Understanding Dizziness

          Dizziness, vertigo, lightheadedness, and  wooziness are symptoms, not medical conditions.  Common otolaryngology causes of dizziness include Meniere’s Disease, Benign Paroxysmal Positional Vertigo, Labyrinthitis, Vestibular Neuronitis.  Doctor Neeta Kohli-Dang and myself, Kari Kingsley, CRNP in Huntsville, Alabama treat many patients suffering from these conditions.    Please visit us at Huntsville ENT or call (256) 882-0165.

          Define dizzy.  It’s not as easy as it sounds.  What one person may describe as an intermittent spinning sensation may be described as lightheadedness to the point of almost passing out by another.  Others may feel they are experiencing a constant drunk and staggering feeling at all times.  Dizziness is a catch-all term for a variety of different sensations caused by many medical problems.  Because dizziness is subjective rather than objective, it can be difficult for patients to describe.  For those of us on the front-line of medicine, it can be Pandora’s box in terms of evaluation and differential diagnoses.  That one simple sentence, “I’m dizzy”, could range from a simple ear infection to a brain tumor.  Our job as clinicians is to know the difference.

               Webster defines dizzy as an adjective that causes “a feeling that you are turning around in circles and are going to fall even though you are standing still”.  The term can also mean mentally or emotionally upset.  Rising co-payments and deductibles are making me maddeningly dizzy! Dizzy also has a connotation of “feeling silly” or “tending to forget things”.  Public misconception and stigma of the word sometimes delay those who want to receive help for fear of scrutiny of hypochondriasis and psychological conditions such as anxiety.  Dizziness is a symptom of a medical condition and not a disease by itself.  Dizziness can be classified as peripheral and central.  Peripheral dizziness is caused by conditions affecting the ears.  Central dizziness arises from conditions affecting the brain and central nervous system such as a lesion in the brainstem or cerebellum.

           So, what qualifies someone to write an article on dizziness?  Well, if you remember the 1980’s infomercial: “I’m not only the president of Hair Club for Men, I’m also a customer!”; that pretty much sums up my perceived knowledge-base and repertoire on the subject.  I have worked in Otolaryngology as a Nurse Practitioner for the last 7 years.  For the last 3 years, I’ve had the privilege of working alongside Dr. Neeta Kohli-Dang at Huntsville Ear, Nose, and Throat.  We devote a large portion of our practice to diagnosing and treating dizziness.  Having been diagnosed with Meniere’s disease myself 6 years ago, I have developed a passion for treating dizziness and feel like I could write a novel on the subject.  I’ll save you the time (and associated papercuts) and give you the Cliff Notes version so that the next time you or a loved one is experiencing dizziness, you’ll have an idea of how to get off the merry-go-round.

           Patients probably wonder, how does a provider assess, diagnose, and treat a dizzy patient?  The secret to delineating a proper dizzy diagnosis begins with obtaining a proper and thorough history.   You must be able to recognize which key words in a patient’s history that scream abracadabra! You are on the right track! The goal of this article is to provide you with the ammunition to delineate symptomatology of dizziness in more detail so that you will obtain a proper diagnosis quicker and begin treatment sooner.   If we pretend that all of the many medical conditions causing or contributing to dizziness are represented by flowers on a dogwood tree, seeking the proper diagnosis seem like finding a needle in a haystack.   But if you think of the word dizziness as the trunk of a tree, with certain key phrases (or “abracadabra” words) directing you down varying branches, the job gets much easier.  Let’s start with the most common conditions and work our way on to the “zebra’s”, as we in the medical field like to call those rare conditions that news shows love to cover (e.g. Brain eating amoeba causes dizziness in 33-year-old nurse practitioner).  For your edification, I’ve notated key “abracadabra” words in bold.

