VERTIGO and BPPV : Causes, Symptoms and Treatment

One of the most common complaints patients bring to me routinely in OPD and in ER (emergency room) is DIZZINESS or FAINTING.

Dizzy patients often have difficulty in describing their symptoms.

Often the patients use the term dizziness to describe different sensations, which are categorized in four groups:

1. VERTIGO: which means a False sense of motion, such as rotation (spinning or whirling)

2. DISEQUILIBRIUM: Unsteadiness, or loss of balance

3. LIGHTHEADEDNESS: Feeling of floating in the air, head fullness, or out of body sensations

4. PRESYNCOPE: Near fainting episodes

TYPES OF VERTIGO

Vertigo is categorized into 2 groups:

(I) PERIPHERAL VERTIGO:

• In peripheral vertigo, the culprit for originating giddiness or instability is EAR.

• It includes Labyrinth and vestibular nerve-related disorders.

• Peripheral Vertigo consists of the following diseases-

a) BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV): Commonest Cause

b) VESTIBULAR NEURITIS

c) SUPPURATIVE LABYRINTHITIS

d) MENIERE’S DISEASE

e) PERILYMPH FISTULA

f) CHOLESTEATOMA

g) HERPES ZOSTER OTICUS

(II) CENTRAL VERTIGO:

• In Central vertigo, the culprit for originating giddiness or instability is BRAIN.

• It includes disorders related to Vestibular nuclei and their central nervous system connections, Brainstem, and Cerebellum.  

Central Vertigo consists of the following diseases-

a) CEREBROVASCULAR DISEASES such as STROKE

b) MIGRAINE

c) MULTIPLE SCLEROSIS

d) CEREBELLOPONTINE ANGLE TUMOUR

Other types of vertigo-

CERVICAL VERTIGO:          
Vertigo triggered by head and neck movements

DRUG-INDUCED VERTIGO:
H/O adverse reaction to medications, alcohol abuse

PSYCHOLOGICAL VERTIGO :          
Associated mood, anxiety, stress, personality disorders

WHICH SPECIALIST DOCTOR TREATS WHICH VERTIGO?

An ENT specialist takes care of only PERIPHERAL VERTIGO.

An MD MEDICINE doctor or NEUROLOGIST OR NEUROSURGEON can take care of CENTRAL VERTIGO.

An ORTHOPAEDICIAN OR NEUROSURGEON can take care of CERVICAL VERTIGO.

A PSYCHIATRIST can take care of PSYCHOGENIC VERTIGO.

WHAT QUESTIONS TO EXPECT THE ENT SPECIALIST WILL ASK?

The most important step in making a diagnosis is an unhurried and detailed history taken by the doctor.

So, the patient should embrace himself/herself for the following questions-

Q.1. Describe your complaint of vertigo in detail.

a) Lightheadedness

b) Disequilibrium and unsteadiness

c) Vertigo

d) Presyncope

Q.2. Describe the Frequency of Vertigo

a) Episodic (यानी कि क्या चक्कर कभी कभी आता है), या

b) Continuous (आपको सारा दिन चक्कर आते रहना का आभास रहता है)

Q.3. Duration of the individual attack of Vertigo

a) Seconds: Suggestive of BPPV

b) Minutes: Suggestive of Transient Ischemic Attack, or Meniere’s disease, or Migraine.

c) Hours: Suggestive of Transient Ischemic Attack, or Meniere’s disease, or Migraine.

d) Days: Suggestive of Vestibular neuritis, Suppurative labyrinthitis, Strokes, Multiple sclerosis.

e) Months: Suggestive of Psychogenic.

Q.4. Effect of head movements

a) Worse (सिर की position change करने से चक्कर और बढ़ जाते हैं)

b) Better (सिर की position change करने से चक्कर बंद हो जाते हैं)

c) No effect (सिर की position change करने से चक्कर में कोई फर्क नहीं पड़ता)

Q.4. Specific positions that induce vertigo

a) Rolling onto the side in bed

b) Getting up from the lying position to the sitting position

c) Sudden head or neck movements

Provoking factors for vertigo	Patient’s diagnosis
(i) Change in head position	Benign Paroxysmal Positional Vertigo (BPPV)
(ii) Change in neck movements	BPPV, Cervical vertigo
(iii) Spontaneous triggers	Vestibular neuritis, Meniere’s disease, Stroke, Transient Ischemic Attack, Multiple Sclerosis
(iv) Change in ear pressure or loud noises	Perilymphatic/ Labyrithine fistula, Superior Semicircular Canal dehiscence, Syphilis
(v) Excessive straining	Semicircular canal dehiscence.
(vi) Stress	Psychiatric or psychological vertigo, Migraine

Q.5. Preceding history of Trauma

a) Physical (Injury to ear, or temporal bones)

b) Surgical (Trauma to the ear due to surgery)

Q.6. Medical conditions:

a) Hypothyroidism

b) Hypertension (HIGH Blood pressure)

c) Diabetes mellitus

d) Anaemia

e) Hypoperfusion of brain from postural hypotension or cardiac arrhythmia

f) CNS disorders

Q.7. Psychogenic disorders:

a) Anxiety

b) Panic disorders

Q.9. Associated/concomitant symptoms

a) Ear symptoms:          

