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Dizziness: Caused by vestibular disorders 

Most of us have felt lightheaded at some point in our lives. However, those who experience faintness or unsteadiness frequently may have an underlying vestibular dysfunction. The vestibular system includes parts of the inner ear and brain that are fundamental for controlling our balance and eye movements. Any dysfunction in these processing areas can result in dizziness or disorders of balance. To understand vestibular dizziness, we spoke to Dilupa Samarakoon. She is an advanced vestibular physiotherapist attached to the Northumbria University in the UK, and has experience working in specialised centres in Perth and Sydney, Australia. 

Dilupa Samarakoon  

Dizziness is a subjective term. Hence the diagnosis can sometimes be problematic as most of us use the words “dizziness”, “vertigo”, “disequilibrium”, and “lightheadedness” synonymously. Regardless of how it’s described, it can have a major impact on the lives of those who suffer, leading to depression, anxiety, and even stopping them from engaging in activities that trigger their symptoms.

Symptoms related to vestibular system disorders

These symptoms can range from mild to severe. Where symptoms last only from a few seconds to a minute in mild cases to total disability in severe cases. Some of the tell-tale signs which may be present in varying degrees are:

  • Imbalance or unsteadiness
  • Vertigo – a spinning or whirling sensation; an illusion of the self or world moving
  • Dizziness – a lightheaded, floating, or rocking sensation
  • Blurred or bouncing vision
  • Nausea
  • Changes in hearing
  • Anxiety
  • Lack of co-ordination
  • Problems with concentration and memory

What is vestibular-related dizziness?

True vertigo is a distinct sense of the outside world moving or spinning, while your head is still. Disequilibrium and lightheadedness are a sense of disconnect and unsteadiness on your feet, off-balance, and veering off to one side. Symptoms may be associated with or without nausea, visual disturbances, fatigue, etc. Consult your clinician for investigations to differentiate between a serious central condition and a peripheral cause of dizziness. Samarakoon further advised refraining from using “Dr. Google”.

Why do we feel dizzy? A look at the vestibular system 

Our brain receives impulses from the environment via our eyes, skin, joints, and inner ear. These messages are processed to understand where our body is in space. Image 1 shows that the inner ear has the hearing organ, the cochlear and the balance organ, the vestibule and semi-circular canals. It has its own nerve and blood supply.

The vestibule has sensory organs and microscopic crystals called otoconia that perceive linear movement and the sense of gravity. The semi-circular canals lie at right angles to each other; they have fluid in them and act like spirit levels. These help to perceive angular motion, control balance and posture, and keep your eyes still while you move your head. When the fluid moves it sends a nerve signal to your eyeball muscles to keep your eyes steady. 

Try this – fix your eyes still on a distant object while moving your head from side to side and then up and down. 
How is it that your eyes haven’t moved? It’s because your semi-circular canals have sent messages to your eyeball muscles to keep them steady. 

When we move our head, the brain expects equal messages from both the right and left inner ear (labyrinths). When the messages sent to these muscles are not symmetrical you can get dizzy.

Common vestibular disorders and their treatments

Benign paroxysmal positional vertigo (BPPV) 

BPPV is the most common, seen in many age groups but predominantly seen between the ages of 50 and 70 years. BPPV can occur after head trauma or a fall, especially in younger individuals. Usually, certain positional movements of their head can create a spinning sensation; it is episodic, sudden (paroxysmal) dizziness that usually lasts less than 20 seconds. To some, it feels like it lasts forever and reports feeling off-balance for a few minutes afterward. BPPV occurs when the otoconia (crystals) dislodges and moves into the semi-circular canals and changes the velocity of fluid movement.

Most people notice these symptoms when they are lying down or getting up or rolling in bed, bending down, and during other movements that cause them to move their head too far backward (e.g. lying back to wash your hair at the hairdresser). For BPPV they are most likely to perform a canalith reposition technique, commonly known as the Epley Manoeuvre or modified Semont technique related to the side and canal in question. Almost 70% of first attempts are successful and some may require follow-up treatment. Most modern literature favours Epley over other techniques but this varies between clinicians.

Vestibular dysfunctions

This can be due to an infection where inflammation of the vestibular nerve causes vestibular neuritis and/or inflammation of the labyrinth causes labyrinthitis. Patients report that there is no distinct trigger that sets off the dizziness and report waking up feeling extremely unsteady, sometimes vomiting, veering off to one side and feeling that their head is moving faster than their eyes. The acute symptoms may last for a few hours and rest will help with coping. However, the unsteadiness may last for days until the swelling goes down. Seek medical attention to confirm the diagnosis and rule out other pathologies.

Your clinician or physiotherapist may recommend vestibular rehabilitation habituation exercises if the feeling of disequilibrium persists longer than a month or two. These are specific exercises that need to be taught correctly and tolerance must be built up over time 

Meniere’s disease

This is often misdiagnosed and over-diagnosed and has led to many patients being prescribed unnecessary medication. It is more common in those between 20 and 60 years. Patients notice episodic dizziness that lasts a minimum of 20 minutes together with some auditory symptoms such as tinnitus (ringing), loss of hearing, or fullness in one ear. Anecdotally, some patients have reported symptoms hours after a very salty meal (e.g. Chinese food due to MSG or after Christmas celebrations or parties).

