VERTIGO- AN INTRODUCTION
Vertigo – a general discussion
Mr. Chatterjee is a 48 year old person working as a bank clerk. He gets frequent attacks of severe giddiness with nausea and vomiting, each attack persisting for about two to four hours and on occasions when he is a little out of luck, it continues for nearly a day. The attacks are followed by a period of imbalance that gradually subsides over a couple of hours. In between the attacks he is perfectly okay. Mr Chatterjee also has a deafness and tinnitus in his right ear, which has been there for the last three years or so, but during the attacks of giddiness, the tinnitus increases, and there is also a definite sense of fullness and blockage of the right ear just prior to and during the attack. Very often he can predict an impending attack as the sense of blockage of the right ear and the increase of tinnitus usually starts a few hours before the onset of the giddiness. Mr. Chatterjee has been experiencing these attacks of giddiness for about three to four years. Initially these attacks used to occur once every two to three months, but lately, the frequency has increased, and now these attacks of giddiness occur three to four times a month. He now finds it difficult to attend office, feels incapacitated, has become extremely depressed and frustrated and practically stays at home more than 10 days a month. Mr.Chatterjee has been to all the well known doctors in town, who have prescribed him some antivertigo drugs, but nothing seems to work, and the attacks keep on happening at more frequent intervals and with increasing intensity. Repeated MRIs and CT scans of the brain have revealed nothing and have only been instrumental in draining his pocket. He had tried acupuncture also but other than a big hole in his pocket and multiple holes in the soles of his feet nothing else happened.
Mr. Chatterjee suffers from Meniere's disease of the right site, which is very definitely a completely treatable and controllable but not totally curable disease, and if proper treatment is given, he is expected to get a much much better quality of life.
Mrs. Mehrotra aged 59 years, spends sleepless nights sitting in a sofa, as whenever she tries to lie down in a bed she gets an attack of severe vertigo with nausea and sometimes even vomiting that lasts for a few seconds only, each attack subsiding automatically after about half a minute to one minute. These momentary attacks of giddiness occur specially when she tries to lie down on the right side. MrsMehrotra just like Mr Chatterjee has also done her rounds with all types of doctors including ENT specialists, neurologists, medical specialists, psychiatrics, orthopedic surgeons and even a gynecologist, but all her forays in medical shopping proved futile. All that she could get, were prescriptions of antivertigo drugs, with each new just doctor changing the brand name of the same two generic products vizcinnarizine and betahistine. She now knows all the brand names of these two antivertigo drugs but what she does not know is what will finally end her ordeal and when, if at all, she will ultimately get relief. MrsMehrotra has now started frequenting faith healers but that too has not been a very successful endeavour.
Mrs. Mehrotra actually suffers from a condition known as Benign Paroxysmal Positional Vertigo or BPPV in short, for which there is no medicine, but can be completely cured by a 6 to 8 minute procedure known as Epley’s maneuver. This is a nonsurgical, painless procedure and consists of moving the head in certain specified directions. Any medical person trained in Epley’s maneuver can do it very effectively and offer complete relief.
Mrs. Das is a 35year old lady, and suffers from repeated attacks of giddiness of sometimes of sudden onset but usually of gradual onset which persists for about 6 to 10 hours and then slowly subsides as she goes off to sleep, and when she wakes up next morning, she is perfectly normal. Quite often, these attacks are time-locked with her menstrual periods. There is no associated deafness or tinnitus, whatsoever. Careful history-taking revealed that since childhood Mrs. Das used to have motion sickness that is nausea and vomiting while traveling. Over and above this, she had a history of migraine, that is headaches on one side of the head that persisted for a day or more a few years back but now these attacks of headache, are rather infrequent. She is now troubled by the recurrent vertiginous attacks only. All investigations including MRI of the brain and vestibular function tests have not revealed any abnormality. An orthopedic surgeon had put a collar on her neck suspecting cervical spondylosis but it only added to her discomfort without even reducing the vertigo a wee bit.
