then to specifically treat the form of vertigo.

    Surgery:

    The role of surgery has diminished over the past years.

    Psychological, psychiatric or behavioral therapy:

    This is useful in patients who suffer from phobic postural vertigo.

    Vestibular Rehabilitation Exercises

    Why is it that Vestibular Rehabilitation Exercises are so important in recovery from vertigo?

    Nature has a very efficient system, known as the vestibular compensatory mechanism by which the balance function of the body is brought back to normal inspite of a damaged organ of balance (labyrinth). When one of the labyrinths is partially or fully damaged, the damage is usually permanent. 1t does not regenerate. However, a person with a deranged labyrinth will NOT remain unstable throughout life. The vestibular compensatory mechanism is nature’s way of treating vestibular disorders. The more the vestibular stimuli like head movements, walking etc. the better does this compensatory mechanism develop.

    Vestibular Rehabilitation Exercises (VRT) Physical therapy for vertigo, are a form of coordinated head, body and eye movements which help to relieve the patient’s symptoms and help the giddy patient to return to normal day to day activities early.

    When the acute symptoms of dizziness pass off, start normal physical activities as soon as possible so the vestibular compensatory mechanism develops properly. Drugs prescribed for the acute phase of vertigo also sedate the central nervous system as a side effect. This can inhibit compensation and should therefore be tapered off as soon as the vertigo is under control.

    Also lack of vestibular stimuli can inhibit  the vestibular compensatory mechanism. Avoid staying in a dark room (lack of visual stimuli) or lying down in bed (lack of proprioceptive stimuli) or remaining immobile (lack of labyrinthine stimuli). These jeopardize the proper development of compensation. Hence, normal physical activity and exercises are a very important part of therapy in balance disorder management.

    Vestibular rehabilitation exercises act in 3 ways:

    ADAPTATION ~ is the process by which the brain learns to adapt itself to the changed vestibular scenario, i.e. improper signals coming from the damaged balance organ. The function of the vestibulo-ocular reflex system (system connecting eyes and ears) is to stabilise the image of the surroundings in the retina and keep it at its most sensitive point – the fovea. In derangement of the visual input and balance organ inputs, this mechanism is jeopardized.

    The gaze stabilisation exercises help adapt and retrain the vestibular reflex system so that it can effectively bring about the stabilization of images in the retina and avoid the unwanted retinal-slip in spite of there being a defect in the visual/labyrinth inputs. Retinal slip means slipping of images in the retina and is one of the major causes of vertigo, which occurs as a result of a defective vestibulo-ocular reflex system.

    HABITUATION ~ is the process by which the vertiginous patient is repeatedly exposed to the mismatched sensory input. This repetitive exposure to the “error” situation induces changes in the brain such that the brain becomes used to (conditioned to) the mismatched sensory input.

    The head and body movement exercises in the vestibular rehabilitation exercises help to enhance habituation.

    COMPENSATION ~ means the proper and fullest utilisation of the remaining sensory components viz.- the visual and proprioceptive senses and also the unaffected labyrinth. The improper input coming from the defective labyrinth is thus overruled.. The brain is trained to use the remaining senses (visual & proprioception) more effectively and efficiently such that they compensate for the partial loss of function of one labyrinth.

    The static & dynamic balance exercises in the vestibular rehabilitation exercises help to enhance habituation

    One of the objectives of the vestibular rehabilitation exercises is to deliberately and systematically provoke tolerable spells of vertigo so that the tolerance level is built-up. Hence some vertigo in the initial stages may occur but passes off with time. Diligence, regularity and perseverance are essential.

    The exercises are performed for 5-10 minutes 2 to 3 times daily.

    Care to be taken before full recovery from vertigo?

    Balance is maintained by 3 sources of input to the brain – Inner ear, the main balance organ, Eyes ­visual information & Sensory inputs ftom feet, ankle and legs which keep us in touch with the floor

    When the main balance organ in the inner ear does not function normally because of damage or disease, dependance on the other 2 sources of input become of prime importance:

    Dependance on vision – Information the brain obtains ftom the eyes Dependance on information from contact with the floor through the skin, joint position awareness, muscle tone awareness

    Environmental Modifications at home and place of work

    I). Adequate lighting. when walking through dark rooms, keep lights or night lights on all the time

    2). Removal of thick carpeting and small rugs.

