My good friend Dr. Bill Wright guest-wrote this post about dizziness. He is the author of Maximum Insecurity: A Doctor in the Supermax, which you should read if you have not! Thanks, Dr. Wright! –Jeff Keller
“Can’t you understand? I’m just dizzy!”
Do these words make you want to head for the clinic exit? If so, you’ll find a lot of company trying to get through the door. Many physicians hate to see dizzy patients because they can’t easily get their heads around the complaint. They can’t see, hear, feel, smell, or touch it, so it’s hard to know where to start. Help is on the way.
For three decades I was a neuro-otologist, a cross between a brain surgeon and an ear doctor. I loved dizzy patients, and now I’ll teach you to love them too.
The absolute first thing to do is shut up and listen. As William Osler, the “Father of Modern Medicine” said, “Listen to your patient. He is telling you the diagnosis.”
The first thing I want to know is what the patient means by “dizzy.” This may seem painfully obvious, but I spend a lot of time pinning down exactly what he experiences.
Dizziness means a lot of different things to people. It might mean a sense of unsteadiness, lightheadedness, or a floating or a swimming sensation. Maybe it’s sleepiness or weakness or a feeling like you might pass out. Sometimes it could be a sense of turning around in space like a merry-go-round.
So who cares? You do if you want to figure out where the dizziness originates. Different disorders produce different kinds of dizziness, and remember that dizziness isn’t a disease, it’s a symptom.
Balance is a state of equilibrium relative to orienting yourself in space. Ultimately balance is maintained in the brain, and the brain has 3 main inputs to do this job:
1. The ears: Sensors in the inner ear detect gravity to tell you which way is up and down and others that tell you if you are turning in one direction or another.
2. The eyes: By referencing outside visual landmarks the eyes give you much of the same information in a different form.
3. Proprioception: This is the system of “strain gauges” in the muscles and joints that tell you where your body is located by the sense of feel. You can feel your feet on the floor or your posterior on the seat of the chair. You can feel where your hand is even when you can’t see it.
Normally all these systems work happily together, feeding the brain congruent information. The systems are redundant. We can maintain balance even if one or even two of them are off-line like walking in a dark room.
Lack of information from a sensor isn’t so bad. Like the stock market, what the brain can’t abide is conflicting information. When the systems send conflicting information the brain is confused, and we experience the sensation of dizziness.
The ear always gets blamed for dizziness. In my otology practice about a third of the patients with dizziness complaints had some kind of ear disease. The rest had it originate somewhere else. I suggest the first thing you do is try to decide if the ear is the likely culprit or not.
Here are things that patients tell me that make me think of ear disease:
• True Rotational Vertigo (TRV): This is a sensation that you or your surroundings are rotating around like a merry-go-round. It’s not a feeling of unsteadiness or any of the others mentioned above. It’s a sensation of being propelled or turning through space. It’s not very subtle. If you wonder whether it’s TRV or not, its not.
• Nystagmus: This an involuntary back-and-forth movement of the eyes. Nystagmus that comes from the ear is present only with the dizziness episode and is usually in a horizontal direction. Vertical nystagmus is more often of central (brain) origin. Rotary nystagmus where the eyes jerk in a rotary motion rather than back-and-forth can be either.
• Nausea and Vomiting: This goes along with TRV. If you get spinning long enough you’re going to lose it. It gives me a clue as to the intensity and duration of the dizziness.
• Hearing Loss: This is hearing loss, usually only in one ear, that comes on with the dizziness and usually goes away when the dizziness subsides. Most adults will have some degree of hearing loss that’s stable. That’s not what we’re talking about here. For it to be a clue, the hearing loss needs to change along with the dizziness.
• Tinnitus: This is a noise that you hear inside your ear or head. Again, many adults will have tinnitus, usually high-pitched, that they hear particularly in a quiet place. This tinnitus is fairly constant. The tinnitus that’s related to balance problems gets worse with the dizziness and gets better after the spell passes. It often is a hollow roaring sound, like holding a seashell up to your ear. Usually only one ear is affected, often the ear that suffers the temporary hearing loss with the spell.
• Dizziness, usually TRV, provoked by moving into particular positions: This is often when lying down and rolling onto one side in bed or looking up to get something from a high cabinet. The dizziness is brief, lasting less than 30 seconds, and is relieved by changing to another position or just waiting it out.
• Drainage from the Ear: This may be a sign of an ear infection that is irritating the inner ear balance mechanism. The drainage is usually yellowish or greenish and smells like old socks. Often the drainage is painless.
• A Painful or Swollen Ear: This may indicate an infection that is remaining within the ear, like an abscess, irritating the inner ear.
• Sudden Loss of Hearing: This is usually only in one ear and may be associated with a “pop” in the ear along with the onset of dizziness.