Mrs Das suffers from migraine related vertigo which is quite a common condition in our country. Treatment with antimigraine drugs was very rewarding and the attacks of vertigo reduced drastically both in intensity as well as in frequency.
Mr. Mitra is a 73 year old person who suffers from a persistent instability and tends to fall while walking. While walking it often appears to him that the entire visual field is jumping and the surroundings are not stable. He has had several falls and during one of the falls had broken his leg. This has been there for quite some time, and it started about two months after MrMitra had an attack of complicated drug resistant tuberculous pneumonia for which he was treated with injections Streptomycin and Amikacin. He has a high frequency sensorineural deafness in both ears which could be due to old age or due to use of these ototoxic drugs i.e. medicines that damage the organs of hearing and balancing in the ear. Vestibular function tests (which assess the functional integrity of the balance system) VNG, VHIT and VEMP showed severe degree of vestibular damage on both sides.
MrMitra actually suffers from bilateral vestibular hypoactivity which is a degenerative change affecting the balance organ in the ear sustained as a result of treatment with ototoxic drugs
Mr. Jain is a 35 year old business executive working in a multinational company. He has been suffering from heaviness and a blocked sensation of the left ear with tinnitus since the last one and half years. Lately he has been having some small attacks of giddiness, but a persistent instability, which is hampering his busy work schedule. Hearing tests showed a mild to moderate degree of sensorineural deafness in the left ear quite marked in the high frequencies. The vestibular function tests showed a very severe degree of canal paresis on the left side, which means the vestibular labyrinth (i.e. the organ of balancing in the ear) on the left ear, has become more on less nonfunctional. The balance problem has been gradually increasing, and now it has reached such a stage where he has lost all confidence and this professional life is being grossly jeopardized. All types of antivertigo drugs had been prescribed by his General physician and specialists like neurologists, ENT specialists, orthopedic surgeons but there was no respite from the persistent imbalance. Due to be unilateral nature of the deafness and the disproportionate balance disorder that is vestibular hypoactivity on the left side, an MRI scan was advised and it revealed a more than 1 cm acoustic neuroma (which is a tumour in the brain) on the left side.
In this patient, the persistent imbalance and vertigo is due to a tumour in the auditory tract deep inside the brain and is a life-threatening condition. In this patient it was due to an acoustic acoustic neuroma, which is a tumour in the brain on the nerve that carries the balance sensation from the ears to the brain. The only treatment option available to the patient now is a surgery in the brain. This is quite a difficult and complicated surgery with considerable morbidity and some degree of mortality also. If the tumour becomes big enough, it may become inoperable, cause a lot of neurological problems and ultimately lead to death.
The cases discussed above are just a few of the many different ways with which patients suffering from vertigo or imbalance may present to the doctor. There are innumerable diseases that may cause vertigo or imbalance to the patient. Just like fever or headache, vertigo or imbalance is just a symptom and not a disease by itself. It is only the symptom of some underlying disease. ‘Vertigo’ is never a diagnosis, though some doctors are in the habit of using the tem vertigo as a diagnosis. No wonder many parients come and tell the doctor that they have been diagnosed as ‘vertigo’. The term vertigo is actually the English translation of ‘chakkar’. The doctor’s duty is to diagnose the CAUSE of the vertigo and not merely translate the symptom of the patient into English.Many different types of diseases ranging from a self-limiting viral infection to life-threatening conditions like tumor in the brain, may present simply with vertigo or imbalance. More than a hundred different diseases may cause the patient to present to the doctor with vertigo or imbalance. Some of them may be extremely complicated and potentially dangerous neurological disorders like multiple sclerosis, a stroke in the brain which is medically known as cerebrovascular accident, a tumor in the brain and other such life-threatening conditions, or it may be just a self-limiting viral inflammation of the nerve of balance or even due to diseases like anemia , diabetes, thyroid disorders, diseases of the eyes or even a side-effect of certain