Dizziness and Vertigo Diagnosis

  • Diagnosis

    While the word "dizziness" is often used to describe a feeling of faintness or loss of balance, true dizziness, or vertigo, is a false sensation that you or your environment are moving or spinning. The classic case of vertigo involves being in a high place and feeling like you are falling when you are not. A person suffering a bout of vertigo might also perceive that his surroundings are spinning —as if on a merry–go–round — even though he or she is stationary. Nausea and vomiting can accompany vertigo, which may last as little as a few moments or as long as a few days. Complaints of "dizziness" usually are not vertigo.

    Dizziness is one of the top reasons that Americans go to their doctors, and is responsible for more than 5 million physician visits every year.

    During vertigo, the sensory organs that control balance and spatial orientation — usually those situated in the inner ear — send confusing signals to the brain Figure 01.

    Abnormalities in the inner ear, in the nerves that connect it to the brain, or in the brain itself may be responsible for vertigo. The most common cause of vertigo is labyrinthitis, a viral or bacterial infection of the system of fluid–filled tubes and sacs that make up the inner ear (labyrinth). Conditions that affect the inner ear, such as Meniere's disease and benign paroxysmal positional vertigo (BPPV), are other possible causes. In Meniere's disease, swelling in the ear canal damages hair cells that respond to motion. In BPPV, debrisin the ear canal interferes with spatial orientation.

    Brain infections, tumors, head trauma, and seizures can all bring on vertigo. Blood flow interruptions to the ear or brain (such as those that occur during a transient ischemic attack or mini–stroke) sometimes cause vertigo.

    Certain drugs can induce vertigo Table 01. Alcohol and the antibiotics streptomycin and gentamycin have been known to damage the inner ear. People taking diuretics and other medications that lower blood pressure sometimes get vertigo when they stand up too quickly. Drugs used for depression, anxiety disorders, and psychosis — as well as the conditions themselves — may also provoke an attack.

    Table 1.  Drugs That Can Cause Dizziness

    Drug class
    Aminoglycosides
    Antihypertensive, diuretic, or dopaminergic agents
    Vasodilators
    Phenothiazines
    Tranquilizers, antidepressants
    Anticonvulsants
    Hypnotics
    Analgesics
    Alcohol
    Caffeine
    Tobacco products

    Motion sickness is a fairly common cause of vertigo. Some people are sensitive to the rocking on a boat (seasickness), as the inner ear's equilibrium mechanisms may have trouble adjusting to unfamiliar head movements. With car sickness, the eyes and ears send conflicting messages to the brain. Both can cause a nauseating, whirling sensation that leads to vomiting.

    A person's specific symptoms will indicate if the vertigo originates in the inner ear or brain, or if it is caused by another problem Table 02.

    Hearing loss, ringing in the ear (tinnitus), nausea, and vomiting all indicate that an inner ear problem is causing vertigo. With Meniere's disease, for example, vertigo comes on suddenly, and is accompanied by tinnitus and hearing impairment. Bouts last for a few minutes to a few hours, and often include nausea and vomiting. Vertigo strikes suddenly in labyrinthitis as well, and gets progressively worse as the hours go by. Stomach upset is common, and the vertigo typically worsens with head movement. BPPV is triggered by changes in head position. For example, getting out of bed or bending over may trigger it.

    Headaches, loss of coordination, slurred speech, impaired vision, and weakness in an arm or leg suggest that vertigo is brain–based.

    Faintness or light–headedness might indicate a circulation problem. If circulation problems are the cause, the vertigo will worsen with standing, and will improve with reclining.

    Confusion and panic — or a general "foggy" feeling — may indicate that the cause is psychiatric in nature.

    Table 2.  What Symptoms Reveal

    Symptom Source Possible cause(s)
    Spinning Inner ear Infection, nerve inflammation, benign paroxysmal positional vertigo, Meniere's disease, motion sickness
    Faintness Cardiovascular system Transient disturbance in brain function caused by lack of blood flow and oxygen to the brain due to low blood pressure
    Confusion Psychiatric disorder Depression, anxiety disorders, psychosis
    Off balance Central nervous system Mini?stroke effecting the balance centers in the brain,head injury, multiple sclerosis, infection causing nerve compression, brain tumors
    Click to enlarge: The Inner Ear

    Figure 01. The Inner Ear

    Although dizziness affects people of all ages, it tends to be most problematic for older adults. About 20% of sufferers over the age of 60 report that dizziness interferes with their daily lives. BPPV is a frequent complaint among the elderly, while labyrinthitis and motion sickness plague people in every age group.

    To determine what is causing your vertigo, your doctor will start with a careful medical history. Because "dizziness" is a vague term, and because the condition has so many possible causes, your doctor first must determine precisely what you mean by "dizzy." For example, did you feel as if the room was spinning, or did you feel faint? Were you off balance, or did you feel "foggy" in the head? Providing details about when the dizziness began, how long it lasted, and what set it off and/or relieved it are important clues for your doctor. It is also helpful to describe other symptoms you may have had, such as nausea and/or vomiting, headache, loss of hearing, or ringing in the ear. Lastly, your doctor will want to know which, if any, medications you take.

    A physical examination will reveal clues about the origin of your vertigo. Irregular eye movements suggest that the problem stems from the inner ear or its nerve connections to the brain. Your doctor may try to provoke rapid to–and–fro flitting movements of eyes (nystagmus) by moving your head a certain way, or by placing some cold water in your ear canal.To test your balance, your doctor might ask you to walk in a straight line; first with your eyes open, and then with your eyes shut. He or she may also have you stand with your feet together, arms extended, and eyes closed. The doctor may also take your blood pressure — while standing and while lying down — for further diagnostic clues.

    Lab tests can help your doctor pinpoint the cause of your vertigo. Hearing tests can reveal an associated ear problem that may suggest that the nearby balance portion of the inner ear has been affected. If your doctor suspects an ear or brain infection, he or she might take a fluid sample from your ear, sinuses, or spine. Computed tomography (CT) and magnetic resonance imaging (MRI)scans of the head will show any tumors pressing on nerves, or other abnormalities that could lead to vertigo. If your doctor thinks that your vertigo could be circulatory in origin, he or she may perform an angiogram. For this test, the doctor will inject dye into your blood and takes x–rays in an attempt to find blocked blood vessels.

  • Prevention and Screening

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