Vertigo
I 
Dr. Ent asks Barbara a series of questions about this morning’s events. He explains that it is important for him to get a clear understanding of exactly what she is feeling. Patients with dizziness often present with an array of confusing complaints. A good portion of this initial visit is dedicated to helping Barbara organize her thoughts. Especially to answer the key question “What do you mean when you say you are dizzy?”
Many people use terms such as vertigo, dizziness, lightheadedness, and fainting interchangeably. However to physicians they have very distinct meanings. Dizziness refers to a disturbed sense of one’s relationship in space and can be caused by problems with a variety of body systems including circulation, cardiovascular, eyes, brain, and ears. Vertigo is a hallucination of motion. Patients feel as if they are spinning or that their surroundings are moving. Vertigo is frequently caused by peripheral labyrinthine (inner ear) dysfunction. Unsteadiness is described as a sense of “falling” and may be due to problems with the ear, brain, or nerves. Lightheadedness usually occurs with rapid changes in position and is usually due to a circulation problem such as low blood pressure.
Diagnosis
After a thorough history of the problem has been carefully obtained, the doctor explains that the evaluation will also include examination of the head and neck as well as a neurotologic exam. Vestibular (inner ear) testing will also be performed. Because the balance system is so close to the hearing mechanism, vestibular testing includes tests of hearing and middle ear function. These tests are performed in a sound-treated room by a certified audiologist. More specialized tests including stapedial reflexes, and recruitment testing may be needed. A non-invasive auditory procedure known as auditory brainstem response testing (ABR) may also be utilized. Surface electrodes are taped to the face and clicking sounds are delivered through special ear pieces. The wave created by the passage of the sound through the brain is electronically analyzed. Even very small tumors, such as acoustic neuromas, or other abnormalities can be detected in this manner. One of the most vital tests for evaluating the dizzy patient is Electronystagnography (ENG). This test battery is used to record eye movements which often hold clues to balance programs. The patient is asked to look at a series of small moving lights and to turn to various directions. At one point, a small amount of water (or air) is placed in the ear. This stimulates the inner ear and for a moment the patient may notice some dizziness often mimicking their symptoms. ENG can be thought of as a “stress test” for the vestibular system much like the treadmill test performed for heart problems. Other tests which may be useful in certain instances include Magnetic Resonance Imaging (MRI), Computed Tomography (CT), and Doppler Tests (to check circulation). Allergy testing may also be useful in selected cases. Blood tests to check for anemia and other blood disorders, blood sugar, thyroid problems, and autoimmune and rheumatological disorders are obtained as needed. If the cause is found not to be vestibular, evaluations with other specialists such as neurologists, internists, cardiologists, opthalmologists, and rheumatologists may be scheduled. Barbara learns that four of the more common ear disorders associated with balance problems are Benign Paroxysmal Positional Vertigo, Meniere’s Disease, Vestibular Neuronitis and Viral Labrynthitis. These disorders are caused by different mechanisms and have somewhat different treatments.
Benign Paroxysmal Positional Vertigo
Patients with Benign Paroxysmal Positional Vertigo (BPPV) typically complain of true vertigo (spinning) brought on by changes in head position. It is common for the symptoms to develop while rolling from side to side in bed, when getting out of bed, and when tilting the head backwards to look up. The vertigo usually lasts a minute or so and tends to go away if the head is kept still. Nausea may accompany the vertigo. Other symptoms such as headache, earache, and ringing in the ears (tinnitus) are NOT seen in this disorder. BPPV is caused by displacement of otoliths (very small stones made of crystals of calcium carbonate) within a part of the balance portion of the inner ear. The vertigo is caused by the collection of the otoliths in a part of the inner ear where they are not normally found. BPPV can occur at any age but is more common with advancing years due to degeneration of the balance system. BPPV may be precipitated by mild head trauma. This disorder is typically self-limiting and will commonly resolve within six to twelve months. Medications are available to help control nausea or to decrease the intensity of the symptoms. There are no medications, however, which will “cure” this problem. Surgery is rarely needed. The most common treatment takes the form of physical maneuvers and exercises. The Epley Maneuver, also known as the canalith or particle repositioning procedure is performed in the office and consists of a sequential movement of the head into four distinct positions which may aid the movement of the displaced otoliths back into their normal location. Vestibular conditioning exercises, such as Cawthorne or Brandt-Daroff exercises, are performed at home and assist recovery.
Meniere’s Disease
In 1861, Prosper Meniere, a French physician, described the symptom complex that now bears his name. Meniere’s Disease is a condition of the inner ear which causes episodes of true vertigo, tinnitus, a feeling of fullness in the ears and a decrease in hearing. Nausea and vomiting may accompany the attacks. The severe vertigo may last from a half hour to twenty-four hours. Severe attacks leave most people exhausted and they usually sleep for several hours. They typically may feel a bit off balance for the next several days. During the recuperation period, the hearing gradually returns. There may be some permanent hearing loss especially in the lower frequencies. As the disease progresses, the hearing gradually worsens. After many years the intensity and frequency of the attacks may diminish. Meniere’s Disease affects both men and women, usually over forty years of age. It is estimated that approximately 0.2% of the population may be affected. Typically only one ear is involved, however, about 20-40% of cases may involve both ears. Although the acute attack is incapacitating, this condition is not life-threatening. While the disease can be managed, there is currently no cure. It is believed that Meniere’s Disease is due to an increase in fluid pressure in the inner ear. [This is in contrast to fluid build-up in the middle ear associated with ear infections.] Medications such as diuretics may be prescribed to regulate the inner ear fluid pressure. Vestibular suppressants are used when needed to control the vertigo. The make-up of the inner ear fluid is controlled by certain substances in the blood and other body fluids. Since these are influenced by the foods we eat, dietary control is a very important part of the management of this disorder. Patients are advised to eat foods low in salt and sugar, and to avoid caffeine, alcohol and tobacco. Strict adherence to this dietary program reduces the frequency and severity of the attacks in the majority of patients. This is important because each attack worsens the hearing. In extremely sever cases, the inner ear may need to be destroyed or surgery may be necessary to control disabling vertigo. Gentamicin can be injected into the eardrum to deaden the inner ear. These injections may need to be repeated. A very effective operation, known as a vestibular neurectomy, is performed to cut the balance nerve located inside the skull. Another procedure, named a labyrinthectomy, can be used in patients in which a vestibular nerve section would be too dangerous or in patients who have lost all of their hearing. This operation involves the total destruction of the inner ear. Another procedure, the endolymphatic shunt procedure, requires the placement of a very small plastic tube to drain away excess inner ear fluid. This operation often fails as the tube frequently becomes clogged. Recent studies suggest that the endolymphatic shunt procedure does not appear to be better than doing nothing at all.