The Dizzy Patient
DISCLAIMER: We do NOT consider ourselves "dizzy" experts, but provide the following info as a service to patients. As we are an ENT practice, we will only perform the appropriate testing and evaluation to see if the ears and/or allergies are a cause of a patient's dizziness. Anything more needs to be arranged through your primary care physician or another specialist. Generally speaking, a neurologist is the specialist able to provide the most comprehensive evaluation of dizziness.
People experience dizziness in many different ways. Some people call their sense of dizziness or imbalance as a feeling of light-headedness. Others may describe it as feeling "drunk" or room-spinning. Even seizures and migraine headaches are sometimes reported as dizziness. As such, it is important that your doctor precisely determines what dizziness means for a given person and obtain information on when, how long, how often, and anything that may trigger a dizzy attack.
Figuring out what is causing a person's dizziness can be quite difficult because a doctor can't touch it, can't see it, can't feel it, can't smell it, etc. It is a sensation that is felt only by the patient and nobody else. As such, diagnosis requires a good history and potentially LOTS of testing.
Click here to try and diagnose your dizziness.
These are the KEY questions that must be answered in order to determine what kind of work-up a dizzy patient gets (from an ENT perspective):
- In exact detail, what does the dizzy sensation feel like (light-headed, drunk, spinning, black-out, etc)?
- How long does each discrete dizzy attack last for (this question refers to each dizzy spell rather than how long has the dizziness as a whole been going on for)?
- Is there anything that makes it come on?
- Do you know it is coming on and if so, how?
- Is there any associated hearing loss, tinnitus, or aural pressure?
Overall, depending on the exact nature and cause of the dizziness, people may describe their dizziness in many different ways (possible causes in parentheses):
- Light-headedness (blood pressure problems, carotid/vascular insufficiency, cardiac arrhythmias, lung problems, allergies, ETD, medication side effect)
- Room spinning or vertigo (BPPV, labyrinthitis, cervicogenic vertigo, stroke, TIA, Meniere's disease)
- "Drunk-like" sensation (medication side effect, allergies, stroke, TIA, neuropathy, spinal cord problem)
- Black-out sensation (seizures, blood pressure problem, carotid/vascular insufficiency, cardiac arrhythmias, lung problems, migraines)
- Unsteadiness (medication side effect, blood pressure problem, allergies, ETD, TIA, spinal cord problem)
- Faintness (blood pressure problems, carotid/vascular insufficiency, cardiac arrhythmias, lung problems, allergies, medication side effect)
- Dysequilibrium (blood pressure problems, carotid/vascular insufficiency, cardiac arrhythmias, lung problems, allergies, ETD, medication side effect, neuropathy, spinal cord problem)
- Inability to walk straight (blood pressure problems, carotid/vascular insufficiency, cardiac arrhythmias, lung problems, allergies, medication side effect, stroke, TIA, neuropathy, spinal cord problem)
- Tunnel vision (migraine, vasculitis, TIA)
- Seizures (TIA, migraine, epilepsy)
As one can see from the list, ears as a cause of a person's dizziness is quite small compared to other possibilities. Workup depends on how the dizziness exactly feels like and may include EKG, bloodwork, ENG, cardiac ECHO, 24 hour holter, 30 day cardiac event monitoring, audiogram, pulmonary function tests, carotid ultrasounds, MRI/CT scans, EEG, chest-x-rays, allergy testing, tilt-table test, etc. As such, one may need to have an evaluation by a neurologist, cardiologist, ENT, pulmonologist, endocrinologist, etc to uncover the cause of your specific dizziness. Once the cause is determined, treatment is based on addressing that specific diagnosis. As one can see, the human body's sense of balance is actually extremely complex making dizziness one of the most difficult symptom to diagnose and treat.
To understand how so many different parts of a person's body can cause dizziness, it is best to use the airplane analogy where walking straight is like flying an airplane straight.
An airplane is able to fly straight due to a complex balanced interaction between the pilot, the pilot's instruments, wiring leading from the instruments to the airplane, and engines. Should any one of these things go wrong, the plane starts to act "dizzy".
Listed below are some examples of why a plane may not fly straight (human body equivalent in parentheses):
- If the oxygen in the cabin (lungs) suddenly gets depleted, the pilot (or brain) becomes affected.
- If the oxygen has trouble moving (heart/vessels) from one part of the plane to the cockpit (brain).
