INTRODUCTION - VERTIGO
Vertigo refers to a sense of spinning dizziness. It is a symptom of a range of conditions. It can happen when there is a problem with the inner ear, brain, or sensory nerve pathway. Dizziness, or vertigo, can happen at any age, but it is common in people aged 65 years and over. Vertigo can be temporary or long-term. Persistent vertigo has been linked to mental health issues. A psychiatric problem may cause the dizziness, or vertigo may affect a person's ability to function in daily life, potentially leading to depression or anxiety.
What is vertigo ???
Vertigo is a sensation of spinning dizziness. It is not, as many people maintain, a fear of heights. It is often associated with looking down from a great height but can refer to any temporary or ongoing spells of dizziness caused by problems in the inner ear or brain. Many conditions can cause vertigo.
Symptoms
Ear problems can lead to vertigo. A person with vertigo will have a sense that their head, or their surrounding environment, is moving or spinning. Vertigo can be a symptom of other conditions, and it can also have its own set of related symptoms. These include:
- balance problems and lightheadedness
- a sense of motion sickness
- nausea and vomiting
- tinnitus
- a feeling of fullness in the ear
- headache
- Vertigo is not just a general feeling of faintness. It is a rotational dizziness.
Treatment
Some types of vertigo resolve without treatment, but any underlying problem may need medical attention, for example, a bacterial infection that would likely need antibiotic therapy. Drugs can relieve some symptoms, for example, and may include antihistamines or anti-emetics to reduce motion sickness and nausea. Patients with an acute vestibular disorder associated with a middle ear infection may be prescribed steroids, antiviral drugs, or antibiotics. Nystagmus is an uncontrolled eye movement, usually from side to side. It can happen when a person has vertigo, due to dysfunction of the brain or inner ear.
Sometimes, inner surgery is carried out to treat patients with intractable benign paroxysmal positional vertigo (BPPV). The surgeon inserts a bone plug into the inner ear to block the area where vertigo is being triggered.
The plug prevents this part of the ear from responding to particle movements inside the semicircular canal of the inner ear or head movements that could lead to vertigo.
Treatment of Meniere's disease
Prescription drugs, such as meclizine, glycopyrrolate, or lorazepam, can be used to relieve the dizziness experienced with Ménière's disease. Looking up can make symptoms worse.
Other options include:
- restricting salt and taking diuretic therapy to reduce the volume of fluid retained in the body that could build up in the inner ear
- avoiding caffeine, chocolate, alcohol, and smoking tobacco
- pressure pulse treatment, in which a device fitted to the outer ear delivers air pressure pulses to the middle ear, reducing vertigo
- surgery to decompress the endolymphatic sac or cutting the vestibular nerve, if nothing else works
Some people have tried acupuncture, acupressure, and herbal supplements such as gingko biloba. However, there is no scientific evidence showing that these are effective. Patients should discuss any alternative treatments with their doctor before using them.
Precautions
Anyone who experiences vertigo or other types of dizziness should not drive or use a ladder. It may be a good idea to make adaptations in the home to prevent falls. Getting up slowly may alleviate the problem. People should also take care when looking upward and not make sudden changes in head position.
Causes
There is a range of different diseases and conditions that can lead to vertigo.
Vertigo often occurs as the result of an imbalance in the inner ear. Less commonly, problems in parts of the brain can cause vertigo. Conditions that can cause the different types of vertigo include:
- Labyrinthitis: This is an inflammation of the inner ear labyrinth, and the nerve within that is responsible for encoding the body's head motion and position as well as sound, known as the vestibulocochlear nerve. It is usually caused by a viral infection.
- Vestibular neuronitis: This is also thought to occur as a result of inflammation of the vestibular nerve, usually due to a viral infection.
- Cholesteatoma: This is a skin growth that occurs in the middle ear, usually as a result of repeated infection. If the growth becomes larger, it can damage the ear, leading to hearing loss and dizziness.
- Meniere's disease: A buildup of fluid in the inner ear can lead to attacks of vertigo with ringing in the ears and hearing loss. It tends to affect people between the ages of 40 and 60 years.
The National Institute on Deafness and Other Communication Disorders (NIDCD) estimates that the prevalence of people in the United States currently diagnosed with Ménière's Disease 615,000. It may stem from blood vessel constriction, a viral infection, or an autoimmune reaction, but this is not confirmed.
BPPV: This is thought to stem from a disturbance in the otolith particles. These are the crystals of calcium carbonate within inner ear fluid that touch the sensory hair cells inside the semicircular canals during movement. They stimulate the vestibular nerve to send information to the brain about a person's position. In people with BPPV, movement of the endolymph fluid continues after head movement has stopped because of the presence of otolith crystals in the semicircular canals. BPPV normally affects older adults, and the cause is usually unknown. It has been linked todementia and twice as common in women as in men.
Vertigo can also be caused by or related to:
- migraine headaches
- head injuries or trauma
- taking certain medication
- ear surgery
- prolonged bed rest
- perilymphatic fistula, a tear in one or both of the membranes separating the middle and inner ear causing leakage of inner ear fluid into the middle ear
- herpes zoster oticus, acute viral infection of shingles close to the ear affecting the facial nerve, also known as Ramsay Hunt syndrome
- otosclerosis, a middle ear bone problem that causes hearing loss
- side effects of medication or drug toxicity
- syphilis
- stroke
- transient ischemic attack
- cerebellar or brainstem disease, such as a tumor or stroke
- acoustic neuroma, a benign growth on the vestibular nerve that traverses between the inner ear to the brain
- multiple sclerosis
Types
There are different types of vertigo, depending on the cause. Peripheral vertigo usually occurs when there is a disturbance in the balance organs of the inner ear.
Central vertigo occurs as the result of a disturbance in one or more parts of the brain, known as sensory nerve pathways.
