Management of the Patient with Chronic Dizziness

Restorative Neurology and Neuroscience 28 (2010) 79–86 79 DOI 10.3233/RNN-2010-0530 IOS Press Management of the patient with chronic dizziness A.M. Bronsteina,∗ and Th Lempertb aNeuro-otology Unit, Division of Neuroscience and Mental Health, Imperial College London, Charing Cross Hospital, London, UK bNeurology Department, Schlosspark Klinik, Berlin, Germany Abstract. In this review we present a pragmatic approach to the patient with chronic vestibular symptoms. Even in the chronic patient a retrospective diagnosis should be attempted, in order to establish how the patient reached the current situation. Simple questions are likely to establish if the chronic dizzy symptoms started as benign paroxysmal positional vertigo (BPPV), vestibular neuritis, vestibular migraine, Meniere’s disease or as a brainstem stroke. Then it is important to establish if the original symptoms are still present, in which case they need to be treated (e.g. repositioning maenouvres for BPPV, migraine prophylaxis) or if you are only dealing with chronic dizzy symptoms. In addition the doctor or physiotherapist needs to establish if the process of central vestibular compensation has been impeded due to additional clinical problems, e.g. visual problems (squints, cataract operation), proprioceptive deficit (neuropathy due to diabetes or alcohol), additional neurological or orthopaedic problems, lack of mobility or confidence, such as fear of falling or psychological disorders. A general neurological examination should also be conducted, amongst other reasons to make sure your patient’s ‘chronic dizziness’ is not due to a neurological gait disorder. Treatment of the syndrome of chronic dizziness is multidisciplinary but rehabilitation and simple counselling should be available to all patients. In contrast, vestibular suppressants or tranquilisers should be reduced or, if possible, stopped. 1. Introduction patients with chronic dizziness have? and, then, what can we do for them? Perhaps the most dreaded of all patients with balance or vestibular disorders is the one with longstand- ing, continuous dizziness. If you are an ENT doctor 2. The origin of chronic dizziness this patient may have already seen a neurologist. If you are a neurologist your patient has definitely seen Patients with chronic symptoms of dizziness and un- an ENT. If you are a neuro-otologist the patient is like- steadiness describe their problem in many ways. They ly to have seen both an ENT and a neurologist. The can feel dizzy or giddy in the head, including some- patient almost certainly has had many sophisticated times mild rotational feelings, a bit ‘drunk’, detached, tests, including brain scans, audiograms, neck x-rays slightly off balance or unsteady, that they seem to veer and maybe vestibular function tests, so there seems to to one or both sides whilst walking, that they feel more be little room for manoeuvre for the doctor seeing this steady if they touch or hold on to furniture, that they patient for the first time. Here, we intend to present feel as if they were walking on a mattress or on cotton our personal approach to this problem (see Bronstein wool. These symptoms are fairly constant but there and Lempert 2007) and organise a plan of action. It is maybe minor fluctuations, ‘bad and good days’. We therefore useful to ask to sequential questions, what do feel that the description of the current symptom is important but perhaps not as useful as the description of the history of the symptom. We feel that there are es- ∗Address for correspondence. E-mail: [email protected]. sentially three types of history, the patient who started uk. with one or more attacks of rotational vertigo, the pa- 0922-6028/10/$27.50 2010 – IOS Press and the authors. All rights reserved 80 A.M. Bronstein and T. Lempert / Management of the patient with chronic dizziness tient with a progressive history of disequilibrium and tinue with long term residual dizziness and unsteadi- the patient with neither of these. ness (Kammerlind et al., 2005; Palla et al., 2008). Un- fortunately, because acute and recurrent vertigo are so prevalent in the general population, these patients fill 3. The patient with a past history of vertigo up specialised dizziness clinics and experience consid- erable psychosocial and working disability. Patients in this category report that at some point Why do some patients not recover fully after one or in the preceding months or years they suffered one or more episodes of vertigo? We suspect that long term many vertigo attacks. Detailed history taking should let symptoms are the consequence of some difficulty in you reach a retrospective diagnosis of vestibular neuri- the process of vestibular compensation. It is difficult tis, BPPV, vestibular migraine (migraine-related