How is vertigo diagnosed and treated in Singapore?

Doctor's Answers 3

I hope you are well now - giddiness can be very debilitating and dramatically affects one's daily functioning due to their unpredictability.

If your giddiness had been a sensation of the room spinning, that would be vertigo.

If the giddiness worsened with changes of position, the most common cause would be benign positional paroxysmal vertigo (BPPV).

However, giddiness is actually a very complex symptom which can be caused by many different system disorders in our body. The giddiness symptom is not very specific, and people describe it in different ways and experience it differently. Thus, if it is recurrent or persistent, a detailed and careful examination and investigation is needed to exclude less common causes.

Even whilst evaluating for an ENT cause (50% of the cases), I would need to see if there are suspicions of non-ear related causes like:

  • medications
  • dehydration
  • low sugar or anaemia
  • poor vision
  • orthopaedic/ heart/ brain disease.

Your question was how is vertigo diagnosed, and how you can get it treated.

I have found that a full battery of tests may be needed to do a complete examination of the balance system. During examination, I would check for neurological signs, eye movements, gait stability. I would do a Dix Hallpike Test to see if it is BPPV, and reposition the loose calcium stone in the inner ear during that same visit if it is indeed -BPPV.

Careful testing for positional vertigo of all 3 semicircular canals, not only the better known posterior canal, is needed, or there can be missed diagnoses. Simple checks to exclude Neck-spinal and neck-brain circulation and blood pressure changes are done.

I then get my in-house audiologist to do hearing test to exclude inner ear diseases and hearing nerve tumors as a cause of the giddiness. For the complex cases, my clinic will also be able to help with specialized tests of vestibulonystamography (VNG), VHIT, VEMP. The patient does not have to do much, as these are computerised testing and we read brain waves and monitor eye reactions.

What is most important about management is getting an accurate diagnosis. Oral anti-vertigo and anti-nausea medications help the acute giddiness. Injection of gentamicin or steroids into the middle ear may be used in specific instances, but we need to balance hearing and balance needs properly.

A course of balance rehabilitation therapy is often useful too, and it is important we teach the patients exercises that can be done at home regularly, and not only wait for their formal rehabilitation sessions.

Kind regards,

Dr Lynne Lim

Vertigo is a symptom whereby one experiences a sensation of the room or the person himself/herself spinning. It is not a diagnosis.

Quite often, patients with vertigo do experience nausea or even vomiting. The causes of vertigo can be divided into peripheral causes (due to a problem with the inner ear balance system) or central (due to a problem with the balance centre in the brain). Fortunately, majority of vertigo are peripheral. Amongst the common causes of peripheral vertigo include:

1. Benign paroxysmal positional vertigo (BPPV) - This is one of the most common causes of vertigo and is due to calcium deposits or crystals in the inner ear balance system (semicircular canals) The sufferer typically experiences vertigo that is triggered by head movements (e.g. turning the head to the left or right, getting up from bed or when tilting the head up). The vertigo can last between seconds to minutes. It can be diagnosed by a trained GP or an ENT Specialist who will perform a Dix Hallpike manouevre in the clinic. If the test is positive, the GP or ENT Specialist can perform an Epley's manouevre to dislodge the calcium deposits from the inner ear semicricular canal. From the clinical history that you have provided, this may be the cause of your vertigo.

2. Vestibular neuronitis - This is due to a viral infection of the balance nerve of the inner ear. Typically the sufferer experiences a sudden onset of vertigo which last for hours. It may also be associated with nausea, vomiting and tinntius (ringing sound in the ear). After an attack, the sufferer will likely feel groggy for a few days to weeks. The treatment usually involves medications or injections to suppress the signals from the balance system during an acute attack.

3. Labrynthitis - This refers to inflammation or viral infection of the whole balance system of the inner ear. The sufferer will experience vertigo lasting for hours to days, hearing loss and tinnitus. Treatment usually involves a course of oral steroids and medications to suppress the balance system.

There are many other potential cause for your vertigo including Meniere's disease (high pressure in the balance system of the inner ear) and vestibulopathy (weakness of the balance system of the inner ear) but these are less common and sufferers of these conditions tend to have a more prolonged history of repeated attacks of vertigo.

If your vertigo is a recurring symptom, you should visit a GP or an ENT Specialist for an assessment. Quite often, a hearing test will also be required.

Hope this helps and all the best!

I know what a terrible feeling it is to suffer an attack of vertigo, having had to endure the same thing myself last year!

Vertigo isn't a diagnosis but actually just a word used to describe a symptom of feeling as if the whole room and the objects inside it are spinning or moving round and round. It can certainly make you feel like vomiting! The fact that your vertigo becomes worse when you change position, suggests that it is more likely to be due to an inner ear problem, which we call "peripheral" in the ENT world, instead of "central" which refers more to abnormalities involving the brain.

We diagnose vertigo very much based on taking a careful detailed history from you, focusing on the duration, nature, frequency and severity of each episode, as well as asking you if there have been any other associated symptoms like hearing loss, headaches, vision problems or tinnitus (a buzzing noise in your ear). We would also try to find out if there have been any events which might have triggered the vertigo. For example, some of my patients have had a flare up of their vertigo after going on a rollercoaster ride, doing yoga or after a head injury accident.

You would then be carefully examined to make sure that your eyes, ears, nerve function, balance and walking pattern are normal. This is important as it would help us to decide if you may need an MRI scan of your brain and inner ear to rule out more worrying conditions such as rare strokes which can sometimes affect just the brainstem-inner ear junction and present in a similar manner here.

I will reassure you though that by far, the most common condition to cause vertigo is called Benign Positional Paroxysmal Vertigo (BPPV) which is due to tiny calcium crystals which have become loosened inside your inner ear. When you turn your head or change position, these crystals start to swirl round and round, giving rise to the spinning sensation of vertigo. Although BPPV is easy enough to treat with a special exercise we do in my clinic, it is very important that you get the correct diagnosis to confirm that it really is BPPV and to make sure that the correct ear is treated. What does not quite fit here is the fact that you also have headaches, a slightly more worrying symptom, that would indicate more of a need to arrange a scan for you.

Having spent part of my fellowship year in Toronto looking after many complex dizzy patients at a busy university clinic which took in patients whose own doctors found it difficult to help them, I am sure we can help you too but I certainly hope you're feeling much better by now!

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Dr Ethan has provided a good summary on the possible causes of vertigo. Vertigo is a type of giddiness whereby a patient feels that the room is spinning or he/she is spinning. If this is what you experience, then you should see an ENT Specialist first. Most vertigo are due to peripheral causes (meaning there is a problem with the balancing system of the ear). Central causes of vertigo (due to a problem in the brain) are fortunately much rarer.

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