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'VERTIGO' IN GENERAL PRACTICE
V G Kasbekar
Hon. ENT Surgeon, Bombay Hospital, MRC Mumbai 20. Hon. Prof. of ENT, GMC and JJ Hospital.
Vertigo or diziness is a common symptom for which a patient seeks advice from his family doctor. He is anxious to get it investigated thoroughly for proper treatment. If the vertigo is recurrent inspite of the immediate treatment given to him, he inquires whether he should get a CT scan or an MRI done as he is conversant about the modern technological advances from the wide media publicity in the newspapers and TV programmes. More over by updating his medical knowledge on the internet, he feels he knows all there is to know about vertigo. He does not mind the cost of investigations, in his anxiety not to miss the diagnosis of a brain tumour or some serious disease he may have!The family physician has a very important role to play. Many a times his patient does not follow his advice about taking the full course of tranquilizers prescribed to him and is irregular in his follow up visits. He remembers to consult him only when the episode of vertigo recurs and is accompanied by nausea and vomiting. The physician has to render immediate relief by sedatives and stressing the importance of not to panic and rush for costly procedures unless indicated. Availability of modern facilities in cities does not mean every patient should be subjected to the trauma of investigations.
The majority of cases of vertigo are amenable to routine investigations and treatment by a family physician. In case of doubt he should consult an ENT surgeon and a neurophysician as they are the proper persons to decide what further investigative procedures would be advisable and useful for future management of the case.
There is no substitute to a good history taking. A careful clinical examination and routine laboratory investigations are helpful to diagnose the aetiological factors in majority of the cases. A careful history of the patient with vertigo is helpful to differentiate between lesions affecting the peripheral (labyrinth, vestibular nerve and vestibular nuclei) and central (brainstem, cerebellum and cerebrum) pathways of the vestibular system.
A short history of sudden onset indicates a peripheral lesion e.g. endolymphatic hydrops, acute labyrinthitis or a perilymph fistula. The onset of symptoms in case of an auditory neuroma is slow and gradual due to compensation by the central mechanism; hence the patient when first seen by a doctor, complains of unilateral deafness but no vertigo. In peripheral lesions the vertigo is severe, and disturbs the patient. The attack of gidiness in benign positional paroxysmal vertigo (cupololithiasis) lasts only for about 30 seconds and gradually abates; but in labyrinthitis, vestibular neuronitis and multiple sclerosis it lasts for about 24 hours. Patients with tumours of the cerebellopontine angle (central cause) experience constant imbalance. A history of sudden blindness or diplopia is suggestive of multiple sclerosis. A sensation of fullness of the ear, tinnitus and deafness indicate an aural cause. Vertigo may be aggravated by change in position or movement of the head; in a severe attack nausea, vomiting, pallor, sweating can occur and the patient may collapse. The character of vertigo changes in functional cases.
Vertigo as a symptom of a functional disorder is rare. But one has to be careful in making a diagnosis of Meniere’s disease, in patients who want to claim for a permanent disability certificate or avoid long routine hours of duty e.g. police personnel. They complain of vertigo and deafness.Such cases should be referred to the ENT Surgeon. These malingerers can be easily detected with special audiometry tests as the records show marked variations at different times! The observation of nystagmus is very useful. In peripheral lesions it is unidirectional, horizontal and the fine eyeball movements can be suppressed by optic fixation. In central lesions the nystagmus is multidirectional and horizontal or vertical with coarse movements and enhanced by optic fixation.
The family physician due to his long association with the family members, knows about their personal habits like smoking, drinking, temperament, hereditary and susceptibility to drugs. He knows about there being hypertension, TB or diabetes in the family. He knows about the drugs taken by the person which may be responsible for vertigo e.g. the ototoxic antibiotics (aminoglycosides), loop diuretics, anti-inflammatory and anti-malarial drugs and cytotoxic agents (cis-platinum, nitrogen mustard), and Alpha blockers (alfuzocin) prescribed for benign enlargement of prostate. A feeling of fullness or blocking of the ear or vertigo might be the early symptoms of ototoxicity. Tinnitus is a late symptom of sensorineural involvement.
Nonspecific symptoms as light headedness or diziness are not the usual symptoms of TIA - Transient ischaemic attacks. In carotid artery stenosis the focal symptoms may be sudden transient, blindness, diplopia, numbness, dysphagia or dysarthria indicating some cerebrocortical dysfunction; hemiplegia may be due to involvement of the long tract. Routine systemic examination particularly of the nervous system is essential. A family physician must keep in mind that patients suffering from anaemia, diabetes, obesity, hypothyroidism, rhythm disorders, hypertension and cervical spondylitis may present with vertigo as one of the symptoms.
11% of our population suffer from hearing loss and about 40 million suffer from otitis media. The vertigo is due to labyrinthine infection or a cholesteatoma. Early detection of deafness and treatment of otorrhoea in a rural population helps in preventing speech and language disorders developing later.
Patients having vertigo with aural symptoms e.g. tinnitus, deafness and ear discharge require an otoscopic examination to detect chronic otitis media or cholesteatoma. A tuning fork of 512 Kz is a useful instrument for a family physician. A Rinne test, Weber test and an absolute bone conduction test helps in differentiating conductive loss and sensory neural hearing loss. Conductive hearing loss is seen in cases of otitis media and early stages of Meniere’s disease while sensori neural hearing loss is seen in ototoxicity and tumours of the auditory nerve.
The patient must be referred to an ENT surgeon for removal of wax or debris and to confirm the clinical diagnosis arrived by the family physician. Further special investigations for vestibular function like Hallpike’s caloric test, ENG, may have to be carried out. Deafness can be investigated by pure tone audiometry, impedence audiometry, and special audiological tests like ABLB, Recruitment, tone decay, SISI. BERA, and MRI may be useful in selected ones.
Vertigo accompanied by some neurological deficit deserves referal to a neurophysician. A family physician should suspect diagnosis of an auditory neuroma in patients complaining of unilateral tinnitus, deafness and presence of pigmented patches and multiple nodular swellings on the body. Involvement of the VII and VIII cranial nerves are symptoms of pontine angle tumour. Simple tests like finger-nose, knee-heel shin and step test can be done to test for cerebellar function. A positive Rhomberg test indicates pathology in the balance mechanism.which are costly. It is easy for a family physician to screen out many cases of vertigo which he can diagnose and treat and refer only a few cases to an ENT surgeon and a neurophysician which he feels require confirmation of the diagnosis or further investigations thus making their task easier and more effective.
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