|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2020 | Volume
: 13
| Issue : 3 | Page : 226-229 |
|
Otologic cause of giddiness in a tertiary hospital: Our experience
Soumick Ranjan Sahoo, Mandira Sarma
Department of ENT, ESIC Model Hospital, Guwahati, Assam, India
| Date of Submission | 07-Jun-2020 |
| Date of Acceptance | 13-Aug-2020 |
| Date of Web Publication | 05-Oct-2020 |
Correspondence Address:
Dr. Soumick Ranjan Sahoo
T9B Protech Park Hengrabari, Guwahati - 781 036, Assam
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/kleuhsj.kleuhsj_160_20
Context: Giddiness affects a large percentage of population at any time. It also forms a large part of patient group attended by neurologists, cardiologists, and also commonly referred to otolaryngology clinics. Among otologic causes, those commonly regarded are benign paroxysmal positional vertigo (BPPV), Ménière's disease, Labyrinthitis, and Vestibular neuronitis.
Aim: The aim is to study the proportion of patients of vertigo referred to ear, nose, and throat (ENT) Outpatient Department (OPD), having otologic cause of vertigo and to study common causes of otologic cause of vertigo.
Settings and Design: Prospective observational study.
Subjects and Methods: A data was recorded for 125 subjects above the age of 15 years, complaining for vertigo, presenting to ENT OPD of a tertiary care center from January 2019 to January 2020. A thorough detailed history was taken from all patients. Otology and oto-neurological examination was thoroughly done. Computed tomography scan/magnetic resonance imaging kept reserved only for those patients in whom there is a suspicion of cerebellopontine angle tumor or stroke. Based on these batteries of tests a diagnosis of otologic cause of vertigo was made. All the findings were recorded into a Data sheet.
Results: The result it was found that 28.8% of the patients (total 36) who complained of vertigo had an otologic cause for it. From the tests conducted, BPPV occurred as the most common cause (23.2%). Others were vestibular neuronitis (3.2%) and labyrinthine causes (1.6%) Meniere's disease (0.8%). The maximum affected age group was from 41 to 60 years and frequency of females was reported to be higher than males.
Conclusion: The result of this study draws our attention to the causes of vertigo that are from otologic disease. This information can also be used for awareness amongst physicians and the general practitioners around this hospital for referring vertigo cases to ENT OPD. Keywords: Benign paroxysmal positional vertigo, vertigo, vestibular neuronitis
How to cite this article:
Sahoo SR, Sarma M. Otologic cause of giddiness in a tertiary hospital: Our experience. Indian J Health Sci Biomed Res 2020;13:226-9 |
| Introduction | |  |
Giddiness affects a large percentage of population at any time. The incidence of vertigo in general population is about 20%–30%.[1],[2] Almost 1% of population seeks medical advice of general practitioner for symptom of dizziness. It also forms a large part of patient group attended by neurologists, cardiologists and also commonly referred to otolaryngology clinics.[3],[4] Reports from western literature suggest almost 30% of patients in otology led vertigo clinics have an otological cause for their dizzy symptoms.[5] Diagnosis in a patient with vertigo is very difficult. The general practitioner needs to judge as to which cases need referral to specialist and also to refer to which appropriate specialist. Often the symptoms and signs are vague, nonspecific, and hard to define, which presents a significant challenge to the attending specialist.[6] According to studies, following are the causes of vertigo – otologic 40%–50%; neurological 10%–30%; general medicinal 10%–30%; and psychiatric/undiagnosed 15%–50%. Multidisciplinary vertigo clinic in hospital report the incidence of otologic cause of vertigo to be as high as 65%. By the age of 80 years, two-thirds of women and one-third of men will have experienced episodes of vertigo. Among otologic causes, those commonly regarded were benign paroxysmal positional vertigo (BPPV), vestibular neuritis, labyrinthitis, and Meniere's disease. Each has a different approach to treatment and so the exact diagnosis is very essential. Besides, there is a definite dearth of Indian study and data in this regard. The epidemiology of vertigo and vestibular disorders is still an underdeveloped field. Recent studies have underscored the impact of vertigo at the population level, but its determinants and outcome are not well known yet.[7] The present study intends to find out as to what percentage of patients referred to our tertiary care ear, nose, and throat (ENT) center with history of vertigo actually have an otologic cause.
| Subjects and Methods | | |
It is a prospective observational study on patients attending ENT outpatient department (OPD) with complains of giddiness between January 2019 and January 2020. The study was conducted in accordance with the ethical standards of ESIC hospital Guwahati with reference number IEC/ESIC/dt/2018/001 and with the Helsinki declaration.
