Vertigo

Vertigo is not a disease but a symptom of an underlying condition. Symptoms can range from mild to severe and vary from person to person depending on the cause of vertigo. Vertigo can also lead to or occur alongside other symptoms:

• When a person feels they are spinning or the world around them is spinning
• A feeling of abnormal balance or a loss of balance
• A sensation of dizziness or swaying
• Giddiness or feeling faint
• Increased sweating
• A sensation of nausea that may or may not be accompanied by vomiting
• Headaches
• A feeling of fullness in the ear
• Ringing in the ears, pain in the ears, or loss of hearing
• Abnormal or jerky eye movements called nystagmus

The ear is the organ responsible for maintaining vestibular equilibrium in the body. The innermost part of the ear, called the inner ear, has three loop-shaped structures known as semicircular canals, which are responsible for the orientation of the body concerning head movements. Any issue that causes a disturbance in these semicircular canals can lead to vertigo. This type of vertigo, associated with the inner ear or the vestibular nerve (which connects the inner ear and the brain), is called peripheral vertigo and is the most common type. Neurological problems such as brain tumors, stroke, cervical spondylosis, and multiple sclerosis can cause central vertigo. The various causes of vertigo are discussed as follows:

• Benign Paroxysmal Positional Vertigo (BPPV)
  • Benign: Not dangerous to health.
  • Paroxysmal: Presents as a sudden, brief episode.
  • Positional: Set off by particular head or bodily movements.
  • Vertigo: An internal sense of irregular or spinning movement either of oneself or of the surroundings.
  BPPV is the most common cause of vertigo. It is a harmless condition that presents as mild to intense dizziness lasting for a few seconds or minutes. It is often associated with a sudden change in the position of the head or body, such as bending over, turning in bed, or sitting up. BPPV usually resolves on its own and is not serious. The inner ear has a system of canals filled with fluid that informs the brain about head movements. In BPPV, small calcium crystals in the inner ear move out of place, preventing the system from sending correct signals to the brain. BPPV can occur due to a head injury or aging, as the natural breakdown of cells with age or during injury is thought to be responsible for this.
• Meniere’s Disease This rare condition causes severe vertigo, nausea, ringing in the ears, muffled or distorted hearing, hearing loss, and a feeling of a plugged ear. It is characterized by excess fluid buildup in the inner ear. Meniere’s attacks usually occur suddenly and can last from 20 minutes to 24 hours. Patients often feel worn out after the attack passes.
• Ear Infections Viral and, less commonly, bacterial infections can cause inflammation of the nerves in the ears. The vestibulocochlear nerve, a nerve in the inner ear, has two branches:
  • The vestibular nerve sends signals to the brain about balance. Its inflammation leads to vestibular neuritis.
  • The cochlear nerve sends signals about hearing. Its inflammation causes labyrinthitis.
  This inflammation hinders the messages the ear nerves send to the brain, resulting in symptoms of vertigo. Rarely, another viral infection caused by the varicella-zoster virus can lead to Herpes zoster oticus, a type of shingles. This infection of the inner, middle, and external ear is caused by the spread of the virus to the facial nerves, leading to various symptoms of vertigo. If it paralyzes the facial muscles, it is known as Ramsay Hunt syndrome.
• Acoustic Neuroma (Vestibular Schwannoma) This is a benign tumor that develops on the vestibular or cochlear nerves leading from the inner ear to the brain. Pressure from the tumor on the nerve may cause vertigo.
• Vestibular Migraine Migraines are often characterized by painful headaches; however, vestibular migraine may or may not involve headaches along with vestibular symptoms such as vertigo and imbalance. People with vestibular migraine commonly report migraine symptoms, such as sensitivity to light and sound.
• Cholesteatoma Repeated ear infections, skull or facial bone birth abnormalities, or an injury to the eardrum can result in a noncancerous skin growth in the middle ear called a cholesteatoma. As it grows behind the eardrum, it can damage the bony structures of the middle ear, leading to symptoms of vertigo.
• Perilymphatic Fistula The middle ear is filled with air, while the inner ear is filled with fluid called perilymph. Usually, thin membranes separate the inner and middle ear. A tear in these membranes is called a perilymph fistula (PLF), which allows perilymphatic fluid from the inner ear to flow into the middle ear, thereby affecting balance and hearing.
• Central Nervous System (CNS) Disorders Neurological conditions such as brain tumors, stroke, transient ischemic attack, cervical spondylosis, seizures, ataxia, peripheral neuropathy, Parkinson’s disease, and multiple sclerosis can also cause vertigo.
• Trauma Concussion, head trauma, or any trauma during ear surgery can also lead to vertigo.
• Syphilis Late neurosyphilis may affect the ear, leading to hearing loss, fluctuating hearing, or vertigo.

