What is wrong with me?

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Getting a diagnosis becomes important to anyone experiencing dizziness and vertigo symptoms. For the purpose of this section the term "dizziness" is used to describe the myriad of symptoms you may have. Your first step will probably be a trip to your GP. Your GP will run through a full physical examination, listen to your heart and lungs and do some basic neurological checks. They will look into your ears, check the optic nerve in the back of your eyes, ask you to follow a pen with your eyes, evaluate your basic balance when standing and walking, test your general reflexes and take a detailed history of your dizzy symptoms. Assuming that the cause is peripheral - that is, your dizziness is being caused by a problem in your inner ear - you will often be prescribed an anti-vertigo medication to dull the vestibular system.

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There is an increasing body of thought that suggests that vestibular suppressants should only be used during the very worst of the vertigo symptoms (first week or so) and that continued use of such medication may in fact hinder full compensation. Your specialist will be able to advise you fully on this matter. But be aware that GPs will readily prescribe this medication when in fact the inner ear specialists will differ in opinion.

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For many the symptoms of Labyrinthitis clear within a few weeks with little or no residual symptoms.

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For others, dizziness symptoms will be prolonged and if you have not noticed a vast improvement in your symptoms by six weeks from onset - a referral will generally be made to a specialist often an ENT.

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Don’t be surprised if your GP and even your ENT seem to be rather dumbfounded by your continuing symptoms of dizziness, many are not familiar with this, don’t panic. This is a very familiar pattern, one of which we both experienced.

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Many GPs seem shocked when presented with a patient who has had Labyrinthitis for months or years. "Labyrinthitis for a year? That's not possible" was one of the comments Emma experienced from a GP.  The fact is it IS indeed very possible and strictly speaking, it is not Labyrinthitis which remains at this stage - but vestibular or inner ear dysfunction. Many GPs are not aware of "Uncompensated" Labyrinthitis and are only aware of the Labyrinthitis which lasts 8 weeks maximum.

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Recognise this and do not worry about unhelpful or unknowledgable comments.

It must be noted that some ENTs have undergone special training related to the inner ear so do know their stuff. Others however are "general" ENT's and therefore often are not quite as knowledgeable about inner ear problems.

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The name for a specialist in balance and dizziness is a Neurotologist – this is not the same as a neurologist. Neurotologists see dizzy people day in and day out and you will find that rather being the exception your symptoms are experienced by the vast majority of their patients.  They are very aware of Uncompensated Labyrinthitis and daily see patients who have had it for a long time.

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They deal with all causes of dizziness and not solely dizziness confined to the inner ear. We would advise trying to find a Neurotologist if you require further help with getting a diagnosis and/or treatment. For UK sufferers, we can advise you on this if you email us.

Your specialist will repeat the basic checks done by your GP and will often refer you for both an MRI scan and vestibular testing.

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Tests

MRI - Magnetic Resonance Imaging

MRI scans use magnetic and radio waves, to create images in sections of your brain. An MRI scan is considered a safe procedure, is completely painless and there is no exposure to X-Rays or any other forms of radiation. The scan builds up images of the brain and if used with contrast, the blood vessels and arteries too. It is often quite alarming to be told that you will have a brain scan; most people are nervous and apprehensive about this. This test is really just one of many and in the vast majority of cases it will come back entirely normal. In actual fact looking at the images of your brain is quite fascinating! Many specialists will use these tests to reassure dizzy patients that they do not have a serious illness.

Evaluating the vestibular system involves a combination of tests. Vestibular tests are tests of function. Their purpose is to determine if there is something wrong with the vestibular portion of the inner ear.

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The following list of tests are designed to provide you with an overview and not in depth descriptions.  Which tests you have will depend on your specialist. 

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Audiometry - Hearing Test

Because the vestibular system is in close proximity to the hearing apparatus, vestibular testing includes hearing tests. Audiometry is the term used to describe formal measurement of hearing. The tests are used to determine if there is something wrong with the hearing (auditory) portion of the inner ear.  This test is often used as an initial screening to decide if more extensive testing is required. This test can also make the distinction between Vestibular Neuritis (no hearing loss) and Labyrinthitis (some hearing loss which can range between barely noticeable to severe).

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Tympanometry

Tympanometry is a measure of the stiffness of the eardrum and is used to evaluate the function of the middle ear. This test can be helpful in detecting fluid in the middle ear, negative middle ear pressure, and disruption of the ossicles, tympanic membrane perforation, and otosclerosis. It can help diagnose Menieres Disease and Eustacian Tube Dysfunction (ETD). To perform the test, a soft probe is placed into the ear canal and a small amount of pressure is applied. The instrument then measures movement of the tympanic membrane (eardrum) in responses to the pressure changes.

