Frequently Asked Questions

1. Is feeling dizzy the same as having vertigo?

No. Vertigo is just one specific form of dizziness. You can feel dizzy without having vertigo symptoms. If you feel dizzy, it simply means lightheaded or unsteady. Patients often feel dizzy before they faint and this can be secondary to a strong emotion, standing for a long time, standing up too quickly from sitting position. Dizziness and fainting are very common and in most cases not serious. However, if your symptoms are prolonged then you should get in touch with your family doctor to discuss about the diagnosis. Other conditions can also make patients feel dizzy, for example, problem with rhythm of your heart, thyroid gland problems, side effects of some drugs, and other conditions including serious ones related to the brain.

Vertigo is just one specific type of dizziness which is usually caused by problems with inner ears.

2. Can I drive if I am diagnosed with Benign Paroxysmal Positional Vertigo (BPPV)?

If the symptoms are bad then you need to stop driving. If the symptoms are well controlled and you remain symptom-free, you can start driving. Please contact DVLA for further advice. You may also contact your family doctor to discuss in more detail. Drivers having group 2 licence for large goods vehicle and passenger-carrying vehicles, they need to be symptom-free for the duration of the journey in order to be eligible for driving. For further information www.dvla.gov.uk.

3. What will happen when I have the Epley's manoeuvre?

The Epley's manoeuvre is considered to be safe and effective in treating BPPV. You will be asked to sit on the bed and lie on your back with head tilting at the edge of the bed. The head and the body will be rotated to one side followed by rotation to the other side before sitting up again. You may feel dizzy doing the treatment which is a good sign, which shows that the treatment is working.

Epley's manoeuvre should not be painful. However, some people with chronic arthritis of the neck, back problems, advanced heart failure may feel this uncomfortable. Once the clear diagnosis is made, this manoeuvre can be safely performed at home.

4. Is BPPV an early sign of stroke?

BPPV is not an early sign of stroke. Although, some symptoms are similar to the stroke symptoms. Hence, a careful history and examination will help in correctly diagnosing this condition and simple manoeuvre usually helps to get rid of the symptoms.

5. I live alone; can I do these exercises on my own at home?

Most people can do home exercises in the comfort of their own bed. However, it may be useful if a friend or relative can stay for some exercises especially during the early part of the treatment.

6. Why do I need an ECG and a hearing test?

Vertigo and dizziness can be caused by causes other than inner ear crystals. Some of the causes can be quite serious, for example: Tumour of inner ear (Acoustic Neuroma) and Ménière's disease can also present with similar symptoms. Hearing test may help to exclude these causes. Similarly, certain type of heart problems can also cause dizziness; hence, a tracing of the heart may be helpful to diagnose some underlying heart problem.

7. Where do you see patients?

I consult mostly at Bronglais Hospital Aberystwyth between Monday and Wednesday, however appointment at Dolgellau, Tywyn, Machynellth hospital and home visit can be arranged.

8. Do I need a referral from my GP?

It is generally in your best interest to involve your General Practitioner before seeing a Consultant as a private patient. Your GP may be able to supply helpful information about your past medical history which may not have occurred to you. However, this is your choice and if you prefer you can e-mail me with your condition and my secretary will arrange appointment for you.

If you have Private Health Insurance you are advised to read your Policy carefully as many policies require a referral from your GP before authorisation for private care is agreed.

9. Can I see you for a second opinion?

I am happy to see you for a second opinion. Most doctors find that in the case of second opinions it is very useful if your GP provides as much information as possible , together with all the relevant reports, scans, x rays , blood tests and so on as this can save both your time and expense.

10. Can I claim from my Health Insurance?

Please refer to your Policy. Some companies will give pre-authorisation over the phone while others will require a claim form to be completed. Some of the claim forms require the GP's signature and others request the Specialist to complete the paperwork. Usually, a quick phone call to your medical insurance company will clarify matters.

11. Can you recommend exercises to help recover from illness?

Yes, we can recommend exercises that will help you recover quickly and safely from various illnesses, e.g. high blood pressure, obesity, arthritis, osteoporosis, asthma, heart attack, various operations .

