Understanding Vertigo

Dr. Vijay Rangachari, Consultant ENT Head & Neck Surgeon, Manipal Hospitals	Manipal Hospitals is a chain of multi-speciality hospitals in India offering world-class services in the areas of Cardiac Treatment and Heart Surgery, Orthopedic, Organ Transplants, Cancer Treatment, Neuroscience, ENT, Gynecology & Pediatrics and many more.

Dr. Vijay Rangachari has a special interest in Ear surgery & Endoscopic sinus and skull base surgery. He is also an expert in the diagnosis & management of Vertigo. Manipal group of hospitals is one of the largest healthcare brands in India. With more than 60 years of healthcare experience and a panel of 2000+ doctors catering to more than 55 specialties in healthcare, it has touched the lives of more than 75 lakh patients.

Vertigo is one of the most uncomfortable and dreaded medical conditions for anyone to encounter in a lifetime. Usually this leads them to consult an ENT surgeon, a Physician or a Neurologist. The spectrum of the symptoms may range from giddiness, light headedness, fainting, swaying, imbalance while walking, head spinning while getting-up from the bed and rotation of self or surroundings. This is often accompanied by a sensation of nausea or vomiting. At the outset, it is important to understand how the balance of the body is maintained.

Maintaining Equilibrium of the Body
The equilibrium of the body is maintained by mainly four major inputs - the signals from the inner ear, the eyes, the joints and the central nervous system. The balancing part of the inner ear is also called the vestibular labyrinth. The labyrinth sends signals to the brain and along with the other three input systems, helps to attain a sense of balance & equilibrium. An imbalance in any of the four systems leads to a sense of disequilibrium and needs to be restored.

Causes of Vertigo
The different causes of vertigo may depend on the system involved. Vertigo can result from a viral or bacterial infection of the inner ear. If the labyrinth is involved, the symptoms may usually be described as a sensation of spinning of self or surroundings and may be associated with nausea & vomiting, ringing in the ears, ear discharge, ear blockage, reduced hearing, and many more. However, the person is fully conscious and doesn’t have
symptoms like blurring of vision, double vision, headache and fainting, which are more characteristic of involvement of the central nervous system. Other causes include certain drugs like aminoglyco sides, anticonvulsants, antidepressants, anti hypertensives, barbiturates, cocaine, diuretics, quinine and sedatives /hypnotics. Stroke, brain tumors and neurological disorders may also be responsible for vertigo. A careful analysis of the symptoms and the findings in the affected person is mandatory to differentiate the type of vertigo and thereby, arrive at a conclusion about further investigations and management.

"Taking a thorough history is the most crucial step in the treatment of vertigo and a multi-disciplinary approach always goes a long way in the management of this disabling condition"

Approach to a Case of Vertigo
Elucidating the complete chronology of the events leading to the episode of vertigo is a prerequisite for deciphering its cause. Vertigo is an illusion of movement, often horizontal and/or rotatory. A detailed history, including medications, is followed by a detailed examination of the ear, nose, throat and relevant tests like an audiogram, when indicated. Spontaneous horizontal nystagmus (which is an oscillating type of movement of the eyeballs) is consistent with peripheral vertigo like acute labyrinthitis or acute vestibular neuronitis. Patients with peripheral vertigo have impaired balance and rotational giddiness, whereas patients with central vertigo have more severe instability and often cannot walk or even stand without falling. Vertigo, which occurs with changes in the position of the head or body is called Benign Paroxysmal Positional Vertigo (BPPV). This needs to be excluded by both history and Dix-Hallpike's test to check for any vertigo or vomiting provoked by changes in position.

Detailed neurological examination, which includes testing the cranial nerves and the cerebellar functions is also mandatory. Positional provocation tests like the tilt table test to exclude variations in blood pressure with position may be necessary in specific cases. Specific investigations like electrocochleography are indicated for confirmation of certain inner ear disorders like Meniere’s disease in which there is fluid accumulation in the inner ear. Last but not the least, radiologic studies like High Resolution CT Scan & MRI may be needed to exclude specific causes like tumors in the auditory nerve, brain tumors & brain hemorrhage depending on the particular clinical scenarios.

Management of Vertigo
Management of an episode of vertigo includes treatment of the immediate symptoms in acute phase followed by the rehabilitation phase, which includes exercises for prevention of future episodes of vertigo.

The initial management varies depending on the cause of the vertigo as elucidated by the treating doctor. Certain acute forms of vertigo like labyrinthitis respond well to complete bed rest and medications. Others like BPPV need definite interventions like Epley’s maneuver to reposition the displaced otoconia (balance particles in the inner ear). If the investigations lead to causes like brain tumors or brain hemorrhage, they need to be managed by a neurologist or neurosurgeon.

Most forms of vertigo will need long-term rehabilitation with exercises, which are called Vestibular Rehabilitation exercises to retrain the balance functions of the inner ear.

Taking a thorough history is the most crucial step in the treatment of vertigo and a multi-disciplinary approach always goes a long way in the management of this disabling condition. It is important to assuage the fears of the patient and counsel him adequately to understand the nature of vertigo.