Vertigo is the illusion of rotation. It occurs due to unequal neural activity between the right and left vestibular nuclei (the balance organ in the inner ear). Vertigo may develop as a result of sudden unilateral damage to the vestibular end organ, vestibular (balance) nerve or nucleus, or vestibulo-cerebellum, which inhibits the ipsilateral (same-side) vestibular nucleus. Simultaneous bilateral vestibular damage causes imbalance in body movements and shaky trunk position; It does not cause vertigo. Vertigo, as in unilateral vestibular stimulation, never develops in a patient with bilateral vestibular damage.
Vertigo syndrome; In addition to the illusion of rotation (the person perceives it as if he/she is making a movement with his/her whole body or turning his/her head quickly left-right or up-down, for example, he/she is sitting calmly at the time), nystagmus (which occurs only during a medical examination and occurs when looking to the side) It is accompanied by bilateral eye movements in the form of jerks), ataxia (imbalance in trunk movements and/or walking), nausea, vomiting, sweating and pallor. Vertigo occurs as a result of misinterpretation of corticospatial (the main balance-related centers of the brain; interpreting the person's head and / or body position as incorrect and exaggerated) orientation. Nystagmus develops as a result of the imbalance in the vestibulo-ocular (between the inner ear balance organ and the eye structures) reflex. Ataxia is seen due to abnormal or inappropriate activation in the vestibulospinal (nerve cells in the spinal cord that organize the body muscles from the balance organ in the inner ear to the nerve cells that give orders to certain muscles related to that movement in the whole body) pathways. Nausea and vomiting occur in the medulla oblongata. It occurs as a result of chemical activation in the vomiting center (spinal cord bulb).
“ Dizziness ” is used by patients instead of vertigo in Anglo-Saxon culture; However, the word does not have an exact equivalent in Turkish. “Dizziness” is used to describe states such as feeling light-headed, pre-fainting, unbalanced, or feeling like the boat is rocking. It is also used by our patients for complaints describing vertigo, dizziness and imbalance. Therefore, a very good anamnesis should be taken to understand whether the patient's complaint is vertigo, "dizziness" or imbalance. It is necessary to allow the patient to explain his/her complaints.
Vertigo;
1- Presyncope (the feeling of faintness and exhaustion felt just before fainting),
2- vestibulospinal (the path that comes from the inner ear balance organ and continues to the anterior stem cells that control the body muscles in the spinal cord), proprioceptive (includes information from sensory sensors and receptors in the skin), imbalance that occurs as a result of problems with the integration of visual and motor systems,
3-It should be distinguished from conditions that cause non-specific findings such as a feeling of heaviness in the head and feeling like shaking.
This is a common procedure when evaluating patients who present with complaints of dizziness and imbalance. The seven mistakes are as follows:
1- Not being able to distinguish vertigo from imbalance
2- Not knowing or not knowing how to do a positional test
3- Not doing or not knowing how to do a head rotation test
4- Not knowing that migraine causes vertigo even without a headache
5- Not requesting an audiogram or not being able to evaluate it
6- Not planning to evaluate the patient during an attack
7- Magnetic application without examining the patient in detail Requesting first resonance imaging (EMAR-MRI).
Vertigo and "dizziness" are the most common complaints when consulting a physician after headache. In a study involving thirty thousand patients, the prevalence of vertigo was found to be around 17%. It increases to 39% over the age of eighty. Since it is a very common complaint in daily practice, such patients should be evaluated and guided carefully.
Vertigo and "dizziness" are caused by different etiologies (source and cause) and pathogenesis (mechanism of formation), and are interdisciplinary (internal medicine, It is a multisensory (involving many sense and balance organs) and sensorimotor (involving many sensory and movement systems) syndrome that can be clarified with a common approach (involving many different specialties such as cardiology, orthopedics, neurology, physical therapy and neurosurgery).
Detailed neuroophthalmological (neurological and eye examination) and neurootological (neurological and middle-inner ear) evaluation; It is always superior in diagnosis compared to expensive eye movement recording and imaging techniques. In a patient presenting with complaints of vertigo, "dizziness" or imbalance, it is necessary to distinguish whether the cause of the complaint is peripheral or central vestibular interference.
NEUROPHTHALMOLOGIC AND NEUROOTOLOGICAL EVALUATION
Eye movements should be evaluated first in neuroophthalmological and neurootological evaluation. It should be determined whether there is any deviation in the eyes in the primary position (in a completely neutral position, while looking straight ahead at the horizon). Then, the cover-up test is performed and the eyes are checked for deviation in nine different positions. Fixation problems (keeping the patient's eyes fixed on a particular object and/or point) It is investigated whether there is nystagmus (the patient cannot sew for a long time), nystagmus (the occurrence of pulsation in the eye sockets when the patient's eyes are turned to certain angles). Saccadic (entrainer bilateral eye movements that occur when horizontally following a vehicle passing in front of it at slow speed) and tracking eye movements are evaluated.