For the patients who formed part of the prospective study group, a thorough history was taken in regards to the type, character, and duration of vertigo. Detailed history would include the onset, duration, frequency, precipitating, and reliving factors. They were asked if the vertigo was of rotatory type or it was just a feeling of imbalance or if they had black outs on standing from lying position. The presence and association of vomiting along with vertigo was sought for. A proper otological history was taken in the form of ear discharge, ear fullness, and hearing loss tinnitus.
A proper general examination was done to rule out any evident systemic cause. Blood pressure of all patients was checked in lying position. Otology and otoneurological examination were done. Otological examination included otoscopy and tuning fork test. Otoneurological assessment included check for the presence of spontaneous nystagmus. Rombergs tests and tests to rule out cerebellar signs were done in all patients. Fistula test and facial nerve were also evaluated. All patients except those who were too old and weak were told to perform the Unterberger's test. Dix Halpike test was done in all patients to rule out BPPV as the cause of vertigo. Patients were subjected to caloric test. Caloric test would consist of the evaluation of vestibular sensation by stimulating alternately with warm and cold water. Pure tone audiometry was also done in all these patients. If Meniere's disease was detected, the patients were subjected for glycerol test. Head impulse test was performed in a case of acute vertigo to differentiate between vestibular neuritis and stroke.
Radiological investigation in the from of computed tomography scan/magnetic resonance imaging was kept reserved for patients in whom there is a suspicion of cerebellopontine angle tumor of vertebrobasilar insufficiency or stroke.
Based on these batteries of tests, it was diagnosed whether the vertigo was of otologic cause or otherwise. Those patients who had an otologic cause of vertigo were given specific treatment for the condition. Those, in whom no otologic cause detected, were referred to medicine OPD to rule out systemic cause or central cause.
| Results | | |
The maximum affected age group was from 41 to 60 years (46.4%) followed by 26–40 years (32%), >60 years (12%) and <25 years (9.6%), as shown in [Table 1].
The frequency of females was reported to be higher than males as shown in [Table 2].
The result it was found that 28.8% of the patients (total 36) who complained of vertigo had an otologic cause for it as shown in [Table 3].
As shown in [Table 4], BPPV occurred as the most common cause (23.2%). Others were vestibular neuronitis (3.2%) and labyrinthine causes (1.6%) Meniere's disease (0.8%).
| Discussion | | |
The diagnosis of cause of vertigo remains a daunting task for most doctors. A detailed history with a systematic approach is the most important component in evaluating patients with dizziness. Causes of vertigo are most commonly otological, followed by central, somatosensory, and visual.[8],[9] In this regards, these data are of immense importance as this seems to be give the scenario in Indian set up. Our data suggest that 28.8% of patients had otologic cause of vertigo. These data are comparable with similar study done by Wells MD and Yande RD in 1987 where they reported the same to be 30%.[5] A study by Arya and Nunez in 1984 had 41 out of total 91 patients having single labyrinthine cause of vertigo.[10] Study by Sloane et al. in 1994 too has otologic causes to be 30%.[4] In a study by Kumar M and Prasad BK vertigo due to otological causes was found in 41.88% of cases.[11]
In the present study, more patients of vertigo were women (85/125) compared to men (40/125). This trend is supported by study by Yardley et al. who too said that more women report vertigo compared to males.[12]
In the present study of the patients, 23.2% patients had BPPV, 3.2% had vestibular neuronitis, 1.6% had labyrinthitis, and 0.8% had Meniere's disease. A study by Kentala E said that the six most common otologic cause of vertigo were Meniere's disease, vestibular schwannoma, BPPV, vestibular Neuritis, sudden deafness, and traumatic vertigo.[13] Numerous studies quote BPPV to be the most common cause of vertigo and this deserves special mention attention as it is very characteristic and highly treatable.[1],[9],[14],[15] Study by Arya and Nunezhad 40% patients to be of Meniere's and 22% patients to be of BPPV, 2% labyrinthitis.[10] A study by Bansal M had 18.75% patients as BPPV, 12.5% patients as vestibular neuritis, 9.37% as Meniere's disease.[16] A study by Das et al. had 20% patients as BPPV, 6.7% as vest neuronitis, 5.3% as Meniere's disease, and 4% as labyrinthitis.[17]
In the present study, all patients who were diagnosed with otologic cause of vertigo were treated with symptomatic and specific treatment. Symptomatic treatment includes antivertigo drugs. Specific treatment of BPPV includes particle repositioning maneuver in the form of Epley's maneuver. Those diagnosed as vestibular neuritis and vestibular labyrinthitis were treated with steroids. Those who met the criteria of Meniere's were subjected to intratympanic gentamycin. Thus, this study shows that otologic causes do form a large subset of patients with vertigo and the most common of the otologic causes can be managed by ENT surgeons with good symptomatic improvement amongst the patient. Those patients who were suspected to have nonotologic causes such as cardiogenic syncope and postural hypotension were sent to medicine outpatient department for further evaluation. Those with cervvicogenic vertigo were referred to orthopedic specialist. Vestibular migraine though is a central cause of vertigo was managed by multidisciplinary approach of ear, nose and throat specialists and physician.
