The Collison Newsletter January 2016

 

                                          VERTIGO*

Vertigo 

 

Vertigo is a sensation of spinning, a type of dizzy spell. You might feel like you are spinning or that the world around you is spinning.

 

Vertigo is derived from the Latin word verto, which means "a whirling or spinning movement".

Dizziness, Feeling Dizzy 

Dizziness affects approximately 20%-40% of people at some point in time while about 7.5%-10% have vertigo. About 5% have vertigo in a given year. It becomes more common with increasing age and affects women two to three times more often than men. Vertigo accounts for about 2-3% of emergency department visits in the developed world.

 

CAUSES OF VERTIGO 

The most common diseases that result in vertigo are

Benign paroxysmal positional vertigo (BPPV)

Ménière’s disease

Labyrinthitis or vestibular neuritis

Vestibular migraine.

 

Less common causes include

Stroke

Brain tumours

Brain injury

Multiple sclerosis.

 

Physiologic vertigo may occur following being exposed to motion for a prolonged period such as when on a ship, or simply following spinning with the eyes closed.

 

Persistent onset vertigo is characterised by symptoms lasting for longer than one day and is caused by degenerative changes that affect balance as people age. Naturally, the nerve conduction slows with ageing and a decreased vibratory sensation is common. Persistent onset is commonly paired with central vertigo signs and symptoms.

 

Other causes may include toxin exposures such as

Carbon monoxide

Alcohol

Aspirin.

 

Vertigo is a problem in a part of the vestibular system. The inner ear is composed of the semicircular canals, the vestibule (utricle and saccule), and the vestibular nerve. The inner ear sends signals to the brain about head and body movements relative to gravity. It helps you keep your balance.

 

Concerning the most common diseases that result in vertigo:

  • Benign paroxysmal positional vertigo (BPPV)

Benign paroxysmal positional vertigo is more likely in someone who gets repeated episodes of vertigo with movement, and is otherwise normal between these episodes. It is the most common process of vertigo.

 

The episodes of vertigo should last less than one minute. The Dix-Hallpike test typically produces a period of rapid eye movements known as nystagmus in this condition. Calcium particles (canaliths) clump up in canals of the inner ear. When loose calcium carbonate debris brakes off from the otoconial membrane and enters the semicircular canals it creates the sensation of motion.

 

BPPV can occur for no known reason and may be associated with increasing age.

  • Ménière’s disease

Ménière’s disease is an inner ear disorder of unknown origin, but is thought to be caused by a build-up of endolymphatic fluid and change in pressure in the inner ear (endolymphatic hydrops). Ménière’s disease can cause episodes of vertigo. It frequently presents with recurrent, spontaneous attacks of severe vertigo and there is often ringing in the ears (tinnitus) and hearing loss. The attacks of vertigo last more than twenty minutes. There is also a feeling of fullness in the ear, severe nausea and vomiting. As the disease worsens, hearing loss will progress.

  • Labyrinthitis or vestibular neuritis

In labyrinthitis, or vestibular neuritis, the onset of vertigo is sudden, presenting as severe vertigo with associated nausea, vomiting, and generalised imbalance. The nystagmus occurs without movement. In this condition vertigo can last for days. Other, more severe causes should also be considered, especially if other problems such as weakness, headache, double vision, or numbness occur.

 

This is an inner ear problem usually related to infection (generally viral). The infection causes inflammation in the inner ear around nerves that are important for helping body sense balance.

  • Vestibular migraine

Vestibular migraine is the association of vertigo and migraines and is one of the most common causes of recurrent, spontaneous episodes of vertigo. The cause is unclear, but it is suggested that the stimulation of the trigeminal nerve leads to nystagmus in individuals suffering from migraines. It is estimated that vestibular migraines affect 1-3% of the general population and may affect 10% of migraine patients. They are more common in women and rare after the sixth decade of life.

 

SYMPTOMS OF VERTIGO 

Vertigo is often triggered by a change in the position of your head.

 

People with vertigo typically describe it as feeling like they are

Spinning

Tilting

Swaying

Unbalanced

Pulled to one direction.

 

Other symptoms that may accompany vertigo include

Feeling nauseated

Abnormal or jerking eye movements (nystagmus)

Headache

Sweating

Ringing in the ears or hearing loss.

 

Motion sickness is one of the most prominent symptoms of vertigo. It develops most often in persons with inner ear problems. The feeling of dizziness and light-headedness is often accompanied by nystagmus (an involuntary movement of the eye, where the eyes oscillate from side to side, slowly in one direction and rapidly in the other).

 

Symptoms can last a few minutes to a few hours or more and may come and go.

 

Persistent onset vertigo is characterised by symptoms lasting for longer than one day.

 

CLASSIFICATION OF VERTIGO 

Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the vestibular pathway, although it can also be caused by psychological factors.

