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Ability to maintain orientation of the body
and its parts in relation to external space
Continual inputs from visual, labyrynth,
proprioceptive which integrated in
brainstem and cerebellum
Disequilibrium vertigo ( illusion of
movement of the body or environment +
impulsion, oscillopsia, nausea, vomiting,
gait ataxia ) or ataxia ( incoordination or
clumsiness of movement )
Vestibular Ataxia
Caused by the same central and
peripheral lesions that cause vertigo
Nystagmus is frequently present
(unilateral, on gaze away from
vestibular lesion)
Gravity dependent : incoordination
cannot be demonstrated when lying
down but when stand/ walk
Cerebellar Ataxia
Irregularities in the rate, rhythm,
amplitude and force of voluntary
Hypotonia defective posture
Rebound movement phenomena
Jerky appearance mostly during
initiation and termination of
movement (terminal dysmetria
(overshoot) and terminal intention
Sensory Ataxia
Typically affects the gait and legs in
symmetric fashion
The arms are involved to a lesser
extent or spared entirely
Impaired sensations of joint position
and movement, vibratory sense is
also commonly disturbed
Vertigo, nystagmus and dysarthria
Ataxic Patient
The Stance and Gait are wide-based
and unsteady

Often associated with reeling or

lurching movements
Sensory ataxia (and some
vest.ataxia) : visual input
compensating for the loss of
proprioceptive or labyrinthine.
When eye close falling toward the
side of lesion (vestibular) or forward
Cerebellar ataxia unable to
compensate by using visual input
unstable whether the eyes are open
Cerebellar ataxia : wide-based, staggering
like drunkenness, titubation, tendency to
deviate toward the lesion. Tandem gait

Sensory ataxia : wide-based, tandem gait

poor, steppage gait, stability dramatically
improved by using cane or lightly rest a
hand on the examiners arm. Walk in the
dark/with eye closed, gait is much more
Conversion reaction or malingering
wildly reeling or lurching
movements from which they are able
to recover without falling.
The Sense of Balance
Integration of inputs from the visual,
proprioceptive and vestibular system
into the brain
Dizziness is a vague symptom :
vertigo, light-headedness,
disequilibrium, fainting or syncope
Vertiginous should be evaluated to
DD peripheral/central vestibular
The peripheral or central vestibular

Peripheral : labyrinth (inner ear) or

vestibular division of VIII.
Central : brainstem vestibular nuclei
or their connections.
Rarely is cortical
origin (a symptom associated with
complex partial seizure)
Subtypes of Dizziness
Vertigo (spontaneous sensation of spinning,
rocking or tilting). Episodic ? or constant ?
Disequilibrium (unsteadiness or imbalance
when standing/walking). Neurologic /
vestibu- lar symptoms ?, Darkness ?
Dizziness hypotension (presyncope, light-
head edness, foggy head, spatial
disorientation). Heart disease?, Postural?,
Palpitation?, Medication use?, Anxiety?, HV?
Vertigo is a true sensation of motion
(classically spinning) can be caused
by lesions within the peripheral or
the central vestibular
Absence of vertigo does not rule out
the possibility of primary vestibular
Dizziness is usually secondary to
vasovagal reaction, postural
hypotension, hypoperfusion of CNS
True vertigo : acute peripheral
vestibular disturbance
Absence of true vertigo :
- central lesion
- bilateral peripheral lesion
- gradual unilateral loss of vestibular
Conflict sensory

Neural mismatch

Imbalance autonomic nervous


Symptoms and Signs
A thorough history is of prime
Quality of symptoms ?
Duration of a typical episode ?
Associated symptoms ?
Precipitating factors ?
Current use of medications ?
Precipitating factors : head movement/
position (BPPV), stress (Meniere disease),
food intake (migraine), trauma
(perilymphatic fistu)

Recurrent acute episodes + nausea and

vomiting (peripheral vestibular pathology)

