What is vertigo?

The word vertigo derives from the Latin word verto, which means “to revolve”. Vertigo is a false sense of motion, spinning or feeling of imbalance. Sufferers often call it dizziness, imbalance, light-headedness or “chakkar”.

Often the imbalance is associated with nausea, vomiting, sweating, or unsteadiness on walking. It may worsen when you move your head. Vertigo should not be mixed up with acrophobia, which is an extreme fear of heights.

Vertigo and dizziness are common complaints presented by patients to doctors of all specialities and they affect all age groups. It is a fact that 20-40% people are affected by dizziness at some point of time in their life; 15% people have dizziness; 5% have vertigo in any given year; 2.5% of all primary care visitors report dizziness; and 2-3% of emergency visits in the developed world are for vertigo.

But it must be noted that vertigo is not a disease. It is only a symptom of a disorder. Therefore, suppressing the symptom is not the solution. Proper diagnosis of what is causing vertigo / dizziness is possible only if the doctor makes a systematic evaluation. And only a neuro-otological workup will help to find out if a vertigo patient is suffering from disorders like BPPV, Meniere's Disease, Vestibular Neuritis, Labyrinthitis, Acoustic Neuroma, Otolith Dysfunction, Vestibular Migraine, Central Vestibulopathy or psychogenic disorders.

Different disorders causing vertigo have different presentations and require different treatment protocols. A correct diagnosis will enable the doctor to offer the correct treatment which is the only way to give the patient lasting benefit.


Symptoms of vertigo

Patients usually describe their symptoms as though they are

  • Getting chakkar or spinning
  • Swaying
  • Tilting
  • Feeling unsteady or imbalanced
  • Falling
  • Experiencing dizziness.

Vertigo patients also sometimes complain of nausea, difficulty in focusing on moving objects, headaches, change in hearing or ringing in the ears, and inability to focus their thoughts. Their symptoms can come and go, and can range from a few seconds to minutes, hours, even days.

 

Causes, diagnosis & treatment

BPPV

Benign paroxysmal positional vertigo is a common cause of vertigo. It is caused by debris of calcium carbonate stimulating the nerve fibres in the inner ear. BPPV is more frequently seen in elderly patients, after head injury, after prolonged bed rest and in inner ear infections. Vertigo is generally brought on by a change of position, turning in bed or getting up from bed. BPPV is diagnosed by VNG-guided positional testing. It is treated by doing repositioning maneuvers like EpleyManeuver or Barbeque Maneuver according to the position of the particles stuck in the inner ear canal.


Meniere’s disease

It is a disorder of the inner ear which is characterized by episodes of hearing loss and fullness in one ear, tinnitus and vertigo. This is caused by increased pressure of the inner ear fluid. If not treated timely, Meniere’s disease can lead to progressive hearing loss. Meniere’s disease usually affects one ear but it may be bilateral in 15% of cases. Treatment involves dietary restrictions and medical management, and in intractable cases, intratympanic gentanycin injections or surgery may be required.


Vestibular neuritis

This is a viral infection of the balance nerve leading to severe vertigo with nausea and vomiting. Vertigo typically lasts for several hours to days. A timely diagnosis and proper treatment along with vestibular rehabilitation aids in faster recovery of nerve function.


Labyrinthitis

This is a bacterial infection of the eighth cranial nerve (which transmits sound and balance information from the inner ear to the brain) characterized by intense vertigo with sudden hearing loss in one ear. Diagnosis is through audiovestibular evaluation that gives a clear picture of the extent of damage to the cochlea and labyrinth. An early diagnosis and treatment may prevent the hearing loss from becoming permanent. Vestibular rehabilitation aids early recovery of balance function.


Vestibular migraine

Vestibular migraine is one of the common causes of vertigo. Headaches and dizziness are very common symptoms presenting across all age groups. It is important to determine whether the two symptoms are associated or independent of each other or due to migraine. These patients generally do not suffer from any hearing problems. They often have intolerance to loud sounds or bright lights (sensory amplification). The treatment involves lifestyle modifications, dietary restrictions along with medical management and usually lasts several months.


Otolithic disorders

This is characterized by a sensation of rocking, chronic dizziness or feeling of difficulty in standing straight. This dysfunction is recognised by subjective visual vertical test and VEMP. Its treatment involves a specialized rehabilitation programme for otolith disorders along with medication to decrease the sensitivity of the nervous system to the rocking feeling.


Mal de Debarquement Syndrome [MdDS]

This is an uncommon condition in which the patient feels a constant rocking sensation like being on a boat or walking on foam. It usually occurs after long travel by boat as in a cruise or after a long flight though not necessarily so. Exposure to motion like driving a car decrease the symptoms. It is more common in women. These patients are put through rehabilitation with optokinetic visual stimulation and head tilting exercises.


Acoustic neuroma

A tumour involving the balance nerve may cause progressive unsteadiness, unilateral hearing loss and tinnitus. The tumour is usually slow growing. It is diagnosed by audiologial tests like pure tone audiometry and ABR, vestibular tests and MRI.


Perilymph fistula

This is caused by an abnormal connection between the fluid filled inner ear and air filled middle ear. The fluid of the inner ear called perilymphatic fluid leaks into the middle ear to give symptoms of fullness in the affected ear, fluctuating hearing loss and vertigo. These symptoms get worse on coughing, sneezing or lifting heavy weights. The Fistula is most commonly caused by trauma though it may also occur on lifting heavy weights (the person feels as though something popped in the ear), sudden change in pressure during diving or flying or childbirth. The diagnosis is based on history, vestibular tests and lack of spontaneous resolution of symptoms. Treatment involves surgical patching of the round and oval windows under microscope followed by bed rest and a period of restricted activity with no straining.


Vestibular paroxysmia

This is a condition caused by microvascular compression of the vestibular portion of the eighth cranial nerve within the internal auditory meatus. It is characterized by short spells of strong vertigo and motion intolerance. VNG testing for spontaneous nystagmus brought on by hyperventilation is highly suggestive of vestibular paroxysmia MRI with gadolinium can diagnose 95% of cases. Seizure disorders should also be ruled out by the doctor. The initial medical management is with carbamezipine or oxcarbamazipine. If there is inadequate response to medical management,surgical microvascular decompression of the vestibular nerve may be done.


Stroke

Hemorrhage or infarction of the brain may also present as vertigo. Therefore, it is important to diagnose these patients at the earliest because of their life threatening complications. Neurological tests like VNG, CCG and SVV will help in identifying these problems in the central nervous system.


Multiple sclerosis

This is a condition causing demyelination of the nerve fibres leading to difficulty in transmission of nerve impulses. Patients of MS may present with vertigo or dizziness. Oculomotor tests on VNG will help in diagnosis.


Brain tumours

Somethimes, though rarely, tumors of the brain may present with vertigo or dizziness. Often there are spells of loss of consciousness as well.


Superior semicircular canal dehiscence

This condition is caused by a breach in the body lining of the superior semicircular canal. Such patients have an increased sound acuity and can even hear their eyes move. VEMP and HRCT temporal bone will help in their diagnosis.