Prevalence, risk factors and clinical presentations of patients with peripheral vertigo: a retrospective study from a tertiary care hospital

INTRODUCTION

Vertigo is a very common complaint in clinical practice. The epidemiological knowledge on vertigo mainly on its prevalence or incidence character is limited. Peripheral causes of vertigo arise from abnormalities in the vestibular end organs (Semi-circular canals and utricle), the vestibular nerve, and the vestibular nuclei. Most of these causes are benign and readily treatable. Vertigo has multi-causative etiology and hence the patients may consult various specialties including psychiatry, otolaryngology, neurology and cardiology. Although all these disciplines play an important role in the evaluation of the patient, a good history and focal physical examination in the primary care setting can usually reveal the diagnosis. The management approaches employed by these clinicians will be varied considerably. Vertigo is often an untreated symptom and is frequently associated with serious handicap and considerable psychological morbidity.¹ In addition to diagnosis of vertigo, the goal of the primary clinician should be to recognize which patients need inpatient management or emergency intervention. This goal becomes particularly important when evaluating older patients.

Several acute pathologic conditions can present with vertigo as the initial complaint. Otolaryngological investigations are rarely diagnostic, but vertiginous symptoms do predict peripheral vestibular disorders.² A prompt diagnosis is inevitable in order to ensure an adequate treatment as well as to cope with the cost and effectiveness.³ About 46% patients presented with vertigo found to be due to an otological disorder.⁴ The literature on etiology and prevalence generated from retrospective analysis of known cases of vertigo is scanty in Indian scenario especially in tertiary level Otolaryngology units.⁵ Therefore, a retrospective study was conducted to find out the clinical presentations and risk factors of peripheral vertigo.

METHODS

Selection Patients

All the patients, age 20-80 years, presented with peripheral vertigo in the department of ENT, Amala Institute of Medical Sciences, Amala Nagar, Thrissur and Kerala, India during the period of 12 months were included in this retrospective study. A detailed clinical examination and history had been taken out. Patients below age 20 years and above 80 years, patients with central vertigo, vertebra basilar artery insufficiency, CNS tumours and with multiple sclerosis were excluded from the study. Consent was obtained from the patient or their relatives and the study design was approved by the Institutional ethics committee for research.

Statistical analysis

Analysis was done using statistical software SPSS (Version 16). Chi square test was used to know the significant difference between the groups. P < 0.05 was considered as significant.

RESULTS

Total 60 patients of age 20-79 years were included in this study (Figure 1). The gender wise distribution was depicted in figure 2. There were total 15 males and 45 females in the 12 months study period. The prevalence of incidence was significantly found in females (p<0.01). The clinical manifestations presented were spinning, about to faint, light-headiness, disequilibrium and both spinning and about to faint (Table 1). Spinning plus about to faint was significantly (p<0.01) found as the major clinical manifestation in 25 patients (41.6%) with a female dominance (19/25). The female patients with spinning plus about to faint were highly significant (p<0.05) in the age group of 40-59 years (8/19) which is followed by 60-79 years (7/19). Spinning alone was found in 17 patients (28.7%) with significance (p<0.01) in the females (14/17). Disequilibrium (10%) was the least clinical presentation.

The distribution of risk factors was ear infection, ototoxic drugs, history of surgery, trauma (Table 2). Among these, significant risk factor was found in the patient with ear infection (31.6%). The predominance was found for female with the incident rate of (12/19). A similar increase in the prevalence in female (9/11) was found in the trauma patients. Based on the distribution of risk factors, age group 40-59 was highest followed by the age group of 60-79. The only 1 male patient in the age group of 20-39 had ear infection as the risk factor and was presented with both spinning and about to faint.

DISCUSSION

Results of the study revealed that the prevalence of incidence was significantly found in females. The major clinical presentation was spinning plus about to faint. The prevalence was found to be increased with age. In our study, we could find a maximum incidence in the 40-59 years age. It has been generally considered as the vertigo increased with age and reached its peak in the 60s, for both male and female. Gender ratio of 2:1 female: male was reported by Neuhauser et al.⁶ Similarly, in community based studies found that the prevalence of dizziness ranges from 1.8% in young adults to more than 30% in the elderly.^7,8 Similarly, Katsarkas in a study on dizziness in the elderly reported that the prevalence of 63% in women when compared to 37% in men.⁵

According to Hanley et al.⁹ the presentations of symptoms of vertigo can be clinically diagnosed in most cases. The exact cause often remains elusive. Usually it begins in the fourth decade and attains its highest prevalence in the sixth decade.¹⁰ The most common risk factor found in the study was ear infection. Patients with otitis media often complain of vertigo due to the proximity of the vestibular end organs to the middle ear and the infectious process may extend to these structures. Similarly, the other causes reported were labyrinthitis- a peripheral disorder characterized by inflammation of the canals of the inner ear- commonly occurs following otitis media or an upper respiratory infection, it is thought to be a consequence of viral or bacterial infection.

The incidence of dizziness and disequilibrium following head or neck injury is between 40% and 60%, even following minor trauma. Blunt head injury can concuss the membranous labyrinth with preservation of the otic capsule. Patients may complain of mild vertigo, disequilibrium and nausea. Symptoms tend to resolve spontaneously over several days to weeks. Explosive blasts can also result in symptoms of vertigo. In our study, the incidence of trauma was only 18% with the female dominance and prevalence equal in all the age groups.

The most common form of endolymphatic hydrops is Meniere’s disease. Patients may present with the classic triad of tinnitus, fluctuant sensorineural hearing loss, and vertigo. The vertigo attacks may last several minutes to an hour. It is not typical for these attacks to persist longer than several hours. As the disease progresses, attacks occur more frequently and are more severe. In our study only 9 patients were presented with history of using ototoxic drugs-induced vertigo.

The other risk factors such as vestibular neuritis, Ramsay Hunt syndrome- a variant of vestibular neuritis, cholesteatoma (a benign skin growth that occurs in the middle ear be-hind the ear drum) or acoustic neuroma were not manifested in any of the described cases in this limited period of study. Moreover, the most common cause of peripheral vertigo is benign paroxysmal positional vertigo due to the turning their head was also not reported by any of the patients included in this study. A retrospective study by Uneri and Polat¹¹ showed that 93.5 per cent of the elderly patients studied had been diagnosed with peripheral vertigo which had been classified as benign paroxysmal positional vertigo, idiopathic vestibulopathy or migraine vestibulopathy. Short period of the study and small sample size are the major limitations of this study.

CONCLUSIONS

The result concluded that prevalence of incidence was significantly found in females of age group 40-59 with clinical presentation of both spinning and about to faint. Risk factor of ear infection was significantly found. These observations will help a surgeon to recognize which patients need inpatient management or emergent intervention. Furthermore, the need for awareness about the prompt treatment of ear infection is emphasized.

ACKNOWLEDGEMENTS

Authors gratefully acknowledge the valuable help of Dr. Ajith TA, Professor, Department of Biochemistry, Amala Institute of Medical Sciences, Thrissur, Kerala, India during the preparation of the manuscript.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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