Dizziness: Preliminary Considerations--It Might Not Be The Ear

If you have dizziness, please don’t take personally what I’m about to say.  As an ENT doctor, I’m quite hesitant writing about this topic.  “Dizziness” is a term loathed by many Ear, Nose & Throat doctors as well as primary care providers.  Don’t get me wrong; my colleagues and I don’t despise the actual patient, but sometimes we unwittingly associate “crazy” as a synonym for “dizzy.”  Naturally, this is far from the truth with most dizzy people, that is unless you’re authentically crazy, but that’s another topic altogether.  It’s the complaint of dizziness itself that is the bane of our practice, leading some of us to run for the exit.  Why?  Dizziness is merely a symptom and the underlying problem is often difficult to figure out.  Some patients demand to be seen immediately, especially for long-term dizziness, thinking there’s a magic cure if they only can get an appointment and through the front door of their local ENT doctor’s office, believing the doc will render some miraculous treatment and resolve the dizziness forever, even if they’ve had their dizziness “forever.”

Whoa to those misguided folks who believe there’s an immediate “cure” for dizziness.   Oftentimes it’s not there.

Contrary to conventional wisdom, feeling dizzy does not necessarily mean the problem is from the ear.  There are many causes for dizziness, which makes the diagnosis (figuring out what’s causing the dizziness) quite difficult. I’ll explain in a few paragraphs following the myriad problems that can cause someone to feel dizzy.

First things first.  One must determine exactly what is meant by “dizziness,” which is the reason your doctor will insist you use other words to describe your symptoms without using the word “dizzy.”  Feeling dizzy means different things to different folks:

Spinning sensation or the room is spinning
Sense of movement or motion when sitting or standing stationary
Motion sickness in a car or on a boat
Fainting or near fainting,
Feeling off-balance
Disorientation or confusion
Staggering when walking or a need to hold onto something when walking
A feeling of weakness or fatigue
Difficulty concentrating, a sense of feeling “foggy” in the head
Hearing voices (yes, I had a patient referred for dizziness who’s complaint was actually auditory hallucinations, a problem more suitable for a psychiatrist).

So it’s ultra-important to narrow down in more specific language the nature of the complaint, for as you can see, each of these specific symptoms potentially carries a different cause, and as such, the ear is one of many potential causes. 

For some folks this first part is difficult even after explaining the reasons above, and you’ll sometimes see the wheels turning in their head in frustration:  “Well, I feel like it’s…well…you know…it’s a feeling of...of…dizzy!  I feel dizzy, so fix me now!”  This makes the workup and potentially finding a cause all the more difficult.   
Often patients present and are even referred to ENT doctors for dizziness thinking the ear is the cause.  The ear does have associated with it organs of balance, called the labyrinth, comprised of fluid-filled chambers that serve to detect both linear and circular movements of the body.  The labyrinth is one of many parts of the vestibular system.  It sends signal via neurons to the brain, which in turn sends signals to the eyes, down the spine and to various parts of the body in order to ready the body for the movement.  There are various causes for ear-related dizziness.

However, other causes—sometimes more serious or even life-threatening—must be ruled out first prior to being sent to an ENT specialist.  This is the reason, at least in my practice, that patients first be evaluated by their primary care physician to look for these other causes. 
Blood pressure fluctuations, heart arrhythmias, neurologic problems (i.e., a stroke), metabolic problems (ie, poorly controlled diabetes, low blood sugar), medication side effects, recreational drugs (yes, marijuana can cause a sense of “dizziness”), chronic alcohol use, and even bona fide craziness in some cases.  If the onset is acute or sudden onset, emergent attention often is needed to rule out bad things such as a stroke or heart problem.  People sometimes must go to the E.R. in these cases where an evaluation, lab work and imaging can be done on the spot.  If more serious illnesses are ruled out, then the ear may be a consideration.  The emphasis here is to first rule-out potentially life-threatening conditions. 

True case-in-point:
One day as I was about to leave town for a much-needed vacation, I was paged by the answering service for a patient I hadn’t seen for several years.  I did a partial thyroidectomy for a benign nodule.  She was feeling dizzy for a day or so and was told by her friends she needed to see an Ear, Nose and Throat specialist.  Having seen me before, she naturally called, but since my office phones were rolled to the answering service at that hour, I was paged.  She described her symptoms as being lightheaded, no spinning or movement sensation.  We talked a little more when I noticed something strange.

“Your voice sounds different, a bit odd,” I said.  “It sounds like you’re slurring your words.”
“Yeah, one of my friends said the same thing!” she replied.
“Do you feel weak or numb on one side of the body?” I asked
“Do you have a bad headache or are you staggering?”
“No.  None of those things.”
“Can you do me a favor?  I could be wrong, but just want to make sure.  Please go to the E.R. now.”
“What?  Why?”
“Like I said, I could be wrong, but I want to make sure you’re not having a stroke.”

To make a long story short, she heeded my advice, went to the E.R.  Some weeks later she actually called our office for an update on her condition.

“You know what?” she said, “They kept me in the hospital for 4 days!  Four days!  I had a freakin’ stroke!  They said I could have died if I hadn’t come in!  Thanks doc, you saved my life!”

So there’s my point.  Of course, one must weigh other factors such as age, onset of symptoms, the nature of the symptoms and a bunch of other associated symptoms to determine if a person needs immediate attention.  That’s why medical training is so freakin’ long.

Most causes of ear-related dizziness are not life-threatening, though they can be quite debilitating when actively occurring.  Yet often ear related dizziness improves and in many cases resolves with time. 

The workup for dizziness otherwise is quite involved, with a lengthier taking of the history and a much longer physical and vestibular exam.  Often an audio or hearing test is done as well as a means to check the function of the cochlea or inner ear.  I’ll discuss more specific issues of dizziness that are ear-related in future posts.

But for now, don’t take it personally if the ENT doc can’t get you in right away for an appointment for dizziness and insists you be evaluated first by your primary care doctor.  And as the vignette above for acute shows, immediate attention is sometimes needed.

©Randall S. Fong, M.D.