The peripheral vertigo it is the most common type of vertigo. These are episodes characterized by a feeling of dizziness, loss of balance, and ringing in the ears. The patient may experience as if the environment is moving, spinning around him or as if everything is tilting to one side.
Generally, peripheral vertigo is caused by a problem in the inner ear, which is the one that controls balance. It is important to note that this type of vertigo is not a disease in itself; rather, it is a symptom that reflects some underlying medical condition.
The crises that occur in this condition appear and disappear abruptly. In terms of its duration, it is relatively short (lasting from a few minutes to several hours).
For the diagnosis of peripheral vertigo, eye movements and body oscillations are observed. Usually, a neurological exam is carried out.
Once this condition is diagnosed, treatment is aimed at relieving symptoms with drugs, performing specific exercises for the vestibular system, as well as treating the causes that have produced peripheral vertigo..
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Peripheral vertigo is a sensation similar to that experienced after riding a fairground ride such as a roller coaster. Everything seems to revolve around the patient. This results in nausea, vomiting, cold sweat, low blood pressure, pale skin, or bradycardia (slow heart rate)..
These symptoms increase when the head moves, since, as mentioned, there is some involvement of the inner ear. Therefore, peripheral vertigo can be accompanied by cochlear symptoms. These symptoms are characterized by:
- Tinnitus: consist of a perceptual phenomenon in which ringing or ringing is heard in the ears that do not come from the external environment.
- Hearing loss: it is a decrease in the ability to perceive sounds.
- Pressure sensation in the ears.
However, these cochlear symptoms are not always present. In contrast, a very defining symptom of peripheral vertigo is nystagmus. These are deficits to focus the gaze, observing rapid movements of the eyes from one side to the other involuntarily.
Other symptoms include headaches, loss of balance, hearing and vision difficulties, and a feeling of being pushed from one side to the other..
Most cases of peripheral vertigo are caused by some type of condition in the inner ear, which regulates balance. Specifically, some alteration in one of the structures that make up the vestibular system.
The most common causes of inner ear problems associated with peripheral vertigo are benign paroxysmal positional vertigo (BPPV), vestibular neuronitis, Ménière's disease, and labyrinthitis.
This is the most common cause of peripheral vertigo. In this condition, calcium deposits form in the fluid inside a part of the inner ear called the semicircular canals..
Therefore, when the head moves, vertigo appears, since these small crystals stimulate fine "hairs" that cover the inner ear. This causes confusion in the brain, producing vertigo and dizziness..
Benign paroxysmal positional vertigo can be due to normal aging of the vestibular system, some injury to the inner ear, labyrinthitis, circulation problems in the artery that irrigates this area, medications, migraine, etc..
The first time it was described was in 1921 by the physician Robert Bárány. Apparently, approximately 2.5% of the population suffers from this condition at some point in their life. Mainly during old age. In addition, it seems to be more frequent in women than in men..
Treatment for benign paroxysmal positional vertigo is based on exercises to reposition the crystals of the inner ear. This method is known as the Epley maneuver and can be performed by the patient at home with indications previously described by their doctor..
However, most of the time, this disorder goes away only in a few days or weeks. However, if it is never treated, it will usually reappear.
Vestibular neuronitis or neuritis is caused by an infection that spreads in the vestibular nerve. This usually appears after a viral infection, such as a cold or the flu. This condition appears suddenly and can last for two to three weeks. Some of the symptoms are: earache, instability, nausea, even vomiting.
However, in this condition, hearing capacity is preserved, unlike labyrinthitis.
Treatment is focused on reducing the symptoms and the underlying virus. It is often accompanied by vestibular rehabilitation, that is, exercises to control posture or gaze when the position of the head is changed.
This condition is characterized by inflammation of an area of the inner ear called the labyrinth. Normally it appears due to an infection of some virus or bacteria. Therefore, it is common for it to arise after a fever, flu or allergies. Causes peripheral vertigo, earache, and decreased hearing and ringing in the ears.
Treatments are also aimed at alleviating symptoms. It is also recommended to avoid driving vehicles, operating machines, and avoiding bright lights, such as those on television or mobile phones..
Ménière's disease begins by affecting one ear. In many patients, over time, the problem spreads to the other ear. It usually occurs in people between 40 to 60 years old, although anyone can suffer it.
The exact cause of this disease is not known, although it is believed that it may be related to a fluid found in the inner ear, called endolymph. Specifically, there seems to be an accumulation of said fluid, causing pressure in the inner ear.
It has been found that there may be factors that trigger it such as salt consumption, caffeine, alcohol or stress.
Peripheral vertigo episodes in this disease appear abruptly and can last up to 24 hours. Vertigo is usually so severe that it causes nausea and vomiting.