12. You performed an Apley's manoeuvre on a patient. On repeating the Dix-Hallpike manoeuvre, she displays a burst of horizontal nystagmus, what should you do?

The particles have become displaced into the horizontal/lateral canal. Raise the patient to the upright-seated position facing you and immediately perform liberatory manoeuvre for horizontal benign paroxysmal positional vertigo. Have a basin ready for this disorder can cause abrupt vomiting.

13. You suspect that the patient's vestibular symptoms are due to migraine. On what grounds do you base your diagnosis?

Migraine-associated dizziness is the most common cause of chronic dizziness in young adults. Although this disorder often has a benign cause between attacks, it can cause serious debility. Migraine is believed to be genetic in origin, with an age of onset between 5 and 30 years in most cases. Vertigo may occur as part of an aura, as part of the headache phase, or between the headaches, and it varies in duration from seconds to days. Typically, the headaches are moderate to severe, last for hours, and are associated with nausea, photophobia, or phonophobia. Headaches may be accompanied by an aura, often consisting of visual illusions such as scintillating scotomas, or they may occur without aura. There is an association between migraine and other more serious vertigo disorders particularly Ménière's disease.

14. How is migraine-associated dizziness treated?

Migraine with vertigo can be treated with suppressants such as Stemetil if attacks are infrequent. However, prophylactic treatment is necessary if attacks are occurring more than once every few weeks. Tricyclic antidepressants such as amitriptyline are good first line choice, beta-blockers, calcium channel blockers, etc., are also effective in some individuals. Medication should be tried for at least one month before another type is tried because the effect often builds over several weeks. A newer migraine treatment aimed at the headache phase such as sumatriptan is generally not effective for migraine-associated vertigo spells.

15. Why do the elderly people develop imbalance?

Normal balance depends on a normal vestibular system, normal vision, normal tracking, normal sensation, and proprioception in the lower extremities. People with impairments in each of these areas have multi-sensory imbalance. Usually, vision, visual tracking, and sensation in the feet become impaired with age. When coupled with any vestibular disorders or with a gradual age-related decline in vestibular function, multi-sensory imbalance occurs. Affected people usually feel dizzy only when ambulating and their dizziness is relieved when using a grocery store cart, for example.

16. Are any treatments available for multi-sensory imbalance?

First, any correctible deficiencies in vision or sensation should be treated. For example, cataract excision can improve vision, B12 supplementation can be provided for neuropathy due to vitamin deficiency. Vestibular rehabilitation including fall risk assessment can help improve overall balance. During rehab, assistive devices such as canes and walkers can be tried, and training can be given in their proper use. Use of four-wheeled rolling walker with handbrakes can result in immediate improvement in symptoms.

17. What is Ménière's syndrome?

This is a chronic, progressive, destructive disorder involving both cochlea and labyrinth resulting in permanent hearing loss and vestibular injury over time. It can affect one or both ears and follows a relapsing and remitting course. A number of known disorders such as autoimmune disease, human immunodeficiency virus infection, and syphilis can cause identical symptoms. So the term Ménière's syndrome is used only for cases in which the cause is unknown. The term is often used interchangeably with this pathological description endolymphatic hydrops. Since a high accurate method to detect this abnormality in life is not yet available, the diagnosis is primarily subjective. Patients with recurrent vertigo but without evidence of progressive hearing loss or permanent vestibular injury do not need diagnostic criteria for this disorder.

18. Can Ménière's syndrome be treated medically?

Infrequent vertigo attacks should be treated with vestibular suppressant such as diazepam, Stemetil. If attacks occur more than few times a year, an additional intervention is indicated. Traditional treatment has included dietary sodium restriction and the use of diuretic. Steroids can be given orally or by injection into the middle ear. Patients with migraine may also benefit from the use of migraine prophylactic medications.

