Why Am I So Dizzy? By Dr. Arthur M. Echano

 

Dizziness is one of the reasons a patient may see a doctor. The key to the determining what is causing it depends on good history taking. First things first though, a doctor has to make sure what the patient means by being dizzy since it can mean many things to many people.

When we talk about dizziness, the first order of the day is to find out whether the source of the problem is from the inner ear or outside the inner ear. If it is coming from the inner ear, we call it vertigo. Outside of it, it could be either disequilibrium or presyncope/syncope.

Let us exclude the last two first. Disequilibrium refers to a feeling of being off balance but there is no loss of consciousness or definite rotatory sensation. In presyncope/syncope, there is also no rotatory sensation but the patient feels loses consciousness. A person complaining of light headedness or having a “funny turn” could be having syncope. A fainting spell is a syncopal attack.

Someone with funny turn has other possibilities aside from syncope. The patient could be suffering from sudden reduction of blood pressure when changing position (lying down to sitting, sitting to standing). This is called postural hypotension. It could also be due to a heart condition like irregular heart beat (arrhythmias), structural defect (aortic stenosis, mitral stenosis) and blood vessel abnormality (myocardial infarction, pulmonary embolism).

Other conditions to consider when someone has a funny turn are mini-stroke (transient ischaemic attack), epilepsy, side effect of medications and low blood sugar (hypoglycaemia). As you may already notice, even with syncope alone, there are already few medical conditions that the doctor has to rule out to arrive at a reasonable diagnosis. Someone with recurrent or persistent dizzy spells needs to be investigated to find the root cause of the problem.

How about disequilibrium, since the source of the problem is not from the inner ear, where may the doctor look? Dizziness due to disequilibrium could be from stroke involving the cerebellum or even brain tumour. So someone who has difficulty walking because of being off balance needs to see a doctor for proper assessment and management. Of course, if the patient is suffering from either stroke or brain tumour, you should expect other signs and symptoms like headache, slurring of speech, abnormal eye movements, paralysis in one side of the body and abnormal findings when doing cranial nerves examination. One thing to remember with stroke is that it usually occurs suddenly, not gradually. If the patient complains of weakness (paralysis) that took few days to develop, it is most likely secondary to a non-stroke nerve problem.

Dizziness from the inner ear- vertigo is the kind of dizziness where the patient states that either s/he is rotating or the surrounding is spinning around. Consciousness level is preserved. In this category, there are four main medical conditions that the doctor will try to differentiate - vestibular neuronitis, benign paroxysmal positional vertigo, Meniere’s disease and recurrent vestibulopathy. So how do we know how to pinpoint the right diagnosis?

Vestibular neuronitis (acute vestibular syndrome, vestibular neuritis, viral neuro-labyrinthitis) usually occurs suddenly, may last for many hours or even a day. The reason why it is also called viral neuro-labyrinthitis is due a history of viral illness. Those affected may have nausea and vomiting. Treatment is symptomatic, oral medications - Prochlorperazine and anti-histamines.

The second condition in the vertigo list is benign paroxysmal positional vertigo. It occurs intermittently and is normally of short duration, lasting for a minute or less. As the name suggests, it is triggered by change of position, particularly head movement. It is self-limiting and resolves spontaneously. To elicit BPPV, the doctor performs the Hallpike maneuver and for treatment, s/he may do the Epley’s manuever.

Epley’s manuever may be done at home. This manuever is given to us in detail from the British Medical Journal module on Vertigo:

“*Explain the procedure to the patient, and warn them that they may experience vertigo symptoms during it, but that the symptoms usually subside quickly. Ask them to keep their eyes open throughout. Check that the patient does not have any neck injuries or other contraindications to rapid spinal movements - you need to execute movements during the procedure rapidly (in less than one second)

*Ask the patient to sit on an exam couch with their legs extended, close enough to the edge so that their head will hang over the edge when they lie down

*Stand on the side of the affected ear, take hold of the patient’s head with both of your hands, and turn their head 45° towards you. Hold until nystagmus dissipates

*Keeping their head in that position, lean the patient back rapidly until their head is over the edge of the couch. Hold until nystagmus dissipates

*Rotate the patient’s head through 90°, away from the side of the affected ear. Hold until nystagmus dissipates. Ideally, the patient’s head should be below the horizontal at all points when it is turned

*Keeping their head steady with both of your hands, ask the patient to roll their body onto their side, away from the affected ear. While the patient is turning, turn their head a further 90°, so that it faces the floor. Hold until nystagmus dissipates

*While keeping the patient’s head turned to the side, help them to sit up. Hold until nystagmus dissipates

*With the patient sitting up, move their head into the centre line, as you move it forward 45° (chin on chest). Hold until nystagmus dissipates. “

The 3rd one in our vertigo list is Meniere’s disease. The onset with Meniere’s disease is also intermittent, it may last for hours and is associated with deafness, ringing/buzzing in the ear (tinnitus) and feeling of fullness in the ear. While quite a few treatments have been tried with Meniere’s, none has been found to be truly effective. GPs end up referring these patients to ENT (ear, nose and throat) specialists for further management.

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