drugs. Many psychological disorders may also present with vertigo. Vertigo can be the cause or the effect of a psychological disorder. A large chunk of patients presenting to the doctor with vertigo / imbalance do not actually have any disorder in the vestibular system and as per medical literature upto 40% patients presenting to the doctor with the complain of vertigo have a perfectly normal vestibular system. The different causes of vertigo or imbalance need different forms of treatment. The same treatment cannot be prescribed to each and every patient of vertigo. The doctor first needs to carefully find out the exact cause of the vertigo and identify what exactly is the disorder that is causing the vertigo / imbalance if any, and then only can he treat the patient logically and scientifically. Until the exact cause of the vertigo or imbalance has been identified and established it is extremely injudicious and potentially dangerous to prescribe the patient some standard vestibular sedatives, that is the anti-vertigo drugs, just to provide symptomatic relief to the patient. Such medical misendevours may and will camouflage the actual disease and land the patient(and in some cases the treating doctor too) into much bigger trouble later on. In many cases, the disease becomes chronic and persistent if the cause is not identified and the specific treatment not prescribed. Palliative therapy that is symptomatic treatment may sometimes be really necessary to relieve the patient of acute symptoms just as the pain killers are sometimes used to relieve the patient of the pain , but the clinician should never rest satisfied by just providing symptomatic relief. If a patient presents to a doctor with (say) stomach ache, the doctor may be justified in prescribing a medicine to stop the pain in the stomach for the first time when the patient presents to the doctor but no ethical doctor will go on prescribing a pain –killer to the patient beyond a day or two and the doctor is morally, medically, ethically and even legally duty-bound to find out the cause of the stomach-pain by clinical tests and relevant investigations and treat the cause of the pain rather than suppress the pain only. The cause of the vertigo must be found out in each and every case and specific treatment relevant to that particular cause of the vertigo, should be prescribed for the patient. Unfortunately, however, the majority of patients suffering from vertigo or imbalance are treated for symptomatic relief only without going into the cause of the disorder. Though modern medical science aims at treating most diseases by correcting he underlying cause, in the case of VERTIGO, this ethical custom is usually flouted by doctors and symptom-relieving treatment is aimed at in most cases without trying to ascertain the actual cause of the vertigo.
This happens because the diagnosis of the cause of vertigo / imbalance and identification of the underlying pathology and its specific, customized management is quite a difficult and complex task. It requires a detailed history taking which is a pretty time consuming affair, some clinical tests and some very sophisticated investigations called Vestibular Function tests. There are many types of vestibular function tests and special set-ups are required totest the balance system. And this is precisely why the diagnosis and management of vertigo / imbalance is now a specialized medical discipline in itself, which is known as NEUROTOLOGY. The medical persons who specialize in the diagnosis and management of vertigo / imbalance are known as Neurotologists. Very special tests like Electronoystagmography (ENG), Videonystagmography (VNG), Craniocorpography (CCG), Computerized dynamic posturography, Vestibular evoked myogenic potentials (VEMP) , Dynamic Visual Acuity (DVA), Subjective Visual Vertical test (SVV) and certain audiological tests like brain stem evoked response audiometry (BERA), pure tone and impedance audiometry (PTA), Oto-acoustic-emission (OAE) tests, Electrocochleography (EcochG) are needed to evaluate the structural and functional integrity of the balance and hearing systems. The diagnosis and management of sensorineural deafness and tinnitus also comes under the purview of neurotology. The facilities, infrastructure and arrangements for most of the neurotological tests especially tests for balance function (called Vestibular Function Tests) are not widely available and these sophisticated tests can be done only in special clinics dedicated to neurotology. We need many more of such clinics in our country, as the prevalence of vertigo and imbalance is pretty high as discussed below. Most of the very renowned hospitals also do not have the necessary infrastructure to scientifically and logically evaluate a patient of vertigo.