19. When is Ménière's syndrome treated surgically?

When vertigo spells occurs monthly or more frequently in spite of medical management or when spells are severely disabling, surgery should be considered. Although vertigo is the primary problem, however, preservation of hearing is also important. Most surgeries destroy vestibular function in the affected ear and should be used only when a progressive unilateral hearing loss has been clearly documented. In ears with useful hearing, effective surgeries include vestibular nerve section, transtympanic aminoglycoside treatment with the inner ear. Procedures would decompress the hydropic endolymphatic sac having used with variable results. When the patient has no residual hearing in the affected ear, labyrinthectomy is usually effective in ending vertigo spells.

20. What is neurolabyrinthitis?

This acute unilateral vestibulopathy can be preceded by a nonspecific viral illness. Within hours to days, the patient experiences the sudden onset of vertigo. The vertigo reaches a peak rapidly and then gradually declines over a few days to weeks. Cochlea symptoms vary ranging from normal hearing to a mild, high-frequency hearing loss to sudden profound deafness in one ear. If there is no hearing loss, the disease is called vestibular neuritis. Total destruction of all auditory and vestibular function in one ear can occur with certain viruses such as measles, mumps, herpes zoster. After the severe symptoms have subsided, the patient may experience mild lightheadedness with sudden movement that can persist for months. With time, however, the patient's vestibular system compensates and the dizziness really clears.

21. How are viral inner ear infections treated?

If hearing loss does not occur, most patients are managed symptomatically. Vestibular suppressant medications such as diazepam and Stemetil are used to control vomiting. Administration of these medications should be discontinued after a week because they interfere with the normal process of compensation to vestibular injuries. Patients who are still symptomatic at that time are good candidate for a vestibular rehabilitation. If hearing loss occurs, steroids are often given in attempt to prevent deafness in the affected ear.

22. What is vertebrobasilar insufficiency?

Vertebrobasilar insufficiency can cause transient vertigo that usually lasts for several minutes. The vertigo may be accompanied by other brainstem symptoms such as headache, diplopia, loss of vision, perioral numbness, or dysarthria. These attacks are referred to as transient ischaemic attacks. If the symptoms persist for more than an hour, a stroke is likely. Cerebellar strokes can cause rapid herniation and death. So, persons with suspect cases should always be hospitalised. Transient ischaemic attacks are due to a transient decrease in cerebral blood flow, frequently attributed to atherosclerosis. Vestibular symptoms result from ischaemia to the lateral part of the medulla where the vestibular nuclei are situated or from ischaemia involving the labyrinthine artery that supplies blood to the ear. Cerebellar ischaemia can also result in vertigo.

23. What drugs lead to hearing loss?

• 1. Salicylates.
• 2. Aminoglycosides (gentamicin, tobramycin, amikacin)
• 3. Erythromycin.
• 4. Cisplatin and related compounds.
• 5. Loop diuretics, (furosemide, bumetanide, ethacrynic acid)

Aminoglycosides damage cochlear and vestibular hair cells. Cisplatin primarily affects the outer hair cells, and the loop diuretics damage the stria vascularis. The stria vascularis is the region of specialised epithelium in the organ of Corti that is responsible for maintaining ionic balance. Patients receiving more than one ototoxic drug or patients with compromised renal functions are at increased risk of hearing loss. Such patients should undergo serum drug levels monitoring in addition to serial audiometric evaluations. Patients with acute damage initially suffer from tinnitus. Hearing is first affected in the high frequencies reflecting damage to hair cells in the basal turn of the cochlea. Hearing loss in the lower frequencies follows as damage progresses towards the cochlear apex. Hearing loss is typically bilateral and can be permanent.

24. What are other central causes of dizziness?

Trauma can result in post-concussive syndrome or direct brain injury. Other central processes include cerebrovascular accidents, intracranial vasculitis, or other vascular lesions, and demyelinating CNS lesions such as multiple sclerosis. Neoplasms in the posterior fossa such as acoustic neuromas are also an important cause of dizziness or hearing loss.

25. What are your fees?

Privately arranged appointments will cost £75 for examination, treatment and home leaflet. You can pay be cheque made to Medyg K&Q Bashir, or electronically to sort code 40.08.09 Account no 31571826 HSBC Aberystwyth.