dizzi- to ascertain in each individual patient what may have ness), Meniere’s disease or other conditions. Essential- interfered with the fine tuning required to achieve full ly, the patient with vestibular neuritis will remember a vestibular compensation. Possible causes are some- single but disabling attack of vertigo lasting for about times apparent, for instance if there are associated vi- a week; the patient with BPPV will have suffered brief sual, peripheral nerve (proprioceptive) or central neu- episodes (lasting seconds) of rotational vertigo on look- rological problems, reduced mobility or advanced age, ing up or lying down/turning over in bed. Patients with which has all of the above. Often, however, the cause migraine or Meniere’s disease suffer recurrent attacks is not apparent and, in patients with anxiety or depres- of vertigo lasting anything from minutes to a few days; sion, one is tempted to attribute the chronic dizzy symp- in the case of migraine typical migraineous features toms to a psychological problem. Indeed, pre-morbid (headaches, photophobia, phonophobia, visual auras) psychological trends of anxiety and depression do con- may accompany the vertigo whereas in Meniere’s dis- tribute to long term symptoms and disability (Gode- ease there is inevitable progression of deafness and tin- mannet al., 2004, Odman and Maire, 2008) As with nitus, as well as aural fullness due to the raised en- any other chronic disease, psychological adjustment to dolymphatic pressure (Lempert and Neuhauser 2005; protracted or recurrent vestibular dysfunction may play Sajjadi and Paparella 2008). a critical role (de Ridder et al., 2008). At presentation, In chronic stages patients do not experience much 80% have psychiatric comorbidity (Odman and Maire, disabling rotational vertigo but rather a constant sensa- 2008). At the moment, there is no definitive conclusion tion of vague dizziness or subjective unsteadiness. If as to the exact mechanisms leading to chronic dizzi- patients keep on suffering from episodic vertigo attacks ness in patients with previous vestibular vertigo but (e.g. BPPV, Meniere’s disease, migraine) they can eas- there is agreement that the problem is multifactorial ily distinguish between the acute recurrence and the and the solution multidisciplinary. Some specific syn- chronic dizziness (Waterston, 2004). In this case, the dromes of patients with chronic dizziness have been chronic dizziness tends to increase with each vertigi- described and, although the interpretation of these syn- nous episode. dromes is still somewhat controversial, the reader will Chronic dizziness is reported by 0.3 percent of the benefit from being familiar with the different modes of adult population (12 months prevalence) (Neuhauser presentation in the clinic. et al., 2008). However, in specialised clinics these patients are extremely common, accounting for about 3.1. Visual vertigo 11% of referrals, with a female preponderance of 2:1 (Odman and Maire, 2008) These are patients with chronic dizziness who re- A patient who started with vestibular neuritis will port that their symptoms worsen in certain ‘visually describe that, say, 10 months ago he (/she) had the busy’ surroundings. The syndrome is given different ‘flu’ and then severe vertigo nausea and imbalance for names, such as visual vertigo (Bronstein, 1995; Guer- a week. He saw a GP/ENT/neurologist at that point raz et al., 2001), visuo-vestibular mismatch (Longridge and was told that he had a ‘viral infection of the inner et al., 2002) and space and motion discomfort (Furman ear’, that the symptoms will progressively go away and and Jacob, 2001). Frequently reported trigger situa- that he will return to normal or near normal within 2– tions are, walking through shelves in supermarket aisles 3 months. Textbooks state that the majority of patients (sometimes called the supermarket syndrome), view- recover fully within a few months but specific research ing movement of large visual objects such as moving shows that up to 50% of vestibular neuritis patients con- clouds, wind-swept trees, rivers flow, disco lights, mov- A.M. Bronstein and T. Lempert / Management of the patient with chronic dizziness 81 Fig. 1. Examples of the type of visual stimulation employed in the desensitisation of patients with chronic dizziness and visual vertigo. Left: a rotatingdisk.Centre:gaitexercisesduringplanetariumprojection.Right:optokineticstimulideliveredbytheEyetrek(TM)orvirtualreality systems; in this case the patient stands on foam to decrease the accuracy of the lower limb proprioceptive input. Modified from Pavlou et al. 2004. ing crowds, traffic, curtains being drawn, or films with symptoms might originate. Indeed secondary vestibu- car chase scenes. Repetitive visual patterns

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