Dizziness: Causes and Solutions for Eye Movement Issues - Otolaryngology

Dr. Ye Dawei reply Otolaryngology

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Sir, I recommend that you avoid that type of exercise.
Additionally, using medication may lead to improvement.
Attached is an article for your reference:
A Discussion on Dizziness: A Voice from a Dizziness Specialist
I often treat patients with dizziness in my clinic.
From the initial discomfort of attending a specialized dizziness clinic around 1982 to now being able to listen to their pain, my journey in medicine has been filled with many reflections.
Dr.
Yang Yi-Hsiang, in his book "Dizziness Reception," describes this group of patients who can be both amusing and frustrating.
One of the biggest nightmares for any ENT resident is to receive a new patient complaining of dizziness.
I remember when Director Fan assigned me to the dizziness clinic, I, usually mild-mannered, raised my voice in refusal (I respect the director, but I fear dizziness even more :-)).
Those who have followed the dizziness clinic must have a deep impression of how these patients often provide irrelevant answers.
When asked how they feel dizzy, they might respond with complaints about their daughter-in-law's disobedience or their mother-in-law's harshness.
Thus, every Tuesday afternoon's dizziness clinic became a headache for me.

Once, an elderly woman complained about her dizziness and how one side of her head felt like it was splitting, then suddenly switched to discussing how she was mistreated by her mother-in-law in her youth and how fortunate her daughter-in-law is now.
I always took these opportunities to practice translating their complaints in my mind, otherwise, I wouldn't know how to get through those long afternoons.
I have forgotten the face of that elderly woman (they all look alike, even their walking and speaking styles), but I remember how she shed tears in front of me while saying, "I was so beautiful before I married into my husband's family.
When I was a conductor, many young men would deliberately take my bus; it was their torment that caused my migraines and 'dark dizziness'..." After her tears, I had to stop my mental gymnastics, unsure of how to comfort her.
However, after that experience, the time I spent on mental gymnastics during consultations gradually decreased, and my sincere listening to their complaints unknowingly increased.
Behind every patient lies a significant history; those non-academic complaints I once dreaded hearing have become the most pleasant melodies.
The domestic grievances of these dizziness patients have turned into the most intimate secrets shared between us.
After starting my practice, some dizziness patients still come to see me, as they require long-term medication, and I often refer them to the provincial hospital.
Once, a woman recounted her struggles to take her dizzy mother to a medical center in the metropolitan area, detailing how she faced difficulties getting leave from school.
After overcoming many challenges to secure an appointment at the medical center (for hearing tests, eye movement tests, or CT scans), she ultimately had to cancel due to the exhausting journey.
Without listening further to her complaints about unreasonable treatment at the hospital, I looked at the elderly woman sitting in front of me, unable to maintain an upright posture due to dizziness, and felt an indescribable tug at my heartstrings—was it excitement, compassion, or sympathy?
Treating dizziness, no advanced technology can replace a detailed medical history, thorough physical examination, and a compassionate attitude.
In general outpatient settings, the questioning often disrupts the flow of consultations, so I decided to allocate the first 20 minutes of each clinic session to schedule dizziness patients.
Although this added nearly an hour to my daily clinic time, it initially felt physically demanding (the comprehensive history-taking, local ENT examinations, eye movement tests, positional eye movement tests, head shaking tests, postural reflex tests, and stepping tests are quite exhausting), it has become a sweet burden.
If possible, and if there are enough patients, I hope to maintain this practice.
For colleagues who have referred dizziness patients to me, I always strive to treat them with respect.
Although I do not have eye movement charts, EEGs, CT scans, or MRIs, I hope to provide dizziness patients with better care than they would receive at a medical center.
Physiology and Pathology of the Human Balance System
The human balance system relies on visual, proprioceptive, and vestibular functions of the inner ear, also known as the "labyrinth." Renowned writer Yu Qiuyu mentioned in the November 5th edition of the United Daily News that the dizzying Palace of Knossos was home to a half-man, half-bull monster, which required Athens to send seven pairs of young men and women as sacrifices each year.
A young man named Theseus resolved to abolish this evil practice and, after consulting with his father, disguised himself among the youths to infiltrate Crete and find an opportunity to subdue the monster.
This endeavor was fraught with danger; his father promised to watch from a cliff and would signal success with a white sail or failure with a black one.
Theseus defeated the monster but became lost in the labyrinthine paths.
The daughter of King Minos fell in love with him and helped him escape.
Tragically, while at sea, the princess suddenly died, and in his grief, Theseus forgot to change the sail to white.
His father, seeing the black sail, jumped into the sea, believing his son had perished.

This poignant story illustrates the labyrinth's characteristic: once entered, one can only proceed along its spiral paths and never find the exit, which is why "labyrinth" in Latin means "pathway." Physicians studying the labyrinth (inner ear) often find its complex functions difficult to grasp, much like Theseus lost in the maze.

On the same day, another article titled "Understanding the Voice of Vincent" discussed the story of the Impressionist painter Vincent Van Gogh.