    3). Nonskid flooring; Care on slippery floors

    4). Make sure, the floors at home are free from obstructions. Maintain a clear a path to your bathroom Objects that could entangle your feet or could injure you are removed, should you have a fall.

    5). Stable tables and chairs which can support the individual if required.

    6). Reorganization of cabinets and shelves to minimize bending and reaching.

    7). Stairs with railings.

    Behavioral modifications

    1. Learn to plan physical movements consciously.
    2. Avoid hurried movements. Each movement is broken into numbers and performed one at a time.
    3. Work sitting down if possible.
    4. Fix vision on distant objects for stability.
    5. Light touch on objects for balance.
    6. Restrict rapid head movements.
    7. Avoid walking with individuals or with crowds.
    8. Avoiding driving at rught and in poor visibility, stormy weather, etc.
    9. Take great care when walking on soft rugs, carpeted floors, sand or loose gravel etc.
    10. Do not carry large objects which obstruct the view in front.
    11. Use two or more pillows at night and see if it feels better.
    12. Avoid sleeping on the side that precipitates or increases the vertigo.
    13. In the morning, get up slowly and sit on the edge of the bed for a minute.
    14. Avoid bending down to pick up things, and extending the head, such as to get something out of a cabinet.
    15. Avoid any movement that twists the head on the neck in general
    16. Be careful when at office, the beauty parlor when lying back, having ones hair washed, when participating  in sports activities and when lying flat on your back.

    Special care in dangerous situations

    I). Stay off chairs, stools, ladders, roofs for risk of falling and serious injury;.

    2). Special care in the kitchen, near an open flame.

    3). Extra care crossing roads. Avoid heights.

    4). Avoid swimming and diving till after full recovery

    5). Stay off chairs, stools, ladders, roofs

    6). Avoid driving till full recovery.

    7). Avoid riding on two wheelers till full recovery

     

    Ocular causes

    Ocular causes :

    A large number of ocular conditions can give rise to the sensation of vertigo.

    • Oscillopsia: This is an illusion of back & forth movement of the environment. This is due either to a loss of VOR or a hyperactive VOR.

    • Opsoclonus: This is a horizontal & / or vertical oscillation of the eyes, seen in cerebellar & / or brainstem disorders.

    • Ocular Nystagmus: These are equal pendular excursions of the eyes because of abnormal visual fixation & / or loss of central vision.

    • Ocular vertigo ( Adler ’41 ): This is a mild sensation of vertigo, which has to be differentiated from the above mentioned causes. Ocular vertigo can be caused by the following:

    • Abnormal dioptric apparatus causing a distortion of images.

    • Extra-ocular muscle weakness, causing diplopia in gaze towards the paretic muscle.

    • Optokinetic nystagmus.

    • Looking down from heights, thus causing an abolition of the vanishing point, in addition to other psychic factors.

    • Effect of sudden acceleration of the body, causing conflicting sensory input from 2 or more organs of equilibrium.

    • Abnormal dioptric apparatus causing a distortion of images.

    • Extra-ocular muscle weakness causing diplopia in gaze towards the paretic muscle.

    • Optokinetic nystagmus.

    • Looking down from heights, thus causing an abolition of the vanishing point, in addition to other psychic factors.

    • Effect of sudden acceleration of the body, causing conflicting sensory input from 2 or more organs of equilibrium.

    Only when all these causes of vertigo have been ruled out can a patient be suspected to be suffering from psychogenic vertigo in the absence of other leading factors.

    Paget’s disease

    Paget’s disease is a chronic disorder that can result in enlarged and misshapen bones. The excessive breakdown and formation of bone tissue causes affected bone to weaken, resulting in pain, misshapen bones, fractures, and arthritis in the joints near the affected bones. Paget’s disease typically is localized, affecting just one or a few bones, as opposed to, for example, which affects all the bones in the body. Although there is no cure for Paget’s disease, medications (bisphosphonates and calcitonin) can help control the disorder and lessen pain and other symptoms. Elevated levels of serum alkaline phosphatase (SAP) in the blood; display evidence that a bone fracture will occur; require pretreatment therapy for affected bones that require surgery; placing them at risk of developing osteoarthritis; develop a rare condition called hypercalcemia that occurs when a person with several bones affected by Paget’s disease and a high SAP level is immobilized.