  • Peripheral Vertigo

Vertigo caused by problems with the inner ear or vestibular system is called ‘peripheral’, ‘otologic’ or ‘vestibular’ vertigo. The most common cause is benign paroxysmal positional vertigo (BPPV), which accounts for 32% of all peripheral vertigo. Other causes include Ménière’s disease (12%), superior canal dehiscence syndrome, labyrinthitis, and visual vertigo. Any cause of inflammation such as common cold, influenza, and bacterial infections may cause transient vertigo if it involves the inner ear, as may chemical insults (eg aminoglycosides) or physical trauma (eg skull fractures). Motion sickness is sometimes classified as a cause of peripheral vertigo.

 

Patients with peripheral vertigo typically present with mild to moderate imbalance, nausea, vomiting, hearing loss, tinnitus, fullness, and pain in the ear. In addition, lesions of the internal auditory canal may be associated with facial weakness on the same side. Due to a rapid compensation process, acute vertigo as a result of a peripheral lesion tends to improve in a short period of time (days to weeks).

  • Central Vertigo

Vertigo that arises from injury to the balance centres of the central nervous system (CNS), often from a lesion in the brainstem or cerebellum, is called ‘central’ vertigo and is generally associated with less prominent movement illusion and nausea than vertigo of peripheral origin. Central vertigo has accompanying neurologic deficits (such as slurred speech and double vision) and pathologic nystagmus (which is pure vertical/torsional). Central pathology can cause disequilibrium which is the sensation of being off balance. The balance disorder associated with central lesions causing vertigo is often so severe that many patients are unable to stand or walk.

 

A number of conditions that involve the central nervous system may lead to vertigo, including lesions caused by infarctions or haemorrhage, tumours present in the cerebellopontine angle such as a vestibular schwannoma or cerebellar tumours, epilepsy, cervical spine disorders such as cervical spondylosis, degenerative ataxia disorders, migraine headaches, lateral medullary syndrome, Chiari malformation, multiple sclerosis, Parkinsonism, as well as cerebral dysfunction. Central vertigo may not improve, or may do so more slowly than vertigo caused by disturbance to peripheral structures.

Vertigo can also be classified into objective, subjective, and pseudovertigo.

  • Objective vertigo describes when the person has the sensation that stationary objects in the environment are moving.
  • Subjective vertigo refers to when the person feels as if they are moving.
  • Pseudovertigo refers to an intensive sensation of rotation inside the person's head. While this classification appears in textbooks, it has little to do with the pathophysiology or treatment of vertigo.

 

DIAGNOSIS OF VERTIGO 

Tests for vertigo often attempt to elicit nystagmus and to differentiate vertigo from other causes of dizziness such as presyncope, hyperventilation syndrome, disequilibrium and psychiatric causes of light-headedness.

 

Tests for vestibular system (balance) function include

Electronystagmography

Dix-Hallpike manoeuvre

Rotation tests

Caloric reflex test

Computerised dynamic posturography

CT scans

MRI.

 

Tests for auditory (hearing) function should also be carried out.

 

TREATMENT OF VERTIGO 

The treatment of vertigo depends on what is causing it. In many cases, vertigo goes away without any treatment. This is because your brain is able to adapt, at least in part, to the inner ear changes, relying on other mechanisms to maintain balance.

 

For some, treatment is needed and may include:

  • Vestibular rehabilitation

This is a type of physical therapy, aimed at helping strengthen the vestibular system. The function of the vestibular system is to send signals to the brain about head and body movements relative to gravity. Vestibular rehabilitation may be recommended if you have recurrent bouts of vertigo. It helps to train your other senses to compensate for vertigo.

  • Canalith repositioning manoeuvres

This involves a series of specific head and body movements for BPPV. The movements are done to move the calcium deposits out of the canal into an inner ear chamber so they can be absorbed by the body. It is likely that you will have vertigo symptoms during the procedure, as the canaliths move. A physical therapist can guide you through the movements, which are safe and often effective.

  • Prescribed medicines

In some cases, medication may be indicated to relieve symptoms such as nausea or motion sickness associated with the vertigo.

 

If vertigo is caused by infection or inflammation, antibiotics or steroids may reduce swelling and cure infection.

 

For Ménière’s disease, diuretics may be prescribed to reduce the pressure from fluid build-up, as well as a low-salt diet. Surgery may be necessary in severe unresponsive cases.

 

Other therapeutic medications include anticholinergics, antihistamines, beta-blockers and corticosteroids.

  • Surgery

In rare cases (refractory cases), surgery may be needed for vertigo. This may involve making a shunt or ablation of the labyrinth.

If vertigo is caused by a more serious underlying problem such as a tumour or injury to the brain, appropriate treatment may help alleviate the vertigo.

 

CONCLUSION 

Vertigo is a very unpleasant, often scary condition and may be quite disabling.

 

Appropriate diagnosis will allow the correct treatment(s) to be made available.

 

The cooperation of a specialist, such as a neurologist, is essential for recurring, severe vertigo.

 

*Copyright 2016: The Huntly Centre. 

 

Disclaimer: All material in the huntlycentre.com.au website is provided for informational or educational purposes only. Consult a health professional regarding the applicability of any opinions or recommendations expressed herein, with respect to your symptoms or medical condition.

 

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