Vertigo

Definition and Causes:

A condition in which one feels dizzy or off-balance, often seen in the elderly, however; may occur at any age and in both genders.

It can be either:

• Objective vertigo (where the surrounding is moving or spinning)

• Subjective vertigo (the individual feels to be moving or spinning with respect to the surrounding)

Causes:

Benign paroxysmal positional vertigo (BPPV):

• The most common form of vertigo, usually initiated by sudden head movements or on moving the head in a certain direction. This type of vertigo is rarely serious and can be treated

• It is mostly associated with minor to a severe blow to the head or may involve some disorder or damage to the innermost part of the ear

• Inside the innermost part of the ear, there are tiny organs and include structures like circular bony canals fluid and fine hair-like sensors to monitor the rotation of the head

• Other structures also known as “otolith organs” – utricle and saccule monitor the up and down, back and front movements related to gravity. The otolith organs contain crystals that make us sensitive to gravity. Sometimes for a variety of reasons these crystals may dislodge and move into the bony canals and thus make the canals sensitive to head position changes and cause symptoms of vertigo

Labyrinthitis:

• Untreated ear infections caused by bacteria can get into the innermost part of the ear leading to swelling and sudden onset of vertigo with hearing loss

Neuronitis:

• Viral neuronitis is just like labyrinthitis; caused by certain viruses, which may affect the nerves in the region leading to vertigo

Meniere’s disease:

• The symptoms are associated with an increased amount of fluid in the inner ear. The disease presents with sudden onset vertigo, ringing in the ear and hearing loss

Head trauma:

• People who have received a violent blow on the head can suffer temporary or permanent damage to the inner ear, causing balance problems and vertigo

Acoustic neuroma

• A type of tumor of the nerve tissue that can cause vertigo. Symptoms include vertigo with one-sided ringing in the ear and hearing loss

Multiple sclerosis:

• A disease that affects the brain and spinal cord. Swelling (inflammation) caused by the abnormal defence response (immune response) within our body, leads to the injury of the protective covering of the delicate nerve cells within our brain and spinal cord. Patients with this disease usually present with a sudden onset of vertigo as a first symptom

Migraine:

• A severe form of headache which may also cause vertigo

Vertigo:

• Sometimes can be caused by decreased blood flow to the brain

Some medications can damage the human balance system which is controlled by the vestibular system (situated in the innermost part of the ear) in high doses or with prolonged use such as:

• Acetylsalicylic acid (ASA)
• Tranquilizers
• Sedatives
• Some antibiotics

Symptoms:

If eyes are closed during an episode of vertigo, sensation of spinning or falling occurs.

Vertigo should not be confused with symptoms of lightheadedness or fainting, and it differs from motion sickness which is a feeling of being off-balance, caused by repeated motions such as riding in a car or boat.

True vertigo includes a sensation of disorientation or motion. In addition, the individual may also have any or all of the following symptoms.

• Nausea/ vomiting
• Sweating/ dizziness
• Headaches
• Head and neck muscle stiffness
• Abnormal eye movements

Investigations and Treatment:

INVESTIGATIONS:

History:

• Inquire if true vertigo exists, such as presence of sensation of motion
• Duration of vertigo i.e. if they come and go or are constant for sometime
• Are they related to sudden change in position especially head
• Associated symptoms such as nausea, vomiting, sweating or abnormal eye movements
• Any trauma or injury to the head
• Ringing in the ears or loss of hearing

Physical examination:

• Detailed physical exam including the ear and neurological examination is required to evaluate true vertigo

Labs:

• Blood test to check sugar levels and ECG may be helpful if the physician is suspecting the vertigo is due to the decreased blood flow to the brain

Imaging:

Computed Tomography (CT) scan:

• This device uses x-rays. Patients will lie on a table with the head placed inside of the scanner (resembles a large donut). Computer analysis of x-ray images produces detailed cross-sectional images. The scanning time is usually very rapid (less than 1 minute). The scan can provide detailed images of the brain if the injury is suspected to be a cause of vertigo

TREATMENT:

The choice of treatment depends on the underlying cause and may require additional treatment and referrals

• Infection of the middle ear may require antibiotics
• Recurrent ear infections may lead to a hole in the eardrum, requiring referral to an ear, nose, and throat (ENT) specialist for surgery
• In addition to the drugs for benign paroxysmal positional vertigo (BPPV), some physical maneuvers can be used to treat the condition such as:
  • Epley maneuvers: The patient is asked to sit on the edge of a table and lie down to one side until vertigo resolves followed by sitting up and lying down on the other side, again until vertigo completely ceases. The maneuver is repeated until vertigo no longer occurs
• Vertigo caused by Meniere’s disease, in addition to symptomatic treatment, the patient may require a low salt diet

Medications

These medications should be taken only as directed and under the supervision of a doctor.

The most commonly used drugs include:

Risk Factors and Prevention:

Prevention

• Precautions should be taken to prevent injuries from the risk of falling due to the imbalance caused by vertigo
• Encourage smoking cessation
• Individuals with Meniere’s disease should limit salt intake

Outcome:

The prognosis depends on the underlying cause.

• Middle and inner ear infections are self-limiting, in some cases may require treatment and are completely cured or make the condition tolerable
• Vertigo caused by a brain tumor or brain injury may need emergency evaluation by a neurologist and/or neurosurgeon