          Perhaps one of the most common causes of dizziness and least dangerous is Benign Paroxysmal Positional Vertigo.  However, if you ask anyone who has ever suffered from BPPV, they will tell you this condition is anything but benign.  Positional vertigo is condition arising from the inner ear in which people experience brief, repeatable spells of a spinning sensation when changing position.  The condition can be acute and chronic as well as atypical (not responding to common therapy, although this is rare). Tiny calcified otoliths (or “crystals”) that have come loose in the vestibular canals create the sensation of a true vertigo (sensation of spinning) when the head is reoriented relative to gravity.  The condition is diagnosed based on the Dix-Hallpike maneuver eliciting nystagmus (specific eye movements).  Treatment of BPPV consists of a simple procedure called an Epley maneuver, which moves the otolith crystals out of the balance canals to be reabsorbed by the body.  “PLEASE do your Voo-doo maneuver” is a request I frequently get from several patients when symptoms recur.  Many of them get a good chuckle at the fact that, yes indeed, their rocks have come loose and they’ve temporarily lost their marbles. Brandt-Daroff exercises can also be helpful.  Medications are rarely needed for this condition and in fact, can sometimes hinder progress.

               One of the next common inner ear conditions is Meniere’s disease, which is probably my favorite condition as a clinician to treat.  If I were to “speak” all dizzy languages, then this would be my native tongue.  Probably because I have this condition and relate to those with it.  Sadly, what I experience is only a fraction of what other patients feel.  Picture yourself on a seemingly never ending tilt-a-whirl in which your right ear feels as if it might explode from pressure as a car horn blares roaring tinnitus in your ear.  Just about any medical provider assessing a patient with these classic symptoms would suspect an inner ear issue.  Classic Meniere’s patients present with bouts of dizziness that can be described as an “off-balance sensation” all the way to true “spinning-vertigo” usually coming in spells that can last several hours.  Generally, there is significant ear pressure and fullness in one or both ears accompanied by ringing or roaring tinnitus.  Patients may also have low-frequency hearing impairment.  But you can also have atypical forms of Meniere’s, with only some of these symptoms.  Diagnosis is based on the patient’s history, audiogram, and vestibular testing. Magnetic resonance imaging (MRI) should be conducted to exclude transient ischemic attack (TIA), stroke, acoustic neuroma, or a tumor of the endolymphatic sac.  Treatment of Meniere’s disease generally begins with a step-wise approach.  Patients are advised to lower their sodium intake and also eliminate other triggers such as caffeine, tobacco, and alcohol.  As a full-time working nurse practitioner student being told to limit my caffeine intake, I literally spewed coffee from my mouth, laughing, as I spilled Mountain Dew in my lap.  Mediations such as diuretics, steroids, anti-emetics, and vestibular suppressants can be helpful for some patients.  Physical therapy and an exercise regimen are advised for many.  Trans-tympanic dexamethasone perfusion therapy provides a minimally invasive, in-office procedure that provides significant lasting relief for most patients.  Invasive procedures such a endolymphatic sac decompression and shunt placement should be reserved for more severe cases.  Destructive procedures, such as gentamycin perfusions, labyrinthectomy, and vestibular neurectomy can cause irreversible effects such as permanent hearing loss and are reserved for dire cases.  Most patients respond well to steroid perfusion therapy and very rarely require further action.   I am grateful to work for an ENT that uses cutting-edge technology and the safest techniques possible to perform these procedures on myself and her patients.    And likewise, I think she is grateful NOT to have a staggering and stumbling nurse practitioner wobbling around her office!

           Infectious processes such as vestibular neuritis result from inflammation in the inner ear thought to be bacterial or viral in origin.  Symptoms can be precipitated by a head cold and are generally described as severe vertigo in which the patient is unable to walk without assistance.  Labyrithitis is suspected when symptoms are accompanied by unilateral sudden hearing loss. Patients usually experience associated nausea, anxiety, and malaise as the brain receives distorted balance signals from the inner ear. Treatment in the acute phase consists of vestibular suppressants such as Valium or Meclizine, however, patients are encouraged to wean these as soon as possible to avoid potential addiction.  Physical therapy and specific vestibular rehabilitation is crucial for some patients. Physical therapy combines repetitive head, eye, and postural changes with walking exercises in the hopes of achieving permanent compensatory changes in the brain.

