What if vertigo wasn't just about the inner ear?

The balance system, multisensory by nature, can be disrupted by numerous factors. Among the symptoms, vertigo is a frequent manifestation that should always be taken seriously. In order to establish an accurate diagnosis, Dr Pierre Lavagna, an ear, nose and throat (ENT) specialist, does not limit himself to exploring only the possibility of an inner ear disorder. MonacoSanté keeps you informed.

Definition and mechanism

Derived from the Latin vertere, meaning "to turn", the word vertigo refers to an illusion of movement or rotation. "You have the impression that things are moving, spinning or floating. You may experience a sensation of displacement in the vertical or horizontal plane, or have the impression that everything is tilting to the right or left", describes Dr Pierre Lavagna, an ear, nose and throat specialist in Monaco. . Although often attributed to the inner ear, the doctor indicates that vertigo can in reality arise from a more complex mechanism. “The balance system involves vision, sensitivity in the feet, the inner ear and processing of information in the brain. It can be disrupted by a multitude of factors. Our mission is to synthesise this information and not analyse vertigo solely through the reductive lens of the inner ear”. Open for two years, his medical expertise centre Otoneuro Monaco, dedicated to hearing and balance disorders, treats various conditions: deafness, tinnitus, hyperacusis, as well as vertigo and balance disorders. In these latter cases, the inner ear is responsible in only approximately one third of situations. Another third relates to neurological disorders – with migraine playing a significant role – and the final third corresponds to more general functional disorders, such as motion sickness. Intertitre

The importance of a comprehensive diagnosis

During the consultation, he focuses on the chronology of symptoms, the circumstances in which they occur and the patient's experience. Severity, duration, and whether episodes are isolated or repetitive constitute valuable indicators. Medication use, neurological, cardiac or vascular history are also analysed in order to guide the treatment protocol. "During the clinical examination, we first check that there is no problem with the ear. But we also examine the neurological system and the entire balance system using different tests. Finally, it is essential to assess hearing. When an inner ear disorder causes a balance problem, there is often an associated hearing impairment, such as hearing loss or tinnitus", explains the doctor. Thanks to specialised technical equipment, the Otoneuro centre offers advanced investigations. Videonystagmography for example, enables measurement of eye movements, used as indicators of inner ear function. Saccadometry assesses the patient's ability to move their eyes rapidly from one point to another. Stabilometry, finally, analyses how the patient uses different sensory information to maintain balance. "It is also possible to carry out neuropsychological tests to determine whether vertigo forms part of a broader neurological condition", he adds. These additional examinations enable determination of whether the disorder is exclusively linked to the inner ear or whether it forms part of a more comprehensive impairment of the balance system, of neurological or general origin. "Treatment is not necessarily exclusively ENT-related. If the problem extends beyond this scope, we work as a team with physiotherapists, neurologists or internal medicine specialists, particularly in cases of autoimmune disease". This comprehensive approach is essential for understanding the origin of vertigo. "It may reveal a visual disorder, impaired sensitivity in the feet, a neurological disease affecting the brain, or even a psychological disorder that may disrupt the perception of balance".

When is vestibular rehabilitation recommended?

In many cases of vertigo of vestibular origin, crystals are responsible. These are actually otholites, small debris present in the inner ear. When they move abnormally in one of the semicircular canals, they cause brief episodes of vertigo, lasting a few seconds, triggered by head movements. Another possible cause: Ménière's disease . It is characterised by variations in pressure of the fluids in the inner ear, promoted particularly by stress, fatigue or lack of sleep. "This combines severe vertigo attacks with sudden hearing loss during the episode and tinnitus". Whatever the origin of vertigo, treatment is primarily based on vestibular rehabilitation. The objective is to reposition the crystals in benign paroxysmal positional vertigo (BPPV), or to gradually expose the patient to situations that trigger their discomfort, so that they become accustomed to them and symptoms decrease. For BPPV, certain centres, such as Otoneuro Monaco, have specialised equipment, such as dedicated rotary chairs, optimising the precision and effectiveness of these treatments. "Overall, one to two sessions are sufficient". For other types of rehabilitation virtual reality can now facilitate this exposure by recreating problematic situations in a controlled manner. "Generally, between five and ten sessions are planned, with often convincing results within this timeframe, whilst of course adapting the number of sessions to each patient's progress", specifies Dr Lavagna. In cases of disorders linked to excessive pressure in the inner ear, treatment most often relies on medication aimed at regulating and reducing this pressure. Finally, even when a condition appears benign, repetition of symptoms requires thorough investigation. A comprehensive assessment ensures that no underlying disease is concealed behind these manifestations and allows treatment to be adapted appropriately.