• One-sided Hearing Loss: A gradual loss of hearing in one ear especially associated with difficulty understanding speech in that ear is a warning sign.
All of these things are clues to different disorders of the ear that might be responsible for dizziness. The words to remember are “clues” and “might.” None of these things make a hard-and-fast diagnosis. As much as we’d like to think of medicine as a precise science, diseases often don’t show up with classical symptoms.
But let’s say that some of these red flags in the list above are fluttering in the wind, and we suspect that the dizziness is related to the ear. What next? Now we start to go down the list of common ear disorders and see what fits best.
Remember that common things are common. You are more likely to see an uncommon presentation of a common disease than you are to see a common presentation of an uncommon one. Read that sentence again. Few diseases grace us with a classical presentation.
One of the most common causes of ear-related dizziness is a mouthful called benign paroxysmal positional vertigo (BPPV).
You can diagnose BPPV over the phone in most cases, as the presentation is usually clear-cut. Al is a typical patient with BPPV. Here’s what Al tells me:
I’m fine most of the time, no dizziness at all. I don’t have any hearing problems or ear pains. When I lie down at night, I’m OK for maybe 5 or 10 seconds. Then all of a sudden I get this horrible intense spinning sensation. It goes away pretty quickly if I sit up again. If I stay down, it lasts maybe 30 seconds or so and then goes away. If it lasted any longer, I think I’d be sick to my stomach.
It doesn’t happen all the time, and if I lie down again it might not come back. Sometimes I’m OK lying flat, but it I roll onto my left side it hits me and I have to straighten up again. If I roll on my right side, it doesn’t seem to happen as much.
I like to work on my car. Sometimes I get it if I’m looking up to get something off a high shelf in the garage. If I’m on my creeper under the car it can hit me pretty hard too.
What’s Al telling me? He gets true rotational vertigo (TRV) when his head is in certain positions relative to gravity. It doesn’t last long, but it’s pretty intense. There doesn’t seem to be anything else (pain, hearing loss, tinnitus, etc) going on with it. What’s more, Al has given me a clue as to which ear is the culprit. It’s usually the one that’s pointing down when the dizziness starts.
This is BPPV. The inner ear has three fluid-filled semicircular canals you remember from biology class. They each have a little compartment with nerves that sense fluid motion in the canal when your head turns. The canal sensors combine to tell your brain which way your head is turning. Neat.
The canals all meet in a more primitive chamber of the inner ear, the vestibule, which contains calcium crystals embedded in a gelatin kind of substance. The crystals don’t move much, but are pulled one way or the other by gravity. The nerves connected to them tell the brain which way is up and down. So far so good.
In BPPV some of the crystals break loose from the gelatin and slosh into the semicircular canals. The crystals will roll back and forth in the canals with head motion and will settle to the lowest spot in the canal according to gravity, usually the posterior semicircular canal.
When our patient Al moves his head into a certain position, the crystals will crash into the sensory organ of the semicircular canal, stimulating the nerves that signal rotation movements to the brain.
Al’s ear tells his brain that he’s rotating. His eyes and body tell the brain that he’s not. This conflict scrambles his balance system and produces the sensation of vertigo. As soon as Al moves out of that position, the crystals roll away from the sensory organ, the nerves stop firing, and his brain quickly sorts things out to restore his equilibrium. If Al toughs it out and doesn’t move, the canal nerves get over the stimulation of the crystals and quit feeding bad information to the brain. Either way the dizziness quits.
So does Al take Antivert? He does not. For one thing, the dizziness is over before he could even reach the bottle. For another, the medication is too weak to help with the vertigo.
In years past, Al’s option was pretty much to either put up with it or to have a complicated inner ear surgery to cut the nerve from the semicircular canal. About 1980 a Portland, Oregon ear doctor named John Epley reasoned that if the crystals could roll into the canals, he could roll them back out. He devised a simple set of maneuvers to do this right in the physician’s office.
Since Epley’s maneuver was so simple, most doctors rejected it out of hand. He took the show on the road, teaching doctors, including me, how to do it. I went back to my practice in Indianapolis and tried it out. Amazingly, it worked! A risky and difficult inner ear surgery was replaced by a simple and painless five-minute office procedure. Geez…
The Epley maneuver is not rocket science. Anyone can learn to do it in five minutes. You WILL see patients with BPPV and you can CURE them right on the spot with no drugs, surgery or MRI scans. This is your chance to put on your Superman cape and astound your patients that have been putting up with the symptoms for years.
Learn how to do this. It’s simple but, like most simple things, there are tricks and fine points. Find someone who knows how to do it and learn it NOW. You can look it up on YouTube to get the idea.