          Patients that complain of lightheadedness should be evaluated for syncope and near syncope.  Although sometimes these symptoms can be descriptive of otogenic causes, more often the culprit is vascular.  Workup for orthostatic hypotension, poor blood circulation, TIA, cardiomyopathy, heart attack, and heart arrhythmia should be considerations for patients that present with dizziness.  Syncope work-up can be extensive but necessary for some.  Laboratory considerations should include serum glucose, complete blood count, electrolyte levels, renal function tests, cardiac enzymes, creatine kinase, and urinalysis.  Imaging studies are also critical.  Again, use your “tree branch” methodology to elicit a proper diagnosis.  If a patient is dizzy with fever, leukocytosis, and cough, consider a chest x-ray to rule out pneumonia.  Other etiologies that can present with lightheadedness include congestive heart failure and pulmonary masses.  CT head, chest, and abdomen are considerations when accompanying symptoms warrant them.  Rather than a shot-gun approach to medicine, ask as many questions as possible and try to narrow your target range.   MRI and MRA are helpful in delineating brain and neck structures to assess for abnormal vertebrobasilar vasculature.  Ventilation-perfusion scanning is appropriate for patients presenting with symptoms of a pulmonary embolism. Echocardiogram is helpful in evaluating mechanical cardiac causes of lightheadedness.  EKG, Holter/Event monitoring, and stress testing can be helpful (and sometimes critical) to diagnosing arrhythmias, myocardial infarctions, or myocardial ischemia.  Don’t panic!  If you are a clinician, know your scope of practice and call in outside resources.  Consult otolaryngology, neurology, neurosurgery, cardiology, pulmonology, nephrology, or endocrinology. You are not alone!

          A multitude of neurological conditions can present with dizziness.  Migrainous vertigo or vestibular migraine is a type of migraine causing dizziness associated with severe headaches.  Additional neurological conditions causing disequilibrium include multiple sclerosis and Parkinson’s disease. These processes generally cause deconditioning which can lead to progressive loss of balance.  Cerebellar ataxia can be caused by a wide variety of infectious, immune mediated, metabolic, toxic, and degenerative etiologies.  Discussion of any serious head injuries should always be included in the work-up of a dizzy patient.  Brain tumors can also cause dizziness. Again, consult neurology or neurosurgery as needed.

           Medications.  Here’s a biggie!  Run and grab 4 pill bottles from your medicine cabinet.  I’ll bet you a dollar to a donut that somewhere on that long list of “possible side effects” you’ll find dizziness.  Many medications can cause dizziness. Common culprits are blood pressure medications, antidepressants, sedatives, tranquilizers, and stimulants.  However, in clinical trials, the FDA requires manufacturers to list side effects that occurred more often among patients taking the drug than those receiving placebo.  Some companies even choose to list symptoms reported in the experimental AND control groups.  Thus, common conditions like headaches, nausea, and dizziness will commonly show up on medication side effect profiles.  Polypharmacy is another major contributor to dizziness.  Polypharmacy is the use of four or more medications and can affect as many as 40% of elderly adults living at home.  When assessing dizziness, always take in to consideration a person’s medication list.  As I mentioned above, numerous medications can lead to dizziness. Adding medications that cause dizziness to medications that cause dizziness is a recipe for disaster!

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          Many people have multifactorial dizziness or a combination of factors contributing to their symptoms.   Balance requires a person’s eyes, ears, sensory nerves, and proprioception to work properly. When one’s equilibrioception has a kink in the chain, the bicycle won’t work properly. All of these components work together to tell a person where they are in space and time.  Let’s take a classic diabetic male patient for example.  Chronically elevated blood glucose levels have caused permanent damage to the microvascular blood supply in a person’s feet (peripheral neuropathy).  Suddenly he no longer has sensory feedback to tell him where he is standing. The same high blood sugar has affected his eyesight causing diabetic retinopathy.   Now he can’t see.  Lastly, his fluctuating blood glucose levels are sending signals to his brain that “something’s not right” causing disequilibrium and lightheadedness.  A break down in one of the critical faculties for balance can cause an issue.  A break down in them all can mean big trouble.