• Ear Discharge       
• Ear Pain                
• Hearing loss    
• Tinnitus          
• Ear fullness     

b) Eye Symptoms:

• Diplopia
• Vision loss      

c) Headache

d) CNS:                      

• Paralysis 
• Paresthesias
• Dysarthria
• Dysphagia       

e) Sweating         

f) Dyspnoea        

g) Palpitation       

INVESTIGATIONS REQUIRED TO COME TO A DIAGNOSIS-

• DIX HALLPIKE TEST OR POSITIONAL TEST

• FISTULA TEST

• ROTATING CHAIR TEST

• HEAD THRUST TEST

• CALORIC TEST

• ELECTRONYSTAGMOGRAPHY OR ENG

• TANDEM WALKING TEST

• ROMBERG’S TEST

• SHARPENED ROMBERG’S TEST

• AUDIOLOGY TEST like Pure tone audiometry, Tympanometry

• CT scan of Temporal bones

• MRI Brain

Not all tests are required in a patient.

The ENT specialist will advise some of these tests to come to a confirmatory diagnosis/cause of vertigo.

A little about the most common cause of vertigo that comprises of at least 20-40% of peripheral vertigo:

BPPV or Benign Paroxysmal Positional Vertigo

Common Age of onset of BPPV:          

11–84 years; mean age of onset fourth to fifth decades. Incidence increases with age.

Pediatric BPPV:          

Patients have an association with migraine.

BPPV is slightly has increased incidence in females.

In about 52% of cases, one or more of the following factors are present:

• Most common are closed head injury

• Sudden violent jerky movements of head and neck

• Infections

• Old age

• Surgery (stapedectomy or nonotologic)

• Prolonged bed rest and inactivity

The inner ear is responsible for maintaining balance.

The inner ear consists of small calcium crystals. These calcium crystals are called OTOCONIA.

Benign paroxysmal positional vertigo (BPPV) is caused by dislodged otoconia.  

These calcium particles may come loose, and move through the semicircular canals and stimulate nerve endings.

This can cause your brain to think that you’re moving in a direction that actually you’re not, hence resulting in causing dizziness or vertigo, or imbalance.

Clinical Features of BPPV-

Sudden brief (seconds) spells of severe vertigo associated with a change in head position, such as-          
– Rolling over in the bed
– Getting into bed and assuming a LYING DOWN position
– Arising from a bending position
– Extending or Stretching the neck
– Turning neck or body rapidly

• Rhythmic involuntary movement of eyes

• Vertigo spell lasts for seconds and NEVER MORE THAN A MINUTE

• Vertigo free period may last for months or more

• Some patients have chronic balance problem, which may be worse at the time of awakening from the sleep

TREATMENT OF VERTIGO-

1. REASSURANCE AND BED REST

2. OTOCONIA REPOSITIONING MANOEUVRES

These are maneuvers that should ideally be done by an ENT specialist in a hospital/clinic setup.

These are a set of exercises or maneuvers in which your head is moved in different-different positions in a sequentially predesigned manner so as to bring the loose otoconia that are flowing freely in the canal to their original position.

Bringing the otoconia by these repositioning exercises to their original position brings immediate relief from vertigo.

3. ANTIVERTIGO MEDICINE

They can be given intravenously if vomiting precludes their oral use.

They take care of vertigo and anxiety and include –

Prochlorperazine (Stemetil®),
Promethazine theoclate (Avomine®),
Dimenhydrinate (Dramamine®), and
Diazepam.
Betahistine (Vertin®), Cinnarizine (Stugeron ®), Meclizine (Diligan®), etc.

4. Symptomatic medications.

They are beneficial in reducing the symptoms and in improving tolerance, and include-

Antiemetics (to control associated vomiting with vertigo)
Sedatives (to give a restful sleep to the patient)
Antidepressants
Psychiatric treatment.

5. In a few cases, SURGERY can treat vertigo

6. Many a times many patients tell that their vertigo went away on its own.

RELATION BETWEEN COVID-19 AND VERTIGO

There are cases reported now and can easily be found in PubMed where patients developed vertigo or BPPV post-COVID-19 illness.

There are also cases where many patients report the development of vertigo post-COVID vaccination.

However, it is important to mention that the number of such patients is very less.

THANKS

WATCH INTERESTING ENT-related VIDEOS ON MY YouTube CHANNEL…..Dr.Sharad ENT Videos

MEDICAL ADVICE DISCLAIMER:

This blog including information, content, references, and opinions is for informational purposes only. The Author does not provide any medical advice on this platform.

By viewing, accessing, or reading this blog does not establish any doctor-patient relationship.

The information provided in this blog does not replace the services and opinions of a qualified medical professional who examines you and then prescribes medicines.

And if you have any questions of medical nature, please refer to your doctor or the qualified medical personnel for evaluation and management at a clinic/hospital near you.

The content provided in this blog represents the Author’s own interpretation of research articles.