Though the exact prevalence of vertigo in our Indian population is not well-documented, yet if one goes by the statistics from the American Institute of Health statistics, it is found that vertigo and / or imbalance is one of the commonest reasons for which a patient visits the doctor. 10% of all patients visiting the ENT specialists or neurologists and five percent of all patients going to the general practitioner present with vertigo or imbalance only. The estimated cost of medical care for patients with balance disorders exceeds $1 billion annually in the US according to a recent study.Vertigo or imbalance is one of the three commonest medical disorders in patients above the age of 65 years. More than 50% of all accidental deaths, above the age of 65 occur in patients who suffer from vertigo or imbalance.Statistics show that the incidence of falls is 25% in subjects older than 65 years. Another international study published many yrs back reported that 65% of individuals older than 60 years of age experience dizziness or loss of balance, often on a daily basis. Vertigo and dizziness accounted for 2.5% of presentations in emergency rooms in US. American statistics say that the overall incidence of dizziness is 5-7% of the population, 35% in patients older than 40 years. There should not hence be any doubt that vertigo is one of the commonest medical disorders with a very high prevalence rate.
The management of vertigo is quite an enigma and only a specialized neurotologist can do justice to a patient of vertigo. All types of treatment modalities namely, physical therapy i.e. certain special exercises, pharmacotherapy i.e. medical treatment and even surgery (in very rare and obstinate cases) is advocated for the treatment of vertigo and / or imbalance. The treatment of course, will depend upon the cause of the vertigo. Each patient is different and needs different especially customized therapeutic protocols for treating the condition. There is obviously no blanket therapy for vertigo and the same treatment limited to two or three anti-vertigo drugs (that primarily) offer symptomatic relief cannot and should not be offered to all patients of vertigoinspite of the unethical promotion by the pharmaceutical companies who try to promote and advertise antivertigo drugs as the panacea for all vertigo and imbalance. The clinician must not fall prey to the illogical promotion of anti-vertigo drugs by the pharmaceutical companies and must remember that it is extremely injudicious and unethical if not criminal to prescribe drugs for providing symptomatic relief only for prolonged periods without trying to correct the cause of the vertigo or the imbalance. The different modalities used for the treatment of vertigo are :-
1) Physical therapy i.e. exercises:- certain specified exercises like the Cawthrone-Cooksey exercises expedite the vestibular compensatory mechanism. As already mentioned, these exercises enhance and expedite the vestibular compensation which is the mainstay of treatment especially in unilateral peripheral vestibular lesions. Internationally, physical therapy is now medically recognized as a major part and probably the most effective part in the management of balance disorders. This is all the more effective especially in cases where the balance disorder is peripheral in nature for example if the balance disorder is due to a damage in one of the vestibular labyrinths that is the organ of balance in the ear. The exercises help to enhance and expedite the vestibular compensatory mechanism, which is a natural process to relieve the patient of the balance disorder and reinstall stability in the patient after the balance system has been damaged by disease. If the balance organ in the ear has been damaged by disease, the damage is usually permanent and for all practical purposes, the damaged portion cannot be regenerated by any known medical or surgical means. Yet then, a patient having a damaged vestibular labyrinth does not stay vertiginous throughout life and regains stability over a period of time irrespective of whether any medical treatment has been offered or not. This is not because the dead cells in the vestibular labyrinth has been brought back to life i.e. the cells have been regenerated or revived by any treatment, but because nature has been kind enough to provide us with an unique system known as the vestibular compensatory mechanism , which is instrumental in restoring stability even though a part of the balance system has been permanently damaged Some exercises of yoga (asanas) and Tai chi exercises are also known to be very effective and helpful in enhancing vestibular compensation and in improving balance function and restoring stability after a vestibular assault. Poor compensation will occur if the patient has a CNS disorder that is some disorder in the brain, or if the patient is under sedative medication like sleeping pills or medicines that cause drowsiness, is non-ambulatory, is kept in a dark environment, or has a poor motivation for recovery. Some other specific physical maneuvers, like the Epley’s or Semont’s maneuvers or the Bar-Be-Que maneuver are excellent and pretty efficient methods for correcting positional vertigo which cannot be treated effectively by any medical or simple surgical means. Physical therapy is hence very important in ameliorating the patient's vertiginous symptoms and restoring stability in the balance disorder patient.
