 Good morning everyone, I am Dr Jayanthi Shastri, Interhidrenic Surgeon, Vanipal Hospital, Maleshwara. Today I would like to speak about the second half of the vertigo which I had already done for the first half I had already done a few weeks ago. Welcome back to the second session of vertigo. So as I explained in my last video that when patients come to us with kidney disease or imbalance with associated symptoms, we first do the preliminary examination to rule out all other problems, then come to a conclusion that it is vertigo, it could be of central origin or peripheral origin, then we take up the patients for further investigation. So central origin means the vertigo is arising from the brain, peripheral origin is with any of the peripheral organs, maybe nerves or maybe ear, basically ear. So what I do, the first thing I tell the patient is that I reassure the patient, yes this can be brought under control provided the patient has some patience and perseverance to take the medications and do the exercises as we teach and things like that. If they have the patience then this condition can be brought under control. This problems cannot be solved in a hurry. So if it is the highly suspicious of central origin vertigo, then central origin as I said is arising from the brain, then we would want to do MRI brain. So here I would like to mention one thing. Is that many a times the highly suspicious means the peripheral as well as central, they will be overlapping each other, the symptoms will be overlapping each other and sometimes they co-exist, both peripheral and central vertigo co-exist. So what happens is MRI brain becomes a must. So some patients do not want to undergo MRI brain, maybe financial issues but some patients they feel that when we say get an MRI and they feel just for a giddiness why this MRI. Of course so for such people my sincere advice and request is to undergo this investigation because if we do not, for example if we do not recognize a tumor in the brain in early stages, it becomes difficult to later on operate also as well as it may become impossible also to remember the tumor sometimes. So initially if the anti-surgeon suggests an MRI it may be because for these reasons. So we have ruled out all that and when you come to our vertigo clinic, so if it is a peripheral vertigo we have to start doing some tests. So first of all as a patient is sitting we look for nystagmus. Nystagmus is movement of the eyes without actually shaking the head. So actually the patient will be feeling the giddiness when the eye movement is occurring. So first of all a positional testing is done with the head in the supine position with the patient lying down in the supine position that means straight on the bed and then on the right side turn the head to the right and to the left. Also when we see that there is a direction changing this nystagmus that means to say it should be a peripheral vertigo. So the next comes the head thrust test. This actually is a simple bedside test. It can detect unilateral or bilateral vestibular disorders or sometimes even it can differentiate it from the central disorders. So this test is done as shown in the picture. Patient is seated in front of the examiner and patient's head is held with the hands of the examiner then ask the patient to look at the nose of the examiner and turn the head to one side and then to the other side. So while turning we note something called corrective saccades. So if this is present that means to say it is peripheral vertigo. Then coming to the rhombus test here the patient is made to stand straight as shown in the picture and if first with eyes open then with eyes closed. If there is swaying when there is when the patient crosses his eyes then that means to say the test is positive. Then the next comes the Anton Berger's test where in the same position the patient has to walk in the same place that is do something like a march past in the same place. So if the patient turns to with eyes open first and then eyes closed. When eyes is closed if the patient turns to one side that means to say on that side the vestibular system is weak. So this is how we try to lateralize means to which side which side the vestibular system is weak that is how we try to lateralize. And then next coming to the Dix-Hulpact test. This test you can see the patient is first seated as shown in the picture and in the next picture you can see the patient lying down and turning the head to 45 degrees. So once the patient is seated like this and then the head made to lie down and turn the head there can be nishtagmas. So we note down the nishtagmas until the nishtagmas abates or until gidiness subsides that the patient is or for 30 seconds whichever is later we ask the patient to lie in that position and then turn the head to the other side. So this way again we'll be able to either lateralize the disorder which side is affected or sometimes both sides may be affected. So these are the tests to help us to lateralize the disorders. Next test is supine lateral head turns. In the previous test