Vertigo can happen to anyone at any point in their life. It may occur as a one-time brief episode or may be long-lasting with intermittent periods of symptoms. Certain factors can increase the chances of developing vertigo, such as:

• Head and neck injuries
• Old age
• Gender (females are more prone than males)
• A medical history of past episodes of dizziness
• Having a family member who has vertigo
• Certain medications, such as antidepressants, antipsychotics, and antihypertensives
• Vitamin D deficiency

If you have symptoms of vertigo, you must visit your doctor who will perform a detailed physical examination, note down the history of symptoms, and may order certain diagnostic tests essential to determine the cause.

History: Before confirming the patient is experiencing vertigo, it is essential to rule out conditions that may mimic vertigo symptoms or indicate brain disorders. A physician performs a detailed overview checkup, reviewing the patient’s history, and may ask the following questions:

• The characteristics of the dizziness the person is experiencing. Does dizziness lead to imbalance and light-headedness?
• How long does the dizziness last?
• What is the frequency of vertigo attacks in a day?
• What symptoms does a person face right before a vertigo attack?

Balance Tests: The vestibular system, located in the inner ear along with the central nervous system, is responsible for maintaining body balance. The following tests can evaluate the functioning of these systems:

• Fukuda-Unterberger’s test: The doctor asks the patient to march in place for 30 seconds with their eyes closed. If they rotate or lean to one side, it could indicate a problem in the inner ear, causing peripheral vertigo.
• Romberg’s test: The doctor asks the patient to stand with their feet together, arms by their sides, and then shut their eyes. If the patient becomes unbalanced, it may indicate a problem with the central nervous system.
• Rotary chair test: This test records eye movements while the patient is seated on a rotational computerized chair. It evaluates the vestibular system, which regulates balance, posture, and the body's orientation in space.
• Computerized dynamic posturography (CDP): Also called the test of balance (TOB), it evaluates the ability to remain standing in either stationary or moving conditions.
• Vestibular evoked myogenic potentials (VEMP) test: This test assesses vestibular function by measuring the reaction of muscles to a repetitive sound stimulus.
• Video head impulse test (vHIT): The doctor gently moves the patient’s head to each side while recording eye movements as the patient focuses on a stationary object, like a spot on the wall.
• Vestibular test battery: This includes several tests that assess whether vertigo is due to problems in the inner ear or neurological causes, aiding in the development of an appropriate treatment plan.
• Electronystagmography (ENG) and videonystagmography (VNG) tests: These tests record and measure eye movements. In ENG, electrodes or small sensors are placed around the eyes. In VNG, special goggles are worn. The patient is asked to follow light patterns on a screen and move into different positions while watching the light pattern. Warm and cool water or air is introduced into each ear, which should cause specific eye movements. Lack of response may indicate damage to the inner ear nerves.

Imaging tests: Radiologic imaging tests may be performed to determine the cause of vertigo. The following tests can help identify whether the cause is inner ear disturbances or other head and neck conditions, such as cervical spondylosis or brain tumors:

• CT Scan (Head)
• CT Neck
• MRI Brain
• MRI Cervical Spine

Other specific tests:

• Audiometry: This test aids in diagnosing Ménière's disease, a rare disorder of the inner ear that causes episodes of vertigo.
• Brainstem auditory evoked potentials (BAEPs): This test evaluates the function of the auditory nerve and auditory pathways in the brainstem, which could contribute to vertigo.

By avoiding certain activities, it is possible to prevent spells of vertigo.

• Do not suddenly move your head from one position to another.
• Do not insert sharp objects or foreign matter deep into your ears for cleaning purposes, as it may damage the inner ear.
• Avoid activities that involve swift, fast movements, such as joy rides.
• Always cover your ears while deep diving or swimming for a prolonged period, as prolonged exposure to water may irritate the inner ear.
• Take care of your cervical spine by following the prescribed treatment if you have cervical spondylosis.
• Certain medications may precipitate spells of vertigo. In such cases, consult your doctor to make the necessary adjustments.

