Otolithiasis, Meniere's disease, post-circulation infarction... What other diseases of dizziness do you have to think of?

Dizziness/vertigo and balance disorders are very common in neurology patients and are often ignored as an age-related normal. However, many elderly patients have dizziness/vertigo and balance disorders of a single etiology, and may be the result of a combination of multiple diseases and factors, so it is crucial to determine the cause.

In this paper, the clinical characteristics and common causes of dizziness/vertigo and balance disorders in the elderly are reviewed.

Clinical features of dizziness/vertigo, balance disorders

The maintenance of balance depends not only on peripheral sensory afferation (mainly proprioceception, vision, and vestibular sensations) and their integration in the center, but also on motor control and other functions of the nervous system such as cognition, and older people may also have non-neurological factors.

Elderly dizziness/vertigo and balance disorders have the following characteristics:

1) Physiological aging: the peripheral sensory afferation and central information integration function of the elderly have decreased in all aspects, mostly manifested as chronic balance disorder (mostly mild) and dizziness;

2) Non-nervous system causes, such as hypertension, arteriosclerosis, myocardial ischemia, arrhythmias, etc., while taking a variety of drugs and drug side effects, some drugs can cause orthostatic hypotension leading to dizziness or balance disorders;

3) The elderly often have leukopathy, which affects cognitive function or damages the sensory and motor nerve fibers between the lower limb area of the cerebral cortex and the thalamus, basal nucleus, cerebellum and spinal cord due to white matter lesions, causing balance disorders;

4) Combined with anxiety depression or long-term dizziness caused by psychosocial changes, coupled with oral anti-anxiety and depression drugs can increase the occurrence of dizziness / vertigo and balance disorders;

5) With age, the elderly will have degenerative bone and joint changes or combined bone and joint diseases can also lead to the occurrence of balance disorders.

Common causes of dizziness/dizziness

01. Acute single-onset vertigo

1) Post-circulating acute infarction:

The proportion of acute vertigo is not high, but if the diagnosis is missed and treatment is delayed, it can cause serious consequences, and patients with acute vertigo should be completed as soon as possible after the removal of Cranial MRI after circulating infarction:

Risk factors for cerebrovascular disease; Sudden severe hearing loss; Central eye movement abnormalities (eg, vertical nystagmus, gaze-induced nystagmus, etc.); Cranial nerve involvement; Other manifestations of posterior circulating ischemia (dysarthria/hoarseness, drinking cough/dysphagia, trunk/limb ataxia, limb/facial numbness and weakness); Horner syndrome.

2) Vestibular neuritis:

About half of patients have a history of previous respiratory infections, with vertigo peaking in minutes or hours, accompanied by vibrational hallucinations, nausea and vomiting, and tilting to one side, with changes in head position that exacerbate dizziness. Most patients are unable to walk, and severe vertigo can last from days to weeks. Some patients can get better naturally, leaving few sequelae.

3) First episode of vestibular migraine (VM):

VM is a genetically predisposed disorder characterized by recurrent episodes of dizziness/dizziness, which can be accompanied by nausea and vomiting, and/or headache. VMs can present as various types of central and peripheral spontaneous nystagmus and central positional nystagmus, and may be similar to posterior circulating stroke if accompanied by ataxia or other central signs.

A history of migraine attacks or migraine features at the onset of vertigo, such as pulsatile headache, photophobia, soundophobia, or aura, can support the diagnosis, but can only be confirmed if similar episodes occur multiple times. Therefore, for patients with suspected migraine vertigo whose symptoms persist and are the first onset, it is recommended to perform a cranial MRI to rule out post-circulating lesions.

4) First episode of Meniere's disease:

Meniere's disease is an unexplained inner ear disease characterized by hydrops in the membrane labyrinth, and it is not difficult to diagnose the first Meniere disease with hearing loss, tinnitus, and a feeling of ear fullness;

However, Meniere's disease is often initiated with simple cochlear symptoms (more common) or single vestibular symptoms (less common), and its previous history of fluctuating hearing loss and tinnitus attacks is of great diagnostic value, otherwise the diagnosis of isolated vertigo is not easy, attention should be paid to follow-up, and if recurrent episodes of vertigo have been without cochlear symptoms, other diagnoses should be considered.

5) Sudden deafness:

Clinical manifestations are often sudden unilateral hearing loss, which may be accompanied by tinnitus, ear blockage, dizziness, nausea and vomiting.

6) Other reasons:

Exolymphatic fistula; bacterial labyrinthitis; drug or alcohol intoxication; cerebellar drug intoxication: the first symptoms are mainly dizziness (rather than dizziness) and balance disorders.

02. Recurrent dizziness/vertigo

1) Benign paroxysmal positional vertigo (BPPV):

BPPV is an peripheral vestibular disorder induced by changes in head position relative to the direction of gravity and characterized by recurrent transient vertigo and characteristic nystagmus. Often self-limiting, prone to recurrence, and is the most common positional vertigo in older adults, with the highest incidence of BPPV among all vertigo disorders and later semicircular canal BPPV being the most common.