Modern medical research suggests that Van Gogh suffered from Meniere's disease, as evidenced by his letters indicating frequent experiences of tinnitus and dizziness in daily life.
His famous painting "Starry Night" has even been interpreted by ENT specialists as depicting the counterclockwise rotation caused by left ear pathology during a Meniere's episode, visible in the swirling patterns of the painting.
The disturbances of tinnitus, a feeling of ear fullness, and auditory hypersensitivity led him to famously sever his left ear and frequently argue with fellow artist Gauguin, further exacerbating his dizziness.

In my first year of college, I listened to Don McLean's song "Vincent," which begins with "Starry, starry night, paint your palette blue and gray..." At the time, I simply thought the melody was beautiful, unaware of the tragic life of the song's protagonist.
The vestibular receptors in the inner ear consist of two types of structures: three ampullae (crista ampullaris) in each of the three semicircular canals, and the maculae (saccule and utricle) in the otolith organs.
The semicircular canals are responsible for detecting angular acceleration and deceleration, such as rotation, pitch, and roll, while the otolith organs detect linear acceleration and deceleration in vertical (saccule) and horizontal (utricle) movements.
Constant velocity does not stimulate the vestibular system.
The vestibular system transmits gravitational and acceleration stimuli to the central nervous system, first to the vestibular nuclei in the brainstem, which then integrates information from the eyes and proprioceptors and sends it to five areas:
1.
The cerebral cortex, which interprets head position and spatial orientation.
2.
The cerebellum, responsible for muscle coordination to maintain balance.
3.
The ocular muscles, to maintain visual fields.
4.
The spinal cord, to maintain muscle tone for posture.
5.
The vagus nerve nuclei, to maintain normal gastrointestinal motility.
If any pathology affects the normal balance system, the vestibular nuclei will receive imbalanced signals, leading to the following conditions:
1.
The cerebral cortex interprets this as dizziness or vertigo.
2.
The cerebellum may cause ataxia.
3.
Excitation of the ocular motor nuclei may lead to nystagmus.
4.
Excitation of the spinal cord may lead to righting reflexes.
5.
Excitation of the vagus nerve nuclei may lead to retroperistalsis, resulting in nausea and vomiting.

Additionally, the cerebellum sends signals to suppress the function of the vestibular system on the normal side, reducing imbalance and promoting central nervous system compensation.
Discussion of Dizziness Disorders
Clinically, we often simply categorize dizziness into peripheral dizziness—indicating pathology limited to the inner ear—and central dizziness—indicating pathology in the brain, including motion sickness.
The central nervous system can compensate for inner ear imbalances, typically developing within one to two days and completing within three weeks.
Therefore, symptoms of peripheral vestibular disorders should not persist for more than four weeks.
Peripheral vestibular imbalance is always accompanied by nystagmus and dizziness.
Nystagmus, derived from Greek, means "to doze," as the head slowly tilts downward during drowsiness, and at a certain point, it suddenly corrects itself, resembling the eye movements of a dizzy patient.
Nystagmus consists of a slow phase followed by a rapid phase, with the slow phase controlled by the inner ear and the rapid phase reflexively controlled by the brainstem.

The phenomenon of visual fixation suppression means that keeping the eyes open can diminish or eliminate nystagmus; if this ability is lost, meaning that keeping the eyes open actually intensifies nystagmus, or if nystagmus occurs with eyes open but not closed, it indicates a central nervous system disorder.
Below are common dizziness disorders:
1.
Meniere's Disease: When the general public thinks of dizziness, they often think of "Meniere's," and even general practitioners may diagnose it as such.
However, there are not as many cases of Meniere's disease as one might think; many patients complaining of dizziness are often overdiagnosed by physicians.
Therefore, if the number of Meniere's cases is disproportionately high in a neurotology clinic, the physician's competence may be questioned.
In simple terms, if a patient presents with dizziness, tinnitus, and hearing loss, the physician will consider this disease.
The renowned Japanese physician Ichiro Chikuwata even described it as a "7-point disease" due to the following characteristics:
1.
Severe dizziness: It feels as if the world is spinning and can last for several hours, with the first episode being the most intense.
2.
Spontaneous dizziness: It occurs without any apparent trigger and can strike suddenly.
3.
Recurrent dizziness: Patients with Meniere's disease often experience repeated episodes, rarely having just one.
4.
Reversible dizziness: There are periods of complete normalcy between episodes, and dizziness does not persist for days.
5.
Dizziness accompanied by cochlear symptoms: Patients often experience fluctuating hearing loss, with severe tinnitus during acute episodes, and sometimes perceive sounds at different frequencies.
6.
Hearing loss is often more pronounced at lower frequencies.
7.
A "reverberation phenomenon," where patients complain of sensitivity to loud noises, feeling uncomfortable in noisy public places like markets or train stations.
To date, no laboratory tests can definitively diagnose Meniere's disease, making detailed medical history and basic physical examination crucial.
Patients often experience unforgettable episodes of severe dizziness accompanied by tinnitus, a feeling of ear fullness, and hearing loss.
These episodes do not occur daily and last longer than the brief episodes seen in benign paroxysmal positional vertigo (BPPV) or the days-long episodes of vestibular neuritis.
