Journal of Surgery Forecast: Vertigo: A Spectrum of Cases

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Research Article

Published: 27 Apr, 2018

Journal of Surgery Forecast


Vertigo: A Spectrum of Cases
Kumar M1 and Prasad BK2*
1
Department of ENT and Head & Neck Surgery, Maharashtra University of Health Sciences, Maharashtra, India
2
Department of ENT and Head & Neck Surgery, King George Medical University, Lucknow, India

Abstract
Background: Dizziness, including vertigo and disequilibrium, is a common clinical problem
affecting approximately one third of the population in one form or another at some time in their
life. The patient often finds it difficult to choose the specialty he should consult for his troublesome
disability. Epidemiology of vertigo is still an under-explored territory. Broad based demographic
studies have always shown that vestibular disorders are under-diagnosed and undertreated.
Methods: This study was conducted to evaluate cases of dizziness in Vertigo Clinic. All the patients
in ENT OPD were screened for symptom of dizziness. Thorough otoneurological examination was
done in all cases. Specialized tests of vestibulometry, radio-imaging investigations, biochemical
parameters and consultations with other specialists were done in needy cases. The results were
analyzed with special attention to the causes of otologic and non-otologic dizziness.
Result: Out of entire ENT outpatients, 2.21% presented with dizziness. Females were more affected.
The symptom was more common in elderly. Majority of patients had identifiable cardiogenic or
otogenic causes. Uncontrolled hypertension and BPPV were the commonest causes in Cardiogenic
and otogenic dizziness respectively.
Conclusion: Peripheral vertigo can easily be diagnosed and differentiated from other causes if
studied in details. Management of patients with dizziness can be effectively done through Vertigo
Clinic.
Keywords: Dizziness; Giddiness; Vertigo Clinic; Otologic; BPPV

Abbreviations
ENT: Ear Nose Throat; OPD: Out Patient Department; CT: Computerized Tomography;
OPEN ACCESS
MRI: Magnetic Resonance Imaging; BPPV: Benign Paroxysmal Positional Vertigo; TIA: Transient
*
Correspondence: Ischemic Attack
Prasad BK, Department of ENT and
Introduction
Head & Neck Surgery, King George
Medical University, Command Hospital Dizziness is one of the most common complaints among patients presenting to primary health-
(Central Command), Lucknow, UP, care physicians, neurologists, cardiologists and otolaryngologists. ‘Dizziness’ and ‘Giddiness’ are
India. common terms used by the patients to describe their condition when they feel unsteady, off balance,
Tel: +91-8698075965 rocking, swimming, walking on cotton wool, clumsy on their feet or dizzy in their head. These
Fax: +913324490079 symptoms are nonspecific and cover broad differential diagnosis which includes disorders like light
E-mail: bipin_rupa@rediffmail.com headedness, disequilibrium, ataxia, syncope and the true vertigo. They do not include the obligatory
Received Date: 02 Mar 2018 illusion of movement of either themselves or their surroundings, which is necessary to establish that
Accepted Date: 23 Apr 2018 they have true vertigo [1].
Published Date: 27 Apr 2018
The term ‘Vertigo’ has been derived from Latin words ‘Vertere’ meaning ‘to turn’ and ‘igo’
Citation: Kumar M, Prasad BK. Vertigo: meaning ‘condition of turning about’. Vertigo can be defined as a sense of feeling the environment
A Spectrum of Cases. J Surg Forecast. moving when actually it does not. It is an illusion of either oneself or the environment rotating
2018; 1(1): 1013. [2]. It is debilitating to the patients and frustrating for the clinicians. Due to the multi-causative
Copyright © 2018 Prasad BK. This is etiology of vertigo all patients reporting to various specialties like general medicine, cardiology,
an open access article distributed under neurology, neurosurgery, psychiatry etc are not evaluated at one single platform. Consequently, a
the Creative Commons Attribution basic limitation exists in evaluating the magnitude of the problem at large. There are few reports in
License, which permits unrestricted the world literature and very less in Indian literature on etiology and prevalence generated from
use, distribution, and reproduction in retrospective analysis of known cases of vertigo seen in the specialized vertigo clinics which are run
any medium, provided the original work by handful at tertiary level. A study was therefore conducted with the aim to give a general overview
is properly cited. of the approach to dizziness and to assess the importance of Vertigo clinic.

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Prasad BK, et al., Journal of Surgery Forecast

Table 1:
Patients with vertigo Percentage with respect to total number of patients
Subjects Percentage with respect to cases of vertigo
(n=234) (n=10555)
Male 99 42.30% 0.94%

Female 135 57.70% 1.27%

Total 234 2.21%


Prevalence among patients with true vertigo.

