Remember, when you were a kid, twirling around and around until you fell, laughing, in the grass, while the world seemed to continue spinning around you? That delightful feeling is not so delightful when you’re an adult — and you’re not twirling around on purpose. The sensation that you are spinning, or that the world around you is spinning, is called vertigo. It’s a specific kind of dizziness not to be confused with lightheadedness, which is a feeling of weakness, as if you were about to faint. Experiencing vertigo may cause you to lose your balance and possibly your lunch. It may begin suddenly.
Mary Smith,* 68, was lying on her stomach with her head turned to one side. When she rolled onto her back and opened her eyes, she felt that everything was spinning. She closed her eyes tightly until the feeling subsided. Then she started to sit up. Falling back on the bed, she called for help from her husband. Gripping her husband’s supportive hands, Smith was able to stay upright, but nausea made her gag. It took about half an hour of sitting upright, facing straight ahead, sipping ginger tea and nibbling soda crackers before she felt relief. Turning or tilting her head or — even worse — trying to lie down brought back the disturbing symptoms. After a night of trying to sleep sitting up, Smith visited her primary care physician, who diagnosed Benign Paroxysmal Positional Vertigo (BPPV).
BPPV is one of the most common causes of dizziness, causing about 40 percent of dizziness among the elderly, according to a 2008 study in the Journal of Laryngology and Otology. And the elderly are more prone to dizziness than younger people. Vertigo is typically associated with the vestibular system, a part of the inner ear used for balance and spatial orientation. In BPPV, microscopic crystals in the inner ear get loose and float in the fluid of the inner ear canal. Changing the position of your head or body causes the crystals to swirl around, stimulating the hair cells in the inner ear and sending a false message to the brain that the body is moving, even though it is not. The false information doesn’t match perceptions from the eyes, muscles and joints, and creates the sensation of spinning.
“You sometimes see BPPV in people who have had some type of head trauma that’s caused some of those crystals to loosen,” said Michael Byrd, M.D., assistant professor of otorhinolaryngology-head and neck surgery. “But most times, we don’t really understand why people get it.”
The term “benign” is applied to BPPV because it is not life-threatening, but BPPV can be problematic in daily life. Looking up at a high shelf, such as at the grocery store, or leaning back in the chair in a hair salon or dentist’s office often brings on the spinning sensation.
An antinausea medication, like Antivert (meclizine), relieves the symptoms in some people but causes drowsiness. The standard treatment for BPPV is a maneuver intended to move the crystals to a less sensitive part of the ear canal. Sometimes patients can perform exercises at home to gradually reposition the crystals over several weeks. In other cases, the patients are referred to specially trained physical therapists for vestibular rehabilitation, which helps train the balance system in the brain to function better. Even without treatment BPPV is a self-limiting disorder. “Eventually, those crystals dissolve,” Byrd said. “If you did nothing, the majority of the time, it would burn itself out.”
Another cause of vertigo is Ménière’s disease, an inner ear disorder that causes episodes of vertigo along with tinnitus (ringing in the ears), hearing loss and ear fullness. Ménière’s disease is thought to occur when an obstruction in the inner ear causes the fluid to back up and increase fluid pressure. With Ménière’s disease, episodes are much more severe than with BPPV. While episodes of BPPV usually last seconds to minutes, those with Ménière’s may last for hours or even days.
The standard treatment for Ménière’s is a low-salt diet, less than 2,000 milligrams per day. The occasional use of a diuretic can also decrease fluid volume and pressure. For symptomatic relief of vertigo, if meclizine is not effective, Valium (benzodiazepine) may be used.
“Valium blunts the response in that dizzy center in the brain, but it’s potentially addictive, and you shouldn’t drive when you’re taking Valium,” Byrd said.
Because 80 percent of Ménière’s disease is one-sided, in extreme cases, the antibiotic gentamicin may be injected through the eardrum to destroy the vestibular function in that side. Studies have shown that the treatment is effective in controlling vertigo, but gentamicin carries a significant risk of destroying the hearing in that ear. A newer treatment for Ménière’s is injection of a steroid through the eardrum. This treatment’s effectiveness is still being evaluated.
While BPPV and Ménière’s disease may begin suddenly, another type of vertigo usually follows an upper respiratory infection and is believed to be caused by a virus. Called labyrinthitis, this inflammation of the balance organ may take months to resolve.
“Sometimes, if we catch it early, we’ll treat labyrinthitis with an oral steroid to decrease inflammation around the nerve. Sometimes, I’ll send the patient to vestibular rehabilitation, where they’ll do exercises that help strengthen the good side and help the patient recover a little faster. But you really have to let it run its course, let the body heal itself,” Byrd said.
If vertigo doesn’t improve with simple remedies, the primary care physician usually refers the patient to an otorhinolaryngologist. The otorhinolaryngologist first uses the clinical history to distinguish among potential causes.
“If it’s still unclear, we can do a number of vestibular tests to determine if it’s an inner ear cause or a brain cause. Vestibular testing also will give you information about how people’s eyes are tracking, since the ocular system also plays a part in the vestibular system. If there’s a dysfunction there, an ocular problem could be causing the vertigo, and we’ll refer the patient to neuro-ophthalmology,” Byrd said.
The most common cause of vertigo related to the brain is vertiginous migraine, which would be referred to a neurologist. Patients with migraines may have vertigo or other types of dizziness even when they’re not having a severe headache. An acoustic neuroma, a tumor located between the ear and the brain, is a rarer cause of vertigo, occurring in only 10 to 20 people per million, according to a 2004 study in the Archives of Otolaryngology-Head and Neck Surgery. This benign tumor of the vestibular nerve can cause vertigo, one-sided hearing loss, tinnitus and sometimes facial numbness. Because the tumor grows very slowly, a small one may just be observed. If treatment is needed, the otorhinolaryngologist and a neurosurgeon would collaborate on microsurgery or on very precisely targeted Gamma knife radiosurgery.
*The patient’s name has been changed to protect her privacy.