    Paget’s disease is rarely diagnosed in people less than 40 years of age. Women are more commonly affected than men. Prevalence of Paget’s disease ranges from 1.5 to 8.0 percent, depending on age and country of residence. Prevalence of familial Paget’s disease ranges from 10 to 40 percent. Other tests such as a bone-specific alkaline phosphatase test, bone scan, or X-Ray may be required in these cases.

    Contamination has been suggested to have played a role in producing past positive results.

    There is also a hereditary factor

    Symptoms

    Many patients do not know they have Paget’s disease because they have a mild case with no symptoms. Sometimes, symptoms may be confused with those of arthritis or other disorders. In other cases, the diagnosis is made only after complications have developed. Symptoms can include:

    •           Bone pain is the most common symptom.
    •           Increased head size, bowing of limb, or curvature of spine may occur in advanced cases
    •           Headaches, deafness and vertigo may occur when Paget’s disease affects the skull.
    •           Hip pain may occur when Paget’s disease affects the pelvis or thigh bone.
    •           Chalkstick fractures can occur.
    •           Mosaic bone pattern is symptomatic.

    Diagnosis

    Paget’s disease may be diagnosed using one or more of the following tests:

    • Pagetic bone has a characteristic appearance on X-Rays. A skeletal survey is therefore indicated.
    • An elevated level of alkaline phosphatase in the blood in combination with normal calcium, phosphate and aminotransferase levels in an elderly patient are suggestive of Paget’s disease.
    • Bone scans are useful in determining the extent and activity of the condition. If a bone scan suggests Paget’s disease, the affected bone(s) should be X-rayed to confirm the diagnosis.

    Prognosis

    The outlook is generally good, particularly if treatment is given before major changes in the affected bones have occurred. Any bone or bones can be affected, but Paget’s disease occurs most frequently in the spine, skull, pelvis, femur, and lower legs. In general, symptoms progress slowly, and the disease does not spread to normal bones. Treatment can control Paget’s disease and lessen symptoms, but is not a cure. Osteogenic sarcoma is an extremely rare complication that occurs in less than one percent of all patients.

    Associated medical conditions

    Paget’s disease may lead to other medical conditions, including:

    • Arthritis may be caused by bowing of long bones in the leg, distorting alignment and increasing pressure on nearby joints. In addition, pagetic bone may enlarge, causing joint surfaces to undergo excessive wear. In these cases, pain may be due to a combination of Paget’s disease and osteoarthritis.
    • Deafness in one or both ears may occur when Paget’s disease affects the skull and the bone that surrounds the inner ear. Treating the Paget’s disease may slow or stop hearing loss. Hearing aids may also help.
    • Cardiovascular disease can result from severe Paget’s disease ventricular hypertrophy and eventually high-output congestive failure.
    • Pagetic bone can cause nervous system problems, such as pressure on the brain, spinal cord, or nerves, and reduced blood flow to the brain and spinal cord.
    • Rarely, Paget’s disease is associated with the development of osteosarcoma (malignant tumor of bone). When there is a sudden onset or worsening of pain, sarcoma should be considered.
    • Rarely, when the skull is involved, the nerves to the eye may be affected, causing some loss of vision.

    Paget’s disease is not associated with osteoporosis. Although Paget’s disease and osteoporosis can occur in the same patient, they are different disorders. Despite their marked differences, several treatments for Paget’s disease are also used to treat osteoporosis.

    Treatment

    Endocrinologists (internists who specialize in hormonal and metabolic disorders), rheumatologists (internists who specialize in joint and muscle disorders), orthopedic surgeons, neurologists and otolaryngologists are generally knowledgeable about treating Paget’s disease, and may be called upon to evaluate specialized symptoms.

    Vertebro-Basilar Artery Disease

    Vertebro-Basilar Artery Disease

    The two vertebral arteries and the basilar artery may be considered for con­venience as the vertebro-basilar arterial system. This system is prone to two main types ischemic disease.

