The first thing to rule out are the dangerous types of dizziness and vertigo. These include heart attacks and strokes.
If you have any of these symptoms you must go to A&E now:
Vertigo is actually a symptom not a disease. It is the hallucination of movement. I.e. you feel movement when there isn’t any. Typically it is rotatory spinning motion but it can be linear. There are a huge range of causes and practically a problem in any part of the body can cause it. For this reason it is extremely difficult to get to a diagnosis which is why it is considered a specialist subject even amongst ENT doctors. Seeing an appropriate specialist is essential for any chance of a diagnosis. With so many potential causes a diagnosis is important in order to receive the correct treatment.
The balance system is extremely complex. 3 sensors feed our brains with information on nearby objects and our position relative to them. Dizziness is the broad term people use to describe the feeling when something is off with their balance system. Using this word alone is going to make a diagnosis impossible so it’s important to try and describe the feeling in more detail. Vertigo is a type of dizziness and is an excellent start to trying to pin point where in the system the problem is. The diagram below shows the main parts of the body responsible for keeping you steady. The 3 main sensors are the eyes, the inner ears and the touch sensors in your feet. They tell the brain where you are elective to everything else and the speed and direction you are travelling in. The brain uses that information to tell the muscles of posture which way to lean to keep you from falling over. This process happens thousands of times a second. When you are standing still you are actually moving very slightly back and forth as you brain constantly adjusts your posture muscles.
The brain requires nutrients from your gut and oxygen from your lungs. This relies on blood to get it there. As you can see from the diagram a problem anywhere in the system can lead to dizziness. Low blood pressure from dehydration means reduced blood supply and nutrients reaching the brain. Guess what? You become dizzy. Back or neck pain causing inhibition of the posture muscles. Guess what? You feel imbalanced. Sitting inside a boat with your eyes telling your brain the wall in front of you is not moving but your ears feeling that movement. Guess what? You feel sick and unsteady.
The inner ear is made up of a hearing part (cochlear) which looks like a snail’s shell. The balance part consists of 3 semicircular canals which sense head movement in the 3 different planes of travel. These spaces are filled with fluid and little hairs that sense movement or sound depending on the part they are in. Notice the separate nerves that carry signals separately, 1 from the hearing part and 2 from the balance part.
The leading reason for this is benign paroxysmal positional vertigo (BPPV).
Inside our ears, there are tiny crystals that play a role in maintaining equilibrium. BPPV happens when these crystals shift from their usual position. These loose crystals can keep moving once a head movement has finished and cause extra movement signals to be incorrectly sent to the brain. Typically these signals result in powerful vertigo attacks which last about 30 seconds on a specific head movement. Rolling over in bed is a classical cause.
It is easily treated with manouvers such as the Epley (see procedures) which push the crystals into a part of the ear where they no longer stimulate the movement sensors.
We don’t fully understand the cause of this condition. We believe it is of a result of high pressure of the fluid of the inner ear where the balance organ lives. Typically it comes on in cycles lasting a few months at a time with a few months of resbite in between. During the bad months attacks come several times a week and last for hours. The attacks consist of rotatory vertigo, hearing loss, tinnitus and pressure in the ears. Eventually the inner ear becomes damaged and deafness develops slowly. Typically the disease burns out after a few years but hearing loss persists. There are several good treatments available to control vertigo attacks in Méniére’s. My first line choice is a steroid injection through the ear drum into the middle ear (see procedures).
Everyone thinks of headache and visual symptoms when they think of migraine but that isn’t always the case. If the migraine occurs in the balance part of the brain then a patient experiences vertigo. These can exist with or without headache. The look very similar to an attack of Ménière’s but without the long term hearing loss. In the first 6 months of symptoms it is very difficult to distinguish the two conditions. Migranes can be successfully controlled with lifestyle measures and failing that medication.
These two conditions look very similar with vertigo lasting for 24-48 hours. The terms are often used indiscriminately by patients and doctors but this is incorrect. They are a single one off attack. They both result from inflammation and temporary failure of the inner ear. Vestibular neuritis is inflammation only to the balance nerve whereas Labyrinthitis is inflammation to the whole inner ear. Neuritis therefore just causes vertigo, Labyrinthitis causes vertigo and hearing loss. Typically they last They are difficult to distinguish from a stroke as they too typically last days or longer. There is a recovery period of weeks to months where the patient feels unsteady and easily off balance. Eventually the symptoms abate unless the body cannot compensate as is typically the case with a weakness somewhere else in the balance system (eyes or touch sensors). Medication and balance physio is the mainstay of treatment (see procedures)
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