Most patients experience dizziness for about 3 to 4 hours before gradually improving, only to have another episode weeks later.
Many elderly patients report having recurrent dizziness since their youth, with gradually worsening hearing and constant tinnitus.
This disease typically occurs between the ages of 20 and 40 and has a maternal inheritance pattern.
The cause is believed to be endolymphatic hydrops in the inner ear, leading to a sensation of ear fullness.
Treatment primarily involves medical management, including neuroprotective agents, vasodilators, and mild sedatives.
If episodes occur once a month, treatment should last at least four months; if they occur every two months, treatment should last at least five months, which is the interval between episodes plus three months.
If medication is ineffective or the patient cannot tolerate long-term medication, endolymphatic decompression surgery may be considered.
2.
Vestibular Neuritis: The eighth cranial nerve, which innervates the inner ear, consists of the cochlear nerve for hearing and the vestibular nerve for balance.
The vestibular nerve is more susceptible to viral infections, which can cause severe dizziness.
Its characteristics include:
1.
Severe dizziness, often preventing the patient from getting out of bed, but without symptoms of cochlear nerve involvement like tinnitus or hearing loss.
2.
Typically occurs in individuals aged 20 to 50.
3.
Dizziness often occurs only once but can last for several days, while the sensation of imbalance may persist for weeks or even months.
4.
The affected ear may show a reduced response to water irrigation, with no dizziness and no central nervous system symptoms.
5.
Patients usually recover within six months.
6.
A recent history of upper respiratory infection within the last 1 to 3 weeks.
3.
Benign Paroxysmal Positional Vertigo (BPPV): As the name suggests, this is a benign, sudden-onset condition related to changes in head position, known as BPPV.
Its characteristics include:
1.
Dizziness occurs when the head is turned to a certain angle but resolves with a change in position.
For example, lying on one side may trigger dizziness on that side.
2.
Dizziness typically lasts only seconds and does not exceed 30 seconds.
3.
There is a latency period of about 5 to 10 seconds before dizziness and nystagmus occur when the head is turned to a certain angle, and it gradually subsides after maintaining that position for about 5 to 45 seconds.
Repeated head movements can alleviate dizziness.
4.
Dizziness episodes are often accompanied by autonomic symptoms such as nausea, vomiting, and cold sweats, but there are no symptoms of cochlear nerve involvement like tinnitus or hearing loss.
5.
When the head is in a hanging position, clockwise nystagmus is observed, and upon sitting up quickly, counterclockwise nystagmus is seen, which is a unique counter-rolling phenomenon of BPPV.
Regarding the pathogenic mechanism of BPPV, Dix and Hallpike noted in 1952 that the pathology is not in the brain but in the utricle of the inner ear.
Harvard's Schuknecht further theorized that the condition arises from dislodged otoliths that float into the endolymph of the semicircular canals, stimulating the sensory receptors and inducing dizziness.
What causes otoliths to dislodge?
1.
Head trauma is the most common cause.
2.
Noise exposure, such as shooting.
3.
Drug toxicity, such as with gentamicin or streptomycin.
4.
Chronic otitis media affecting the otolith organs.
5.
Surgical trauma to the utricle.
6.
Obstruction of the vestibular artery supplying the utricle.
7.
Aging.
The utricle and saccule are both otolith organs in the inner ear, with the semicircular canals responsible for rotational sensations and the otolith organs responsible for linear motion sensations.
The saccule detects vertical movements, while the utricle detects horizontal movements.
Even without treatment, the otoliths floating in the endolymph will eventually dissolve on their own, leading to spontaneous recovery within 3 to 6 months.
Medications can alleviate symptoms, and patients are encouraged to slowly turn their heads toward the affected side to reduce dizziness.
4.
Sudden Hearing Loss: "Sudden" means that the patient can clearly indicate a specific day or even moment when they suddenly lost hearing or experienced significant ringing.
This is considered an ENT emergency, and patients are generally advised to seek immediate hospitalization.
Some patients may also experience dizziness and vomiting, necessitating differentiation from Meniere's disease.
Typically, dizziness occurs only once, lasting a day or several days, and does not recur, but hearing loss and tinnitus persist.
Meniere's disease, on the other hand, tends to have recurrent dizziness with quicker recovery of hearing after episodes.
Some cases of acoustic neuroma may also present with sudden hearing loss, requiring CT scans for differential diagnosis.
The causes are widely accepted to include inner ear circulatory disturbances, viral infections, and autoimmune diseases.
Treatment has shifted from a "shotgun" approach to targeting the specific underlying cause in each case:
1.
Inner ear circulatory disturbances: This occurs due to obstruction or spasm of the blood vessels supplying the inner ear, leading to hypoxia and hearing impairment.
It is more common in patients with systemic vascular diseases such as diabetes, hypertension, or hyperlipidemia.
Treatment focuses on plasma expanders (e.g., Dextran), which is a glucose polymer that reduces blood viscosity and prevents thrombosis.
2.