Named for the French physician, Prosper Ménière who first described it in 1861, Ménière’s disease gets incorrectly blamed for a lot of dizziness. Agnes is a patient with classical Ménière’s disease:
I’m feeling fine, and then I start to get this full, stuffy feeling in my left ear. I get a hollow, roaring sound in the ear, kind of like holding a seashell over it. My hearing drops off in that ear and I get a spinning sensation.
I have to lie down right away, but the spinning only seems to get worse. I usually vomit and just have to lie there and be miserable for 3 or 4 hours. Then everything seems to slowly go in reverse. The dizziness goes away, my hearing gets better, the seashell noise and stuffiness goes away and I’m OK again.
Sometimes I get a spell if I eat too much salt or drink more than a cup of coffee in the morning. I never really know when it’s going to hit. I’ve had 3 spells in a week, and then I might go a couple of months without problems.
What are the key points here? Classical Ménière’s has four:
• Fullness in one ear (sometimes both)
• Roaring tinnitus in the affected ear(s)
• Decreasing hearing in the affected ear(s)
• True rotational vertigo (TRV)
There aren’t any tests that give the diagnosis, but the symptoms are pretty definitive. In cases where just the hearing fluctuates without the dizziness (cochlear Ménière’s), it can be a little tougher, but this condition is much less common.
Another clue is the timing. Ménière’s lasts for anywhere from 20 minutes to 24 hours, usually falling in the 3-4 hour range. If the spell lasts longer or shorter than those limits, the diagnosis is in doubt.
We still don’t know the cause of Ménière’s disease, but we know what happens, more or less. Here’s the most popular theory in a nutshell. The inner ear is filled with fluid. When the pressure in that fluid gets too high, you get an attack of Ménière’s. When the pressure goes down to normal, the spell goes away. Over time, the hearing tends to recover a little less with each spell and can eventually lead to loss of useful hearing in the affected ear. Ménière’s often affects only one ear, but bilateral involvement isn’t rare.
The object of the game in Ménière’s to get rid of the attacks of vertigo. A secondary goal is to preserve the hearing. There are multiple treatments depending on where we’re starting with hearing function. The thing to remember is we can almost always get rid of the dizziness, but since the hearing mechanism is closely tied to balance function in the inner ear, saving the hearing can be problematic.
For those with mild or infrequent spells, simple lifestyle changes can prevent the dizzy spells. Limiting the amount of salt and caffeine in the diet often will keep the inner ear pressure from getting too high. Rigorous sodium-restricted diets are tough to follow and usually not necessary. A good rule is to avoid foods that are obviously salty and to stay away from the salt shaker.
The next step up the therapeutic ladder is adding medications that seem to lower inner ear fluid pressure. Diuretics that are often used in blood pressure control can help with Ménière’s as well. Other medications like Antivert are useless. Between spells they aren’t needed, and during a spell they’re too weak to be of any help.
During a spell, stronger medications like Valium or Ativan may help suppress the vertigo, but they don’t do anything to alter the course of the disease. Beyond these simple steps, we’re looking at surgery to fix things. Several surgeries can fix Ménière’s, many can be done in a few minutes in the ENT doctor’s office. Nobody should have to put up with the recurrent attacks of vertigo. Find a knowledgeable otologist and refer your patient.
Vestibular neuronitis, sometimes called viral labyrinthitis, is an odd duck. Jennifer is a typical patient with this disorder:
I felt fine until a couple of weeks ago. I just started to get this really bad spinning dizziness whenever I move my head even a little. I’ve not noticed any change in my hearing and I don’t have any ringing or stuffiness in my ears.
If I try to tough it out and do some housework, I get so dizzy I vomit and just have to lie on the floor until it settles down. The only time I’m halfway comfortable is sitting or lying quietly without moving my head.
Here are the clues: There aren’t any disturbances of hearing, and the dizziness is true rotational vertigo that can progress to vomiting. It’s precipitated by head motion in any direction and it’s been going on for at least 2 weeks. Something Jennifer didn’t mention is that she had a cold a few days before this all started.
Vestibular neuronitis used to be called viral labyrinthitis because we thought a virus infected the vestibular system. We were half right. It is a viral infection, but it affects the balance nerve itself rather than the structures of the labyrinth. Does this distinction matter to you as you lie on the kitchen floor? I’m guessing not.
Several theories try to explain what happens in vestibular neuronitis. The most popular is that a viral infection affects the vestibular (balance) nerve, causing a loss of coordination between the two ears. Nobody is quite sure why this happens or even if the theory is valid. Some patients report having an upper respiratory infection a few days before the onset of the symptoms, but even this is a weak association.
Patients typically report unsteadiness when walking and frequently have some difficulty focusing their vision because of involuntary eye movements called nystagmus.
