The sudden onset of vertigo without aura often brings patients a very scary experience. Patients feel that the peripheral world or themselves suddenly rotate, shake, and walk unsteadily, often accompanied by nausea or even vomiting, which is not only physically and mentally painful at the time of vertigo, but after the vertigo attack, the fear of the next vertigo attack makes experienced patients afraid to go out alone and work safely. People who have no experience of vertigo can imagine the pain of patients when they see the symptoms of motion sickness.
Normally, we can move freely without difficulty, such as walking, jumping, cycling, etc., but in addition to having sound limbs, we need to have a balance system to coordinate. The sensory part of the balance system includes the vestibular, visual and proprioceptive systems, which are coordinated by the center to accomplish somatic balance, visual clarity and daily movements through the motor system. Of these three balance sensory systems, the vestibular system is the most important, with the other two systems playing a complementary role. A disorder in the vestibular system will produce vertigo and balance disorders, and the receptors of the vestibular system, are located in our inner ear.
Vertigo is just a symptom, like coughing, sneezing or headache is not the name of the disease, but there must be some underlying disease behind it. There are quite a few ailments that can cause vestibular disorders in the inner ear, and because the inner ear is in a dense bone cavity with tiny and precise structures, it is difficult to use conventional MRI or CT to examine the cause of vertigo, so the cause of vertigo is often difficult to diagnose.
Understanding the inner ear
The inner ear is located in the deepest part of the ear and is surrounded by the temporal bone. It can be divided into two parts: one is called the cochlea, which is the auditory apparatus, and the other is called the vestibule, which is the balance apparatus. This is why the inner ear is also called the balancing apparatus. The vestibular and cochlear receptors are immersed in a common internal and external lymphatic fluid, thus creating some complex relationships in terms of clinical symptoms. In other words, vertigo may be accompanied by auditory symptoms such as hearing loss, tinnitus and ear congestion.
The vestibular balancer can be divided into two parts: one is the symmetrical left and right ear, the main control of the rotational balance of the three semicircular canals. The three semicircular canals are perpendicular to each other, and the three degrees of space can be considered to be all-inclusive, so that no matter what position your body or head is in, the three semicircular canals can manage any dead space. Therefore, it can maintain the balance of any posture. The other part is the ellipsoidal and bulbous sacs, which control linear balance, including gravity.
The flow of endolymphatic fluid due to body movement stimulates the sensory cells in them to generate electrical waves. At rest, the left and right vestibular balancers send signals of equal intensity to the brain, while when the body or head is tilted or moved, the two vestibulars send waves of unequal intensity to the brain to perceive changes in head position. If one side of the vestibular receptors is impaired, even if the patient is stationary, the unilateral vestibular lesion will result in asymmetrical signals from both sides of the vestibule, and the brain will think that there is a change in body position or movement of the external environment, but the brain receives signals from both visual and proprioceptive receptors, and the information transmitted to the brain by the latter two conflicts with the vestibular system, and the symptoms of vertigo appear. On the other hand, the brain gets the wrong information that there is self rotation or external rotation, so it sends instructions to change the body posture and visual positioning to try to maintain “balance”. The body then tilts involuntarily, causing skewed walking and falls, and nystagmus.
In the brainstem, the vestibular nucleus is connected to the vagus nucleus, and vagal excitation produces nausea, vomiting, sweating, and diarrhea, so vertigo patients often experience nausea and vomiting.
Consultation of vertigo
After the onset of vertigo, many patients go to neurology first, but in fact, more than 80% of vertigo is caused by inner ear lesions. For elderly patients who have their first vertigo attack, or patients with cardiovascular disease, we recommend that they first consult a neurologist to rule out cerebrovascular disease. Patients who have recurrent attacks with similar symptoms each time, no difficulty in vocalization or swallowing, clear consciousness, and normal sensation and movement of the limbs can be seen in the ENT department.
At present, the diagnosis of vertigo disease depends mainly on medical history and physical examination, so it is very important to present the condition accurately to the doctor for the correct diagnosis and treatment of the disease.
We should tell the doctor the specific symptoms of vertigo (whether there is rotation, self or peripheral rotation, and the direction of rotation), the frequency and duration of the attacks, whether there are any triggering factors (whether it is caused by a certain action, what you are doing when the vertigo attacks), whether there are any auditory symptoms (which ear hearing loss, tinnitus, dullness), and whether there are other accompanying symptoms (such as vision changes, vocal disorders, difficulty in swallowing, changes in consciousness, etc.). difficulty swallowing, altered consciousness, headache), any underlying physical diseases (such as hypertension, hyperglycemia, heart disease), any past headaches and motion sickness, any family members with a history of vertigo or headaches, etc.