Viral infections: Many viruses can infect the inner ear, such as the rubella virus, cytomegalovirus causing congenital deafness; mumps virus, measles virus, herpes zoster virus, and the recently prevalent influenza virus can cause acquired deafness.
Treatment involves administering corticosteroids, starting with a dose of 60mg for six days, then tapering over two weeks.
3.
Autoimmune diseases: Patients often have systemic autoimmune diseases, such as lupus or rheumatoid arthritis, and may experience bilateral hearing loss.
Diagnosis is based on medical history, physical examination, and ENG (electronystagmography) findings to differentiate between central and peripheral causes.
Patients are generally advised to be hospitalized for at least a week; if hearing does not improve, they may be discharged; if it does improve, they may stay for another week.
During hospitalization, daily hearing tests and monitoring of eye movement changes are conducted, with follow-up every two weeks after discharge for three months.
Several indicators affect prognosis: 1) The earlier treatment is initiated, the better the prognosis; 2) High-frequency hearing loss indicates a poorer prognosis; 3) Patients with dizziness have a poorer prognosis, while those with tinnitus retain cochlear nerve function, indicating a better prognosis; 4) Older patients tend to have a poorer prognosis.
5.
Cervical Dizziness: Each side of the neck has a vertebral artery connected to the basilar artery in the brainstem.
If cervical spine deformities, bone spurs, or foraminal stenosis compress the vertebral artery, it can lead to poor blood flow to the inner ear, causing dizziness.
This condition must be differentiated from BPPV; generally, cervical dizziness is shorter in duration, milder in symptoms, occurs at an older age, and lacks counter-rolling nystagmus.
Patients often report neck or shoulder stiffness and pain.
6.
Tumarkin's Catastrophe: Patients may suddenly collapse without warning, remaining fully conscious throughout the episode, which can occur several times a day.
The cause remains unclear, but it may be due to sudden loss of muscle tone in the affected side due to dysfunction of the otolith organs.
7.
Acoustic Neuroma: The acoustic nerve runs from the inner ear to the brainstem, with tumors most commonly occurring at the opening of the internal auditory canal (cerebellopontine angle).
Initially, patients may only experience gradual unilateral hearing loss or tinnitus.
This tumor grows very slowly, so even if it compresses the vestibular nerve, central compensation may prevent dizziness.
As the tumor enlarges and compresses blood vessels, it may lead to sudden hearing loss or dizziness, with symptoms becoming increasingly diverse as the disease progresses.
If the tumor is confined to the internal auditory canal and is less than 1 cm, it may be difficult to detect on CT scans.
Therefore, some have proposed performing a lumbar puncture to introduce air into the brain's ventricles, allowing the patient to lie on their side to see if air fills the internal auditory canal; if there is an acoustic neuroma, the air will not fill the canal.
This is known as "air CT," but it can cause headaches for about a week due to the air in the skull.
With the advent of MRI, even tumors smaller than 1 cm can be easily diagnosed.
If the tumor grows larger and extends toward the cerebellum or brainstem, it may pose a life-threatening risk.
Clinically, patients may present with normal hearing and no dizziness but show no response in auditory brainstem responses, necessitating consideration of this condition.
8.
Labyrinthine Dysfunction: I often use this diagnosis in my clinic because I frequently encounter patients who do not fully meet the definitions of the individual diseases, and the clinic lacks specialized instruments for differential diagnosis.
However, it can still be confirmed that the pathology is limited to the inner ear without involving the central nervous system, providing reassurance to both patients and their families.
Although this condition can resolve spontaneously (remember that the central nervous system has compensatory mechanisms), medication can shorten the course and alleviate suffering.
Central Dizziness: "Central dizziness" refers to dizziness caused by brain disorders, the most common being "vertebrobasilar insufficiency." This artery begins with the two vertebral arteries in the neck and merges into the basilar artery at the brainstem, which then branches into the posterior inferior cerebellar artery, anterior inferior cerebellar artery, and superior cerebellar artery.
The anterior inferior cerebellar artery further branches into the inner ear artery, making it sometimes difficult to distinguish from peripheral disorders.
Clinically, peripheral disorders tend to present with sudden and intermittent episodes lasting seconds to days, with dizziness being intense and exacerbated by changes in head position, while the affected ear facing up may experience less dizziness.
In contrast, central disorders are typically gradual and persistent, lasting for months, with less intense dizziness, and changes in head position do not exacerbate symptoms, with the affected ear facing down experiencing less dizziness.
These are basic principles, but accurate diagnosis requires consideration of medical history, physical examination, blood tests, and instrumental examinations.
Vertebrobasilar Insufficiency: This condition often presents initially as dizziness, sometimes accompanied by nausea, vomiting, or bilateral tinnitus.
Another characteristic is the presence of neurological symptoms such as dysarthria, dysphagia, diplopia, sensory disturbances, and limb weakness or numbness.
Elderly patients with hypertension, diabetes, hyperlipidemia, or cervical spondylosis are more likely to develop this condition, while younger patients often have a family history or genetic predisposition.
Basilar Artery Migraine: This is a type of migraine where dilation of the artery causes headache, and constriction leads to dizziness.