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Brainstem Auditory Evoked Responses

Brainstem auditory evoked responses (BAER), also known as auditory brainstem evoked response (ABR), measures the timing of electrical waves from the brainstem in response to clicks in the ear. The tests involves sitting or lying down in a sound proof room with small electrodes taped on and simply listening to a range of sounds.

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ECOG - Electrocochleography

ECOG is a variant of BAER where an electrode is placed on or in the eardrum. ECOG is also only useful diagnostically when a positive result is detected.

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VEMP - Vestibular Evoked Myogenic Potentials

The purpose of this test is to detect abnormally sensitivity of the otoliths as well as their central connections, to sound. This is a quick and painless test whereby you will hear a range of fairly loud noises and electrodes record your response to those noises. 

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ENG – Electronystagmography

The ENG test is considered the gold standard for diagnosis of ear disorders affecting one ear at a time. This test can help establish the cause of your dizziness as sometimes dizziness problems that appear to be vestibular have another cause.

The main reason is that if dizziness is being caused by the inner ear it is often shown in your eye movements. The way your eye’s move will hold important clues as to vestibular dysfunction. To record eye movements, physicians use a technique called Electronystagmography (ENG). The purpose of the ENG is to determine whether or not dizziness may be due to inner ear disease. There are four main parts to the ENG. The calibration test evaluates rapid eye movements. The tracking test evaluates movement of the eyes as they follow a visual target. The positional test measures dizziness associated with positions of the head. The caloric test measures responses to warm and cold water circulated through a small, soft tube in the ear canal.

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In ENG testing, surface electrodes are placed on the face both above and below and on either side of the eyes. The patient is then placed in a variety of situations, and resulting eye movements are electronically recorded.

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Sometimes this test will find no vestibular dysfunction, this does not always mean that you have no vestibular problem. It can depend which inner ear canal(s) are damaged. The ENG at present only tests two of the three inner ear canals and therefore cannot detect all damage.

When the ENG is performed, also can affect the result - if it is performed on a "good" day for the patient, then often this test comes back showing no abnormality. Finally, we have found out that many ENGs are not done correctly in many hospitals - "Frenzel goggles" must be used in order to see the patient's eye movements in detail - and in many places, they are indeed not used during this test.

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In summary, do not be alarmed if your ENG comes back negative - this does NOT mean your problem is not inner ear related. A good specialist will know the shortcomings of the ENG and diagnose you based on your symptoms history also. If your ENG is negative and your ENT says you do not have an inner ear problem - though you believe you do - seek a Neurotologist. Trust your own instinct. In general, Neurotologist's ENG testing is more reliable and more thorough.

The ENG is not used in isolation and all tests (and symptom history) together are used to make a full and accurate diagnosis.

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Rotary Chair Testing

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The purpose of rotational testing is to determine whether or not dizziness may be due to a disorder of inner ear or brain. There are three parts to the test. The chair test measures dizziness (well jumping of the eyes really - called nystagmus) while being turned slowly in a motorized chair. People with inner ear disease become less dizzy than do normal people.

The Optokinetic test measures dizziness caused by viewing of moving stripes. Optokinetic testing is sometimes useful in diagnosis of bilateral vestibular loss (both sides) and central (brain) conditions. The fixation test measures nystagmus whilst the person is being rotated - while they are looking at a dot of light that is rotating with them.

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Posturography Platform

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Balance is an essential component of vestibular functioning. During balance testing, patients may be asked to stand on special platforms that record the movement of the body. This kind of testing is called moving platform posturography.

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Moving platform posturography (MVP), or posturography for short, is a method of quantifying balance (although the definition of balance can be tricky). It is most applicable in situations where balance needs to be followed quantitatively – that mans simply measured – this will help determine if a disorder is getting better or worse, or the response to treatment.

This test is very simple to have done and causes no discomfort. You will be strapped into what looks like a parachute and then the platform moves under your feet. The machine simply records your automatic reactions, it is as simple as that.

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You will most probably not have all of these tests - different hospitals have different resources and expertise. The ENG will be pretty much everywhere whilst tests such as the Posturography platform are becoming far less popular now.

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All of these tests are painless, but some will make you feel a little dizzy and may induce actual spinning vertigo. This is a normal response to the tests, all dizziness is short lived and most will recover completely before leaving the hospital.

Many people are scared or nervous about the tests and worry about making themselves dizzier than they already are.

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But it is important to remember that without the tests a complete diagnosis is more difficult.

Both Isla and Emma have had the tests and lived to tell the tale - for Emma it increased the dizziness for about 10 days but this was no worse than the dizziness inner ear patients experience with a mild cold. The important thing to remember is - this dizziness will go back to "how it was" so do not worry if you feel worse for a while - as we have said, it is worth it - for a proper diagnosis.

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