Table 2: department was 10555 out of which 234 patients presented with
Age group Number of vertigo patients Percentage of vertigo patients dizziness. Prevalence of dizziness observed was 2.21% with female
(years) Male Female Total Male Female preponderance (Table 1). Dizziness was more common in patients in
5th decade followed by 7th and 4th decade (Table 2).
10–19 - 2 2 - 0.85%

20–29 10 7 17 4.27% 2.99% Cardiovascular causes being 42.74% were the most common cause
30–39 21 29 50 8.97% 12.39%
of dizziness. Otologic causes of rotatory vertigo being 41.88%, came
a close second. Neurologic causes constituted 11.11% of all vertigo
40–49 23 35 58 9.83% 14.96%
patients. Other cause included psychogenic (1.71%), metabolic
50–59 13 21 34 5.55% 8.97% (0.85%) and miscellaneous (1.71%) (Table 3).
60–69 23 33 56 9.83% 14.10%
Benign Paroxysmal Positional Vertigo was the commonest
70–79 9 8 17 3.85% 3.42% otologic cause found in this study. It was seen more in females.
Total 99 135 234 42.30% 57.70% Meniere’s disease and vestibular neuronitis were the other common
Age distribution. causes. Some cases remained undiagnosed inspite of thorough
Materials and Methods evaluation (Table 4).

The study was conducted in Department of ENT and Head & Among the non-otologic etiology, cardiovascular causes were
Neck Surgery, in a tertiary care hospital of Indian Armed Forces. All the commonest with hypertension forming the maximum number of
cases (32.48% of all vertigo patients). In neurologic causes migrainous
the patients presenting in ENT outpatient department with sense of
vertigo was the commonest entity followed by cervical spondylosis
imbalance were screened. The patients were soldiers, ex-servicemen
(Table 5).
and the dependants of the soldiers and ex-servicemen.
Vertigo is often an untreated symptom and is frequently associated
Patients with dizziness were further evaluated in Vertigo Clinic.
with serious handicap and considerable psychological morbidity [3].
Detailed history was taken. Thorough clinical and otoneurological
Though a variety of etiology has been studied and described, the exact
examination was done. Bithermal Caloric test was done in all cases
cause often remains elusive.
except patients with tympanic membrane perforation and in patients
having spontaneous nystagmus. Pure tone audiometry was done in all Approximately one quarter of people experience dizziness at
patients presenting with vertigo associated with hearing loss. Further some time in their life and in 80% of cases this is severe enough to see
audio-vestibular examination which included impedance audiomerty, a doctor [4]. It usually begins in the fourth decade and attains highest
tone decay test, test for recruitment, brain stem evoked response prevalence in the sixth to seventh decade [5]. In this study, the highest
audiometry, electrocochleography and electronystagmography were prevalence was found in the fifth decade and lowest in the second
performed wherever indicated. Imaging studies such CT scan and decade. The overall prevalence in the dependant population of our
MRI were undertaken as indicated. Relevant blood tests including hospital was found to be 2.21%.
haemogram, biochemical parameters, glucose tolerance test, renal
Women (57.7%) were found to be affected more commonly than
and hepatic function tests etc were carried out as and when required.
the men (42.30%), the ratio being 4:3 approximately. Katsarkas in
Wherever needed, opinions of consultants of relevant departments
1994, in a study on dizziness in the elderly reported a prevalence of
like medicine, neurology, neurosurgery, cardiology, ophthalmology
63% in women as compared to 37% in men [6]. In another population
and psychiatry were obtained.
based study on incidence of benign paroxysmal positional vertigo,
Results and Discussion 64% of affected patients were women [7].
Total number of patients attending ENT outpatient It is important to ascertain whether patient has presented with
Table 3:
Percentage of prevalence
Etiology Number Percentage with respect to cases of vertigo Percentage with respect to total number of patients
(n=234) (n= 0555)
Otologic 98 41.88% 0.93%

Cardiovascular 100 42.74% 0.95%

Neurologic 26 11.11% 0.25%

Psychogenic 4 1.71% 0.04%

Metabolic 2 0.85% 0.02%

others 4 1.71% 0.04%


Etiologic spectrum.