It primarily affects young women and is often related to menstruation, with a maternal family history.
Symptoms include dizziness, tinnitus, blurred vision, unsteady gait, occipital pain, and even altered consciousness.
A detailed dietary history often reveals a preference for cheese, chocolate, tomatoes, and orange juice, as these foods contain amino acids that can cause abnormal vascular constriction.
Patients must take calcium channel blockers for three months and avoid these foods.
Benign Recurrent Vertigo in Children: This condition, known as BRV, involves children experiencing unexplained recurrent episodes of dizziness lasting about 20 minutes, occurring several times a month.
Symptoms often arise in the morning due to changes in posture, such as nausea, vomiting, pallor, or cold sweats, sometimes accompanied by headaches but without tinnitus.
Due to the sudden and severe nature of these episodes, parents often worry.
It is now believed to be caused by spasms of the basilar artery leading to insufficient blood supply to the inner ear.
Family histories often reveal multiple instances of migraines or dizziness.
Treatment primarily involves calcium channel blockers, which are highly effective; over 90% of children show improvement within two weeks, but treatment should continue for three months.
If children do not continue treatment for three months, they are more likely to develop basilar artery migraines in adulthood.
Orthostatic Dysregulation: Also known as O.D., this is a common dizziness condition in children caused by autonomic nervous system dysregulation.
Sudden standing can lead to dizziness, pallor, cold sweats, or even inability to stand.
Many schoolchildren complain of discomfort upon waking, which gradually improves by the afternoon.
Patients experience a drop in blood pressure and increased heart rate when standing, which reverses when lying down.
Cerebellar Hemorrhage or Infarction: Early cerebellar lesions are challenging to diagnose, as they may only present with dizziness.
In addition to detailed medical history and physical examination, ENG can reveal characteristic abnormal eye movements in the early stages of the disease.
The cerebellum can be anatomically divided into three parts: the "primitive cerebellum," which refers to the lower vermis and nodulus, primarily responsible for maintaining posture (also known as the vestibulocerebellum); the "old cerebellum," which includes the anterior and posterior vermis, connected to the spinal cord and responsible for higher-level continuous movements; and the "new cerebellum," which comprises the two hemispheres, responsible for coordinating movements of the trunk and limbs.
If there are lesions in the cerebellum or its connecting fibers, symptoms of motor system disorders may arise, such as unsteady gait, headache, dizziness, and vomiting.
Cerebellar Tumors: The most common type is "cerebellar meningioma," which typically occurs in women aged 40 to 50 during menopause.
Initially, there are no specific symptoms, and during menopause, women may experience nonspecific complaints such as headaches, depression, or anxiety, which Japanese doctors refer to as "indeterminate complaints." If middle-aged women present with such complaints, clinicians must rule out the possibility of cerebellar meningioma.
Cerebellar or Brainstem Infarction or Hemorrhage: In dizziness clinics, the greatest fear is misdiagnosing this condition as a common peripheral disorder and delaying treatment, which could be fatal.
The characteristics include persistent and severe dizziness, intense headache, altered consciousness, and specific changes in eye movements.
If this condition is suspected, CT or MRI scans are necessary.
Motion Sickness: "Dizziness" results from an imbalance in the balance system, while motion sickness differs from peripheral and central disorders.
It can be described as reflexive dizziness caused by the motion of various transportation modes, leading to abnormal impulses in the semicircular canals and otolith organs, resulting in dizziness and nausea.
The triggers can be numerous, including internal factors (fatigue, colds, alcohol consumption, lack of sleep, or gastrointestinal discomfort) or external factors (excessive motion of vehicles stimulating the semicircular canals and otolith organs; visual stimuli causing "perceptual conflict," such as looking at waves on a boat or scenery from a train; and sensory stimuli like unpleasant odors, witnessing vomiting, or hearing engine noise).
These factors collectively create a predisposed state for motion sickness, triggering autonomic nervous system dysregulation, leading to symptoms such as nausea, vomiting, gastrointestinal discomfort, cold sweats, unsteady gait, increased heart rate, elevated blood pressure, dizziness, and headaches.

To prevent motion sickness, it is essential to avoid the aforementioned internal and external factors.
If necessary, Bonamine can be taken 30 minutes before travel; taking it after symptoms have developed is ineffective.
If nausea persists during travel, focusing on an object one meter ahead can help suppress symptoms through central visual fixation suppression.
Medications typically include antihistamines and anticholinergics to calm the autonomic nervous system, with each treatment course lasting three months.
Motion sickness can improve through training, as fishermen, astronauts, and pilots have become highly adapted to it.
What Dizziness Doctors Want to Know
As mentioned earlier, dizziness patients often provide irrelevant answers during consultations, making it especially important for physicians to guide the questioning process.
I often use a "Dizziness, Tinnitus, and Headache Special Clinic Questionnaire" to ensure I do not miss any crucial information.
- What is your occupation? Are there any potential chemical exposures? Is your work environment noisy? Painters, gas station attendants, drivers, or aircraft engine technicians may be exposed to organic solvents like toluene or styrene, causing dizziness.