The good news with vestibular neuronitis is that the symptoms spontaneously resolve with no effect on the hearing and recovery of normal balance. The bad news is that it can take its own sweet time doing this. I typically will look for gradual lessening of symptoms over a period of several weeks. To help with recovery, I encourage patients to gradually increase head movement to help the balance system “recalibrate” but not to the point of getting nauseous.
Medications to suppress the dizziness can be helpful if the symptoms are severe, but this has the downside of prolonging the recovery process. Some patients have a persistent unsteadiness after the vertigo spells have resolved. For these people a physical therapy program called vestibular rehabilitation is quite effective.
Labyrinthitis is an actual bacterial infection in the inner ear. This usually starts in the air-containing cavities of the middle ear or the honeycombed mastoid bone, the bony lump right behind your ear canal. Daniel is a case in point:
I’ve been having some drainage from my left ear for a couple of years off and on. It doesn’t hurt and never really bothered me, but lately I’ve been getting real unsteady when I walk. My hearing in that ear isn’t very good, but I don’t notice that it’s changed.
Daniel has a hole in his eardrum dating back to when he was a kid. Skin from the outer ear canal gradually grew through the hole into the middle ear where it’s not supposed to be. Skin is dumb and doesn’t know when to quit, so it just kept growing and shedding skin cells into the middle ear and the connected mastoid. This gradually filled up the space and eroded the middle ear bones causing hearing loss.
Since the mass of skin, now called a cholesteatoma, is open to the outside through the hole in the eardrum, sometimes it gets infected and drains out through the ear canal. Since there’s no pressure buildup to stretch the eardrum, it doesn’t hurt.
But in the fullness of time the cholesteatoma gets larger and doesn’t drain so easily. The infection is right next door to the inner ear and the bacterial toxins seep into the vestibule causing it to malfunction.
The stapes or stirrup, the smallest and lightest bone in the body, seals a window between the middle and inner ears. It has a thickness of only 0.2 mm or 1/64 of an inch, about ¼ the thickness of a Pringle potato chip. Not much of a barrier. Voila, dizziness.
If Daniel is lucky the bacteria themselves don’t get into the inner ear which has almost zero resistance to infection. Surgical removal of the cholesteatoma can remove the infection and also give the chance to rebuild the hearing structures at the same time. Crisis averted.
But if Daniel is unlucky the bacteria erode into the inner ear itself. This is catastrophic on a couple of fronts. Even with prompt antibiotic and surgical intervention, the hearing and balance function in the ear is usually a total loss. The fluids of the inner ear are only a hop, skip, and jump from the fluids surrounding the brain. It can be a superhighway to encephalitis.
Although the opposite ear will eventually take over the whole job, sudden loss of balance function in an ear leads to a prolonged period of first vertigo and then unsteadiness. Vestibular rehabilitation is again a lifesaver in eventually restoring equilibrium.
Anything that retains infection in the middle ear can lead to this kind of trouble. Children with a middle ear infection can get this because of pus sitting next to the inner ear. Usually before this happens the eardrum ruptures and the pus drains or the infection resolves by other means. Whew!
Other infections like syphilis or West Nile virus can cause dizziness. These aren’t the most common, but you have to think of them to make the diagnosis.
Leakage of inner ear fluid from pressure changes, simple motion sickness, ototoxic drugs, and benign tumors of the balance nerve (acoustic neuroma) blend into the mixture of conditions causing dizziness. The key here is to be suspicious of ear-related problems mentioned above and to refer your patient to an ENT for further evaluation.
So far I’ve talked about the more common ear diseases associated with dizziness. If the dizziness isn’t coming from the ear, where is it coming from? Of course the answer is – somewhere else.
Disorders of the brain itself, problems with vision and proprioception (remember diabetic neuropathy?) are the “somewhere elses” that need evaluation when the symptoms don’t seem to fit with ear disease.
You can grow to love the dizzy patients who show up in your clinic. Some you’ll be able to fix yourself. At least you’ll be able to make the appropriate referral to the internist, ophthalmologist, neurologist, or ENT based on a solid evaluation rather than guesswork. Good hunting!
I like magic It is so much less fun when you have to use science.
Seriously though, after watching a YouTube video of the Epley maneuver it seems quite manageable in an outpatient setting – and working as advertised will make a hero of the provider.
One question though, how to keep an inmate upright for 48 hours?
Using extra mattresses as a wedge may work – any ideas?
Thanks for the comment, Al. Keeping anyone upright for 48 hours is impossible. I tell my patients to try and avoid bending over, e.g. to pick something up or to tie their shoes. Stooping down is okay. Lying with a pillow under the head is something they’re going to do anyway.
Nobody is sure whether this caution is really necessary or not. It makes sense that if you can roll the crystals back into position, they could roll out again before they get recaptured. Worst case is you might have to do the Epley maneuver again. Not really a big deal.