as I said Dix-Hulpact test there's a pillow given below the shoulder. But whereas in the next test that is supine head lateral test the patient is asked to lie down flat on the bed. And then first in the supine position then turn the head to one side 90 degrees then turn the head to other side 90 degrees each time we have to wait for 30 seconds at least or till the gidiness subsides. So that we'll be able to make out which side the patient is getting the gidiness more. Then so these and there are some tests like a caloric test where we induce ice cold water into the ear and this is done mainly for menius disease. So of course the menius disease don't come in this positional but I'm just mentioning it. It is done to rule out this menius disease and things like that. And except when the patient comes in a very severe with a very severe vertigo we should always include audiometry. Audiometry is a hearing test so that we can rule out certain conditions like menius disease as well as some orthotoxic conditions. Because sometimes some drugs do cause some toxicity to the ear or some chemicals do cause toxicity to the ear. So we have to rule out such conditions hence audiometry is a must. Where there will be a lot of hearing deficiency also along with gidiness. So now coming to the principles of management. As I already said empathy and reassurance that is the most important thing when the patient comes to us. We have to elevate the anxiety by explaining the cause of vertigo and the nature of the disorder. And we have to give a positive counseling. Then comes the pharmacotherapy. Then comes the vestibular rehabilitation. Surgery is not very much in there for these kind of disorders. Very rarely it is done. Then coming to the pharmacotherapy we give anti histaminex, anti vertigo drugs like synaresine, beta estin and anti ametics to avoid vomiting. So initially these are given in a high dose. Then the dose is reduced subsequently. In some cases like menius disease we do ask them to do salt restriction and give them diuretics. And of course beta estin and intra tympanic injections of corticosteroids or gentramycin. Now coming to the most important thing, the vestibular rehabilitation manoeuvres. What we do when the patient comes to the hospital. These manoeuvres, there are many manoeuvres. I'll explain only a few of them. The first one, epilepsy manoeuvre. As you can see in the picture, it's a series of pictures. In the first picture the patient is sitting up. In the second picture the patient is made to lie down and turn the head to one side 45 degrees. And then wait for the nystagmus to come down or the gidiness to come down. Then turn the head to 90 degrees on to the other side. Wait for the gidiness to come down. Then the patient is made to lie down on the opposite side of the problem. Then she's back to sitting position. So these are the four positions that normally done each time we wait for 30 seconds or until the gidiness subsides. So once this is done, many a times, many a times the gidiness completely comes down. So this is the next manoeuvre we do is the sermons manoeuvre. Of course we decide which manoeuvre to do for which patient. So sermons manoeuvre is as it is seen, the patient is sitting on the side of the leg down. Then she is made to lie down. Then her head is turned to one side 45 degrees. Maybe if the problem is on the left side, the patient is asked to turn to the opposite side 45 degrees and then made to lie down as shown in the picture. And she has to look up at the ceiling and wait for about 30 seconds. Then get up and come back to this position. And with the 45 degrees head turn like that only, she has to lie down onto the other side with her face looking at the floor. So this completes the sermons manoeuvre. Next comes the gufoni or api-anime manoeuvre. This is done for the horizontal canals. Okay, as I had explained in my first slide, there are three canals, horizontal, posterior, and anterior. So of that, if there is a problem with the horizontal canal, this manoeuvre is done. Patient is made to lie down straight, away from the affected side. The head is turned to 90 degrees to look down later. Then she is made to sit up and then the head is corrected. So this is done for the lateral sensor canal. Next comes the yako-vino manoeuvre. Here, this is done for the posterior semicircular canal. Actually to diagnose which side in posterior semicircular canal is difficult. So this is a central manoeuvre done for patients like this. So with the patient is made to lie down with the head dangling beyond the bed. And then the patient is asked to flex the head up to the such that her cheek touches the neck as shown in the picture. Then there is one more manoeuvre called log roll or barbeque manoeuvre. Like this one is done in the barbecues. So also the patient is first, suppose the left side is affected. The patient is asked to lie down on the left side. Then he or she is asked to turn on to supine position. Then he or she is asked to turn to the right side. Wait each time, wait for 30 seconds. And then he is