Suffering from dizziness?

You are rarely aware of your vestibular system. Yes, you may know you have one, but you don’t give it much thought. But this changes when something is wrong with that fragile part of your inner ear. You’re dizzy, and not a little. So you go to the doctor, who will refer you to an ENT specialist, who in turn will ask you a lot of questions to find out what exactly is going on. A doctor like Stephanie Winters of the Apeldoorns Dizziness Center (ADC), part of the Dutch Gelre Hospitals. The doctors at this expertise center are trained in further questions.

How dizzy are you?

“Dizziness is a difficult complaint to interpret,” says Winters. “People can experience it in many different ways. Dizziness is actually a collective term for all kinds of complaints, illnesses and disorders. It is therefore important to listen carefully to the patient’s story and to get as concrete as possible what the complaint is. can vary quite a bit: from bloating, a light-headed feeling, seeing blackened eyes to the feeling of fainting, but it can also be that someone is vertigo and has the feeling of being on a merry-go-round. appear, have seizures, or only occur when you turn around in bed. Through the patient’s story, we need to figure out exactly what’s going on.” Sometimes it’s two or three things mixed up. “Many of our patients have multiple forms of dizziness. And then you also have to try to distil from the story what exactly is going on. Very often there are several disorders at the same time.”

Is it the ear or is it the brain?

For example, a visit to an ophthalmologist is a different experience than a consultation with an ENT specialist who specializes in the vestibular system. An ophthalmologist is especially wiser from eye measurements, but such an ENT doctor has to rely mainly on the conversation. “Of course we also do research and diagnostic tests for vertigo, but this specialty is more than ‘measuring is knowing’. The patient’s story is priority number one. The main problem with the inner ear is that you can’t research it very well. It is located in the skull, behind the ear. The vestibular system is very small, which makes it difficult to assess it on a scan. In addition, it is also very fragile, which means that direct examination is not possible.” So asking and listening are the most important tools. And Winters doesn’t serve it alone. “With us, the ENT doctor and the neurologist always hold consultations together. ENT doctors know a lot about the ear and the vestibular system. The neurologist knows a lot about the brain. We always sit together in the consultation room because brain disorders can also cause dizziness. Based on the patient’s story, our physical examinations and the balance examinations, we together form a conclusion.”

Complicated system keeps your balance

Stephanie Winters puts a plastic model of the ear on the table and explains. “Behind the concha you feel a solid bone. That is the rock bone. It contains the vestibular system, which in turn is part of the balance system. This also includes the eyes and the feeling in the muscles and tendons. Your eyes are especially important in the “keeping your balance. In addition, you also have receptors that sense how gravity acts on your body. Together, these subsystems help you to maintain your balance and with your spatial orientation.” So the vestibular system is just one cog. “But it is a very important cog. It consists of five parts. You have three semicircular channels with liquid in them, which are perpendicular to each other. They measure the accelerations in the different directions of rotation.” With every movement of the head, those fluids start flowing. The sensory cells, or small hairs that stick in the liquids, will bend due to the current. This sends signals to the brain about how the head moves and what position it is in. “You also have two small organs that measure the linear accelerations, for example in a train or in an elevator.” These organs also have sensory cells with small ear stones on them. These ear stones lag behind during movement, causing the hair cells to bend and send a signal to the brain. All this information is processed in the brain. “From there, stimuli go to the muscles of the body, so that you can adjust your posture and keep your balance.”

When you get motion sickness, your brain is confused

Dizziness occurs when wrong or unfamiliar signals enter the brain. An example of this is motion sickness. If you’re reading in the back and the car makes a turn, the liquids will flow into the channels. As a result, the sensory cells bend in a certain direction. “They tell your brain: we are moving. But your eyes signal something else: we are standing still. Your brain gets confused and that makes you nauseous. It then helps to look outside and see that you are indeed moving.” This example also illustrates that the brain can adapt quickly. “Fortunately, we have a very plastic brain that can handle disturbances quite well. There are many people who can function very well with partially or half-functioning vestibular organs. If one of the vestibular organs no longer works or is partially damaged – by whatever reason – your brain can often compensate for that.”

Usually it’s the stones

Unfortunately, the brain cannot do everything. And any disturbance somewhere in the vestibular system can cause dizziness and balance problems. For example, the ear stones can come loose and start to wander. “Those stones, also called ‘grit’, cause one of the most common forms of dizziness. It often goes away on its own, but not always. Fortunately, it can be treated well and so you really shouldn’t have to carry around with it.” This form of vertigo is officially called ‘benign paroxysmal position-dependent vertigo’ (BPP) and occurs mainly in the elderly. “These are short vertigo attacks, lasting seconds to minutes. They are triggered by certain movements of the head: bending over, looking up, turning over in bed, lying in and getting out of bed. We treat this with a kind of tipping manoeuvre. Very quickly placed backwards, causing the grit to move away from the place where it causes vertigo. We do this hundreds of times a year. When it works, it’s magical. Someone with this complaint can be freed from vertigo for good after a tipping maneuver. Then it’s just over, gone.”

Or is it the hormones?

A completely different condition is balance migraine: vestibular migraine. “We see this especially in women, especially around menstruation, but also around menopause. Why? Migraines are somewhat hormonally regulated and women often have it cyclically, i.e. monthly. What we often hear is that women who have or have had migraines in the past have sudden attacks of vertigo around menopause These attacks are often accompanied by other migraine symptoms, but not always Some medicines, such as beta-blockers or anti-seizure medicines can help to prevent new attacks, but are not for suitable for everyone.”

Dizzy for days?

Inflammation! Inflammation can also affect the balance organs. “People then suddenly become very dizzy. That takes about three days. All that time they lie in their bed very nauseous. After three to five days they get up and they often have balance problems, because one of the balance organs has been damaged by that inflammation It is important to get back in your legs quickly after such an inflammation and to start walking briskly. This sets the compensation mechanisms in motion, so that you do not have to experience any lasting complaints from the damage that the inflammation has caused. “

Vertigo and half deaf

Ménière’s disease is a different story. “That’s a really nasty condition,” Winters says. “These are attacks of vertigo that are accompanied by unilateral hearing loss, ringing in the ears and a feeling of pressure in one of the ears. Those attacks last half an hour to hours. People are very ill: vertigo, nausea, vomiting. It is especially the unpredictability that makes it hard. If you can always have a vertigo attack, it makes you very insecure.” The main therapy: injections behind the eardrum. “That sounds more exciting than it is. We give those injections here under local anaesthetic. Then we put a little anti-inflammatory (dexamethasone) or antibiotics (gentamicin) behind the eardrum with a thin needle. These agents work well and reduce the number of attacks. start with dexamethasone, because that has hardly any side effects. If that doesn’t help, we switch to gentamicin. There is a small chance that the hearing damage will worsen. That’s why we are a bit more cautious with that.” If an anti-inflammatory can be effective, it seems that inflammatory processes play a role in ménière. “We think so, yes. But the exact background of this disease is still being researched. The idea is that through a tear in a membrane the fluids in the inner ear mix with each other. This causes damage to the hearing and vestibular system, with dizziness and reduced hearing as a result, but we don’t know yet how we can prevent that.”