Noise exposure or acoustic trauma can also lead to tinnitus and dizziness.
- Is there a family history? Some diseases, such as Meniere's disease and basilar artery migraines, tend to have maternal inheritance patterns.
- Are you taking any long-term medications? Many medications can cause dizziness, including contraceptives, antihypertensives, and anticonvulsants.
In the past, children often received injections of kanamycin or streptomycin, which could also lead to dizziness and tinnitus.
- Have you had a cold recently? Have you been in the mountains or the ocean? Have you flown recently? Recent colds may lead to vestibular neuritis, while mountain climbing or diving can cause sudden pressure changes, potentially leading to serous otitis media or inner ear window rupture, resulting in dizziness.
- What is the nature of your dizziness? Is it spinning, floating, rolling, or swaying? If the dizziness is "clockwise or counterclockwise," it is often indicative of inner ear pathology, but cerebellar or brainstem hemorrhages or infarctions can also present similarly.
"Back-and-forth" dizziness may suggest central nervous system disorders, while "floating" dizziness, where walking feels heavy-headed, may indicate cerebellar vascular disease.
"Swaying" dizziness, akin to an earthquake, may suggest tumors in the cerebellum, brainstem, or vermis.
- Do you lean to one side when walking? Do you fall suddenly? Generally, falling forward or backward suggests a central disorder, likely cerebellar; falling to the left or right suggests a peripheral disorder, such as inner ear pathology, which would cause a fall toward the affected side.
"Tumarkin's catastrophe" may lead to sudden falls while remaining conscious.
- How long do your dizziness episodes last? How often do they occur? During the day or at night? "Benign paroxysmal positional vertigo" lasts only seconds, while "Meniere's disease" episodes can last several hours, and "vestibular neuritis" can last several days.
Central disorders typically last seconds to minutes, so additional symptoms are needed for differential diagnosis.
"Meniere's disease" often occurs upon waking during the day, while "vertebrobasilar insufficiency" may occur at night, especially when getting up to use the bathroom.
- Is your dizziness related to a specific posture? Does a certain posture exacerbate or alleviate your dizziness? Patients with Meniere's disease often prefer to keep the affected ear facing up, while those with cerebellar hemorrhages may prefer the affected ear facing down to allow the blood clot to expand outward and not compress brain tissue.
Patients with BPPV experience dizziness when turning their heads to a specific angle, but repeated movements can desensitize them to dizziness; those with malignant paroxysmal positional vertigo can hardly move their heads at all.
- Are there any accompanying symptoms such as nausea, vomiting, cold sweats, pallor, flushing, shoulder pain, neck stiffness, headache, or heaviness in the head? The vestibular nuclei in the brainstem are interconnected with the vagus nerve nuclei, so dizziness patients may experience these autonomic symptoms.
"Headaches and heaviness" must rule out the possibility of central tumors, while "occipital pain and heaviness" may suggest toluene poisoning or inhalation of strong adhesives.
"Neck stiffness, shoulder pain, and head pain" may indicate vertebrobasilar insufficiency.
- Are there any hearing impairments, tinnitus, a sensation of ear fullness, sensitivity to loud sounds, ear pain, or ear discharge? "Benign paroxysmal positional vertigo" and "vestibular neuritis" do not typically present with tinnitus, while "Meniere's disease" involves a sensation of ear fullness and sound sensitivity.
- Are there any numbness in the limbs or around the mouth? Blurred vision or temporary blindness? Difficulty speaking or swallowing? "Numbness in the limbs" may indicate vertebrobasilar insufficiency or a stroke warning, while "blurred vision or blindness" may suggest central vascular disease, and "difficulty speaking or swallowing" may indicate blockage of the posterior inferior cerebellar artery.
Dizziness Examinations
The advancements in modern medicine are remarkable, with cutting-edge instruments evolving rapidly.
However, when it comes to diagnosing and treating dizziness, one must not overlook the importance of medical history and basic physical examinations.
I personally believe that these are far more important than advanced technologies like ENG, CT scans, or MRIs, as often, instrumental examinations merely confirm our hypotheses.

What examinations should we perform for dizziness?
1.
Detailed Medical History: Many clues are found in the questionnaire; experienced physicians can often preliminarily distinguish between central and peripheral disorders based solely on the questionnaire and assess any immediate life threats.
2.
Local ENT Examination: This can rule out other ENT diseases, earwax, otitis media, cholesteatoma, sinusitis, or nasopharyngeal carcinoma.
3.
Gaze-Evoked Nystagmus Test: Position yourself about 50 cm from the patient, asking them to focus on your fingertip while you move it up, down, left, and right by 30°.
A special concave lens (Frenzel goggles) can magnify eye movements and eliminate external stimuli, making it easier to observe changes in nystagmus.
4.
Head-Shaking Nystagmus Test: This method has the highest induction rate for nystagmus, and any resulting nystagmus is significant, making it a common screening test for follow-up patients.
5.
Positional Nystagmus Test: Have the patient lie flat and turn their head left and right while observing for nystagmus; patients with benign paroxysmal positional vertigo can be induced to show nystagmus through this test.
