About three and a half months ago I started having dizzy spells. In some
episodes the world "spins" but in most episodes I just feel slightly
off-balance, as if my perceptions don't match with the world. It's
somewhat comparable to being slightly drunk or to the first day with a
much stronger eyeglass prescription. I have not fallen over, nor have I
vomited, although on occasion it's been bad enough to bring me to the
edge of nausea. It's worse when I'm sitting still, especially when I'm
working on my computer, and when I'm standing up, especially when I'm
cooking. I've been treated by various practitioners (student clinic
nurse, internist, ENT, neurologist) with decongestants, antihistamines,
steroids and diuretics, Valium, Ativan, and Xanax. The last three drugs
each relieve the symptoms somewhat, with .25 mg of Xanax working pretty
well, although I can clearly tell when it wears off. My hearing checks
out fine, as does my vision and ocular nerve. An MRI showed nothing. I
had an ENG a few days ago but have not been informed of the results. My
ENT ruled out Meniere's disease, a stroke, an aneurysm, a tumor, and MS.
My neurologist found nothing wrong neurologically. The currently popular
theories are viral labrynthitis or anxiety disorder. Could you advise on
other possible explanations or on how to confirm those two theories?
Thank you.
Answer -----------------------
The complaint of "dizziness" is often used to describe a variety of different sensations which can result from many different and unrelated conditions including central nervous system disorders, visual problems, vascular insufficiency, inner ear disorders, metabolic conditions such as diabetes or thyroid dysfunction, musculoskeletal problems, or drug side effects to name a few.
Vertigo describes a specific form of dizziness in which there is a sensation of movement - either a sensation that the subject is moving or a sensation that the world is spinning around the subject. Vertigo is commonly a manifestation of vestibular system dysfunction. In brief, the vestibular system encompasses a portion of the inner ear; the nerve from the inner ear to the brainstem; nerve endings in the musculoskeletal system, especially the extremities; the nerve tracks leading from those nerve endings travelling through the spinal cord; as well as the nerve tracks and nuclei of these nerves in the brainstem and cerebellum. In addition there are various inter-relationships with other nerves - for example there is a close association between the nerves that control eye movement and the vestibular system. Theoretically, the sensation of vertigo may be a result of dysfunction at any one or several of these areas. The list of all possible causes of vestibular dysfunction is quite lengthy. However, generally speaking, the symptom of true vertigo particularly when it is associated with auditory or other ear symptoms such as ringing, alteration in auditory acuity, or pressure sensation in the ear and when there is an absence of other neurologic conditions such as swallowing disorder, speech disorder etc., should lead the physician to initially consider an inner ear disorder.
The history is very important in determining the cause of vertigo. For example, it is important to try to define any precipitating or aggravating factors; alleviating factors; duration of symptoms (ie a few seconds vs several days); associated symptoms such as alteration in hearing, ringing in the ears, pressure in the ears etc.; other medical conditions , etc. The common tests performed during the investigation of vertigo beyond a careful neuro-otologic physical examination might include hearing tests, electronystagmogram (ENG), platform posturography, brainstem auditory-evoked response test, MRI scans, and various blood studies - not necessarily all, and not necessarily in that order.
Unfortunately, it is not uncommon for the physician to be unable to categorize the condition causing vertigo into a well-defined diagnostic entity like Meniere's syndrome, labyrinthitis, vestibular neuronitis, etc., the latter conditions typically being associated with characteristic constellations of symptoms, physical exam findings, and test results. When test results fail to localize the exact location of a vestibular problem, it may be that the only thing that can be done is to treat the symptom.
Vestibular suppressants are medications designed to sedate the vestibular system in an effort to suppress the symptom of vertigo. Many of these medications have the side effect of generalized sedation or drowsiness. The goal is to avoid excess sedation while controlling vertigo in a fashion that preserves normal daily functioning. Common medications utilized for this include meclizine (Antivert), antihistamines (Claritin, Seldane, Benadryl), or mild sedatives like low-dose valium, Xanax, lorazepam, etc.
Many forms of ill-defined vestibular dysfunction can be improved upon or corrected by a treatment commonly used for a condition known as benign positional vertigo, a condition causing fleeting episodes of whirling vertigo induced by head movement. The treatment involves a form of physical therapy designed to "re-train" the vestibular system by means of various neck exercises. This treatment is known as vestibular adaptation therapy.
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Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
NOTICE: OFCN is not engaged in the rendering of professional medical services. The information contained on this system or any other OFCN system should not supplant individual professional consultation. It is offered exclusively as a community education service. Advice on individual problems must be obtained directly from a professional.
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