By Mara Brugés Polo
Is vertigo properly diagnosed? During Colombia’s Otology Week in Bogotá, a workshop was held on vestibular disorders with a practical approach.
Mexican otorhinolaryngologist Jorge Madrigal, founder and medical director of the MedBalanZ Clinic, directed this session and explained the physiological foundations and the technique involved in the vHIT (Video Head Impulse Test), which consists of a cephalic impulse test quantified by evaluating the equilibrium of the inner ear through a high-speed mini video camera through which the vestibular ocular reflex gain is obtained, comparing the speed of ocular movement with that of the head, in other words, the reflex between the eyes and the balance system.
Vertigo is Not the Same as Dizziness
In order to understand different pathologies associated with hearing loss, one must differentiate between vertigo and dizziness, two totally different concepts that are widely conflated. When someone has a subjective sensation of movement, either their own or that of their surroundings, but without this actually being the case, we are talking about vertigo. In the case of dizziness, the sensation is different, since this is loss of balance and can be associated with a sensation of bewilderment in the head.
Guatemalan Dr. Carlos Alfonso Figueroa Recinos, general surgeon and otorhinolaryngologist, currently second-year resident at the Nueva Granada Military Hospital, explained that “some vertigo or dizziness cases are not diagnosed because the specialists involved are not familiar with certain conditions that involve vertiginous symptoms.”
Among the most common causes of dizziness and vertigo are phobic postural vertigo, vestibular migraine, and chronic subjective dizziness. The otoneurological examination for the first and third of these generally brings a normal result, so if the doctor does not know the pathology or is not familiar with the prescription of anti-depressive medicines or those exclusively for migraine, the patient will not receive correct treatment.
It is normally believed that an otorhinolaryngologist will spot vertigo, but the fact is that only 35 to 40% of the causes behind a case are found; the rest fall to other professionals, among them neurologists and psychiatrists. Benign paroxysmal positional vertigo is the most common cause of vertigo in all ages. Meanwhile, phobic postural vertigo presents in 12% of cases and can be suffered by middle-aged patients with obsessive-compulsive or hysterical personalities. In these cases, the otorhinolaryngologist is not fully aware of many of the medicines this type of patient needs, and this leads to barely-effective treatment and imprecise diagnosis.
Experience shows that benign positional vertigo is the most diagnosed kind among Colombians; this is the most common cause of chronic dizziness in middle-aged patients presenting subjective dizziness and balance disorders. It affects patients with obsessive-compulsive or hysterical personalities who present a combination of non-rotational vertigo with fluctuating subjective postural imbalance. Generally, the symptoms follow periods of stress or can develop after suffering a vestibular dysfunction (vestibular neuritis or any type of illness, flu for example). The percentage increases following cervical whiplash syndrome (fracture or soft tissue sprain in the neck) and cranial trauma.
There is also a classification for vertigo associated with functional disorders, in other words pathologies or conditions whose cause is not structural but function-related, among the most common being vestibular migraine, a type of vertigo associated with migraine but distinguished by the patient having no headache when experiencing vertigo symptoms. Approximately 35% of ‘migraine’ patients have a complaint of the vestibular system or balance system.
Finally, there are patients who are suffering from somatomorphic complaints, those which have no organic cause and respond to an adverse balance event; among the most common are phobic postural vertigo and chronic subjective dizziness. The first is distinguished by a combination of non-rotatory vertigo, short attacks of non-rotatory oscillation with fluctuating subjective positional imbalance, in patients with an obsessive-compulsive or hysterical personality.
Generally, the symptoms follow periods of stress or can develop after suffering a vestibular dysfunction such as B.P.P.V. (benign paroxysmal positional vertigo) or vestibular neuronitis. Diagnosis is based on unsteadiness and dizzy spells occurring in vertical position while in movement in a patient with a normal neurological examination. Meanwhile, chronic subjective dizziness is a very common vestibular disorder that is identified when patients present persistent non-vertiginous dizziness, unsteadiness, and an increase in sensitivity to movement stimulus.
These symptoms can last months or years following an acute vestibular event, and are not associated with vestibular abnormalities or oculomotor reflexes. In 50% of cases, patients have anxiety-related or depressive personalities, and they feel dizzy but this is not vertigo. Treatment is through anti-depressive medicine.
“Half a Loaf is Better Than None”
This is the expression used by Dr. José Antonio Rivas with regard to a problem his Colombian scientific peers are tackling, one that requires auditory imaging, a specialty that enables greater precision in diagnoses when it comes to evaluating peripheral vestibular function through the latest techniques, including x-rays, TAC, and magnetic resonance scanning of the ear and ear with brain.
“We have been lucky enough in Colombia to have doctors who want to work exclusively in imaging for the hearing sector, and you need this because in countries with them it works well for these specialists and they have come to play a key support role in identifying the problems of patients with pathologies in the head and neck organs,” explained Rivas (photo below).
In fact, being a ‘head and neck radiologist’ in Colombia would be a very new thing in itself, since the specialty is not present in all Latin American countries, so this rise must be a promising trend; however, the reason radiologists give for not working exclusively in this area is that there are other imaging fields that bring more economic reward.
“While there are professionals in Colombia who support us, they are not devoted entirely to this area, so sometimes we have to learn how to interpret these images somewhat, though as they say: half a loaf is better than none, and although we are not experts, we get on with the task,” concluded Rivas.
14th Otology Week took place in March 2016.
Source: Audio Infos Latin America; images courtesy Bajstock, Clínica Rivas, M.B.P.
Editor’s Note: By mutual agreement, this article is republished with permission from Audiology World News, where it originally appeared on August 11, 2016.