siliconindia | | July 20189systems, helps to attain a sense of bal-ance & equilibrium. An imbalance in any of the four systems leads to a sense of disequilibrium and needs to be restored. Causes of Vertigo The different causes of vertigo may de-pend on the system involved. Vertigo can result from a viral or bacterial in-fection of the inner ear. If the labyrinth is involved, the symptoms may usually be described as a sensation of spin-ning of self or surroundings and may be associated with nausea & vomiting, ringing in the ears, ear discharge, ear blockage, reduced hearing, and many more. However, the person is fully conscious and doesn't have symptoms like blurring of vision, double vision, headache and fainting, which are more characteristic of involvement of the central nervous system. Other causes include certain drugs like aminoglyco-sides, anticonvulsants, antidepressants, antihypertensives, barbiturates, co-caine, diuretics, quinine and sedatives/hypnotics. Stroke, brain tumors and neurological disorders may also be re-sponsible for vertigo. A careful analy-sis of the symptoms and the findings in the affected person is mandatory to dif-ferentiate the type of vertigo and there-by, arrive at a conclusion about further investigations and management. Approach to a Case of VertigoElucidating the complete chronology of the events lead-ing to the episode of vertigo is a prerequisite for deciphering its cause. Vertigo is an illu-sion of movement, of-ten horizontal and/or rotatory. A detailed history, including medications, is fol-lowed by a detailed examination of the ear, nose, throat and relevant tests like an audiogram, when indicated. Spontaneous horizontal nys-tagmus (which is an oscillating type of movement of the eyeballs) is consistent with peripheral vertigo like acute laby-rinthitis or acute vestibular neuronitis. Patients with peripheral vertigo have impaired balance and rotational gid-diness, whereas patients with central vertigo have more severe instability and often cannot walk or even stand without falling. Vertigo, which occurs with changes in the position of the head or body is called Benign Parox-ysmal Positional Vertigo (BPPV). This needs to be excluded by both history and Dix-Hallpike's test to check for any vertigo or vomiting provoked by changes in position. Detailed neurological examina-tion, which includes testing the cranial nerves and the cerebellar functions is also mandatory. Positional provocation tests like the tilt table test to exclude variations in blood pressure with posi-tion may be necessary in specific cases. Specific investigations like electroco-chleography are indicated for confir-mation of certain inner ear disorders like Meniere's disease in which there is fluid accumulation in the inner ear. Last but not the least, radiologic studies like High Resolution CT Scan & MRI may be needed to exclude specific causes like tumors in the auditory nerve, brain tumors & brain hemorrhage de-pending on the particular clinical scenarios. Management of Vertigo Management of an episode of vertigo includes treat-ment of the immedi-ate symptoms in acute phase followed by the rehabilitation phase, which includes exer-cises for prevention of future episodes of vertigo.The initial management varies de-pending on the cause of the vertigo as elucidated by the treating doctor. Cer-tain acute forms of vertigo like laby-rinthitis respond well to complete bed rest and medications. Others like BPPV need definite interventions like Epley's maneuver to reposition the displaced otoconia (balance particles in the inner ear). If the investigations lead to causes like brain tumors or brain hemorrhage, they need to be managed by a neurolo-gist or neurosurgeon. Most forms of vertigo will need long-term rehabilitation with exercises, which are called Vestibular Rehabili-tation exercises to retrain the balance functions of the inner ear. Summary Taking a thorough history is the most crucial step in the treatment of vertigo and a multi-disciplinary approach al-ways goes a long way in the manage-ment of this disabling condition. It is important to assuage the fears of the patient and counsel him adequately to understand the nature of vertigo. Taking a thorough history is the most crucial step in the treatment of vertigo and a multi-disciplinary approach always goes a long way in the management of this disabling conditionDr. Vijay Rangachari
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