Initial Approach to Patients with Balance Disorders

Abstract

Balance disorders can be due to many different reasons. Some possible causes are: Inner ear problems: Located in the inner ear, the vestibular system controls the balance of the body. Factors such as infections, traumas or aging in the inner ear can affect the vestibular system and cause imbalances. Brain damage: Damage to the brain, especially damage to areas responsible for balance control, such as the brain stem, cerebral cortex, and cerebellum, can cause imbalances. Nervous system problems: Nervous system problems can cause imbalances by causing problems in communicating with your body’s sensory information and motor functions. Medication side effects: Some medications can cause symptoms such as dizziness or unsteadiness as a side effect. Eye disorders: Visual disturbances, especially problems with coordination between the eyes or damage to the retina, can cause imbalances. Low blood pressure: Low blood pressure can also cause imbalance, especially when you get up suddenly or go to high altitudes. Stress and anxiety: Stress and anxiety can cause symptoms such as dizziness and unsteadiness in some people.

1. Introduction

Achieving balance depends on the harmonious functioning of the vestibular system, proprioceptive system, and visual systems. Disorders of the balance system can cause a wide range of symptoms, defined as vertigo, dizziness, and sudden falls of the patients.

Vertigo is not a disease name, it is a hallucination of the spinning of the patient himself or his surroundings, caused by an unusual stimulation of the vestibular system. These stimuli are either physiological or pathological. There are three systems that keep our balance [1].

2. Vestibular system

The vestibular system is the most important part of the human balance system. It consists of two parts:

1. Peripheral Vestibular System: Systems starting from the vestibular apparatus (semicircular canals, utriculus, and sacculus) till to the vestibular nuclei in the brain stem.

2. Central Vestibular System: It consists of parts starting from the brain stem to the cerebellum, formatio reticularis, thalamus, and vestibular cortex (Figure 1).

Figure 1.

Vestibular system.

When there is a problem in one of these systems, the cortex perceives this disorder as a movement and rotation of the body. Vertigo is the result of this misperception.

3. Proprioceptive system

They are the pathways that transmit position and movement signals from the joints and muscles to the brain.

4. Visual system

It is an important part of the balance system that informs the position of our head to the central vestibular system.

In addition, the cardiovascular and hematological systems are necessary for the correct functioning of the whole vestibular system.

Vertigo is the movement hallucination that develops with the unusual stimulation of these systems, either without a disease (physiological) or due to a disease (pathological).

A person becomes dizzy when he suddenly stops after turning around quickly several times. The event here is the unusual stimulation of the semicircular canals in the inner ear. Dizziness occurs in people who are not accustomed to looking down from extreme heights. These are examples of physiological vertigo. Pathological vertigos, on the other hand, are vertigos due to diseases that affect the systems that maintain our balance. Therefore, pathological vertigo requires a multidisciplinary approach [2].

When the patient comes to the doctor, he says “I feel dizzy” or “I have vertigo”. In such a case, our approach to the patient should be with an algorithm (Figure 2).

Figure 2.

Algorithm of evaluation of patients with vertigo.

The first step of the algorithm should be the inquiry, that is, ANAMNESIS.

Vertigo-causing diseases are usually either specific or have common characteristics with other diseases. For this reason, inquiries should not be made randomly, but with questions that will include the characters of those diseases. The most important way to affect the treatment of a patient with vertigo is correct anamnesis. When choosing these questions, it is necessary to know the diseases that cause vertigo.

These questions will make it easier to reach the diagnosis

1. Asking about the form and duration of complaints. It is a great guide in the differentiation of peripheral, central, cardiovascular, and psychic causes.

2. Factors triggering complaints. They are guiding questions in the differentiation of common causes of vertigo, especially vestibular migraines, BPPV.

3. Additional events accompanying the complaints. These are important questions, especially for the definition of Meniere’s disease, migraine, and some other central or psychic vertigos

4. Duration and continuity of the complaints. Asking whether the vertigo is in the form of attacks, whether it is continuous and if it is in attacks, the duration of the vertigo are questions that make it easier to distinguish peripheral diseases from central pathologies.

5. Self and family history. Asking whether the patient has other systemic diseases and family history may also help in the diagnosis.

5. Anamnesis questions

5.1 Forms of complaints

□ Turning sensation of one’s self or around – perıpheric or central pathology?

□ Feeling of fainting – usually neuro cardiogenic, orthostatic pathology?

□ Imbalance – usually central, proprioceptive or bilateral peripheral pathologies?