CNS disease can be acute in onset but more

likely to be prolonged and persistent

Falling, difficulty ambulating with eye closed

or in darkness (decreased vestibular
The presence of associated ear
symptoms e.g. tinnitus or hearing
loss (peripheral vestibular)
The presence of visual field defect,
diplopia, limb ataxia, dysarthria,
paresthesia or other neurologic
symptoms (central vestibular)
Episodic vertigo, duration of the
attacks can assist in DD :
- seconds,hearing loss /HL - (BPPV) ;
HL +
(perilymphatic fistula)
Sudden onset of disequilibrium
(infarct or hemorrhage in the
brainstem or cerebellum)
Episodic disequilibrium of acute
onset (TIA basilar artery, BPPV,
Meniere) TIA is
usually accompanied by cranial
nerve deficits, neurologic signs in the
limbs or both Meniere dis is usually
associated with progressive hearing
loss and tinnitus
Chronic,progressive (weeks-months
nutritional disorder), (months-
Vitamin B12 deficiency, syphilis
(affect sensory pathways)
Hypothyroidism, paraneoplastic
syndromes, tumors (affect
Ethanol, sedativa, phenytoin,
aminoglycoside, quinine, salicylate
(impairing vestibular or cerebellar
Spinocerebellar degeneration,
Friedreich ataxia, ataxia-
teleangiectasia, Wilson dis
(chronic,progressive cerebellar
Physical Examination
Cranial nerves
Limb coordination
Ability to walk tandem
Stand with feet together and eyes
closed (Romberg)
Nystagmus (hor, rot, vert, visual
Fukuda stepping test
Bedside testing of
Vestibulo-spinal reflex : past
pointing, Romberg, Fukuda stepping
Vestibulo-ocular reflex : Oculo-
cephalic reflex, head thrust test,
dynamic visual acuity, caloric
Nystagmus : spontaneous, positional,
after head shaking
Diagnostic Studies
Electronystagmography (ENG) :
vestibulo-ocular response to various
stimuli e.g. gaze, positional, tracking,
saccadic, optokinetic, bithermal
Rotatory chair testing
Static and dynamic posturography
CT and MRI of the brain and internal
auditory canal ( Towne X-ray)
Common Causes of
Vertigo : BPPV, Meniere,
Labyrinthitis, Vestibular
neuronitis, Inner ear autoimmune
disease, Perilymphatic fistula,
Migraine, Labyrinthine concussion,
Transverse temporal bone
fracture, VB ischemia, Wallenberg
syndrome, Cervical injury
Dysequilibrium : Peripheral
neuropathy, Acoustic
neuroma, Ototoxic drug,
Cerebellar atrophy /infarction,
Posterior fossas tumors,
aging, Multiple sclerosis,
Wernicke encephalopathy
Dizziness, light-headedness :
Cardiac arrhythmia,
Vasovagal reaction, Postural
hypotension, Systemic
viral/bacterial infection,
Hypoglycemia, Electrolyte
disturbance, Thyrotoxicosis,
Anemia, Psychophysiologic,
Primary Challenge
Determine whether the complaint is
vestibular or non-vestibular in origin
Pts difficulties : explaining and
differentiating their symptoms :
vertigo, light-headedness, imbalance,
other symptoms of dizziness
Traditionally vertigo (vestibular
pathology), non-vertiginous dizziness
(non-vestibular diseases)
Benign Paroxysmal Positional Vert
Recurrent episodes of vertigo lasting
for seconds, precipitated by changes
in head position, especially neck
extension, bending down, lying
supine (affected ear down),rising
from bed, rolling over in bed to the
affected side.
History of trauma or labyrinthitis
Otolith (Ca2CO3) dislodge into the
post. SCC
Dix-Hallpike test reproduce symptom
Meniere disease
Episodic attacks of vertigo, tinnitus,
low-frequency fluctuating deafness,
aural fullness.
V. lasts several min-hr + nausea and
Increase endolymphatic pressure and
volume e.c. Trauma, infection,
immune-mediated, genetic
Diagnosis : episodic vertigo +
fluctuating sensorineural hearing loss

Glycerin 1,2 ml/kg BW Caloric and

Audiogram test before and 2 hr after.
Significant improvement (audiogram
10 dB, ENG 7 degree/second

Th/ salt restriction, diuretic,

antihistamine, corticosteroid,
labyrinthine suppressants
Intratympanic steroid/gentamycin,
shunt, labyrinthectomy, vestibular
Vestibular Neuronitis
Sudden and severe vertigo lasting a few
days + nausea and vomiting
Self-limited ( vestibular suppressants)
History of viral illness
Caloric stimulation : unilateral reduced
Audiologic evaluation normal
Unsteadiness for a few weeks after
attacks early ambulation to facilitate
Perilymphatic Fistula
Vertigo + unilateral sensorineural
Abnormal communication between
the perilymph-filled inner ear
and the air-filled middle
Cause : head injury, barotrauma,
secondary to IIP (coughing, sneezing,
straining, lifting)
Th/ bed rest, surgery to patch the
Labyrinthine Concussion
Follows immediately head trauma
w/wo temporal fracture
Vertigo and imbalance
Audiometry : normal (sometimes
high-freq sensorineural deafness)
Spontaneous resolution 6 mo- 1 yr.
Vestibular exercices can hasten
Whiplash Injury
Positional nystagmus (PD or ENG)
Audiologic test normal
Spontaneous resolution weeks-
Diazepam (vest.suppres. + muscle
Cervical neck collar + vest.
Migraine-associated Vertigo
Precede or occur simultaneously with
the headache or during headache-
free periods
Positive family history of migraine
Th/ the same as for migraine
Vertigo + cranial nerve palsy,
seizures, ataxia or signs of IIP
further investigation to SOL
Acoustic neuroma (vest.
Schwannoma) and other tumors of
cerebellopontine angle
vest.symptoms + deafness + tinnitus
Imbalance > true vertigo
Early diagnosis preserve hearing
and facial nerve function