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Sponsored by: Jordan Hearing and Balance, LLC South Jordan Utah
Lynn S. Alvord PhD
Vertigo refers to a symptom of “movement” when no movement exists, most commonly a spinning sensation but can also be a rocking motion, an up and down feeling, or any other sensation of movement. In its mildest form, vertigo is sometimes described as just a mild sensation of “being a little off” that is not always recognized as motion per se. Vertigo is usually caused by an inner ear problem (peripheral vestibular). Sometimes, however, vertigo is caused by a central nervous system disorder. Fortunately, vertigo is nearly always successfully treatable and is not something the patient just has to live with. If untreated, vertigo can linger months to years. If not treatable with direct medical intervention, vertigo is usually successfully treated with rehabilitation such as “gaze stabilization” or other forms of “vestibular rehabilitation” performed by audiologists or physical therapists.
The most common cause of inner ear vertigo is “benign positional vertigo”, or BPPV, which is caused by “crystals” being in a sensitive area of the inner ear (see the section devoted to BPPV). This disorder often causes a short burst of vertigo when the patient moves the head into certain positions such as looking up, bending down, or lying back or to the side. The vertigo usually lasts less than one minute. There is also usually a bit of general imbalance with the disorder, sometimes causing falls in the elderly. Some cases of BPPV are not severe enough to cause spinning, just a mild sensation of being “a little off”.
Epley maneuver –
BPPV is often easily solved by the Epley maneuver, which is a simple, often one-time maneuver performed by a therapist, audiologist or physician. The Epley maneuver moves crystals out of the semicircular canals back into the “utricle” where they serve the purpose of helping the balance system sense head movements. Crystals fall into the “wrong” areas (semi-circular canals) usually for unknown reasons without there being other underlying ear disorders. Less commonly however, there can be an additional underlying inner ear disorder of some type, which causes the crystals to be disturbed and fall into the wrong areas. Such disorders can be ruled out using “vestibular” tests performed by audiologists trained in this type of testing and rehabilitation, “vestibular audiologists”.
Vestibular Neuritis -
The second most common cause of inner ear vertigo is vestibular neuritis. This disorder is sometimes wrongly referred to as viral labrynthitis, this name applying only when the disorder includes a new hearing loss (sensorineural loss). Vestibular neuritis, which includes no hearing loss, is thought to be caused by a virus that attacks the inner ear nerve but causes no ear symptoms (see separate vestibular neuritis section). This disorder causes constant severe vertigo in its beginning stages, worse with head movements, with symptoms remaining to some degree for several weeks or longer. Finally, symptoms either resolve completely or require “vestibular rehabilitation” therapy. Again, it is good to involve a vestibular audiologist early in the process for both testing and rehabilitation. In the early stages, the disorder is easily determined by testing (see “nystagmus” below), otherwise the patient often gets the run around, and later, testing is less certain because vestibular signs are not as easily seen at that point. Research has shown that symptoms of vestibular neuritis resolve more quickly with vestibular rehabilitation such as “gaze stabilization” exercises. Certain audiologists and physical therapists are trained in this specific form of balance rehabilitation. With vestibular rehabilitation, which involves head movement while looking at a target, the nervous system recalibrates and compensates so that the patient has no feelings of dizziness even with rapid head movements. The process may take several months.
Other ear disorders causing vertigo include Meniere’s syndrome (probably less common than once thought), more rare “fistulas”, superior-semicircular canal dehiscence, and viral labrynthitis, which can be thought of as vestibular neuritis with a new hearing loss.
The term vertigo is technically defined as a “hallucination” of motion, not because the feeling is not real but because neither the patient nor the surroundings are actually moving. With any type of vertigo it is the eyes that are moving (“nystagmus”) caused by an abnormal stimulation of the vestibular-ocular reflex. Because of the eyes’ quick jerking motion, the patient’s surroundings seem to be moving, which typically causes the vertigo feeling and nausea. In nystagmus, the eyes usually jerk horizontally with a fast-slow pattern, fast in one direction and slow in the other. The fast phase of the jerking is usually away from the affected ear. Sometimes, however, the fast phase will be toward the affected ear, as in some stages of Meniere’s disease or when over compensation has occurred.
Following is information that may help clear up some misconceptions. Many patients and even some professionals feel that to be considered vertigo there must be a feeling of spinning. This is not the case. When a disorder causing vertigo is very mild, the patient may not perceive an actual spinning sensation or a sensation of motion, instead feeling that they just got off an amusement park ride, the patient saying “something is just not right”, or, “my balance is just a little affected”.
There are usually no ear symptoms with inner ear vertigo, the cause being due to a problem with the ear’s nerve of balance (vestibular nerve) rather than the ear’s hearing (auditory) nerve. While there are usually no ear symptoms, there may be pressure behind or around the eyes because the muscles of the visual system are trying hard not to jerk. Many inner ear vertigo disorders do not cause any ear symptoms such as hearing loss, pain, tinnitus (sounds in the ears) or pressure, although occasionally some of these may be present. A typical case of vertigo, one that is caused by the ear, usually takes the patient to the emergency room. From there, after ruling out serious causes, the patient is usually given some anti-vertigo/nausea medication and sent either to an “ear, nose and throat” physician (otolaryngologist), neurologist, or cardiologist depending on the doctor’s suspicions. If the patient doesn’t have any signs of neurologic disorder (such as weakness, slurred speech, memory difficulty) or abnormal cardiology test results the patient may just be sent home. This is unfortunate because sometimes the patient assumes incorrectly that the mild vertigo that remains is something that can’t be determined by doctors and will just have to be lived with. It is therefore better to have the situation checked out by an ear, nose and throat specialist or audiologist. Hopefully, the patient will be sent to the correct specialist from the ER. On the other hand, if at the ER the patient is found to have other issues of concern, he or she may be admitted to the hospital for observation and further testing, or receive a neurology consultation. There are strategies and protocols currently under study that hopefully will help prevent the run around. With inner ear vertigo, the sooner the problem can be evaluated, the greater the chance of correct identification. This is because vertigo is best evaluated while symptoms are still quite severe. Getting the patient the right type of help earlier on would also lessen hospital admissions and save the system millions of dollars. Patients with inner ear vertigo may have common misconceptions such as, “I will just have to live with it”, or, “it will go away on its own”. The truth is, people usually don’t have to just live with vertigo and usually some rehabilitation will help the problem resolve more quickly. Without this help, Inner ear vertigo, while sometimes being self-limiting, can last for weeks, months or indefinitely untill treated.
Whereas the term “vertigo” has a very specific definition meaning a sensation of motion, the term “dizziness” is a broader, less precise term, referring to a variety of other patient symptoms including lightheadedness, woozy, faint, off balance, confused, etc. Vertigo in this sense, is a sub-type of dizziness. Dizziness is caused by a wide variety of disorders including those of the inner ear, cardiogenic, metabolic, neurologic, respiratory, visual, and others.