Many patients will emphasize that they have symptoms of sweating, vomiting, or diarrhea, but these symptoms are not specific and are caused by vertigo itself and play little role in the differential diagnosis of vertigo.
In the examination of vertigo disease, hearing test is very important, it can reflect the involvement of inner ear. If patients feel tinnitus and stuffy ears or hearing loss, they must check their hearing, and if they have hearing loss, they should also observe the dynamic changes. Vestibular function tests can observe whether the patient has decreased function and asymmetry, and whether there is nystagmus. If there are multiple brain nerve function abnormalities or if there are limb sensory and motor deficits, MRI needs to be checked to rule out cranial lesions.
Common inner ear disorders that cause vertigo.
1. Benign paroxysmal positional vertigo
This is the most common type of vertigo. About one-third of the patients who come to the hospital with vertigo are suffering from this disease, and the percentage is higher in elderly patients. This kind of vertigo often occurs after changing head position, such as drying clothes, picking up objects with low head or tying shoelaces, lying in bed or turning over, and most patients have strong vertigo. Patients with mild symptoms may only show vertigo when turning their heads or walking unsteadily. A dislodged and displaced otolith can be easily treated by repositioning, and an experienced physician can bring relief within a few minutes.
2.Ménière’s disease
Also known as Meniere’s disease in the past, the typical symptoms are episodes of vertigo, tinnitus and fluctuating hearing impairment. Episodes of vertigo often last longer than 20 minutes to several hours and are often accompanied by vomiting, nausea or diarrhea, but no other neurological symptoms in the brain. The hearing curve is mostly low-frequency decline. In atypical Ménière’s disease, there is no hearing loss and the diagnosis is sometimes not easily confirmed in the early stages.
The cause of Ménière’s disease is unknown, but the pathology of the temporal bone after the patient’s death revealed endolymphatic effusion, which may be the pathological mechanism or the result of the disease. After the vertigo attack, the patient rests in bed for a few hours and most of the symptoms are relieved, or the vertigo symptoms can be controlled with drugs such as Halohypnin. In terms of prevention, it is now mostly advocated to have a light diet, limit salt intake, drink less coffee and strong tea, not to smoke or drink alcohol, and pay attention to rest. There is a misconception among patients and some doctors that if water accumulates in the inner ear, they should restrict drinking water, which is not true. Patients with Meniere’s disease are encouraged to drink water instead of restricting it.
3. Vestibular neuritis
Viral infection or activity causes inflammation and impaired function of the vestibular nerve, with sudden onset of vertigo, vomiting and nystagmus. There may be tinnitus but no hearing loss. The patient’s vertigo symptoms are heavy and prolonged, often extending over several days. Treatment advocates hormonal control of inflammation, short-term use of sedatives to control symptoms, and encouragement of functional exercise after vertigo subsides.
4.Sudden deafness with vertigo
The symptoms of vertigo are similar to those of vestibular neuritis, but accompanied by hearing loss. In addition to controlling the symptoms of vertigo, these patients need to treat hearing loss as soon as possible, and sometimes, because the symptoms of vertigo are very heavy, patients may ignore the symptoms of hearing loss and delay the treatment.
5.Auditory neuroma
It often starts with tinnitus and high-frequency hearing loss, which may be accompanied by a sense of gait instability. In the late stage, there are other symptoms of cerebral nerve, progressive hearing loss, sometimes headache, etc. Early diagnosis can be made by special hearing tests, CT or MRI images. Surgery or Gamma Knife treatment is used after the diagnosis of this disease.
6.Other otogenic vertigo diseases
Patients with hallux valgus can get vertigo after loud stimulation, forceful exclusion of air or pressing the ear screen. Labyrinthine fistula is often caused by cholesteatoma that damages the bone wall of the semicircular canal, and vertigo is often present after pressing on the ear screen. Labyrinthine fistula can also be confirmed by CT, and the bony defect of the semicircular canal can be repaired after surgical removal of the lesion.
Rehabilitation and prevention of treatment
During vertigo attacks, patients often cannot eat well, and with vomiting, they are prone to water and electrolyte balance imbalance. Therefore, it is necessary to supplement water and nutrition by eating less and more meals as much as possible, and those who have difficulty in eating can maintain fluid balance by intravenous rehydration. Inner ear vertigo can often be relieved quickly after treatment, but after the acute vertigo symptoms are relieved, patients often have balance disorder, which is caused by decreased vestibular function or asymmetry on both sides. Patients should be encouraged to move more, especially head movement in all directions. Usually, we should pay attention to light diet, no coffee and strong tea, no smoking and no alcohol to prevent cardiovascular diseases.