6.
Head Position Change Nystagmus Test: Observe for nystagmus when the patient quickly lies down from a sitting position; patients with vertebrobasilar insufficiency often show downward nystagmus.
7.
Stepping Test: A normal person can maintain balance with eyes closed, with a deviation angle not exceeding 30° and a distance of no more than 1 meter.
Those with poor inner ear function will lean toward the affected side, while cerebellar patients may be unable to maintain balance even with eyes open.
8.
Postural Reflex Test: This includes the Romberg test to assess the patient's ability to maintain an upright position and tandem walking, where the patient walks in a straight line with heel-to-toe steps.
Cerebellar patients often cannot perform this test.
9.
Vertical Writing Test: Have the patient write a line of text with their elbow suspended vertically, comparing the slant of the writing with eyes open and closed.
Patients with inner ear disorders will show a slant toward the affected side when eyes are closed, while cerebellar patients may struggle to recognize the text.
10.
Eustachian Tube Test: Using a Politzer balloon, place it against the external auditory canal, have the patient tilt their head back 60°, and alternate squeezing the balloon.
If there is a Eustachian tube dysfunction (e.g., inner ear syphilis, cholesteatoma, or inner ear window rupture), dizziness and nystagmus will occur.
11.
Temperature Response Test: Have the patient lie flat and flex their head forward 30°, then irrigate with water at 30°C and 44°C.
A normal patient will show nystagmus within about 15 seconds, lasting 2 to 3 minutes; less than 1 minute suggests inner ear dysfunction, typically peripheral pathology; more than 3 minutes indicates loss of cerebellar control over the inner ear, indicating central pathology.
12.
X-ray Examination: X-rays of the middle ear, mastoid, inner ear canal, and cervical spine can reveal conditions like otitis media, tumors invading the inner ear canal, or bony spurs or deformities in the neck.
13.
Blood Tests: Complete blood count, blood glucose, cholesterol, triglycerides, syphilis serology, and thyroid function tests, as related systemic diseases can also cause dizziness.
14.
Hearing Tests:
- Pure Tone Audiometry (PTA): A simple screening for conductive or sensorineural hearing loss.
- Tympanometry: Checks for middle ear effusion, Eustachian tube obstruction, and ossicular chain mobility.
- Auditory Brainstem Response (ABR): Assesses the auditory nerve pathway from the inner ear to the brainstem, with five waves; if there is a lesion, the wave may be absent or delayed.
If PTA is normal but ABR is abnormal, acoustic neuroma must be considered.
- Otoacoustic Emissions (OAE): Generally believed that cochlear cells only receive sound; however, they can also emit echoes.
This is now commonly used as a screening tool for newborn hearing loss.
15.
Electronystagmography (ENG): This can reveal specific abnormal eye movements associated with cerebellar lesions in the early stages of the disease.
Electrodes are placed on either side of the eyes to record the electrical potential difference between the retina and cornea, allowing differentiation between central and peripheral disorders.
"The eyes are the windows to the soul" is particularly fitting in neurotology, as many neurotological diseases can be diagnosed early by observing changes in eye movements before physical symptoms appear.
16.
Center of Gravity Oscillation: ENG examines the vestibulo-ocular reflex, while center of gravity oscillation measures the vestibulo-spinal reflex, allowing for quantitative assessment of postural reflex tests using computer technology.
Treatment of Dizziness
Common medications used by physicians to treat dizziness can be categorized into the following classes:
1.
Vasodilators: Many dizziness patients experience symptoms due to poor blood circulation, so vasodilators are commonly used.
Since microvessels have a diameter of about 3 micrometers and red blood cells about 7 micrometers, merely dilating blood vessels is insufficient; medications that enhance red blood cell deformability and reduce blood viscosity are ideal.
Common vasodilators include:
- Tebonin: Commonly known as ginkgo biloba, it promotes cerebral circulation, has antiplatelet effects, and clears free radicals.
- Euclidan: A well-known peripheral dizziness vasodilator.
- Cephadol: An anti-histamine and anti-cholinergic medication for dizziness.
- Sibelium: A calcium channel blocker that prevents calcium ions from entering vascular smooth muscle, inhibiting vasoconstriction and promoting vasodilation.
2.
Neuroprotective Agents:
- Alinamin F: An active form of vitamin B1 with anti-neuritis effects.
- Methycobal: An active form of vitamin B12 that accelerates nerve cell metabolism and repairs damaged nerve fibers.
- Vitamin E: Promotes peripheral blood circulation.
3.
Sedatives: Including Valium, Librium, and Serenal.
4.
Antidizziness Medications: The most famous is Bonamine.
5.
7% Sodium Bicarbonate 60cc IV Injection: This medication is commonly used for acute dizziness episodes, providing rapid symptom relief, and can be administered multiple times a day until dizziness subsides.
It is safe for use in pregnant women, hypertensive patients, or diabetics, with no side effects.
In outpatient settings, patients often ask why they need to take medication continuously for three months.
This is because continuous medication for three months significantly reduces the recurrence rate, and the central nervous system's compensatory mechanisms typically take about three months to stabilize.
