Dizziness is a condition in which the patient’s ability to orient him or herself in space is altered. This condition can lead to symptoms of vertigo (spinning or abnormal sense of motion), imbalance, or a sense of lightheadedness. This can occur as a result of the inner ear, brain, or a combination of these and other disorders.
BPPV is the most common cause of vertigo or dizziness. Symptoms consist of brief episodes of spinning lasting less than 30 seconds that occur when an individual lies down in bed, sits up from bed, rolls over in bed, or tilts the head forward or backward.
If the condition is not resolving spontaneously, treatment can include a procedure to reposition the otoliths within the inner ear, called an Epley maneuver. This procedure can be done in the otolaryngologist’s office. The calcium deposits are repositioned in the inner ear through a series of head movements. This allows the otoliths to settle into an inert position in the inner ear. Occasionally the Epley maneuver may need to be repeated to be fully effective.
Although BPPV is a benign condition, other types of vertigo can represent more serious underlying inner ear or neurological conditions. All vertigo should be evaluated by a physician to differentiate between benign and more serious causes of dizziness.
Endolymphatic hydrops is a condition in which the fluid balance in the inner ear is disturbed. This can occur as a result of inner ear inflammation, trauma, or unclear reasons. Endolymphatic hydrops resulting from unclear reasons is called Ménière’s disease.
Hearing loss associated with Ménière’s Disease is nerve hearing loss, which cannot be corrected surgically. Hearing aids are typically the main treatment option. These devices now employ modern programmable electronics that make them function much better than older aids that are not programmable. Hearing aids typically allow patients to hear better and reduces the sensation of tinnitus. Patients whose hearing is so severe that hearing aids are not useful may be candidates for a cochlear implant.
Dizziness associated with Ménière’s Disease responds well to treatment with a low salt diet, avoidance of triggering factors (e.g., stress) or treatment of triggering factors (e.g., allergy), and diuretic medication. The few patients who do not respond well to these conservative treatments may undergo additional treatments. These include office procedures such as intratympanic steroid or gentamicin injection and surgical treatments such as endolymphatic sac surgery, labyrinthectomy, and vestibular nerve section. Very few patients currently require surgical treatment due to the success of the office procedures.
Labyrinthitis and vestibular neuronitis are conditions of true vertigo. The patient experiences a sensation that the surrounding environment is spinning. The onset is usually sudden. Half of the cases are preceded by an upper respiratory tract infection or cold. The sensation of vertigo usually lasts for several hours or several days. It is unusual for this phase to last more than 48 hours. This is caused by a viral infection of the inner ear (labyrinthitis) or the nerve going to the inner ear (vestibular neuritis). Many people will seek immediate attention in the emergency room or with their primary care physician because the symptoms are so extreme.
After the powerful symptoms of vertigo have passed (usually within 48 hours), patients are usually left with a feeling of disequilibrium (unsteadiness) that can last for days to months. The viral infection weakens the inner ear on one side, which creates an asymmetry within the balance centers of the brainstem. This creates a constant sense of unsteadiness. The disequilibrium is tolerable at rest, but sudden movements of the head or body will trigger vertigo or light-headedness. As the affected inner ear recovers, the sensation of balance gradually returns.
The treatment of this condition is usually supportive. Medications, such as Meclizine, Antivert, or Valium, can be given to help with acute vertigo. These medications will help the patient if they are having symptoms of vertigo or nausea. These medications essentially cut off communication between the inner ear and the brain so that the patient can have temporary relief of vertigo.
It is important to keep in mind that these medications are not therapeutic, meaning they do not cure the problem. They are prescribed to make the patient comfortable in the short term until the inner ear recovers. In fact, if these medications are taking too regularly, they will delay recovery. The brain and the inner ear have to interface for the natural function of the inner ear to recover. If these medications are constantly cutting off this interface, recovery will occur much more slowly.
Unfortunately, patients have to go through a period of compensation, where they will experience some dizziness before the inner ear recovers. This period of compensation can be seen as a time when the inner ear is returning to full strength and getting back “on-line” with the brain so that balance function can be re-established. This process usually takes several weeks, but it can take months.
Patients who do not recover with several weeks of observation will require more intervention and investigation. This can include vestibular physical therapy to help strengthen the inner ear. It may also include a CT or MRI scan of the brain and an ENG (Electronystagmogram). An ENG is a specialized test that evaluates the strength and function of the inner ear’s balance function. Sometimes, something that was believed to be labyrinthitis when initially presented turns out to be a completely different medical problem. This is why it is important to follow up with the ENT doctor until the symptoms are resolved or controlled.
People who suffer from chronic dizziness may be suffering from vestibular migraines. This condition involves a sense of disequilibrium rather than vertigo. Disequilibrium is a feeling that either the patient or the environment is swaying. Most patients describe it as “unsteadiness.” It is a sense of slow, rotational movement of one’s surroundings that can be mild or debilitating. The sensation can last from seconds to weeks and has a wide variety of manifestations. The exact neurological pathways responsible for a vestibular migraine are not completely understood.
Treatments include observation, vestibular physical therapy, or medical therapy. The medical therapies designed to treat vestibular migraines are the same medications used as prophylactic therapy for migraine headaches.