Dizziness: A Common Problem
Guest: Dr. Paul Lambert – Otolaryngology/Head & Neck Surgery, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Paul Lambert, Professor of Otolaryngology and Chairman of the department here at MUSC. Dr. Lambert, let’s talk, in this podcast, about something that’s such a common complaint for people, dizziness. If you have a patient that comes and says that’s their chief complaint, what are the sorts of questions you ask first to just clarify what’s going on?
Dr. Paul Lambert: Right, Linda. Thank you for very much. And, indeed, I think dizziness is one of the most common problems we see. It’s not only common, but it’s one of the more difficult things that we, as ENT physicians, take care of. And I think it’s difficult because of several things. First, the balance system is a very complicated system. It involves the inner ear, which is what we focus on, and, specifically, the balance canals within the inner ear, the visual system; something that we call the proprioceptive system, which is the nerves in our arms and legs that tell us where our limbs are in space, and then, of course, the brain which integrates all of that together, particularly the back part of the brain; the cerebellum. Any abnormality in those areas can cause dizziness, so it’s a very broad field to begin with.
Secondly, what one person describes as dizziness isn’t necessarily what another person experiences, so dizziness is a very broad term. For some, it’s a light headedness. For some, it’s a positional imbalance; when they move quickly. For others, it’s an actual vertigo, where things spin around. For, still, others, it’s simply an incoordination when they walk. So, we really have to dig down deeply in the history to try to ferret out exactly what a person means when they say dizziness.
We think of all the systems that I just mentioned. So, if someone has a problem with vision, with cataracts, that could be the etiology. Certainly, the cardiovascular system, the heart specifically, arrhythmias of the heart, high blood pressure, at times, can cause dizziness. Things that cause the nerves in our arms and legs not to work as well; neuropathies, which are common with diabetes, can cause imbalance, and then more serious things, such as a brain tumor. Fortunately, something like that is very rare. But that could, obviously, cause dizziness. Minor strokes; we call them TIAs (transient ischemic attacks), can be the etiology of dizziness. And, another huge category would be medication. Many medicines that we use, that are life-saving, medicines can, unfortunately, have a side effect of dizziness. So, we have to go very thoroughly into someone’s medication record. And then, simply, the aging process. I think everyone age 50 and above would agree that they’re not quite as coordinated now as they were at age 20. So, the aging process does affect the balance system.
So, all of these things have to be considered. As we discuss this with a patient, probably the most important thing is the history. We want to determine exactly what a person means when they complain of dizziness. And we look specifically for vertigo, which would direct us toward the inner ear. Vertigo is an illusion of movement. We would ask a person if, when they have this attack, the room is spinning, if objects on the wall are moving or not. So that, again, would direct us toward the semicircular canals of the inner ear.
Dr. Linda Austin: So, it’s the feeling, then, that you get if you turn around very fast, or if you spin yourself around? That’s vertigo?
Dr. Paul Lambert: Exactly. That would be vertigo.
Dr. Linda Austin: So, the other causes of dizziness, then, you would typically refer to other doctors, such as a heart doctor, or a brain doctor, or an eye doctor? Correct?
Dr. Paul Lambert: Correct. That’s right. So, if someone said, every time I get up very quickly from a seated position, I feel dizzy, that’s likely to be postural hypotension, for example. That could be medication-related. It could be heart-related. In addition to determining exactly what a person means when they say dizziness, we also look to see what the time course of that dizziness is. Is it seconds, minutes, hours, days? Has it been there for years? Each of those answers gives us a little hint. The inner ear, for example, would be more on the time scale of seconds to an hour. If someone says that they’ve had dizziness for years and years, that’s unlikely to be inner ear-related. And then, associated symptoms: are there any ear problems, such as hearing loss, tinnitus, fullness in the ear? That would, again, point us toward the inner ear. Do they have chest pain? That would, obviously, point us more toward the heart. The history takes up a large portion of the time that we spend with a patient, because it is, indeed, the most important.
Dr. Linda Austin: Now, what are some of the inner ear causes of vertigo, or dizziness, that you end up taking care of?