2) Post-loop TIA:

There are many risk factors for cerebrovascular disease, accompanied by other manifestations of posterior circulating ischemia, such as: dysarthria/hoarseness, drinking cough/dysphagia, trunk/limb ataxia, limb/facial numbness, and diplopia.

3) Meniere's disease:

Episodes of vertigo last from 20 minutes to hours and are accompanied by hearing loss, tinnitus, and a feeling of full ear, with progressive hearing loss over several years.

4) Vestibular migraine:

Spontaneous or positional vertigo, each episode lasting from seconds to days, with a history of migraine; vertigo attacks are accompanied by migraine symptoms; vertigo is mostly induced by migraine-specific triggers.

5) Vestibular paroxysmal:

For recurrent transient spin or non-rotational vertigo, vertigo lasting less than 1 minute, symptoms are stereotyped, and carbamazepine/oxcarbazepine therapy is effective.

6) Orthostatic hypotension:

Mostly episodes of transient dizziness lasting from seconds to minutes, mostly induced in the upright position, relieved in the sitting or recumbent position, may have had syncope, and are accompanied by changes in blood pressure in the upright position (systolic blood pressure drop ≥ 20 mmHg or decreased diastolic blood pressure ≥ 10 mmHg).

7) Arrhythmias:

Paroxysmal arrhythmia-associated dizziness often lasts for several seconds, and prolonged dizziness due to persistent arrhythmias is rare. Dizziness is mostly a pre-syncope symptom, manifested by top-heavy and fatigued feelings, accompanied by blurred vision or blackness, tinnitus or hearing impairment or even syncope, dizziness is often accompanied by palpitations, angina and dyspnea.

8) Drug-induced dizziness:

Dizziness usually occurs after an increase in the dose of a drug or after taking a new drug, which is classified according to the different mechanisms of action of the drug and its effects on the human body: sedation, vestibular inhibition, ototoxicity, cerebellar toxicity, orthostatic hypotension, hypoglycemia, and others.

Chronic dizziness/vertigo, balance disorders

1) Chronic vestibular migraine: VMs in the chronic phase are mostly manifested as a feeling of seasickness that is mild and severe and aggravated when the head is active.

2) Advanced Meniere's disease: chronic dizziness and balance disorders occur later in the course of the disease.

3) Bilateral vestibular function loss: there are many causes, the most common are aminoglycoside drug poisoning, meningitis sequelae, inner ear diseases, etc., patients will have a sense of instability and vibration hallucinations, and the instability will be aggravated when walking in the dark.

4) Persistent-postural-perceptual dizziness (PPPD): the presence of one or more symptoms of dizziness, instability, and non-rotational vertigo for ≥ 3 months; upright posture, active or passive movement, exposure to mobile visual stimuli can lead to aggravation of symptoms;

Usually triggered by disorders that cause dizziness/vertigo, balance disorders, including acute onset/chronic vestibular syndrome, other neurological, internal medicine disorders, and psychiatric disorders; symptoms cause severe distress or dysfunction; symptoms cannot be better explained by other disorders.

5) Positive pressure hydrocephalus: patients mostly present with a triple sign of gait disorder, urgent urinary incontinence and dementia, gait abnormalities are the earliest and most significant symptoms, characterized by slow start-up, poor movements, often accompanied by stiffness, mild broad-based gait and balance disorders when turning.

6) Mental and psychological factors: anxiety and depression, agoraphobia, fear of falling, cautious gait, etc., mostly manifested as top-heavy, mental trance, fear of falling, about to faint, etc.

7) Presbycutan disease: prominent symptoms are postural balance and gait instability, and symptoms are aggravated when walking in dark environments and uneven ground.

8) Peripheral neuropathy: peripheral neuropathy caused by diabetes, alcoholism, vitamin deficiency, etc., the common first symptoms are numbness or tingling sensation in the foot, unstable when walking or standing in the dark, distal sensory loss, decreased vibration sensation in the toes and ankles, positive Romberg sign.

9) Cerebral white matter lesions, cerebral small blood vessel disease and other injuries to the subcortical and thalamus, basal ganglia, spinal cord, cerebellum sensory and motor nerve fibers, resulting in balance disorders and gait abnormalities, while this part of the patients are more combined with cognitive decline, but also aggravate balance disorders, and even lead to falls.

10) Spinal cord disease: subacute combined degeneration can involve instability and balance disorders due to spinal cord and peripheral nerve injury, and posterior spinal artery infarction can also involve deep sensory balance disorders.

11) Parkinson's disease / Parkinson's syndrome: may be combined with postural / balance disorders.

12) Sleep disorders (such as insomnia, sleep apnea syndrome) and long-term use of tranquilizers and benzodiazepine sleep drugs can lead to dizziness, dizziness, instability and balance disorders during the day.

13) Systemic state: such as anemia (dizziness mainly occurs when changing from sitting to standing), malnutrition, cachexia;

14) Orthopedic diseases: hip and knee joint diseases, cervical spondylosis and lumbar spondylosis, etc., can aggravate balance disorders.

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