2) Drug therapy , that is medical management of vertigo:-
the objectives of prescribing medicines to a vertiginous patient are
a) provide symptomatic relief. But it has certain drawbacks. Most drugs that can provide symptomatic relief in vertigo or in the concomitant nausea, vomiting that accompanies vertigo, cause some degree of depression of brain function i.e., they sedate the brain which is detrimental to the development of vestibular compensation. These drugs should hence be discontinued immediately after the acute symptoms have subsided (maximum period is 5days preferably just 1-3 days) and the patient should be put on vestibular rehabilitation exercises as early as possible. The treating clinician has to keep in mind that the stimulus for the vestibular compensatory mechanism comes from the feeling of vertigo, hence suppressing the vertigo jeopardizes and inhibits the vestibular compensatory mechanism which is the natural process to restore balance after the balance organ has been damaged by disease. The commonly used symptom relieving drugs are prochlorperazine, cinnarizine, dimenhydrinate, meclizine and betahistine,
b)Treat the underlying disorder causing the vertigo:- there are specific drugs for each of the diseases causing the symptom of vertigo like Vestibular neuritis, Meniere’s disease, labyrnthitis, vertiginous migraine, phobic postural vertigo etc,
c) Increase cerebral and inner ear blood flow -- one of the known causes of balance disorder is degeneration of the inner ear and the brain tissue due to inadequate blood supply to the brain and the inner ear. This is prevented by medicines that enhance supply of blood to the brain and inner ear. This of course does not mean that every patient of vertigo is suffering from hypoxia and hypoperfusion to the brain and the increase of cerebral and inner ear blood flow is advocated only for those patients where there is any cause of suspicion of cerebral hypoxia. for example , in vasculopathic subjects that is old aged patients suffering from atherosclerosis and definitely not in all patients of vertigo
d) increase the neural and neuronal metabolism --- that is supply nutrients to the neural tissues of the brain and to protect the inner ear and the neuronal cells from further damage. This is possible by prescribing neurotropic agents and antioxidants
e) treat the concomitant psychological and cognitive disorder:- in many patients SSRIs and / or benzodiazepines are required to manage the psychological disorders that accompany chronic or recurrent vertigo; many vertigo patients are found to have cognitive impairment that requires treatment by drugs that are known to enhance cognitive skills like piracetam, donepezil, etc
The so-called antivertigo drugs which are very commonly prescribed, unnecessarily for very long periods of time, have practically NO role to play in curing the disease or in the reversing the etiology. Their main role lies in just providing symptomatic relief during the very acute phase of the disease and nothing much beyond it in spite of all the crap advertised by the manufacturers. Many of these anti-vertigo drugs are known to induce very serious long term side-effects like Parkinsonism and other neurological disorders.
It has been found that psychological symptoms and psychiatric disorders are common in patients of vertigo and imbalance. Balance disorders and psychological disorders go hand-in-hand and are comorbid conditions. Vertigo and imbalance and psychiatric disorders coexist as a result of neurological links between the vestibular and the autonomic nervous systems. There are neuro- anatomic connections between these two systems. Uncertainty about the severity and the timing of the attack and inefficiency of diagnosis and treatment leads to anxiety, helplessness, panic disorders, agoraphobia that is fear of going outdoors, somatisation that is always being mentally occupied by the disease and depression which are all recognized psychological symptoms very common in patients of vertigo and imbalance. The psychological problems have to be taken care of and managed very efficiently. If this is not done, the vertigo and the psychological disorder will not only persist but perpetuate one another . The management of psychological aspects of vertigo is by reassurance, psychotherapy and if required some psychiatric drugs.