| Conclusion | | |
The present study demonstrates that otological disorder does form a large subgroup (28.8%) of patients with vertigo referred to ENT OPD. In addition to this the most common of otologic cause of vertigo can be managed with good benefit to the patient. Thus a dedicated otology based vertigo clinic should form the first referral center of patients of vertigo from the general practitioners.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Karatas M. Central vertigo and dizziness: Epidemiology, differential diagnosis, and common causes. Neurologist 2008;14:355-64.  |
| 2. | Sonawale SK, Deshmukh S, Mishra P. Proportion of patients referred to ENT clinic, having Otologic cause of vertigo. Indian J Basic Appl Med Res 2018;7:5-12. |
| 3. | Jayarajan V. Rajendrakumar D. A survery of dizziness management in General Practice. J Laryngol Otol 2003;117:599-604. |
| 4. | Sloane PD, Dallara J, Roach C, Bailey KE, Mitchell M, McNutt R, Management of dizziness in primary care. J Am Board Fam Pract 1994;7:1-8. |
| 5. | Wells MD, Yande RD. Vertigo in a district NHS hospital. J Laryngol Otol 1987;101:1235-41. |
| 6. | Hanley K, O'Dowd T, Considine N. A systematic review of vertigo in primary care. Br J Gen Pract 2001;51:666-71. |
| 7. | Neuhauser HK. Epidemiology of vertigo. Curr Opin Neurol 2007;20:40-6. |
| 8. | Newman-Toker DE, Hsieh YH, Camargo CA Jr, Pelletier AJ, Butchy GT, Edlow JA. Spectrum of dizziness visits to US emergency departments: Cross-sectional analysis from a nationally representative sample. Mayo Clin Proc 2008;83:765-75. |
| 9. | Kroenke K, Hoffman RM, Einstadter D. How common are various causes of dizziness? A critical review. South Med J 2000;93:160-7. |
| 10. | Arya AK, Nunez DA. What proportion of patients referred to an otolaryngology vertigo clinic have an otological cause for their symptoms? J laryngol Otol 2008;122:145-9. |
| 11. | Kumar M, Prasad BK. Vertigo: A spectrum of cases. J Surg Forecast 2018;1:1013. |
| 12. | Yardley L, Owen N, Nazareth I, Luxon L. Prevalance and presentation of dizziness in a general community sample of working age people. Br J Gen Pract 1998;48:1131-5. |
| 13. | Kentala E. Characteristics of six otologic diseases involving vertigo. Am J Otol 1996;17:883-92. |
| 14. | Halmagyi GM. Diagnosis and management of vertigo. Clin Med (Lond) 2005;5:159-65. |
| 15. | Kentala E, Rauch SD. A practical assessment algorithm for diagnosis of dizziness. Otolaryngol Head Neck Surg 2003;128:54-9. |
| 16. | Bansal M. Common causes of vertigo and dizziness in Gujarat. Int J Clin Trials 2016;3:250-3. |
| 17. | Das S, Chakraborty S, Shekar S. Dizziness in a tertiary care centre in Sikkim: Our experience and limitations. Indian J Otolaryngol Head Neck Surg 2017;69:443-8. |
[Table 1], [Table 2], [Table 3], [Table 4]
|
Search Pubmed for