□ Sway – possible central pathology?

□ Tendency to fall to one side – possible unilateral peripheral pathologies?

□ Floating sensation – possible central, visual, psycho-somatic pathologies?

□ Feeling like walking in space – medications, possible metabolic disorders?

□ Vision darkening – possible vasovagal attacks, cardiogenic, orthostatic dysregulations?

□ Loss of consiousness – possible epilepsy.

□ or Other…………

5.2 Complaint initiating stimuli

□ Rapid head movement – peripheral pathology?

□ Head and body position changes – BPPV?

□ Walking in a dark room – proprioceptive, central pathologies?

□ Loud noises – migraine, superior SSC dehiscence pathologies? Meniere’s disease (Tullio phenomenon)

□ Blowing nose – labyrinthine fistula, SSSC dehiscence?

□ Some foods – migraine?

□ Stress – migraine, psychosomatic?

□ Standing up swiftly – orthostatic dysregulation?

□ Airplane or car ride – migraine, motion sickness?

□ In malls or supermarkets – migraine?, PPPD (persistent postural perceptual dizziness)?.

□ Menstrueal periods – migraine?

□ Exercise – migraine or cardiac diseases?

□ Head trauma – migraine or central pathologies?

□ or Other…………

5.3 Accompanying complaints

□ Hearing loss – unilateral Meniere, Labyrinthitis, tumor?; - Bilateral ototoxic medicaments, central?; □ Tinnitus – Meniere, Tumor?; □ Fullness in the ear – Meniere?; □ Fear, depression, crying, panic etc. –psychiatric, somatoform?; □ Double or blurred vision – vertebrobasillar disease, migraine, visual?; □ Photophobia – migraine?; □ Feeling of emptiness in the head presyncope – vasovagal?; □ Headache – migraine, hypertension?; □ Disorders in any organ (sight, smell, taste etc..) – epilepsy, migraine?; □ or Other…………

□ Hearing in echoes – acoustic neuroma, Meniere?; □ Impairement in walking – central or Proprioceptive pathology?; □ Nausea-vomiting – peripheral or central pathology?

5.4 Duration of complaints

□ Continuous; V. Neuritis, Migraine?; □ by İctal periods; Epilepsy?; □ 2–3 sec. Orthostatic,?; Psychogenic?; □ Minutes; Migraine, Meniere’s Disease?

□ Hours Meniere’s Disease, Migraine Stroke?; □ Days V. Neuritis,; Meniere’s Disease; □ Months.; Cardiogenic, Central Nervous system tumors?

Familial or past illnesses: …………?

To rank these diseases according to their incidence rates [3]:

1. The most common peripheral vestibular system diseases: benign paroxysmal positional vertigo (BPPV), vestibular neuronitis, Meniere, labyrinthitis.

2. The most common central vestibular system diseases: vestibular migraine, cerebrovascular diseases.

3. The most common deep sensory system diseases: spinal dorsal root diseases such as Tabes dorsalis, disk pathologies.

4. Eye diseases, Sudden visual disturbances.

In addition to the symptom of vertigo, some patients may complain of feelings such as imbalance, shaking, being pushed, a feeling of emptiness in the head, and dizziness, and may describe these complaints as dizziness. The Anglo-Saxons named such complaints DIZZINESS. In order to distinguish such complaints from true vertigo, the doctor should ask what the vertigo complaint is like in the anamnesis. First of all, the questions should be selected according to the symptoms of these diseases. Shows the questions that can lead to the diagnosis.

6. Bedside tests

These are the examinations to be done in the first place.

1. Nystagmus examination

2. Head thrust test (head impulse test)

3. Eye cover test for skew deviation

4. Positional tests

5. Head shake test

6. Balance tests (Romberg and Fukuda)

7. Cerebellar examinations (dysdiacokinesia, knee-heel test)

8. Blood pressure measurement and pulse assessment.

9. Nystagmus examination: Nystagmus is the involuntary movements of the eyeballs. In order to maintain our balance in head and body movements, external object images must fall into the fovea in accordance with the movements. This is provided by the vestibulo-ocular reflex (VOR). Here, nystagmus develops as a result of an imbalance in this vestibulo-ocular reflex. It is very diverse.

Nystagmus are classified according to their i. their direction, ii. their phases, and iii. Their severity.

Nystagmus are observed as horizontal, vertical, or rotatory according to their direction [4].

They are biphasic (fast and slow phase) or monophasic (single phase).

