Dizziness and Vertigo

Normal balance function relies on vision, information from one's skin and joints (somatosensory input) and the inner ear balance organs (peripheral vestibular system).

This sensory information is integrated and interpreted within the brain, in order to stabilize posture (i.e. keep us upright) and coordinate eye movements (this allows our vision to remain stable so that what we see does not bob up and down when we walk or run).

Interpretation requires cross referencing of sensory information with previously generated templates. A mismatch between the information the brain receives and hose templates results in symptoms of “dizziness”, “unsteadiness” or “vertigo”.

Normal individuals often experience situations where their sense of balance does not behave as it should. An example where we may not have a suitable template includes sitting on a stationary train and having an adjacent train pull out from the station. Many people find this uncomfortable and may feel giddy.

A common misconception, and one that is wholly unfounded, is that there is little that can be done for patients suffering from vertigo or dizziness. A review of the primary vestibular diagnoses of patients attending the multidisciplinary balance clinic at Guy's and St Thomas' Hospital in 2009 would seem otherwise with the vast majority of cases treated effectively.

Assessing a dizzy patient

Patients who develop dizziness or vertigo should be thoroughly assessed.

This involves taking a careful detailed history and performing a thorough examination. The vast majority of patients also require hearing tests.

Get Flash to see this player.

As well as sophisticated balance tests that can assess the function of the inner ears and balance pathways.

Get Flash to see this player.

Some patients also require a brain scan to complete their assessment.

Accurately diagnosing a patient with dizziness involves bringing together the history, examination and special tests. The majority of patients with dizziness and vertigo can be cured.

Common balance problems

Benign paroxysmal positional vertigo (BPPV)

This is the commonest cause of vertigo in all age groups. Patients classically describe the room spinning when they rise or turn over in bed. Some describe waking with vertigo in the middle of the night. Although the vertigo lasts for seconds, they feel unsteady for a great deal longer, but are then able to go about their normal daily activities. Patients invariably, though not universally, describe a previous head injury or an episode of labyrinthitis.

Symptoms arise due to debris accumulating within the inner ear and falling onto a sensitive paddle that over-excites one part of the inner ear balance system (usually the posterior semicircular canal). The mismatch of information relayed to the brain by this over-stimulation results in profound vertigo and nausea. The first episode is extremely frightening with many patients fearing they have suffered a stroke or are about to die.

This common cause of vertigo is easily cured with particle repositioning manoeuvres, but only after a thorough assessment. Dix-Hallpike testing, will produce geotropic torsional nystagmus. An Epley manoeuvre may be performed which is curative in approximately 90% of cases. A repeat manoeuvre may on occasion be required. Alternative particle repositioning maneouvres for posterior semicircular canal BBPV include Brandt-Daroff and Semont manoeuvres. Gan's manoeuvre may be used if the anterior semicircular canal is involved.

Labyrinthitis/vestibular neuritis

This relatively common cause of vertigo arises due to a sudden failure of one balance inner ear organ (peripheral vestibular organ). This results in severe and persistent rotatory vertigo and profuse vomiting. Stemetil may be used to settle symptoms initially but patients must gradually mobilise in order to compensate (recalibrate) for this loss. Some patients, unfortunately, do not compensate fully and continue to suffer from dizziness and vertigo.

It is essential that patients undergo a formal audiovestibular assessment in order to exclude any other balance problems.

Treatment involves generic or customised physiotherapy exercises. Those with visual vertigo (over reliance on visual input) benefit from combining physiotherapy exercises and visually stimulating environments.

Vertiginous migraine

Also known as "vestibular migraine, "migraine variant" or "migrainous vertigo", this common cause for vertigo produces symptoms that may mimic Menière’s disease. Patients suffer spells of vertigo or disequilibrium that lasts for hours or days. They often describe the need to rest in a quiet, darkened room.

It is essential that all patients undergo a full audiovestibular assessment and MRI scan to exclude other balance problems, as in my opinion, this diagnosis can only be reached once all other pathology has been excluded.

This is generally easily treated with dietary changes (avoidance of migraine triggers), although some may also require medication.

Multilevel vestibulopathy

Dizziness and vertigo are common symptoms amongst elderly patients.

A gradual decline in one sensory input can be compensated for within the brain with little or no functional loss. However, a reduction in the quality and quantity of sensory information from more than one input, in addition to changes within the brain may result in multilevel vestibulopathy which is much more difficult for the brain to compensate for.

Patients benefit from a combination of physiotherapy exercises (e.g. generic, customised or strength and balance exercises) and life style changes (e.g. the use of a stick, visual acuity/cataract correction).

Cholesteatoma (CSOM)

Skin within the middle ear may be shed behind the ear drum. This can expand and erode into the inner ear. This may go on to cause a brain abscess or meningitis and patients require surgery to remove this disease.

Hyperventilation syndrome

Anxiety may result in hyperventilation and light headedness with patients presenting with dizziness. In some, anxiety may be the residual effect of a previous balance problem that may have settled. Patients benefit from a cognitive behavioural therapy review.

Menière's disease

Meniere's disease is a rare cause for vertigo.

This condition is caused by a tear in a thin membrane that separates two compartments within the inner ear. This results in an initial feeling of aural fullness followed by hearing loss, severe vertigo, and tinnitus. Attacks are unpredictable and severe, lasting up to 24 hours.

It is essential that all patients undergo a full audiovestibular assessment and MRI scan to exclude other balance problems. This condition can only be diagnosed with a history that is consistent with this disease, serial hearing tests showing a hearing loss, and an MRI that clearly excludes any other pathology.

Treatment includes Buccastem for acute episodes, and bendroflumethiazide or betahistine to reduce the frequency and severity of attacks.

For those not controlled medically, surgery may be indicated.

Uncommon conditions

Other relatively uncommon conditions that may present with vertigo or dizziness include multiple sclerosis, acoustic neuroma and vertebro-basilar ischaemia. In each an MRI scan is required to establish a diagnosis.

Superior semicircular canal dehiscence is a rare condition whereby a defect in the bony covering of the superior semicircular canal results in a third window through which a pressure wave may be transmitted from and to the intracranial cavity. This results in momentary vertigo in response to loud sounds (Tullio’s phenomenon). Treatment may involve surgery and physiotherapy.