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Dizziness

Dizziness is a strange term because it has so many meanings; a whirling sensation and a tendency to fall, bewilderment, confusion, impulsive haste, silliness or being scatter-brained. Even in a medical context patient descriptions using the word ‘dizzy’ often imply completely different symptoms.

Dizziness is a vague term which may occur alone or as

part of an illness. In many people it comes and goes, may be prolonged or transient, inconvenient or debilitating and of known or unknown cause.

Vertigo is similar to dizziness but it is not the same. It describes a spinning sensation of the surroundings, rather than an intrinsic feeling of instability, and it may be caused by head movements (see below) The body normally maintains itself in a

state of balance and stability through several different and inter-related mechanisms.

Each mechanism, which involves the receipt of stimuli by sensory organs, leads to the passage of nerve impulses from those organs to the brain where they are

correlated so the individual knows where they they are in time and space.

Truly amazing!

The three principal methods of accumulating information are:

• The eyes which allow the individual to see where they are in relation to their environment

• Sensory receptors in the muscles, tendons and joints in the legs and other parts of the body which detect position and even the smallest of movements.

• The inner ear balance mechanism. It is composed of three semi-circular canals which are laid out in different planes, lined with sensitive nerve

receptors and filled with fluid containing tiny pieces of calcific material.

As the head moves, the calcific bodies move in the fluid and touch the nerve receptors which are stimulated.

The pattern of movement governs the pattern of nerve stimuli and the brain collects the impulses transmitted to it from the receptors and is able to deduce position and maintain stability.

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only

and should not be regarded as an endorsement of their use.

Medicine for Managers Dr Paul Lambden BSc MB BS BDS FDSRCSEng MRCS LRCP DRCOG MHSM FRSM

Good balance is a combination of all three mechanisms but, with the eyes shut, balance will normally remain good because the inner ear balance mechanism is so effective.

Clues to the cause of dizziness may be obtained depending on whether it occurred in association with an illness or infection and whether the problem is intermittent and recurrent.

Vertigo is a feeling that one is spinning. It may be accompanied by nausea or vomiting. It can occur as a temporary phenomenon following, for example, revolving fairground rides because the brain cannot process the continual nerve impulses received from the semi-circular canals it therefore registers ‘dizzy’. The symptom generally settles following cessation of the activity although it may take a significant time to do so.

Labyrinthitis is simply inflammation of the inner ear or labyrinth. Usually caused by viral infection, it commonly accompanies a cold or ‘flu symptoms. The symptoms may last from a few days to several weeks. They resolve spontaneously and are treated symptomatically.

Vestibular neuritis is inflammation of the acoustic nerve rather than any part of the labyrinth. The symptoms are similar to those of labyrinthitis. Viral infection is also thought to be the cause and the symptoms settle with resolution of the infection. Treatment is again symptomatic.

Ménière’s disease is a rare cause of vertigo affecting about 1 patient in 1,000, usually aged between 40 and 60. It also causes tinnitus, headache, hearing loss and

a feeling of pressure. Patients may have up to a dozen attacks a year lasting from minutes to several hours. Eventually the attacks subside and may disappear but hearing loss and tinnitus may persist and be permanent.

Benign Paroxysmal Positional Vertigo (BPPV) does what it says on the tin. It is not serious, intermittent usually lasting less than a minute, positional when for example looking up or down and causes vertigo. It is believed that the condition is induced by a calcific deposit in a semi-circular canal that is dislodged and moves

inappropriately causing the sensitive receptors in a canal to send inappropriate stimuli to the brain. It often settles after weeks or months. The BPPV may be accompanied by nystagmus (involuntary eye movements). It can be largely avoided by restricting sudden movements.

Other more rare causes of vertigo include migraine, multiple sclerosis and following a stroke. An acoustic

neuroma (a benign tumour of the acoustic nerve) may also cause vertigo, tinnitus and hearing loss. Such symptoms usually persist and steadily worsen.

Dizziness (vertigo) must be distinguished from feeling faint and from disturbed balance.

Feeling faint has been experienced by most people and may occur when tired, hungry, anxious or frightened. Faintness may also accompany a raised temperature, a low blood pressure may occur when standing up suddenly, anaemia and abnormalities of heart rhythm. Anxiety

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only

and should not be regarded as an endorsement of their use.

RULE OF THUMB

In general, if dizziness

only happens when upright

the cause is probably not

related to the ear. If it

happens when lying down

the cause is usually an ear

condition.

may also prompt attacks as may a range of medications.

Impaired balance may be associated with the use of too much alcohol or with drugs and it may accompany vertigo. It is also a feature of some degenerative nerve diseases, such as multiple sclerosis, brain disorders such as tumours, and as part of other generalised illnesses.

Although the types of vertigo and faintness and balance problems all sound discrete and distinguishable, in fact for the doctor they are often complicated to separate and need further testing to identify. It is estimated that, in about 10% of cases, the cause of dizziness is never identified.

People are often very anxious about the sudden onset of giddiness. It prevents them from working and they may fear that it heralds something sinister. There are occasions when it is important to see a doctor.

• If it is of acute onset and the constitutional symptoms are severe.

• If it is persistent or recurrent over weeks or longer

• If speech is affected • If there is a high fever, a history of

head injury or any convulsions • If it is accompanied by tinnitus

(ringing in the ears) or a severe headache

• If it is accompanied by reduced hearing, disturbed vision or any feelings of weakness or numbness.

The doctor can usually make the diagnosis without much difficulty. Watching eye movements whilst the individual tracks the movement of an object gives clear signs. Head movements can reproduce the symptoms.

Most causes of dizziness are not sinister. Self-help includes such things as:

• Not moving quickly. Getting up suddenly should be avoided

• Keep well hydrated but avoid alcohol and drugs and reduce coffee intake

• Don’t do anything stupid; driving, climbing ladders, skydiving and tightrope walking should all be avoided because they could be dangerous if dizziness comes on.

There are a variety of medications used to treat the symptoms of vertigo and they rely on damping down the nerve impulses reaching the brain from the semi-circular canals.

Stemetil (prochlorperazine), Serc (betahistine) and Stugeron (cinnarizine) are amongst the more commonly used medications.

Of course there are many medicines capable of causing dizziness; blood pressure lowering drugs, anti-depressants and tranquillisers, diuretics, anti-diabetics and so on.

Treatment of dizziness may need the adjustment or substitution of concurrent medications.

paullambden@compuserve.com

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only

and should not be regarded as an endorsement of their use.