They are divided into three degrees according to their severity:

Fırst-degree nystagmus: nystagmus that occurs when looking at the lesion side. Second-degree nystagmus is seen even when the patient is looking ahead. Third degree nystagmus is the nystagmus flashing toward the sick side even when looking on the healthy side (Figure 3).

Figure 3.

Degrees of nystagmus.

These nystagmuses are either spontaneous, gaze (looking to one side), or occur as a result of a provocation. These provocations are revealed either by positional or head shake movements.

For nystagmus examination, the patient is made to look across, right, left, up, and down. It is determined whether there is nystagmus or no. If present, it is a sign of either peripheral or central pathology. Nystagmus of peripheral diseases and nystagmus of central diseases are often different:

6.1 Peripheral nystagmus

1 – Horizontal or torsional. 2 – Direction is unilateral, and it does not change with the direction of gaze. 3 – Visual fixation suppresses nystagmus. 4 – It gets better within days. 5 – Dizziness is evident. 6 – Tinnitus may accompany. 7 – There are no additional brain stem and cerebellar signs.

6.2 Central nystagmus

1 – It has pure vertical, pure torsional, pure horizontal, or mixed appearance. 2 – Its direction changes with the gaze direction or it can be unilateral also. 3 – Visual fixation does not suppress nystagmus. 6 – It does not improve within days. 7 – Dizziness may not be evident. 8 – It is usually not accompanied by tinnitus. 9 – Brain stem findings and cerebellar findings may be present.

1. Head thrust (impulse) test: in this test, vestibulo ocular reflex (VOR) is examined. The patient is told to look fixedly at the doctor’s nose, and the head is suddenly turned to one side. Normally, the eyes are fixed on the target even if the head is turned to one side. If it is observed that when the head is pushed to the lesion side, the eyes are directed to that side and then return to the target with a saccadic movement, and this is usually a sign of peripheral vestibulopathy (Figure 4).

2. In the skew deviatıon test, when the covered eye is uncovered suddenly, it is checked whether the eye makes a vertical movement or not. If there is such a movement, it is said that there is skew deviation. This is a sign of central pathology (Figure 5).

3. Positional tests: nystagmus during a positional test is the most common indicator of benign paroxysmal positional vertigo (BPPV) [3]. They may also give positive findings in some rare central or cervical events. Dix-Hallpike (Figure 6) and Roll tests (Figure 7) are done.

4. Head shake test: it is helpful in understanding the sick side in peripheral vertigo. Head shakes left and right several times and is stopped, and nystagmus begins to beat toward the healthy side [7]

5. Balance tests: Romberg and Fukuda.

Figure 4.

Head thrust test positive on the right: The eyes are directed to the side where the head is turned, then back to the target [5, 6].

Figure 5.

Skew deviation test: Vertical movement of the eyeball is considered pathological when the eye is uncovered. (a, B normal skew test; C, D pathological skew test).

Figure 6.

Dix-Hallpike maneuver: Nystagmus in addition to severe vertigo indicates the presence of BPPV.

Figure 7.

Supine roll test: The patient is placed on his back and the head is turned to the right and left and the nystagmus is examined. If nystagmus occurs, it is in favor of BPPV.

In Romberg, the patient stands up and is told to put his legs together and close his eyes. If the patient’s balance is disturbed when he closes his eyes, there is probably a neurological disorder in the deep sensory system. It requires neurology consultation.

In the Fukuda test [8], the patient is asked to step 50 times while standing, with his arms extended forward, with his eyes closed. It can be used to determine the side of the lesion in acute-stage vertigo. The patient deviates toward the lesion side.

1. Cerebellar tests: dysdiacokinesia (rotating one hand on the palm of the other hand) and knee-heel test (touching the heel of one foot to the knee of the other leg) are performed.

As a result of these preliminary examinations, it is tried to find out whether the vertigo is peripheral or central.

1. To rule out a cardiovascular pathology, blood pressure should be measured and pulse rate should be checked whether there is a rhythm disorder.

7. Most common peripheral vertigos

7.1 Benign paroxysmal positional vertigo (BPPV)

□ It is the most common type of peripheral vertigo.

□ Nystagmus is observed during acute transient vertigo attacks initiated by certaın head posıtıons and lasting seconds, mınutes. Nystagmus decreases in repeated tests (tired nystagmus).

□ Calcium carbonate crystals called otoliths, which are attached to the utriculus and sacculus, break off and escape into the semicircular canals, creating this type of vertigo.