Peripheral vertigo
This type of vertigo is typically linked to the inner ear. The labyrinth of the inner ear has tiny organs that enable messages to be sent to the brain in response to gravity. These messages tell the brain when there is movement from the vertical position. This is what enables people to keep their balance when they stand up.
Disturbance to this system produces vertigo. This can happen because of a source of inflammation, often due to a viral infection. Various conditions are associated with peripheral vertigo.
Central vertigo
Central vertigo is linked to problems with the central nervous system. It usually involves a disturbance in one of the following areas:
- the brainstem
- the cerebellum
These parts of the brain deal with the interaction between a person's perception of vision and balance.
Symptoms can involve disrupted balance, dizziness, or both, at some time.
Diagnosis
A doctor will carry out a physical examination, and they will ask the patient how their dizziness makes them feel. This will enable the doctor to find out what kind of dizziness a patient has. The doctor will ask about ask about the patient's medical history, including any history of migraine headache or a recent head injury or ear infection. The person may undergo a head CT or MRI scan.
Nystagmus testing
The doctor may also try to provoke nystagmus, as this can occur with vertigo.
Similar eye movement happens when you try to fix your eyes on one position while looking at something that is passing quickly by, for example, when looking out from a train window.
To check for nystagmus, the doctor may carry out the following exercise:
- The doctor rapidly moves the patient from a sitting position to lying down on the examination bench.
- The head is turned and held 45 degrees toward the affected side before this quick maneuver, and moved 30 degrees down at the end of it, over the end of the bench, below the horizontal position of the rest of the body.
If the patient experiences vertigo shortly after, and if the doctor observes specific eye movements, those of nystagmus, this can indicate that the patient has vertigo.
This is achieved through a number of tests, including:
- Electronystagmography (ENG): This can electronically record the nystagmus. The patient wears a headset that places electrodes around the eyes. The device measures eye movements.
- Videonystagmography (VNG): This is a newer technology can provide a video recording of the nystagmus.
The person with vertigo puts on a pair of special glasses that contain video cameras. These record horizontal, vertical and torsional eye movements using infrared light. Computer processing can analyze the data collected.
The head impulse test
The patient is asked to fix their gaze on the tip of the doctor's nose while the head is moved quickly to one side. If the patient can keep their eyes on the nose of the examiner during this movement, the test is negative. The cause is not an inner ear problem, so the doctor may then carry out tests to see if the symptoms are due to a central nervous system issue, such as blood vessel narrowing or blood clots in the brain.
The test gives a positive result if the patient cannot keep the eyes on the examiner's nose during the quick head movement and quickly moves their eyes back to look at the nose. By determining if this effect is seen when the head is moved to the left or the right, this may assist the doctor in finding out which side's inner ear is affected, should the patient have vestibular dysfunction. However, a positive test could be due to a central nervous system problem.
Romberg's test
A person who is steady standing in place with arms at the sides and feet together when they have their eyes open is asked to shut their eyes. If they become unsteady, this could be a sign of an inner ear problem. The side they fall toward is typically the side on which the inner ear is affected.
Unterberger's test
The patient marches on the spot for 30 seconds with their eyes closed. If peripheral vertigo is present, there may be sideways rotation, toward the affected side.
Exercises
A person with vertigo can carry out a number of exercises to help symptoms improve without visiting a doctor.
The Epley maneuver for BPPV
If the vertigo is caused by benign paroxysmal positional vertigo (BPPV), a technique known as the Epley maneuver may help. The aim is to move particles from the semicircular canals to the open area, called the vestibule, of the inner ear, where they are more easily resorbed and do not cause trouble.
Take the following steps:
- Place a pillow on the bed.
- Sit on the bed in front of the pillow, and rotate your head 45 degrees to the affected side.
- Keep your head in position as above, and lie down on your back with your head on top of the pillow, tucking it behind the nape of the neck so that the head is tilted back slightly.
- Hold this position for 30 seconds.
- Rotate the head to the opposite side by 90 degrees, and hold this position for 30 seconds.
- Keeping your head in the position of rotation relative to the rest of your body as above, gently flip over on the side your head is turned to, and hold this position for 30 seconds.
- Put your chin to your chest, and slowly sit up.
- Swing the legs over the edge of the bed and hold this position for several minutes while the inner ear makes adjustments.
- The sensation of vertigo will hopefully have started to resolve when you stand up again.
Brandt-Daroff exercises
These are used to break up the crystals that can lead to vertigo. The following steps should be repeated five times in the morning, afternoon, and evening. Carry out these exercises for 2 weeks.
One repetition goes as follows:
- Sit upright on the edge of the bed.
- Rotate the head to the left as far as you can without causing discomfort.
- Lay down on the right side of your body and stay there for 30 seconds or until the end of any dizzy sensations.
- Sit back up and return your head to a central position.
- Rotate the head to the right and then lay down on your left side, again remaining for 30 seconds or until the dizziness has stopped.
- Sit up and return your head to the center.
Visit a doctor if these exercises do not resolve symptoms.
Home remedies
There are steps an individual can take at home to help resolve vertigo and limit its impact on day-to-day living.
Lifestyle changes
The following steps can help reduce the impact of vertigo:
- Sit down as soon as you feel dizzy.
- If you know a movement normally makes you feel symptoms, do it slowly.
- Use good lighting when getting up at night.
- If vertigo impacts your ability to walk or sense of balance, use a cane to help prevent falls and serious injuries.
- There are also herbal solutions that make help to improve symptoms. These include:
- cayenne
- turmeric
- ginkgo biloba
- ginger root
- While these may help, it is useful to see a doctor about vertigo and any other symptoms, as many conditions can cause vertigo, and any harmful underlying health issues will need to be treated.
