Vertig : Causes and treatment

Vertigo is not a disease but a symptom of balance disorder which can be due to any number of causes. It is defined as an “illusion” or “hallucination” of movement. It is the feeling that you or your environment is moving or spinning when there is no actual movement.

vertigo

Dizziness and imbalance are common causes of visit to primary health care physician and includes a broad range of sensations from severe vertigo to momentary lightheadedness. Vertigo is most common cause of referral to otolaryngology clinic.

Vertigo should not be confused with other terms related to imbalance like lightheadedness, unsteadiness, or drop attacks.

Vertigo is not fear of heights

Even today vertigo is confused as fear of heights (Acrophobia—meaning Dizzy feeling often experienced when looking down from a high place), which is not true vertigo.

“Alfred Hitchcock’s” movie “Vertigo” (1958) shows its lead character a San Francisco detective (James Stewart) has Acrophobia but people confused it with vertigo because of the name of the movie.

Mild Vertigo is very common, and the symptoms are not usually serious. Most patients who experience vertigo have disorder of the vestibular system.

Normal Balance requires

Accurate sensory information from eyes, inner ear and proprioceptors (Muscles and joints)
Co ordination of information by brain (brain stem and cerebellum)
Normal motor output to muscles and joints

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Resulting in movement of head and neck, legs, eyes and rest of the body to maintain the balance and have clear vision while person is moving.

Vertigo is caused by

conflict of information between inner ear and other sensory system or defect in central integration of vesitbular information in brain.

I. Causes of vertigo

Vertigo may be because of otologic, neurologic, or systemic reasons. Cause can often be diagnosed by patient’s description of the problem and thorough physical examination; other tests are sometimes needed

Causes of Otologic Vertigo

Benign paroxysmal positional vertigo
Meniere’s disease
Vestibular neuritis and related conditions
Bilateral vestibular loss (about 1%)
SCD and Fistula (rare)
Chronic otitis media
Eustachian tube dysfunction (the tube that links the inner ear with the space behind the nose)

Central (Neurologic) Causes of Vertigo

Multiple sclerosis
Tumor (Acoustic neuroma)
Vascular causes

Transient Ischemic Attacks or stroke
Vasculitis: SLE, PAN, Temporal arteritis

Systemic causes of Vertigo

Anaemia (Low Hemoglobin)
Hypogycemia
(Low Blood sugar)
Hypotension (Low Blood Pressure)
Drugs- Medicines such as salicylates, quinine and aminoglycosides
Viral Infection

II. Benign paroxysmal positional vertigo

III. Meniere’s disease

IV. Acute peripheral vestibulopathy

V. Superior canal dehiscence syndrome (SSC

Presence of dehiscence (break in the continuity) in the bone covering superior canal is characterized by vertigo induced by loud noise, may be associated with conductive hearing loss, sensation of increased loudness of patient’s own voice (autophony) and pulsatile tinnitus .

Loud sound, positive pressure in the external auditory canal and valsalva maneuver results in vertigo and nystagmus.

Perilymph fistula

Leakage of inner ear fluid into the middle ear can occur after a head injury, drastic changes in atmospheric pressure (such as when scuba diving), physical exertion, ear surgery, or chronic ear infections.

Patient with perilymph fistula has dizziness, nausea and unsteadiness while walking or standing which increases with activity and decreases with rest. Sometimes it is present at birth along with congenital hearing loss.

Central Dizziness

Migraine- associated vertigo (Vestibular Migraine) is a common but under diagnosed cause of episodic vertigo. The vertigo is usually followed by a headache. Some patients have prior history of similar episodes with periods free of headaches.

There is no definitive diagnostic test for migraine and sometimes typical headache is absent; the diagnosis can only be verified by the response to the migraine treatment

Treatment is gradual cessation of pain killers (NSAIDS) along with avoidance of triggers of migraine caffeine , chocolates, cheese, red wine yoghurt and fermented food, stress. Vestibular suppressants are usually prescribed.

Vascular causes –

Stroke or TIA -The most feared diagnosis of true vertigo is a transient ischemic attack or stroke. It should always be excluded especially in patients with cardiovascular risk factors and central neurological findings.

Disruption of the blood flow to the inner ear can cause damage to balance and hearing system.

Occlusion of blood supply to cerebral cortex (Middle cerebral artery), cerebellum (Distal posterior inferior cerebellar artery) or brain stem (Proximal Posterior inferior cerebellar artery) or vertebro bacillar artery insufficiency) Cardiovascular risk factors modification and anticoagulation treatment can help prevent further episodes.

Cardiovascular Risk Factors

High Blood Pressure
Elevated cholesterol
Smoking
Family history of stroke or heart attack
Age
Overweight
Sedentary life style
Diabetes Mellitus
Collagen Vascular disease
Heart problem

Hemorrhage (Bleeding) into the cerebellum (back of the brain) (cerebellar hemorrhage) is characterized by vertigo, headache, difficulty walking, and inability to look toward the affected side.

Tumors of the posterior fossa

Vestibular schwannoma (acoustic neuroma) is an uncommon lesion with progressive, hearing loss and tinnitus in one ear.

Once suspected, the diagnosis can be confirmed with MRI. Surgery should be considered for patients with more-than-mild symptoms.

Multiple sclerosis

Recurrent CNS demyelination due to autoimmune disorder. Symptoms include optic neuritis, ocular motor dysfunction, trigeminal neuralgia, sensorimotor deficits, myelopathy, ataxia, and bladder dysfunction.

Vertigo is often the presenting symptom in Multiple sclerosis. The onset is usually abrupt, and examination of the eyes may reveal the inability of the eyes to move past the midline toward the nose.

Careful history Physical examination combined with MRI and spinal-fluid analysis helps in reaching to the diagnosis

Psychogenic vertigo

Anxiety disorder, hyperventilation and depression can manifest as chronic vertigo. Reassurance and counseling, cognitive behavioral therapy and medication are useful.

Trauma induced Vertigo

Head trauma -By direct injury to the labyrinth or by canalith dislodgement

Barotrauma- sudden atmospheric pressure changes (such as in pilots or divers) may cause perilymphatic fistula. Fistula usually heals in 2 weeks time with appropriate with bed rest and avoidance of straining and coughing. Surgical repair is required if there is progressive hearing loss.

Most disorders of the balance system are self-limiting and can be satisfactorily managed if the clinical tests and investigations point to a specific disorder but when the clinical tests and investigations point to vestibular disturbance of unknown etiology management becomes challenging task due to large number of potential underlying conditions. In theses cases Treatment for vertigo is mainly symptomatic with Reassurance to the patient, Physical therapy ,medicines. and sometimes surgery.

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Vertig : Causes and treatment

Normal Balance requires

Vertigo is caused by

Psychogenic vertigo

Trauma induced Vertigo

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