• They occur after factors such as head trauma, viral infection, after vestibular neuritis, degenerative disease, hypertension attack, migraine, or idiopathic.

• A sense of movement arises due to the reception of different signals from the contralateral vestibular system.

□ It is diagnosed by history and posıtıonal tests (Dix-Hallpike or Roll maneuvers).

□ Particle repositioning maneuvers are commonly used in treatment. These maneuvers vary according to the semicircular canal where the otoliths are located (e.g. Epley maneuver, Gufoni maneuvers, etc.). It is necessary to refer to an ENT specialist.

7.2 Meniere’s disease

□ Pathogenesis: It begins as a result of insufficient absorption of endolymph and accumulation in the scala media of the inner ear (endolymphatic hydrops) [9].

□ Highest incidence (40–60 years),

□ Characterized by vertıgo, hearıng loss in one ear, tınnitus and a feeling of fullness in the ear, +/− falling attacks, nystagmus.

□ Vertigo (lasting about 20 minutes or 12 hours) disappears over time and the patient remains with only hearıng loss.

□ In the early stages of the disease, hearing returns to normal during attack-free periods.

With the repetition of attacks, unilateral, low-frequency hearing loss becomes permanent.

□ Treatment

Bed rest in the acute period, IV antiemetics, antivertiginous drugs (dimenhydrinate, betahistine) (Serc). Besides the attack treatment, the therapeutic measures later in the attack-free period are very important Long-term follow-up with an ENT specialist is recommended.

7.3 Vestibular neuronitis

□ Unknown etiology (it usually starts after an upper respiratory tract virus infections).

□ Severe vertigo with nausea, vomiting, and inability to stand or walk.

□ Acute symptoms may last 3 to 4 days (risk of dehydration from vomiting).

□ The central compensation period can leave the patient unstable for months [10].

□ Head thrust test is positive, and there is horızontal nystagmus beating toward the healthy side. Romberg is (+) toward the sick side. No hearing loss, no tinnitus, there is no feeling of fullness in the ear.

• Medications that suppress the vestibular system can be given in the first 48 hours to relieve vertigo, but they are not used continuously because they delay recovery. It is treated by an ENT specialist.

7.4 Labyrinthitis

This is an inflammation of the inner ear, mostly as a complication of middle ear infection.

□ They develop as a result of an infection of the inner ear, mostly due to an infection of the middle ear, rarely after meningitis (labyrinth).

□ Sudden onset of vertigo, nystagmus, nausea, vomiting, tınnıtus, and total hearing loss may be present. There is a history of ear discharge and pain.

□ It is treated with IV antibiotics and sent to an ENT specialist for middle ear drainage and mastoidectomy.

8. The most common causes of central vertigo

Vestibular migraine [11], transient ischemic attack [12] (TIA) in the central nervous system (vertebrobasilar transient ischemic attack), cerebellar or brain stem strokes (stroke), less commonly cerebellopontine angle tumors, demyelination, or vertigo due to alcohol and drug toxicity.

The head thrust test is normal in central vertigo. While the nystagmus is generally vertical, they can also be horizontal or horizonto-rotatory. Nausea and vomiting are common in TIA and stroke. Peripheral findings such as tinnitus, hearing loss, and a feeling of fullness in the ear do not generally occur in central diseases, unless the stroke affects the anterior inferior cerebellar artery. Cerebellar tests are usually pathologic.

Patients with peripheral vertigo should be referred to ENT physicians, and if central vertigo is suspected, neurology or neurosurgery consultation should be requested while referring them to radiology for computerized tomography (CT) or magnetic resonance imaging (MRI).

In addition to vestibular system examinations, cardiovascular examinations should be performed in the patient who comes with the complaint of dizziness. While looking for the presence of hyper or hypotensıon, the presence of cardiac rhythm disorder should also be checked, and if a pathology is found, cardiology consultation should be requested.

9. Treatment

Treatment for balance disorders depends on the underlying cause. Some medications, physical therapy, or surgery may be needed. In some cases, vestibular migraine lifestyle changes such as avoiding certain foods and activities that trigger symptoms can be sufficient to manage the condition.

If there is an acute peripheral vertigo disease, antivertiginous and antiemetic drugs are applied as symptomatic treatment to relieve the patient. If there is no contraindication, preparations such as dimenhydrinate, piracetam, trimethobenzamidem, and betahistıne can be applied most frequently in emergency services.

Peripheral pathologies should be referred to ENT specialists, and central pathologies should be referred to neurology or neurosurgery.