When evaluating nystagmus, the differences between central and peripheral nystagmus should be well known.
Peripheral nystagmus (which concerns only the middle and inner ear and is more benign and provides more successful treatment than the other) :
1-Horizontal and torsional (a sphere rolls in style).
2- Its direction is unilateral and does not change with the direction of gaze.
3- Visual fixation (if an obstacle is placed in front of one eye while the patient follows an object with both eyes) suppresses nystagmus.
4- It gets better within days.
5- Dizziness is evident.
6- It may be accompanied by tinnitus (unilateral and/or bilateral tinnitus).
7- There are no additional brainstem findings and cerebellar findings.
Central nystagmus:
1- Pure vertical (vertical), pure torsional, pure horizontal (horizontal) horizontally parallel to the line) or mixed in appearance.
2- Its direction is unilateral or changes with the direction of gaze.
3- Visual fixation nystagmu is not suppressed.
4- It does not improve within days.
5- Dizziness is not obvious.
6- It is usually not accompanied by tinnitus.
7- Brainstem findings and cerebellar symptoms. It is accompanied by symptoms.
The fact that the direction of the nystagmus does not change with gaze and is suppressed by visual fixation is very important in distinguishing peripheral vestibular nystagmus from other nystagmus. For this reason, patients with nystagmus must be evaluated by eliminating visual fixation.
To eliminate visual fixation, 20-diopter Frenzel glasses are used or fixation is eliminated by temporarily closing the fixing eye during ophthalmoscopy. It should not be forgotten that the movement in the retina is opposite to the direction of the nystagmus.
The test known as Head turn test or Halmagyi test is >tests the vestibulo-ocular reflex (VOR) in the horizontal plane. To test horizontal VOR, the patient's head is held with both hands and the patient is asked to fixate his eyes on a target in front of him (for example, the examiner's nose) and the patient's head is turned left and right. In a healthy person, these head turns cause the eyes to turn to the opposite side. In patients with unilateral labyrinth (balance organ in the inner ear) affected, rapid eye movement to the opposite side cannot occur during the head turn movement towards the affected ear, as a result, a corrective saccade (catch-up) occurs to fix on the target. The corrective saccade is easily noticed by the examiner. The fact that it is easily applicable and has a specificity of 97% in vestibular (inner ear) losses due to different reasons makes this test very important; but requires patient compliance.
Head nodding nystagmusu; It is the nystagmus that occurs in a patient wearing Frenzel glasses, after shaking his head from side to side for 15-20 seconds, preferably by tilting it 30 degrees down, with his eyes closed. Nystagmus occurring in the horizontal plane suggests unilateral peripheral vestibular involvement; The fast phase is towards the healthy ear. The occurrence of vertical nystagmus, downbeat or upbeat nystagmus suggests central vestibular involvement. Its specificity is 75% and its sensitivity is 46%. has been found. Sensitivity and specificity are related to the degree of unilateral vestibular involvement.
Positional test; It is one of the most important steps in the evaluation of patients complaining of dizziness, dizziness and imbalance. It must be applied to every patient.
In cases where there is a mechanical problem, as in benign positional paroxysmal vertigo (BPPV), certain maneuvers may cause nystagmus.
Dix-Hallpike maneuverWhile the patient is sitting on the examination table, his head is turned 45° to one side and he is quickly laid down with his head hanging off the examination table. For example, if there is a complaint of BPPV of the left posterior semicircular canal, a certain After latency (approximately 30 seconds), crescendo-decrescendo-like nystagmus (increasing to the highest level-decreasing to the lowest degree and then disappearing) occurs; It usually takes less than 30 seconds. When the patient is brought back to the sitting position, the direction of the nystagmus changes. Before performing this test, it is necessary to inform the patient; because a sudden dizzy attack can disturb the patient greatly.
Caloric test: After checking whether there is a plug in the external auditory canal, the patient's head is tilted 30°. is removed and the horizontal canals are brought to the vertical plane. Water at temperatures of 30° and 44° is administered to both outer ears and eye movements are recorded. There should be a break of at least five minutes between the ears when performing a caloric test. Asymmetry of more than 25% between responses is considered pathological. It should not be forgotten that the caloric test only tests the horizontal channel.
In the Positive Romberg Test, a patient who does not have a balance problem with the eyes open, loses balance when the eyes are closed. Severe proprioceptive loss in patients with acute vestibular loss
In the sensitized Romberg test or Tandem Romberg test, the patient is in the toe-heel position on a straight line. You are asked to keep your eyes closed. In addition to the disorders that lead to a positive Romberg test, chronic vestibular losses and normal old age over the age of 65 also cause a positive sensitized Romberg test. normal load
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