Dr. Paul Lambert: Yes. Probably the most common would be something called benign positional vertigo. That’s when a person turns over in bed, looks up quickly, turns quickly, and they have just a momentary episode of actual vertigo. So, it would last seconds or, perhaps, as long as a minute. And that, fortunately, can be corrected right in the office, in many cases, using a physical therapy technique. We have a specialist in our department, Dr. Jack King, who also does some of that physical therapy for some of the cases that are more persistent. But that’s probably one of the most common inner ear problems. And I would suspect that, maybe, 20 to 25 percent of the population, at some point in their life, have a bout of that. It’s usually self-limited. It may only occur for days or a week or two.
A second problem that we see frequently is Meniere’s disease. Meniere’s disease is dizziness; or vertigo, actually, that occurs and lasts hours, so not seconds or minutes, and not days, but hours. These spells are usually associated with a change in hearing, with fullness in the ear, and with a ringing-type sound, or a roaring sound, in the ear. That can be treated with medications, with avoiding salt. Rarely, a person would require surgery. But, obviously, we offer that only if they don’t respond to the conservative approaches.
There’s a newly diagnosed, or newly understood, condition of one of the balance canals where the bone is dissolved over a portion of the bony canal. Patients that have that condition, it’s probably congenital but then gets worse as they get older. They have a particular set of symptoms. They become dizzy to a loud sound. A clanging pot in the kitchen is a common scenario, or any type of loud sound that suddenly grabs them and causes them momentary dizziness. That usually requires a surgical procedure to correct, and that can be diagnosed.
We have very extensive testing, I’m sure the most extensive battery of balance testing available in the state. We do a number of different laboratory studies, x-rays, and then specific balance testing to try to determine which of these may be an issue.
Dr. Linda Austin: How about an infectious cause? I understand that vertigo can actually be caused by a virus.
Dr. Paul Lambert: Exactly. That is a type of dizziness that will last for days, and maybe up to a week or two. So, we think that a virus does get into the inner ear. And a virus can not only affect the balance side of the inner ear, it can also affect the hearing side of the inner ear. A person may have a sudden and complete loss of hearing. A person may have a sudden severe onset of vertigo, or they may have the two in combination. Typically, this type of viral process; we call it a viral neuronitis, puts a person to bed for three days, up to a week, or even two weeks, and then they gradually improve over time. But it can take months to actually improve. Fortunately, that’s relatively uncommon. But we can see it in all age groups of patients.
Dr. Linda Austin: Surely, somebody listening to this will have come to our website because they’ve just had an onset of vertigo. How long should that person wait before they get it checked out? Is it safe to just watch it for a few days and see if it gets better?
Dr. Paul Lambert: Well, I think it’s probably safe to watch it for a day or two, assuming that there are no other symptoms. If there was severe headache or any other type of neurologic symptoms, then they should probably get that checked out, because it could be an early sign of something more serious going on. But, assuming that it’s just some dizziness, they could probably wait a couple days and then, certainly, check with their primary care physician, or an ENT physician.
Dr. Linda Austin: So, in other words, stroke would not present that way unless there were other symptoms? Is that true?
Dr. Paul Lambert: That would typically be the case. It would be uncommon for a stroke to simply present with vertigo without something else. And that something else may be an incoordination of being able to move the hands or feed oneself. That would be something else; a severe headache, any type of visual change, any type of change with speech, any of those things. But, a lot of times, dizziness will resolve. It may have been something as simple as what a person ate. And, over the course of 24, 36 hours, that may subside. But, if not, it’s always best to check it out.
Dr. Linda Austin: How about following trauma?
Dr. Paul Lambert: The most common type of dizziness that follows trauma is, actually, the benign positional dizziness that, again, lasts seconds with a sudden head movement. A whiplash injury can cause some dizziness. The muscles of the neck are connected to the balance system of the inner ear, and that can cause a type of unsteadiness; not actual vertigo. And then, a severe head trauma, where there’s actually been a fracture, or something of that sort, which can disrupt the inner ear balance system. Fortunately, as initially stated, the balance system is a very complex system. You not only have the other ear from which you can compensate a loss on one side, but you have other systems. So, it’s a redundant system that allows the body to recover. There are some types of problems that we deal with in our specialty where we actually have to remove the entire inner ear from a patient, so the entire balance center on one side. And, within months; at least within six months, they are back to normal. The body has an amazing capacity to compensate after a particular loss.
Dr. Linda Austin: Dr. Lambert, thank you so much.
Dr. Paul Lambert: Thank you.
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