Often, episodes of vertigo are mild and resolve on their own without requiring treatment. In cases where the attacks do not subside or are so severe that they interfere with a patient’s daily activities, treatment is necessary. The treatment for vertigo depends on the cause and severity of the symptoms.

• Antivertigo medications: This group of medications is known to relieve vertigo (dizziness). One of the most commonly used drugs to treat vertigo arising from Meniere’s disease is betahistine. It improves blood flow to the inner ear and reduces the pressure of excess fluid, which causes the symptoms of vertigo. Other examples include cinnarizine.
• Antiemetics: This class of drugs helps ease the symptoms of nausea and vomiting frequently associated with vertigo. Some commonly used preparations effective against nausea and vomiting related to vertigo include:
  • Promethazine
  • Ondansetron
• Antibiotics: If the cause of vertigo is a middle or inner ear infection, it must be treated with antibiotics to resolve the infection and, consequently, the vertigo. Oral antibiotics and antibiotic ear drops help combat bacterial infections of the ear, thereby reducing the inflammation that causes vertigo.
• Vestibular suppressants: These medications reduce the intensity of vertigo due to vestibular imbalance. There are three main categories of drugs:
  • Antihistamine preparations: These are the most commonly prescribed medicines that help reduce symptoms such as dizziness and can prevent motion sickness.
  • Anti-anxiety medications: Medications like benzodiazepines can also act as vestibular suppressants in low doses and help reduce the symptoms of an acute vertigo episode. These medicines are not routinely prescribed, as their use is restricted to acute severe vertigo episodes or to manage anxiety associated with vertigo.
  • Anticholinergic drugs: Medications like scopolamine help alleviate dizziness and motion sickness.

A one-off episode of vertigo does not require any special care. However, if the episodes are severe and frequent, the patient needs to take utmost care.

• Avoid sudden, jerky movements of the head and neck.
• Sit down or lie down immediately when symptoms occur.
• Use walking aids, such as a cane or walking stick, if you have severe vertigo and an increased risk of falling.
• Avoid places with crowds, bright lights, and loud, startling noises.
• Sleep with your head slightly raised on two or more pillows.
• Get out of bed slowly and sit on the edge of the bed for a while before standing up. Try to relax, as anxiety can worsen vertigo.
• Do not bend over to pick things up; squat to lower yourself instead.
• Do not stretch your neck, for example, while reaching up to a high shelf.

If vertigo is left untreated, the underlying cause may worsen and lead to several complications, such as:

• Increased falls due to loss of balance
• Loss of hearing
• Loss of consciousness

Along with medications, alternative therapies are known to improve the symptoms of vertigo.

• Canalith repositioning maneuver: This involves a specific sequence of head movements where the doctor places the head in different positions slowly to allow the semicircular canals in the ear to adjust to normalcy. The doctor gently turns the patient's head in predetermined positions, changing the position of the inner ear and semicircular canals. These positional changes may dislodge any debris in the inner ear that may be exerting pressure and causing the symptoms of vertigo.
• Physiotherapy: Vestibular rehabilitation and balance training exercises are a specific set of exercises that can help improve balance, thereby decreasing the chances of falls and reducing dizziness. Vestibular rehabilitation consists of head and neck exercises that help the patient cope with symptoms and may also address the underlying cause if related to physical changes, such as those arising from improper neck posture associated with cervical spondylosis.
• Balance training: This includes exercises such as maintaining balance on increasingly unstable surfaces, standing on a wobble board or disc, standing with eyes closed, catching and throwing a ball on an unstable surface, and walking with side-to-side head turns.
• Homeopathy: Studies have shown that homeopathic preparations can be as effective as conventional medications in controlling the symptoms of vertigo. Homeopathic medicines made from Ambra Grisea, Anamirta Cocculus, Conium Maculatum, and Petroleum Rectificatum have been found to be effective in treating vertigo.

Vertigo can often impose certain restrictions on an individual's lifestyle. As symptoms of vertigo are aggravated by sudden rapid movements of the head, a person with vertigo may not be able to enjoy adventure activities like joyrides and may experience increased motion sickness, which can hinder traveling.

Patients with vertigo may also be sensitive to:

• Bright lights
• Loud noises
• Startling sounds

Thus, they may not interact well in crowds or noisy places. Severe forms of vertigo that impair balance may predispose the patient to an increased risk of falls and complications arising from such falls.