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Prasad BK, et al., Journal of Surgery Forecast

Table 4:
Disease Number of patients Percentage with respect to otologic diseases

BPPV 43 43.88%

Meniere’s disease 19 19.39%

Meniere’s syndrome 5 5.10%

Vestibular neuronitis 13 13.26%

Labyrinthitis 3 3.06%

Chronic otitis media 7 7.14%

Miscellaneous / undiagnosed 8 8.16%

Total 98
Common otologic causes.
Table 5:
Category Etiology Number of patients Percentage Prevalence

Hypertension 76 32.48% 0.72%

Cardiovascular Anemia 21 8.97% 0.20%

Ischemic heart disease 3 1.28% 0.03%

Migraine 13 5.55% 0.12%

Cervical spondylosis 5 2.14% 0.05%

Neurologic Cerebellar tumour 3 1.28% 0.03%

Seizures 3 1.28% 0.03%

Cerebellar infacrtion 2 0.85% 0.02%

Metabolic Diabetes mellitus 2 0.85% 0.02%

Psychogenic 4 1.70% 0.04%


Miscellaneous
undiagnosed 4 1.70% 0.04%
Non-otologic causes of vertigo.

single episode of vertigo, recurrent episodic vertigo or chronic cases of vertigo, they attributed 32 cases (45%) to cardiovascular
dizziness. Vestibular neuronitis, acute labyrinthitis and brain stem diseases, of which hypertension alone accounted for 23 cases (32%).
stroke present with acute severe rotatory vertigo which is inevitably Overall prevalence of vertigo due to cardiovascular diseases in the
prolonged and is associated with autonomic symptoms. Identification general population was found to be 0.32%. Neurologic etiology was
of trigger factor is critically important for diagnosis in cases with found in 19.7% cases, common being cervical spondylitis (15.5%)
recurrent vertigo or dizziness. Certain triggering by head movements, and migraine (2.8%). Only 11.4% cases of vertigo were attributed
e.g. looking up, lying down or turning over in bed is highly suggestive to otologic causes of which BPPV formed 7% and Meniere’s disease
of BPPV. One should not think of cervical or vertebrobasilar vertigo 7.2%. Among the metabolic disorders associated with vertigo,
before excluding BPPV [8]. Triggering by loud sound or Valsalva diabetes mellitus was found to be the leading cause, accounting for
maneuver suggests labyrinthine fistula. Migraine associated vertigo 5 cases (7%).
may be triggered by anything that triggers migrainous headache.
In our study also, cardiovascular diseases were the commonest
Careful history taking to include associated symptoms is equally cause of vertigo (42.74%) as in the study by Abrol et al. This was
important for diagnosis in cases with recurrent vertigo or dizziness. followed closely by the otologic causes contributing 41.88%. Diabetes
Aura, aural fullness, tinnitus and hearing loss suggest Meniere’s mellitus was the only metabolic disorder found to cause vertigo
disease. Brain stem symptoms indicate TIA whereas palpitation, accounting for 0.85% cases. The analysis of otologic causes of vertigo
breathlessness, syncope etc suggest cardiac arrhythmia. showed benign paroxysmal positional vertigo to be the commonest
disorder constituting 43.88% of the total otologic causes which
In cases of chronic dizziness the clinician should also keep in
matched with the findings of Neuhauser et al [10].
mind the possibilities of general medical disorders, concomitant
visual handicaps, associated neurological disorders, excessive use of Meniere’s disease and vestibular neuronitis were the other
psychotropic and antivertiginous medication. common otologic causes. Four patients had strong psychiatric
element of depression. Only four cases remained undiagnosed after
Due to multi-causative etiology of vertigo, the patients report to
thorough evaluation in our vertigo clinic.
various specialists. They do not usually get evaluated at one platform.
Most published studies have, in fact, analyzed the prevalence of Conclusion
otologic vertigo based on known cases of vertigo who have already
In a survey of 10555 patients attending ENT OPD, 234 patients
undergone evaluation in specialized vertigo clinics. Their data,
had vertigo. The most common cause was cardiovascular causes
therefore tend to be biased in favour of otologic vertigo.
followed by otologic and neurologic causes. Peripheral vertigo can
In a study conducted by Raman Abrol et al [9] in the year 2001, easily be diagnosed and differentiated from other causes if studied
cardiovascular diseases were the leading cause of vertigo. Out of 71 in detail. This study conducted also emphasizes the importance of

ScienceForecast Publications LLC., | https://scienceforecastoa.com/ 3 2018 | Volume 1 | Edition 1 | Article 1013


Prasad BK, et al., Journal of Surgery Forecast

Vertigo Clinic. 5. Bhatia R, Deka RC. Clinical profile of cases with vertigo. Indian Journal of
Otolaryngology and Head & Neck Surgery. 1985; 37: 144-146.
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