          Ok, now the zebras.  These conditions are rare but do exist (remember, I said zebras, not unicorns).  Arnold Chiari Malfomation is a neurological condition in which brain tissue extends into the spinal cord.  Patients often times present with headaches and dizziness described as a bouncing sensation when walking.  Treatment varies based on the severity of prolapse and symptomatology. Mal de Debarquement Syndrome is a rare neuro-vestibular condition that occurs when a person exits a sustained motion event such as a cruise or aircraft flight.  A major diagnostic indicator is that patients may feel better while in passive motion such as driving or riding in a car. Medications such as vestibular suppressants and vestibular rehabilitation are the mainstay of therapy.  A perilymph fistula or labyrinthine fistula is an abnormal opening in the bony capsule of the inner ear causing perilymph fluid to leak from the semicircular canals into the middle ear.  PLF is usually caused by trauma although can be congenital or a complication of some ear surgeries. Middle ear exploration is often required for diagnosis. Treatment usually includes watchful waiting and avoidance of activities that increase intracranial pressure (weightlifting, scuba diving, etc).  Again, vestibular rehabilitation may be indicated for some.  Superior semicircular canal dehiscence syndrome is a rare thinning or complete absence of part of the temporal bone overlying the superior semicircular canal portion of the vestibular system. Patients often present with dizziness, autophony (hearing one’s own self-generated noises such as speech, eye movements, heartbeats, etc.), and positive Tullio’s phenomenon (sound induced dizziness).  Diagnosis is made through coronal CT scan of the temporal bone.  Treatment again depends on severity of symptoms but can include middle fossa craniotomy with soft tissue grafting or use of bone cement to surgically resurface the affected bone. Vestibular schwannoma or acoustic neuroma is a benign tumor growing along the vestibulocochlear nerve.  Incidence is thought to be 1 to 2 people per 100,000 per year.  Symptoms generally include asymmetrical hearing loss with speech discrimination impairment along with tinnitus and dizziness.  Any patient presenting with these symptoms should undergo a MRI contrast with specific cuts through the internal auditory canal. Treatment options vary based on symptoms and patient’s age but include watchful waiting, surgical resection, and radiation treatment.

          Dizziness can be an overwhelming symptom unless you know what key phrases in a person’s history to watch for.  Ask questions. Look for the “abracadabras” and Ah-hah! moments!  Don’t become overwhelmed. Use your resources.  Consult ENT.  The goal of treating dizziness is to find the underlying cause and manage the condition effectively.   There is nothing more gratifying as a clinician than properly diagnosing a patient, starting the proper treatment regimen, and having your patient come back to me and say, “THANK-YOU, I’M MUCH BETTER”.

          So… after reading this article, if you weren’t dizzy before…. You probably are by now! 😊 And yes, brain eating amoebas probably cause dizziness.  I’ll let you know when I see a case.

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Kari Kingsley, MSN, CRNP works as an otolaryngology nurse practitioner in collaboration with Dr. Neeta Kohli-Dang.   Together they share nearly forty years of ENT experience. They treat dizziness, ear infections, hearing loss, nasal congestion, sinus infections, thyroid nodules, tonsillitis, neck masses, hoarseness, trouble swallowing, and a multitude of other ear nose and throat conditions.   Please call 256-882-0165 to schedule an appointment with Dr. Neeta Kohli-Dang and Kari Kingsley or visit Huntsville ENT.

                                                   Published by Inside Medicine.

2 comments

  1. This was a fantastic post and I appreciate you sharing. I get really bad dizzy spells from the MS lesions on my brain, but I have learned to manage them better. I am looking forward to reading more of your posts! Take care!!

    Like

    • Thank you so much for your kind words Alyssa! I’m sorry to hear you suffer from MS, but I hope some of the information in my article helps. Dizziness can be one of the most difficult symptoms to describe, and let alone treat. Best of luck to you and please keep following my blog and consider sharing this information! If you don’t mind me asking, which search engine referred you here?

      Liked by 1 person

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