The criteria for determining whether dizziness has resolved are based on the patient's subjective experience: no episodes of dizziness for over three months, all previous discomfort has disappeared, and objective examinations show no abnormal eye movements.
Generally, peripheral dizziness can often be successfully treated with three months of continuous medication; however, about 30% of patients may require treatment for six months or longer.
In addition to medication, patients can perform simple balance exercises at home.
First, have the patient stand with their eyes open, arms extended, and march in place for fifty steps; then have them close their eyes and repeat the exercise.
This should be done twice daily, observing any tilting of the body during the exercise to assess progress.
Some People and Events Related to Dizziness
Records of dizziness date back to ancient Greece during the time of Hippocrates, although the relationship with eye movements or the inner ear was not understood.
In 1820, Czech physiologist Purkinje (discoverer of Purkinje cells in the brain) observed that rotation could induce dizziness and rapid eye movements, attributing it to brain stimulation.
In 1824, French anatomist Flourens first discovered that destroying the anterior semicircular canals in pigeons caused them to fall forward, while damage to the posterior canals caused them to fall backward, and damage to the horizontal canals caused them to spin in place and exhibit nystagmus.
This led to the famous "Flourens' Law"—each semicircular canal only induces eye movements in its plane: the horizontal canal induces horizontal nystagmus, the anterior canal induces rotational nystagmus, and the posterior canal induces vertical nystagmus.
He also observed that removing the brain eliminated sensory function, while removing the cerebellum resulted in loss of balance, and removing the medulla was fatal.
In 1861, French physician Meniere published the famous "case of the girl," a 17-year-old who experienced sudden dizziness accompanied by unilateral tinnitus and hearing loss, developed pneumonia on the third day, and died suddenly on the fifth day.
Meniere noted blood-like effusions in the girl's semicircular canals, suggesting that dizziness might be caused by inner ear pathology.
From a modern medical perspective, the girl likely suffered from leukemia, leading to inner ear bleeding and subsequent dizziness and hearing loss, rather than what we now refer to as "Meniere's disease." German physician Politzer, who attended Meniere's lecture in Paris, returned home and proposed a similar case in 1867, attributing it to inner ear bleeding and naming it "Meniere's disease," thus securing Meniere's place in the history of neurotology.
In 1870, German physician Goltz published findings that destroying the semicircular canals would cause dizziness.
In 1892, German Ewald published that the direction of endolymph flow is closely related to head and eye movements, proposing the famous Ewald's Law.
In 1906, Austrian Barany discovered that cold or hot stimulation of the ear canal could induce nystagmus, leading to the well-known COWS (Cold Opposite Warm Same) principle, which refers to the temperature response test—"irrigating cold water into the ear causes nystagmus toward the opposite side, while irrigating warm water causes nystagmus toward the same side." The Nobel Prize in Physiology or Medicine in 1915 was awarded to Dr.
Robert Barany for proposing this theory of convection, making him the first ENT physician to receive this honor.
Retzius (1842–1919) was a Swedish tissue professor who used optical microscopy to observe inner ear tissues and illustrated the structure of the inner ear.
In 1938, Professor Yamazaki Kyojiro from Osaka University published a pathological report on a Meniere's disease patient, who was also a gynecology professor at the same university.
Yamazaki discovered endolymphatic hydrops during the autopsy, concluding that excessive production of endolymph led to increased pressure in the endolymphatic space, causing dizziness, tinnitus, and hearing loss.
That same year, British Hallpike published two similar pathological reports on endolymphatic hydrops, commemorating Meniere's initial proposal that dizziness arises from inner ear pathology, thus naming endolymphatic hydrops "Meniere's disease."
In 1942, Hallpike and Fitzgerald proposed the cold-warm alternating stimulation method and introduced the concepts of canal paresis and directional preponderance.
In 1944, Cawthorne first published the labyrinth training method, though it was not widely adopted.
In the 1950s, Glorig invented ENG to record eye movement patterns.
In 1970, McCabe refined the labyrinth training method, establishing it as an effective vestibular rehabilitation technique.
In 1974, the visual suppression test incorporated information from the vestibulocerebellum.
In 1978, changes in head position induced the second phase of nystagmus, suggesting the involvement of the otolith organs.
In 1983, experiments aboard the European Space Agency's Spacelab contradicted Barany's "convection theory," suggesting that thermal expansion and contraction caused volume changes leading to dizziness and nystagmus.
In Chinese history, figures such as Emperor Gaozong of the Tang Dynasty suffered from dizziness, which even allowed Wu Zetian to seize power.
The "Records of the Three Kingdoms" notes, "Emperor Taizu suffered from wind, causing confusion and dizziness." The "Romance of the Three Kingdoms" mentions that Cao Cao felt dizzy two days before his death, stating, "I felt my head and eyes spinning, so I got up and lay down on the table." Ming Dynasty Emperor Shenzong refrained from attending court for 25 years due to dizziness, and Qing Dynasty figures such as Zeng Guofan and Li Hongzhang also suffered from dizziness.

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Reply Date: 2006/08/22