Updated on 05/01/2024
Dizziness or, in other words, vertigo is the feeling of the person himself or his surroundings spinning, moving. Vertigo is the Latin name for dizziness, and therefore it is a symptom, not a disease. In daily practice, we often hear from our patients that they have vertigo as if it were a diagnosis. However, this is false as vertigo is not the disease. There are many diseases that cause this symptom. The important thing is to diagnose the underlying disease causing dizziness.
The causes of dizziness can be divided into central and peripheral. The most common causes of vertigo are diseases related to the inner ear, which we call peripheral. However, in every vertigo, central, that is, brain-related diseases, must be analysed and excluded. In particular, diseases such as stroke and tumours that may occur in the cerebellum or brain stem, which is our balance organ, are included in the differential diagnosis.
Most common peripheral causes of dizziness are as follows;
1. Benign positional vertigo (BPV)
2. Vestibular neuritis or labyrinthitis
3. Meniere’s disease
It is a sudden onset of spinning and swaying sensation that occurs with certain head positions. It is the most common cause of dizziness. It can start spontaneously and without any underlying cause. BPV is more common with increasing age and in women than in men. It usually recovers by itself.
Normally, the inner ear sends signals to the brain about the position of the head and body. Thus, it helps to maintain our balance. Canaliths, which are very small calcium crystals that play a role in sending these signals, move from their normal places and escape into the balance canals, or in other words, semi-circular canals, by being released in the inner ear fluid. These canals are very sensitive. Crystals escaping into them cause dizziness by stimulating the nerve endings there due to head movements.
This is a type of dizziness that occurs with certain head movements and lasts for 10-30 seconds. It usually starts when getting out of bed or turning from side to side. It can also start with yoga movements, when washing hair by throwing the head back, or with rapid head movements. During the day, there may also be severe dizziness with head movements such as leaning forward or looking up. There may be a feeling of nausea, and rarely vomiting. The most important features showing that it is benign are that it is unilateral, starts a few seconds after lying down and disappears within seconds if the head position is not changed.
It is diagnosed with a diagnostic manoeuvre called Dix-Hallpike. While the patient is in a sitting position, the head is turned 45 degrees to the side and tilted backwards with the head drooping 30 degrees. After a short time, dizziness and rotatory nystagmus (rhythmic eye movements) occur. Sometimes there may be no nystagmus. Patients may experience nausea. When the findings improve, the patient is seated again. There may also be a milder and shorter-term dizziness. When the same manoeuvre is performed for the second time, a condition called fatigue is observed and the symptoms are not as severe as the first time.
It is treated with very simple position manoeuvres. Through these manoeuvres, the canaliths are moved to another point where they will not cause disturbance.
It is usually a viral infection of the vestibulocochlear nerve, which is the nerve of the inner ear. Normally, this nerve transmits signals about the position of the head and body from the inner ear to the brain. When the nerve is affected, it swells and the brain cannot interpret the incoming stimuli correctly. Vestibular neuritis and labyrinthitis are similar conditions. Vestibular neuritis affects the vestibular part of the vestibulocochlear nerve and balance is impaired. Labyrinthitis affects both parts of the same nerve, resulting in both imbalance and hearing loss.
Vestibular Neuritis has the following signs;
1. Sudden onset severe vertigo
2. Balance impairment
3. Nausea / vomiting
The symptoms of both diseases are similar. In labyrinthitis, there is also tinnitus and/or hearing loss. Usually severe symptoms last for several days. Vestibular neuritis attack rarely recurs; the lifetime risk of recurrence is 2%.
In the first 1-2 days, treatment can be performed with supportive and vestibular suppressors. In case Varicella zoster is suspected, antiviral treatments can be started.
Meniere disease is an inner ear condition that causes recurrent episodes of severe dizziness, tinnitus, hearing loss, and ear fullness. Dizziness can be very severe and cause the person to lose balance and be unable to walk. It occurs equally among men and women. The most common ages occur to be between 40-60 years.
The role of the neurologist in the diagnosis of Meniere's disease is to distinguish the neurological diseases and make the correct diagnosis. It is valuable for diagnosis if the patient has noticed fluctuating hearing loss or new hearing loss. Detection of hearing loss at low frequencies with an audiogram is valuable for diagnosis. Vestibular migraine is the most prominent disease in the differential diagnosis. Vestibular migraine is accompanied with a medical history of migraine but not hearing loss. The first Meniere's attack may also be confused with vestibular neuritis. Vestibular neuritis can be set aside with a relapse of attack.
Antivertiginous drugs are used during an attack of vertigo. In addition, salt restriction and diuretics may be recommended to prevent relapse.
One of the most common causes of central vertigo is vestibular migraine. In addition, stroke, multiple sclerosis, tumours and infectious diseases of the central nervous system can cause dizziness depending on the area they are involved in. Epileptic vertigo and craniocervical junction anomalies (Chiari malformation) constitute other causes of central vertigo. Apart from stroke, vertebrobasilar insufficiency can also lead to vertigo. In vertebrobasilar insufficiency, there may be stenosis in the vertebral or basilar arteries that irrigate the brain stem and cerebellum. If the stenosis is in the arteries to the arm, it can steal blood from the vertebral artery, causing dizziness. There are definitely additional findings in the neurological examination of the person in dizziness if due to central causes.
Fife TD. Dizziness in the outpatient care setting.
Continuum April 2017, Vol 23, No 2