Vestibular Cardiovascular Central and brain Musculoskeletal Dizziness Medications

Vestibular Cardiovascular Central and brain Musculoskeletal Dizziness Medications Psychological

Vestibular System Input

Anatomy of Inner Ear Ant. SCC Utricle Lat. SCC Post. SCC Saccule Cupula

Causes of Dizziness • Organic • Psychogenic

Organic Dizziness • Non-vestibular • Vestibular

Vestibular Dizziness • Peripheral (inner ear & nerve) • Central

Common Cause of Vertigo • Otologic disorders Benign paroxysmal positional vertigo Meniere’s disease Vestibular neuritis(labyrinthitis) • Neurologic disorders Migraine-associated dizziness VBI, cerebellar infarction Panic disorder

Diagnosis and Physical Treatment of BPPV Oh’s Neurology Clinic Oh, Hui-Jong

Vertical vs Horizontal

Canalolithiasis vs Cupulolithiasis

Force of cupular deviation Endolymphatic flow Gravitational force

Sitting with Frenzel-Video

Diagnosis of Vertical Canal Dix-Hallpike Maneuver

PC BPPV (Rt)

Diagnosis of Horizontal Canal Lying-down Nystagmus Head rolling test

HC BPPV

HC BPPV (Rt)

Physical Therapy of PC-BPPV • Brandt-Daroff Exercise(1980) • Epley M(1992) • 3 D Flight Simulator(1997)

Brandt-Daroff Exercise(1980) 1 Until vertigo subside 30 sec 2 3 30 sec 1 → 2 → 3 → 1 Repeat until vertigo subside every 3 hrs Terminate after two consecutive vertigo-free days. Complete relief in 66/67 within 3 -14 day.

Brandt-Daroff Exercise(1980)

Epley Maneuver(1992) ① ⑤ ② ④ ③

360 degree Rotation of PC BPPV (Lempert, 1997) 4 steps of backward rotation 110 30 55 30 sec

Physical Treatment of HC Canalolithiasis • Barbecue maneuver • Forced Prolonged Position(1994, 1997) • Gufoni’s M(1998)

Barbecue Rotation(360˚) 1 4 2 5 3 6

Forced Prolonged Position (FPP, 1994, 1997)

Gufoni’s maneuver(1998)

Gufoni’s Liberatory Maneuver(1998)

Vestibular Neuritis • • 25세 가정주부 3일전부터 spinning, vomiting Unsteadiness, imbalance, blurred vision 2주전 flu-like symptom No tinnitus, no HD, no ear fullness Imbalance in the dark Spatial disorientation after head move.

Vestibular Neuritis

Stepping test

Caloric Test 우측 좌측

Pathophysiology

Central Compensation

International classification of migraine 1. 1 Migraine without aura 1. 2 Migraine with aura 1. 2. 1 1. 2. 2 1. 2. 3 1. 2. 4 1. 2. 5 1. 2. 6 Typical aura with migraine headache Typical aura with migraine one-headache Typical aura without headache Familial hemiplegic migraine Sporadic hemiplegic migraine Basilar type migraine 1. 3 Childhood periodic syndromes that are commonly precursors of migraine 1. 3. 1 Cyclic vomiting 1. 3. 2 Abdominal migraine 1. 3. 3 Benign paroxysmal vertigo of childhood

International classification of migraine 1. 4 Retinal migraine 1. 5 Complications of migraine 1. 5. 1 1. 5. 2 1. 5. 3 1. 5. 4 1. 5. 5 Chronic migraine Status migrainosus Persistent aura without infarction Migrainous infarction Migraine-triggered seizures 1. 6 Probable migraine 1. 6. 1 Probable migraine without aura 1. 6. 2 Probable migraine with aura ICHD-2, 2004

Epidemiology • In specialized dizziness clinics MV : at least 7% of diagnosis • Vertigo : migraine(21%)/tension headache(8%) • Migraine : BRV(61. 1%)/control(10%)

Nomenclature • • Migraine related vestibulopathy Vestibular migraine Migrainous vertigo Migraine associated vertigo

Migraine syndrome presenting as vertigo • Benign paroxysmal vertigo of childhood(BPVc) • Basilar migraine(BM) • Benign recurrent vertigo(BRV) • BPPV

Benign paroxysmal vertigo of childhood • 9 yr-old boy, dizziness for 4 months, -2/wk • Spinning, imbalance, tendency to fall • Continued normal activity → N/V • No HL, no tinnitus, no ear fullness • Difficulty in gym class 1

Additional History • Car sickness • Not notice asso. between dizziness & diet • Mother : pulsatile headache, nausea, photophobia, phonophobia, motion sickness, avoiding amusement parks

Benign paroxysmal vertigo of childhood • • Age onset : 2 -12 yrs Lasting from seconds to a minute N/V(+ or -) Subsequent development of migraine Cyclic vomiting, recurrent abdominal pain, scotomata, photophobia • Hx of motion intolerance : common • Paroxysmal torticollis of infancy(PTI) precede BPVc

Paroxysmal torticollis of infancy(PTI) • • Paroxysmal torticollis Onset in the first yr of life Spontaneous recovery before 5 yrs of age Dysfunction of mesencephalic tegmentum (cf, BPVc : pontomedullary VN) • Close association with migraine • Recurrence, duration, benign course • Precede BPVc

Basilar migraine Two or more the following symptoms • Visual symptoms in both temporal and nasal fields of both eyes • Dysarthria • Vertigo • Tinnitus • Decreased hearing • Diplopia • Ataxia • Bilateral paresthesia • Decreased level of consciousness

Pathophysiology of MV • Vasospasm of internal auditory artery • Spreading depression affecting brainstem • Neurotransmitter release in peripheral & central vestibular structure • Genetic defect of ion channels familial hemiplegic migraine & episodic ataxia type 2 : CACNA 1 A

Treatment of vestibular symptoms 대증요법 • Diazepam • Metoclopramide • Promethazine(25 or 50 mg p. o) : antivertiginous, antiemetic

Treatment of vestibular symptoms 예방요법 • 베타차단제(Propranolol 80 -120 mg #2) Bradycardia, fatigue, reduced energy Contraindication : asthma • 칼슘이온통로 차단제 (Flunarizine) • Acetazolamide(Diamox) 말단감각이상, 신결석 • Lamotrigine(antiepileptic drug) Sodium channel block