Dizziness or Vertigo – January 2015

One of the more challenging situations I encounter in my patient care is the person who suffers from a balance disorder. Very often, the symptoms are so unusual to the patient; they have great difficulty even describing it to me. Balance disorders can range from mild and annoying, to completely disabling, preventing a person from functioning at work, driving or even walking. Balance disorders in older individuals pose a more serious threat, heightening the risk of falling and injury.

Basically, for sake of simplicity, I divide balance disorders into two broad categories. “Dizziness” is a generic term that can mean light-headedness, as one might experience from standing from a sitting position too quickly. “Vertigo”, from the Latin “vertere” (means “to turn”) connotes a specific type of balance symptom in which the individual feels spinning, falling, shifting or dropping. While dizziness can occur from causes ranging from low blood pressure to low blood sugar, vertigo is usually the result of a disorder of the inner ear balance system which connects to the brainstem and brain. It is my opinion that patients with true vertigo should be evaluated by an ENT physician who has the capacity to fully examine the ears and test the function of the balance system.

The typical symptoms patients describe are spinning or turning, often in response to certain head or body positions. Occasionally, the vertigo can be accompanied by ear symptoms such as ringing, buzzing, fluctuating hearing loss and pressure. After a full physical exam of the ears and nervous system, the ENT physician typically will order a few tests to diagnose the specific problem. The “VNG” (videonystagmogram) is a test we run in the office to detect disorders of the inner ear balance system or higher nerve centers in the brain or brainstem. It is a simple test that takes about 45 minutes, and can easily identify conditions we can treat. It is also important to perform a hearing test on patients with vertigo, since the balance and hearing organs are connected within the deep inner ear, and often both involved in a disorder.

I will describe a few common types of vertigo I see in practice. These are typical patients I have seen in the last 4 weeks:

Patient 1:
A 76-year old woman with a 2 month history of severe spinning vertigo causing nausea and vomiting on a few occasions. She did not notice any change in hearing, or other ear symptoms. The vertigo attacks seem to be caused by looking upward, or laying on her right side.

Her VNG testing showed a common disorder called “Benign Positional Vertigo (BPV)”. BPV is caused by normal inner ear crystals becoming dislodged in the inner ear balance canals. Her hearing test was normal for age.

She was treated successfully with simple “Epley maneuvers” which move the inner ear crystals back into proper position.

Patient 2:
A 33-year old female who has noticed vague symptoms of falling or dropping vertigo associated with right ear symptoms of fullness, pressure and fluctuating hearing. She has an aunt that had lived with a similar condition. Hearing test showed a low tone nerve deafness in her right ear, and VNG balance test showed a mild weakness in the right ear balance canals. I diagnosed her with Meniere’s Disease, a common disorder which causes hearing loss and vertigo. She is being successfully treated with a low sodium diet, and a low dose diuretic (water pill) to decrease the causative increased fluid pressure in the inner ear system.

Patient 3:
A 25-year old athletic man who noticed a sudden attack of severe spinning vertigo after bench pressing 300 lb. weights at the gym. The vertigo quickly followed a sensation of a “pop” in the left ear with gradual loss of hearing.

This patient was seen as an emergency. Hearing test showed a severe nerve deafness in the left ear and VNG test showed severe weakness in the left balance system. A condition called “perilymph fistula”, in which an inner ear membrane ruptures due to straining or pressure, was suspected. Surgery was performed during which the inner ear membranes were viewed under high magnification. A leak of fluid was seen from the round window membrane and was repaired with a tissue graft. Al though it is too early to be optimistic, the patient is doing well three weeks after surgery with control of vertigo.

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