In very rare and obstinate cases of vertigo, surgery is also sometimes taken recourse to. If there is any tumor or any structural defect in the brain that is causing the vertigo like a tumor in the nerve of balancing, surgery is definitely necessary. But this is very veryrare cause of vertigo. In very obstinate cases of vertigo like some cases of uncontrollable Meniere's disease, the vestibular labyrinth on that side is damaged by surgical procedures even though there is no tumor. The surgical procedures used are injecting some toxic chemicals in the ear, ablating the vestibular labyrinth or selectively cutting off the vestibular nerve, but these procedures are best avoided as relief is not guaranteed by these destructive procedures. It is merely taking a chance for the vestibular compensation to develop anew. Moreover, there is a chance of the hearing being damaged by surgery.
In summary, it may be said that vertigo or imbalance is a very common symptom that can be caused by numerous types of medical disorders. Diagnosing the exact cause and offering the proper treatment which will correct the underlying medical disorder is quite a complex job and is the domain of a neurotologist , who is a medical specialist to trained in diagnosing and treating vertigo and imbalance. The special investigations viz. vestibular function tests like ENG / VNG, VHIT, ocular and cervical VEMP, DVA, SVV, EcohG, ,CCG.and if possible Computerised dynamic posturography, rather than the imaging studies like CT scans and MRIs are necessary for diagnosis and only centres equipped with such facilities can do justice to patients of vertigo had imbalance. A very detailed history taking and certain clinical tests are also invaluable in diagnosis of the cause of the vertigo. The special vestibular investigations are not an alternative to the detailed history taking and the clinical tests. As regards treatment, Physical therapy that that is some specific physical exercises, rather than long-continued use of anti-vertigo drugs that offer only symptomatic relief is now believed to be more useful in managing patients of vertigo. Symptomatic treatment with drugs like prochlorperazine are necessary to tide over the acute phase only and should essentially be discontinued as soon as the acute symptoms subside; the maximum permissible duration is 3 days which can at most stretched to 5 days in very deserving cases but whenever such drugs are prescribed even for very brief periods (max. 5days) the cost-benefit ratio for the patient should be very carefully weighed as the maximum natural recovery of balance function takes place in the first few days after the damage to the balance organ (vestibular labyrinth) and if in this time the natural process of recovery of balance is impeded then this natural process of restoration of balance will be jeopardized. The natural process of recovery called VESTIBULAR COMPENSATORY MECHANISM is a function of the brain and it is stimulated by the vertigo (called sensory conflicts in medical parlance) and vestibular sedatives or these symptom relieving drugs impede this process. Medicines that prevent the degeneration of the tissues of the brain and inner ear like neurotropic agents and antioxidants are more effective in offering a long-term cure. But before putting the patient on a long term therapy with such drugs one should make sure whether the vertigo / balance disorder is really being caused by lack of blood supply in the brain or by degenerative changes in the brain and inner ear. Empirically prescribing such medicines without ensuring the cause of the disorder is improper. The scope of surgery is very limited and should be a avoided except in very special case. There is a practice of injecting some chemicals into the ear like Gentamicin or steroids in patients presenting with vertigo. Though in some very rare cases this is necessary it has its own drawbacks and is advocated only on confirmed failure of medical treatment. A second or a third opinion should always be sought by the patient before undergoing such aggressive procedures. With the very precise diagnosis and medical treatment for most vestibular disorders now available, any aggressive surgical procedure is very very rarely needed nowadays.
Dr Anirban Biswas
Vertigo and DeafnessClinic BJ-252 Salt Lake Kolkata -91
Vertigo Clinic, Belle Vue , 9, Dr U N Brahamachari Road Kolkata -17