- If poison is administered into the air (medications/poison/alcohol), the pilot (brain) becomes affected.
- If the instruments (eyes, muscles) aren't providing proper information to the pilot (brain).
- If the pilot (brain) becomes injured (stroke).
- If one of the wing engines (ears) suddenly dies or suddenly increases in power without the pilot's (brain) knowledge.
- If the wires (spine) leading from the cockpit (brain) to the rest of the plane malfunctions (whiplash injury or trauma).
As you can probably see, balance in a human body can be due to many different sources: the spine, eyes/muscles, ears, brain, lungs, cardiac, vessels, etc. and that's why the list of causes can be just as extensive: stroke, TIA, vision problems, migraines, headaches, muscle problems, spine injury (whiplash, spinal stenosis), lung problems (emphysema, COPD), cardiac arrhythmias, bradycardia, heart palpitations, carotid stenosis, medication side effects, allergies, labyrinthitis, Meniere's disease, BPPV, etc.
Given our practice is an ENT practice, we will only see if the ears or allergy is contributing to a person's dizzyness and our work-up will include an extensive history, audiogram, VEMP, ENG, MRI scan, and allergy testing. Anything more will need to be arranged through your primary care doctor or with another specialist.
Please contact your local physician for further care and treatment.
Please keep in mind that meclizine and dramamine only treat the symptoms of dizziness without fixing the underying cause and in some cases, may even make dizziness worse (more info here)! You can try to figure out what is causing your dizziness in order to address the root cause by following this flowchart. Regarding the OTC patch, this is NOT the same as the prescription motion sickness patch (scopolamine). Vitamin D3 appears to help decrease risk of BPPV, a very common cause of transient vertigo that occurs with head movements (more info on the relationship between vitamin D levels and BPPV can be found here).
Common ENT Specific Diseases That May Cause Dizziness:
Meniere's Disease:The dizziness with Meniere's disease is typically described as moderately severe spinning usually preceded by hearing loss, ringing, and ear pressure on only one side without any association with position changes. The dizziness can occur at any time at random and usually lasts anywhere from a few hours to days. Rarely lasts more than one week. Hearing loss that fluctuates occur baseline with or without dizziness. Workup includes audiogram, ENG, VEMP, allergy testing, and possibly MRI scan. Treatment is dietary changes first with elimination of salt, caffiene, and alcohol. If this fails, a diuretic is started. In some Meniere's disease patients, aggressive allergy management which may include even allergy shots (if testing positive) are found to be quite beneficial. Food allergies has also been found to be an important trigger (IgE and/or IgG) which can be treated with dietary modification. If conservative treatment fails, endolymphatic shunt surgery can be considered. If that fails, vestibular nerve ablation. Click here to read more about Meniere's Disease.
BPPV: Dizziness described as Moderate to SEVERE spinning that lasts from a few seconds to minutes. Never more than 15 minutes. Usually occurs with a head position change (ie, rolling in bed, turning to look behind you, etc). Workup includes audiogram and Dix-Hallpike maneuver. Treatment with Epley maneuvers is curative (generally). Click here to read more about BPPV.
Labyrinthitis: Also known as "inner ear infection," the dizziness is described as moderately severe spinning lasting several weeks to even months. Usually associated with hearing loss and ringing, though not always. Workup includes audiogram, MRI, and ENG. Treatment is usually high-dose steroids and home vestibular exercises.
Migrainous Vertigo: Dizziness described as moderately severe spinning with severe headaches lasting several hours to weeks. Associated with light and noise sensitivity. Hearing not usually affected, though noises may seem "louder" than normal. Treatment is a neurology referral.
Eustachian Tube Dysfunction (ETD): Dizziness described as a vague sense of imbalance. Lasts for days to weeks. Person usually complains of ear fullness and is actually the main complaint. Workup includes allergy testing and/or audiogram. Treatment is initially with various types of nasal sprays, allergy medications, and/or steroids. If medications fail to resolve, placement of ear tubes/adenoidectomy help. Other options include allergy shots or allergy drops. Click here to read more about ETD.
Allergies: Dizziness described as a vague sense of imbalance. Lasts for days to weeks. Person may or may not have other symptoms including ear fullness/popping/crackling, runny nose, sneezing, etc. Workup includes allergy testing and audiogram. Treatment is with allergy medications and/or allergy shots or allergy drops.
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