While the exact cause is unknown, it is believed to be due to changes in endolymphatic fluid pressure changes within the semi-circular canals. Your doctor may recommend lifestyle changes such as a low-salt diet, limiting caffeine and alcohol intake, or medication. 

Vestibular migraines 

This is most likely in adult women between the ages of 20 and 50 years. Common triggers are stress or monthly cycles. Patients report spontaneous episodes of dizziness associated with migraine headaches. It can last for up to two days but subsides with time.

Because vestibular dysfunctions, Meniere’s disease and vestibular migraines mimic each other, your doctor will advise you and may prescribe something to help with nausea, headache, etc. Some may not prescribe anything and that is completely fine. Medication may allow you to cope in the short term and must be used as per directions by your doctor. It is important not to dampen your balance system by overmedication as your balance system needs external stimulation to allow for vestibular compensation. 

What will your clinician do? 

Your clinician (general practitioner/neurologist/neuro-otologist) will ask you very specific questions regarding timing (onset, duration), triggers (movements, postures), and sensation (spinning, swaying, floating).
Be mindful and as accurate as you can be when answering these questions as subjective history is critical in helping to provide the best conclusions. The clinician will then conduct a neurological examination to differentiate between central or peripheral neuropathy. Neurological examinations will assess sensation, proprioception, the test of skew, reflexes, tone, and co-ordination tests such as finger-to-nose, heel-to-shin etc. and the balance test. Further physical examinations such as checking your blood pressure, oculomotor assessment, and the Dix-Hallpike test (by looking at your eyes and how they move) may be conducted. Most likely a head impulse test will be done to assess the vestibular-ocular reflex – this is the connection between your vestibular organ and eyes.

Based on the subjective and objective assessment, your clinician will treat you accordingly as mentioned above. During examination and treatment, your symptoms may be recreated but do not fear as your clinician will monitor you. If your clinician is concerned about a more serious condition, they may refer you for caloric testing or further testing to an audiologist or further investigations. Your clinician may suggest that since neurological abnormalities were not found on examination, further testing is not recommended. Correct treatment can only be provided by a trained professional. 

Things to do

  1. Have a “dizzy diary” and note down instances where you may be feeling your symptoms
  2. Stay calm and follow the instructions of your clinician. It may take time for the symptoms to subside 
  3. Some dizzy symptoms could be psychogenic, if you think you are suffering from anxiety, please seek help from a trained professional
  4. If you have other conditions that are being managed, make sure all healthcare professionals are aware of any changes to medication
  5. If you are older and having multiple falls, please be assessed by a doctor or physiotherapist 

Things to NOT do 

  1. Do NOT do “at-home” treatments that may exacerbate your symptoms. For BPPV treatment, if not done correctly, you run the risk of worsening your symptoms. Superseded treatments are still unfortunately available online 
  2. Do NOT self-prescribe medication such as stemetil, somac, etc
  3. If you notice hearing loss, loss of memory or consciousness, worsening headaches, numbness, or speech problems then report to your doctor

Common questions asked 

  1. Do the crystals fall out of my ear? No, they don’t. They are in a sealed system called the vestibule
  2. Is there a medication that dissolves crystals? No, they have a function in your body. We all have them 
  3. Why is my clinician looking at my eyes? I thought my problem was in my ear? They are testing the reflex that runs between your vestibular system and exterior eyeball muscles 
  4. How long does it take to go away? It varies
  5. Is it hereditary? There’s no evidence to suggest that vestibulopathy is hereditary except for possibly vestibular migraines. Research is ongoing 
  6. Is there a blood test for it? Your doctor may run blood tests to check your overall health and confirm your iron levels are appropriate. However, this is not a direct indicator of dizziness

Take-home message

Finally, Samarakoon stated that it is important to understand that vestibular pathologies are mostly spontaneous on the first occurrence and there are many reasons behind “dizzy” symptoms. This article only touches on a few common peripheral pathologies. Prophylactic treatment is not advised and following a treatment that worked on someone else will not prevent you from it. A healthy diet, non-sedentary lifestyle, being informed, and listening to professionals is the best way forward.

Key references 

  1. Zhang YX, Wu CL, Xiao GR, Zhong FF. (Comparison of three types of self-treatments for posterior canal benign paroxysmal positional vertigo: Modified Epley maneuver, modified Semont maneuver, and Brandt-Daroff maneuver). Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2012 Oct;47(10):799-803. Chinese. PMID: 23302158.
  2. Harcourt J, Barraclough K, Bronstein AM. Meniere’s disease. BMJ. 2014;349:g6544.
  3. Wipperman J. Dizziness and vertigo. Prim Care. 2014;41(1):115–131