General information. Meniere’s yndrome usually begins at 20–40 years old. It is characterized by sudden bouts of severe vestibular dizziness, lasting from several minutes to several hours. Before an attack, and sometimes after it, there is a feeling of congestion and bursting or a noise in the ear, transient hearing loss. After an attack, an imbalance, especially noticeable when walking, can persist for a long time. The course is characterized by remissions and exacerbations. At the onset of the disease, sensorineural hearing loss (mainly to low sounds) is episodic. As a result of repeated attacks, hearing is progressively reduced, but periods of improvement are possible. Pathogenesis. The main morphological changes in Meniere’s syndrome are wall stretching and an increase in the volume of endolymphatic space (endolymphatic dropsy). The cause may be impaired absorption of fluid in the endolymphatic sac or obstruction of the endolymphatic duct. Treatment. With an attack, bed rest and vestibulolytic drugs are prescribed . For the treatment of Meniere’s syndrome , a low sodium diet in combination with diuretics ( thiazides or acetazolamide ) was recommended ; it was suggested that this could reduce fluid accumulation in the endolymphatic space. A moderate effect was obtained with the use of betahistine (a derivative of histamine) , which helped to prevent attacks. In a small part of cases with frequent, severe, treatment-resistant seizures, surgical treatment is indicated . Ideal surgery for Meniere’s syndrome does not exist. Bypass surgery of the endolymphatic sac reduces dizziness in 70% of patients, however, hearing continues to decrease in 45% after surgery. Intrathimpanic or systemic administration of ototoxic drugs ( gentamicin or streptomycin ) prevents dizziness attacks, but leads to persistent imbalance and an increase in hearing loss. Differential diagnosis. 1. In all cases, it is necessary to exclude a tumor of the cerebellar cerebellar angle. Tumors of this localization cause noise in the ear, hearing loss, imbalance, but only rarely – bouts of dizziness. 2. The cause of dizziness and hearing loss may also be infectious labyrinthitis, perilymphatic fistula, Cogan syndrome, high viscosity syndrome. 3. Congenital syphilis.
1. Bacterial labyrinthitis .
With a bacterial infection of the middle ear or mastoid process (for example, chronic otitis media ), bacterial toxins can cause inflammation of the structures of the inner ear (serous labyrinthitis). Purulent labyrinthitis is a dangerous disease that requires early diagnosis and antibiotic therapy. 2. Viral labyrinthitis. Damage to the auditory and vestibular organs is observed in various viral infections, including influenza, herpes, rubella , mumps, viral hepatitis, measles, and Epstein- Barr virus infection . Most patients recover on their own.
Functional dizziness .
1. In a person who is in a closed cabin of a ship or in the back seat of a moving car, vestibular afferentation creates a sense of acceleration, while visual evidence of the relative immobility of surrounding objects. The intensity of nausea and dizziness is directly proportional to the degree of sensory mismatch . Motion sickness is reduced with a sufficient panoramic view, allowing you to verify the reality of the movement. 2. Visual dizziness occurs when observing moving objects (for example, when a person watches a movie with a car chase). 3. Altitude dizziness is a common phenomenon that occurs when the distance between a person and the stationary objects he observes exceeds a certain critical value.
Transient ischemia of the brain stem.
The clinical picture.
1) Vestibular dizziness and imbalance are the two most common symptoms of transient ischemia of the brain stem resulting from damage to the arteries of the vertebrobasilar basin. At the same time, only in rare cases they are the only manifestations of this disease .. 2) Imbalance and blurred vision occur both with vestibular neuronitis and with trunk lesions, and therefore do not allow to determine the localization of the focus. Acute hearing loss is not characteristic of ischemic damage to the trunk. Treatment ( see cerebrovascular accident ).
The illusion of oscillation of stationary objects .
Oscillopsia in combination with vertical nystagmus, instability and vestibular dizziness is observed with craniovertebral anomalies (for example, Arnold- Chiari syndrome ) and degenerative lesions of the cerebellum (including olivopontocerebellar atrophy and multiple sclerosis).
Treatment. Baclofen (a GABA agonist) is effective if oscillosis is accompanied by periodic alternating nystagmus. The drug is prescribed for 10-20 mg 3 times a day. With damage to the brain stem and cerebellum, oscillosis sometimes decreases under the influence of clonazepam.
Chronic vestibular dysfunction.
General information. The brain is able to correct the broken connection between the vestibular, visual and proprioceptive signals. Thanks to the processes of central adaptation, acute dizziness, regardless of its cause, usually disappears within a few days. However, sometimes vestibular disorders are not compensated due to damage to the brain structures responsible for vestibuloocular or vestibulospinal reflexes. Treatment. Constant dizziness, imbalance and coordination of movements can cause disability of the patient. Drug therapy in such cases is usually ineffective. A patient with persistent vestibular dysfunction is shown a set of special exercises (vestibular gymnastics) to reduce dizziness and improve balance.
Standard complex of vestibular gymnastics.
- Exercises for the development of vestibular adaptation are based on the repetition of certain movements or postures that cause dizziness or imbalance. It is believed that this should contribute to the adaptation of the vestibular structures of the brain and inhibition of vestibular reactions.
- Exercises for training balance are designed in such a way as to improve coordination of movements and use information from various senses to improve balance.
Hyperventilation syndrome and psychogenic dizziness.
A. Hyperventilation syndrome is a common cause of dizziness. Hyperventilation attacks are caused by anxiety or other affective disorders.
General information. Hyperventilation leads to hypocapnia, alkalosis, narrowing of the cerebral vessels and a decrease in cerebral blood flow. Patients complain of an indefinite sensation of lightheadedness, often accompanied by paresthesia of the lips and fingers, a feeling of lack of air, sweating, chills, palpitations and fear. A provocative test with a three-minute hyperventilation has not only diagnostic, but also important psychotherapeutic significance, since the origin of the symptoms becomes clear to the patient. Treatment. First of all, it is necessary to convince the patient that his disease is not dangerous. In severe cases, psychiatrist consultation and psychotherapy are indicated. Hyperventilation attacks can be stopped by inviting the patient to breathe into the bag (in this case, he will inhale the carbon dioxide exhaled by him, which prevents hypocapnia and alkalosis).
B. Psychogenic dizziness
With some neurosis and psychosis, dizziness occurs, not similar to any of the known conditions (vestibular dizziness, fainting, or imbalance) and not reproducible with any of the provocative tests described above. Dizziness occurs in approximately 70% of patients with hypochondriac neurosis and more than 80% of those with hysterical neurosis. Dizziness in such patients often lasts for years and is constant rather than episodic. Many of them call “dizziness” general weakness, impaired attention, a feeling of obscurity in the head.
2 . Anxiety or depression does not necessarily indicate psychogenic dizziness, as they are often not the cause, but the result of acute and chronic vestibular disorders of antidepressants.