Joseph R. Anticaglia MD
Medical Advisory Board
Dizziness is an imprecise word people use to describe symptoms of feeling lightheaded, the sensation that the room is spinning or unsteadiness. Most of the time the problem is not serious or long lasting but it can make your life miserable. Less frequently, it can lead to a permanent loss of hearing or the diagnosis of a life threatening disease.
Dizziness is not a disease. It’s a subjective complaint, a symptom of an underlying problem causing people to visit the doctor’s office or the emergency room. People describe dizziness in different ways: Some tell about being unsteady on their feet or feeling lightheaded when getting up from a chair or bed. Others feel woozy as if they’re about to faint or have the impression that they or their surroundings are spinning even though they are still (Vertigo).
People use the term dizziness to describe three basic types of symptoms:
- Lightheadedness
- Vertigo
- Unsteadiness (off balance, disequilibrium)
Nancy is a 73 lady with a history of hypertension and hardening of the arteries. She becomes lightheaded and feels as if she is going to faint when going from a lying to a standing position. She consulted her family doctor who reduced the strength of the blood pressure medication and solved Nancy’s problem.
Adam had a cold for a few days and one afternoon he returned an hour earlier from work to get ready for his 11year old daughter’s concert. She plays the trumpet and he looked forward to the “solo” part she had been practicing in school and at home.
About a half an hour after arriving home, the living room started to spin violently. He made it up to the bedroom and onto the bed. His surroundings continued to whirl around. He began to sweat, felt nauseated and was close to vomiting. He couldn’t get out of bed and felt more miserable when he told his daughter he could not go to the concert.
The extreme vertigo lasted 24 hours and was relieved with medication. It took four days before he was able to return to work.
Alexandra, an ear specialist, noticed that she became unsteady walking and occasionally bumped into things. Her hearing in one ear seemed worse than the other and it had a ringing sensation (tinnitus). These symptoms have been going on for a few months.
The audiologist in her office performed a routine hearing test and special hearing tests. The doctor reviewed her own results and concluded she had a brain tumor, an acoustic neuroma. It’s a tumor of the vestibular nerve that connects the inner ear to the brain. She obtained a second opinion which confirmed her original diagnosis.
When a person complains of vertigo or being off balance or unsteady, one must decide if the problem is within the brain (Central) or outside the brain (Peripheral). Nancy needed an adjustment in her blood pressure medication. Adam was prescribed medications to suppress his inner ear vertigo. Alexandra needed brain surgery.
Medical History
Obtaining a relevant medical history is a vital first step in distinguishing a peripheral from a central cause of dizziness. It’s of paramount importance to collect answers to specific questions about dizziness, such as: “What do you mean when you say ‘I feel dizzy’?” How long do the symptoms last and are there other symptoms associated with the dizziness?
Other questions include the timing of the dizziness, what triggers the onset of the symptoms, are the symptoms episodic? What medications are you taking? These and other questions lead one on the path to an accurate diagnosis.
How Do We Keep Our Balance?
We keep our balance by the interaction, the teamwork, of the eyes, inner ear, muscle and joints which sense our environment. They send signals to the brain for interpretation and the brain acts on the information to maintain our balance enabling us to move without falling.
The eyes send signals to the brain about depth perception; where to place the foot on the next step of a staircase without stumbling. They inform us about our surroundings (visual system). The muscles and joints send signals to the brain making us aware of position and movement of the body. They let us know whether we’re sitting in a chair or walking on a sandy beach (proprioceptive system).
Behind the eardrum is the labyrinth, the bony outer wall of the balance or vestibular system. Within this wall are the three semicircular canals. The canals contain a fluid called endolymph which moves in response to head movement.
The flow of endolymph causes nerve signals to be sent to the brain making us aware of the direction of head movements, whether we’re nodding ‘yes’ or shaking our head ‘no’…
- The Anterior or superior canal detects the up and down movement of the head as it nods in a “yes” motion
- The Lateral or horizontal canal detects the side to side movement of the head as in a disagreement “no” motion
- The Posterior canal detects the movement of the head when it tilts down toward the shoulder.
Two other structures that take part in the balancing system are:
- The Utricle is an inner ear structure that contains fluid, sensory hair cells and otoliths, small calcium particles. It detects movement in a horizontal plane. It sends signals to the brain making it known, for example, you’re moving straight ahead as in a car.
- The Saccule is an inner ear structure that contains fluid, sensory hair cells and otoliths. It detects movement in a vertical plane. It sends signals to the brain making it known, for example, you’re going up or down in an elevator.
Another important aspect of how we maintain our balance involves part of the brain called the cerebellum. It receives information from the sensory system, the spinal cord and other areas of the brain. It coordinates movement and muscular activity which helps to prevent us from falling.
Dizziness is due to a myriad of causes:
- Peripheral — inner ear/labyrinth
- Central — the brain or its connecting nerves
- Systemic — diabetes, stroke
- Psychological
Dizziness is a symptom that does not occur in isolation. Being lightheaded is different from vertigo. And episodic vertigo is different from chronic unsteadiness. It’s essential to uncover the reason for the symptom in order to initiate proper treatment.
References
- National Institute on Deafness and Other Communication Disorders (NIDCD); Balance Disorders; March 6, 2018
- Jonathan A. Edlow; Managing Patients with Acute Episodic Dizziness; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, November, 2018
- Muncie, Herbert L: Dizziness, an Approach to Evaluation and Management; Am Family Physician, Feb 1, 2017
- Kevin A. Kerber, Robert W. Baloh; Evaluation of a Patient with Dizziness; Neurology Clinical Practice; Dec 1, 2011
This article is intended solely as a learning experience. Please consult your physician for diagnostic and treatment options.