asked to lie down on the stomach. Then come back to the left side position. So this is something like a barbeque rolling. So it's called a barbeque manoeuvre. So this is also done for some lateral semicircular canals. So these are the manoeuvres. There are some more manoeuvres which it becomes too much. So I'm now coming to the post-manoeuvre care. What do you have to do? Well, at least for one week, the patient should, at least for one week, the patient should take care of all this. He should be, for a few hours after the manoeuvres, the patient should be upright. And while sleeping in the night also, the pillows have to be kept at least 45 degrees. With multiple pillows, the patient should be lying down 45 degrees. And throughout the night, and should not turn the head onto the affected side. And he or she should not go to a dentist or a hairdresser for at least a week. And he should avoid exercises requiring head movements, including sit-ups, toe touches, and freestyle swimming and things like that. This is for one week. Then after one week, we have to, we give them adaptation exercises. The exercises they have to do at home. So the first of them is the head and neck exercises. I showed in the picture. The first anti-front and back, and then side to side. So first slowly, then fast. Each moment, at least it has to be repeated 20 times. Then this is another exercise where you stand from a sitting position, and then turn around. So this is also, what happens is, initially with the eyes open, and then with the eyes closed. The patient turns around so that what happens is slowly, slowly, they get adapted to turning around with the eyes closed. So the giddiness slowly, the body gets slowly adapted to it, and the giddiness subsides. Then coming to the next exercise, this is you have to turn both the head and as shown in the picture, head and trunk, to the right and to the left. So this is also repeated 20 times. So then coming to the next one, where shoulder rotation. Shoulder is rotated anteriorly, anteriorly means to front and behind, each 20 times, as shown in the picture. So then coming to the next one, that is picking up an object from the floor. Patient is made to sit on a stool and the object is placed on the ground, and then he has to pick up that object, pick up again, drop it, pick up and drop it. So this has to also be done 20 times. And the next one is, this is a brand of exercise, it's called brand of exercise. You can see in the picture, that first the patient is seated, the head is turned to 45 degrees away from the affected side, and the patient is made to lie down, like that on the bed. So with the 45 degrees looking up at the ceiling, they have to repeatedly do this 20 times along with the other exercises. So these are a few exercises that we teach the patient so that they continuously do it for, at least for a period of about a month or four weeks to six weeks. Then along with all these exercises, there are certain add-on therapies. We give Jinko by Loba for at least three months and stress management. Many of these diseases, including headache, giddyness, many of these diseases are because of stress. So stress management is the most important thing. Like meditation is a very good tool for stress management. And then yoga, yoga, asanas as well as pranayamas, they're very good for stress management as well as for, they act like a rehabilitation exercises also. And adequate amount of sleep is very much required and hydration, drinking plenty of water, at least about two to one half liters of water per day. And vitamin D, nowadays we see that vitamin D deficiency is there for everybody, almost everybody. So vitamin D is another important thing and avoiding alcohol. Alcohol should be avoided, especially during the rehabilitation exercises and during this therapy. Then there are certain diet changes, like caffeine should be reduced and salt intake should be reduced because it causes some water retention and things like that. And nicotine, absolute no-no, no smoking at all. And as I said already, alcohol. So foodstuffs that should be included are plenty of water, as I said, and tomatoes, which are rich in potassium. And nuts, they provide antioxidants, micronutrients, they're anti-inflammatory also. So nuts should be included in their diet and fresh fruits. So intra-tympanic injections when patients don't respond to any of this procedures and things like that, or pharmacotherapy. Then we are left with no choice but to give some intra-tympanic injections. We may give steroid, aminoglycosid, or a combination of both, into the ear, into the middle ear. So last but not the least is surgical options, which is very rare. We don't do surgery for these conditions, which is quite rare. But yes, there are certain surgical options for this condition also. That is all I would like to tell you about this, what I go. Thank you for watching this FB live session. And if you like this video, then please share it with your family and friends who may be benefited by this. And let us meet in the next session. Thank you so much.