In the pathology of vertigo and balance disorders is especially important a correct clinical history that allows advance in the diagnosis and represents one of the most important parts of the consultation of these patients.
Special attention is paid to the limitation that vertigo generates for the development of daily activities of the patient’s life, trying to assess and determine the degree of disability that the disease produces for the patient and his family.
The examination is performed below and consists of a thorough otolaryngological exploration that includes the ear, nasal pharynx, nasopharynx, oral cavity and larynx.
The objective is not only to explore its conformation, but to carefully evaluate the dependent function of certain cranial nerves (cranial nerves), which can give important information for the differentiation between a central and peripheral vertigo.
What are the causes?
Regarding the alterations of the ear, we should mention, in order of frequency, benign paroxysmal positional vertigo, Ménière’s disease and vestibular neuritis, which represent 54% of queries for dizziness and vertigo.
Other causes of otological or peripheral origin, such as tumors (acoustic neurinoma), traumatic, infectious, toxic or idiopathic, account for 33%.
Within the neurological pathology, vascular origin and multiple sclerosis are the most frequent.
Who can suffer it?
Anyone can suffer from vertigo. Symptoms of instability can arise both in childhood and in old age.
In the case of children, they have vertigo forms very different from those cataloged. It usually undergoes very brief spontaneous crises that with the years are cured or transformed into migraines. These are usually middle ear problems that manifest with vertigo.
In the elderly, pictures of multisensory vertigo are presented that can evolve towards chronic instability. In these cases, the three balance systems that have to be coordinated in the brain (sight, hearing and joints) fail.
Types of dizziness
The vertigos can be classified of very diverse forms. One of them is based on the location of the disease that causes it and divides them into peripheral and central.
- The peripheral vertigo is caused by the involvement of the labyrinth (inner ear) and vestibular nerve (which carries balance information from the inner ear to the brain), and is the most common. Patients also usually have hearing loss and ringing, pressure and pain in the ear.
- The central vertigo is due to the alteration of the neurological mechanisms of the vestibular system itself. In these cases it is frequent the existence of alterations of the gait and posture with very striking instability, double vision, problems for the swallowing, intense headache, etc.
The sensation of movement is usually one of rocking, rotating or displacement, one’s own or of the base of sustentation (as inclination of the ground or precipitation in a vacuum) but, in reality, those modifications in the subject or environment do not occur.
The dizziness is also impaired balance in which we include unpleasant sensations of emptiness in the head, insecurity and instability, feeling of discomfort and impending fainting, all accompanied by nausea and vomiting, pallor and cold sweats.
The vertigo always refers to an alteration of the vestibular system (housed in the inner ear and whose nerve center is in the brainstem), while dizziness is a balance disorder not always related to it.
What are the most common symptoms?
- Sensation of rotation of objects
The treatment of vertigo depends on the underlying cause that produces it.
The treatment will depend on the cause that produces it. As Menière’s disease is caused by an alteration of the inner ear, for its treatment, the patient must first follow a diet low in salt and eliminate liquids, since, when they accumulate in the inner ear, they cause vertigo.
When the care of the feeding is not effective, it is necessary to go to the medical treatment.
There are several drugs that are indicated according to the characteristics of the patient:
- Diuretics: by eliminating water, the amount in the inner ear is reduced, in order to reduce the sensation of vertigo. In this way, the hearing improves and the rest of the symptoms disappear.
- Betahistine: is a very effective drug whose effect is to increase circulation in the inner ear and reduce the excitability of vestibular neurons without drowsiness. The replacement of liquid is faster and the accumulation, less.
- Others, such as calcium antagonists and cellular protectors against local toxic agents (trimetazidine), are of great importance in the mechanism involved in the development of diseases with vertigo, hearing loss and tinnitus.
Approximately 70% of patients improve with adequate medical and dietary treatment. When this is not the case, a treatment with intratympanic gentamicin is performed.
Gentamicin is an antibiotic that is injected through the eardrum, passes into the inner ear and acts on the cells of balance. The application of gentamicin is done on an outpatient basis and is introduced into the middle ear through an orifice made in the tympanic membrane.
In the middle ear it is left for 30 minutes to later remove it. During this time, gentamicin spreads to the inner ear, exerting its effect.
The patient goes to a new revision after a week and, at that moment, the effects of the previous application of gentamicin and the need for a new application are evaluated; If a minimal reaction is found in the inner ear, the treatment is finished.
The effects of the treatment are observed during its own application and, in many cases, there is a progressive reduction in the intensity, severity and frequency of vertigo crises until its complete disappearance.
With intratympanic gentamicin, the vertigo of 90% of patients in whom medical treatment has failed is controlled; for the rest, a surgical procedure should be performed that, depending on whether or not it is useful, will be a vestibular neurectomy or a laberintectomy, respectively.
In laberintectomy all sensory receptors of balance in the inner ear are surgically removed and, consequently, the patient loses hearing. This intervention is performed in extreme cases in which the disease itself would cancel the hearing of the patient.
In vestibular neurectomy, the balance (vestibular) nerve is cut so that the patient maintains hearing.