In addition to peripheral vertigo, this disease causes fluctuating hearing loss, ear pain, headache, abdominal pain, or diarrhea..
It is treated with diuretic drugs to remove excess fluid and other drugs to decrease symptoms.
Other possible causes of peripheral vertigo include autoimmune inner ear disease, perilymphatic fistula, or superior semicircular canal dehiscence syndrome. In the latter there is a lesion in the bone that covers the semicircular canal of the inner ear.
However, it is important to note that transient episodes of peripheral vertigo caused by motion sickness (when traveling in a car, on a boat or on an airplane), poisoning by certain substances (lead or arsenic), certain drugs, drugs, or for migraines.
There are several techniques to diagnose peripheral vertigo. A single test is usually not significant, it is best to combine several.
First, the doctor can examine the ears for signs of infection. You can also perform hearing tests, balance tests, or recommend scanner tests such as an MRI. This last test is useful to rule out other causes of vertigo related to the neck or the brain..
One of the most widely used tests is the Romberg test. To begin, the patient is asked to stand with their feet together. The examiner will check if the person remains upright or has oscillations. He is then asked to close his eyes, although care must be taken, as the patient may move sideways or even fall to the ground..
A sign of peripheral vertigo would be lateropulsion. That is, an involuntary tendency to tilt the body to one side.
Another test is the Unterberger test, which is used to observe if there is a lateral deviation of the body while walking.
The diagnosis of peripheral vertigo is confirmed by rapid eye movements, that is, nystagmus. Mainly it is observed that the eyes deviate involuntarily towards the healthy ear.
To explore nystagmus, the patient must be seated. The examiner will place his finger about 50 centimeters from the patient's nose, and the latter must follow the movements made by the examiner with his eyes, who will move them forward first; and then to the right, left, up and down.
Eye movements can also be observed by changing the position of the head or by shaking the head from one side to the other..
Another widely used test is the Halmagyi test or rapid head impulse test. In this test, the examiner quickly moves the patient's head from side to side with force, to see if the eyes tend to look in the same direction..
A patient with peripheral vertigo will not be able to make compensatory movements of the eyes, being unable to fix them in a point during the movement of the head.
Another similar test is the Dix-Hallpike maneuver. The patient's head is also moved as position is changed, lying down and lifting. This test is essential for diagnosing benign paroxysmal positional vertigo. It is used to check the existence of nystagmus, as well as nausea and dizziness.
To treat peripheral vertigo, the best option is to intervene in the condition that is causing it. As well as pharmacological treatment of the symptoms, physical therapy and education of the patient so that he follows certain recommendations in his day to day.
Plaza Mayor, Onrubia and Hernández Carnicero (2009) state that there are 4 components for the treatment of patients with balance disorders and vertigo:
- Inform and reassure the patient.
- Medication for vertigo symptoms, nausea or vomiting.
- Treatment to intervene on the factors causing vertigo.
- Vestibular rehabilitation.
Treatment must be individualized for each case according to the cause of vertigo and the development of the disease. As vertigo is a very annoying symptom, which usually causes anxiety and concern, it is important to reassure and inform the patient, as well as give a brief explanation of their condition and the functioning of the vestibular system..
Anti-inflammatory medications can sometimes be helpful to relieve symptoms. Especially if the causes are vestibular neuronitis, labyrinthitis or Ménière's disease.
Pharmacological treatments are usually to relieve symptoms, mainly manifestations such as nausea and vomiting. However, they do not eliminate the problem. That is why it is important to avoid these drugs as much as possible, as they can create dependency..
The most commonly used drugs are vestibular sedatives that decrease the activity of neurons in the vestibular nuclei of the ear. Within this group are antihistamines, antidopaminergic neuroleptics or benzodiazepines.
Other drugs are antiemetics, which also have a vestibular sedative effect..
Drug treatment will also vary depending on the underlying cause of the peripheral vertigo. In this way, if there is an ear infection, antibiotics can be prescribed..
For patients with Ménière's disease, a drug called betahistine may be prescribed. This drug helps reduce the pressure that causes fluid to build up in the ear..
When the peripheral vertigo is very intense, it is necessary for the patient to rest in bed and administer intravenous fluid therapy..
On the other hand, vestibular rehabilitation consists of a series of exercises that help the person maintain postural and visual stability. The doctor will recommend and explain the best exercises for each case, although generally these consist of vestibular habituation (performing movements that produce vertigo two or three times a day until the symptoms diminish).
Other exercises are based on focusing your gaze on a specific point, while moving your head from one side to the other..
Physical therapy with a physical therapist is sometimes recommended to improve balance. In this way, the brain would learn to compensate for problems in the inner ear..
In severe and persistent cases where all of the above techniques have been tried, surgery may be recommended. This consists of the removal of part or all of the inner ear.
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