    Intermittent type, resulting from either vertebral artery compression in association with cervical spondylosis or from basilar migraine

    Chronic type associated with generalized vertebro-basilar atherosclerosis. Both types may be associated with vertigo, deafness and tinnitus.

    Intermittent Ischemia

    I. Vertebral artery compression.

    In cervical spondylosis intervertebral disc degeneration leads to production of osteophytes which may protrude into the intervetebral foramina and compress the vetebral arteries. Pressure by disc protrusion is also possible. If the arteries are atheromatous, the effects will be more severe. Compres­sion may occur when the head is in the normal erect position. But it is typical of this condition that compression is intermittently produced by movements of the head  especially lateral rotation or extension.. These movements may cause not only temporary impairment but even abolition of blood flow through one or both vertebral arteries, and may even impair the circulation through one internal carotid artery (Brain 1962).

    Clinical features. Intermittent vertebro-basilar ischemia of this type is characteristically accompanied by vertigo induced by head  posture. Any change of posture may be critical but lateral rotation and extension of the head, i.e. looking round to one or other side or throwing the head back to look upwards, are the commonest associations. Vertigo is usually brief, Occasionally after a “jerk of the neck” the patient was immobilized with vertigo for 2 weeks. Nystagmus may be present. Caloric tests are inconstant.

    Deafness and tinnitus may be present, but it is not certain whether as a result of ischemia of the end organ or brain stem.

    Other symptoms associated sometimes are trigeminal dysaesthesia, diplopia or drop attacks without loss of consciousness called akinetic epilepsy.

    Patients with cervical spondylosis seldom complain of regional pain but may have attacks of brachial neuralgia. Active and passive lateral flexion of the cervical spine is usually limited. Diagnosis of spondylosis is established radiographically.

    Treatment. The problem is fundamentally an orthopedic one of treating so as to diminish the pressure effects upon the vessels, usually by some form of immobilization. Patients themselves learn to avoid critical head movements.

    Chronic Ischaemia

    2.  Vertebro-basilar atherosclerosis

    Chronic brain stem ischemia resulting from generalized vertebro-basilar atherosclerosis may be associated with chronic vertigo (feelings of unsteadiness) often on getting up in the morning and high tone, bilateral, perceptive deafness. Caloric tests are inconstant. Unusual visual symptoms, attributed to poor circulation to the back of the brain like intermittent loss of vision. Positional vertigo elicited by turning the head to the sides is noted in many cases.

    On positional testing, after roughly a 20 second latency, a right or left beating nystagmus, which persists as long as the head is turned to a particular side (vertebral artery test) is noted. This may be accompanied by additional symptoms such as ear fullness, or a spot in the vision, nausea and motion intolerance. Standing up, rapid head movements, walking in a dark room, not eating, exercise, and coughing or sneezing can trigger symptoms.   A CT-angiography / MRAngio helps to clinch the diagnosis.

    Posterior Inferior Cerebellar Artery Thrombosis (Wallenburg Syndrome)

    Posterior Inferior Cerebellar Artery Thrombosis (Lateral medullary syndrome of Wallenburg)

    Wallenburg syndrome: is associated with an infarction of a wedge shaped area of the lateral aspect of the medulla and the inferior surface of the cerebellum usually attributed to obstruction of blood flow in the posterior inferior cerebellar artery or one vertebral artery (Brain 1962).

    The onset is often with severe vertigo, often with vomiting resembling acute paroxsymal vertigo of aural origin. Later symptoms of ipsilateral paralysis of the palatal, pharyngeal and laryngeal muscles due to involvement of.the nucleus ambiguous causes dysphasia and dysarthria. Involvement of the spinal tract nucleus and spinothalamic tract of the trigeminal nerve, gives anesthesia and paresthesias of the ipsilateral face and contra lateral trunk and limbs. Horner’s syndrome is also present on the affected side.

    Disturbance of caloric response is noted in most cases.

    If the lesion is restricted to the zone below the level of entry of the VIIIth Cranial nerves, the chief otoneurological abnormality is a directional preponderance to the opposite side. Deafness is absent.

    If the lesion is situated within or extending into the zone above the entry of the VIIIth Cranial nerves, canal paresis, with or without deafness, appears to be the rule.