CLINICAL STUDY

Causes of Vertigo in Saudi Patients Seen at

Tertiary Teaching Hospital
Ibrahim Shami M. D and Abdulrahman Al Sanosi M.D
Department of Otolaryngology and Head and Neck Surgery
King Abdulaziz University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia

Abstract
Objectives
To investigate the clinical characteristics of vertigo in Saudi patients seen in otology and
neurotology clinic.
Methods
A retrospective chart review was performed of all patients presented with vertigo from
January 2008-December 2010 at otology/neurotology clinic at King Abdulaziz University
Hospital Riyadh. The data reviewed was age, sex, characteristic of vertigo symptoms,
duration of vertigo, provisional diagnosis and categories of vertigo. Patients with incomplete
files were excluded. The data were analyzed using Microsoft excel.
Results
A total of 124 patients; 90(%72.6) women and 34(%27.4) men were incorporated in this study.
Majority of the patients suffered from benign paroxysmal positional vertigo (39.5%) followed
by Meniere's disease (27.4%) and Migraine associated vertigo (8.1%). Peripheral causes were
found in 73.4% of our cases while central etiology was seen only in 15.3% and 9.7% of
unknown etiology.
Conclusion
Peripheral vestibular disorders remain the main diagnostic category in our study group, the
two most common etiologies were benign paroxysmal positional vertigo and Menieres
disease. Information obtained from this study may serve as a reference guideline for
otolaryngologists in Saudi Arabia when dealing with dizzy patients.
Key Words: Benign Meniere's disease, Paroxysmal positional vertigo, Vertigo
Journal of Taibah University Medical Sciences 2011; 6(1): 26-32

Correspondence to:
Dr. Abdulrahman Al Sanosi
Associated professor, Department of Otolaryngology, Head and Neck Surgery
King Abdulaziz University Hospital
King Saud University, 245, Riyadh 11411
Kingdom of Saudi Arabia
+966 1 477 5735
 +966 1 4775748
 sanosi@hotmail.com

26

Shami and Al Sanosi

Introduction

vestibular and radiological tests are done if

required.
Our diagnostic criterion was based on the
American Academy of Otolaryngology
Head and Neck surgery (AAO-HNS)
guidelines.
If the condition does not fit any peripheral
causes of vertigo, or a central cause is
suspected; a referral is made to neurology
department.
The Charts of all patients diagnosed with
vertigo between April 2008 and December
2010 at otology /neurotology clinic were
retrospectively reviewed by the authors. The
information recorded included age, gender,
the characteristics of vertigo symptoms, the
duration of vertigo and the final diagnosis .
Patients with incomplete files were
excluded.
The Medical records of 169 cases were found
and only 124 cases with complete data were
analyzed.

he diagnosis of vertigo is primarily

based on patient's history and neurotologic examinations. However, in some
patients, further investigations such as
audiologic evaluations, vestibular function
tests, radiological studies, blood tests, or
other diagnostic tools may be necessary and
confirmatory.
Major categories of vertigo include
peripheral
vertigo,
central
vertigo,
psychogenic, and undiagnosed causes.
Pathological sites of peripheral vertigo are
in the vestibular labyrinth and vestibular
nerve, patients usually report abrupt, severe
onset of vertigo, nausea, vomiting and ear
symptoms, such as hearing loss, tinnitus, or
aural pressure. Pathological sites of central
vertigo are at the brain stem, cerebellum,
and cerebral hemisphere. Symptoms of
central nervous system disorders, such as
headache, diplopia, dysarthria, dysphagia,
hemiplegia,
paresthesia
or
loss
of
consciousness are common1. Inpatients
whose signs and symptoms of peripheral or
central pathology are unclear psychological
disorders or systemic diseases should be
considered2.
In a survey of the general population, 4.9
21% of people in UK and Germany reported
experiencing symptoms of vertigo at some
point3-4. Published reports as to the
epidemiology of vertigo have primarily
come from Europe and America, or
developed countries where advanced
diagnostic investigations and experienced
clinicians are more readily available. Up to
our knowledge, no study has been done to
look at the pattern of vertigo in Saudi
Arabia before.

Results
124 patients, 90(%72.6) were women and
34(%27.4) were men, ratio 2.6:1. Age at
presentation ranged from 8 to 70 years, with
means of (45.1) years. Average age of men
(43.4 12.8) years; mean standard
deviation and women (45.7 12 years)
(Figure 1).
Most of the patients were referred from
other physicians 66(53.2%), however
58(46.8%) were new patients (Figure 2).
The most common symptom of vertigo
reported was the spinning sensation
115(89.5%). Others included floating 5(4%),
image moving in a horizontal plane 3(2.4%),
drifting 1(0.8%) (Figure 3). Taking into
consideration the duration of vertigo,
majority of cases (46.8%) were for seconds
(Figure 4).
The diagnostic categories of 124 cases were
peripheral vertigo 91(73.4%),
central
vertigo 19(15.3%), psychogenic cause
2(1.6%), and unknown 12(9.7%) shown in
Figure 5.
Twelve diagnoses were made in 90.3% of
cases (Figure 6).
Common causes of vertigo were benign
paroxysmal positional vertigo (BPPV)

Materials and Methods

Dizzy clinic is tertiary service that was
launched 4- years ago at King Abdulaziz
University Hospital and is supervised by
otologist/neurotologists .Our approach for
dizzy patients include detailed history and
medical examinations that are particularly
neurotological.
Further
audiological,

27
J T U Med Sc 2011; 6(1)

Causes of vertigo in Saudi patients seen at tertiary teaching hospital

49(39.5%),
Meniere's
disease(MD)
34(27.4%),
migraine
associated
vertigo(MAV)10(8.1%), vestibular neuronitis
(VN)4(3.2%), cholesteatoma 2 (1.6%),
Delayed
endolymphatic
hydrops
(DEH)1(0.8%),
perilymphhatic
fistula
1(0.8%), meningioma 1(0.8%) acoustic

neuroma(AN)
4(3.2%),
Lateral
pontomedullary syndrome(AICA) 3 (2.4%),
multiple sclerosis 1(0.8%) and psychogenic
2 (1.6%). A definitive diagnosis was not
ascertained in 12(9.7%) cases, but they
predominately had symptoms and signs
compatible with peripheral causes.

Figure 1: Distribution of age and sex by decade is shown.

25
20
15
10
5
0

primary
referred

Figure 2: Primary and referred cases distribution: Benign Paroxysmal Positional Vertigo (BPPV),;
Meniere's disease (MD) , VN; Vestibular neuronitis (VN) , Migraine associated vertigo (MAV), Delayed
endolymphatic hydrops (DEH) and Perilymphatic fistula (PF) .

28
J T U Med Sc 2011; 6(1)

Shami and Al Sanosi

Symptoms
4.0%

2.4%

0.8%

spinning
floating
image moving in a
horizontal plane
drifting
92.7%

Figure 3: Main chief complaints Duration of vertigo during attack.

Duration
4.0%
7.3%
seconds

10.4%
46.8%

minutes
hours
days

31.5%

variable

Figure 4: Duration of vertigo during attack.

29
J T U Med Sc 2011; 6(1)

Causes of vertigo in Saudi patients seen at tertiary teaching hospital

Categories
1.60%

9.70%
peripheral

15.30%

central
psychogenic
unknown

73.40%

Figure 5: Categories of vertigo.

90

2
0

10
2
unknown

1
0

MS

AICA

AN

meningioma

DEH

PF

cholesteatoma

VN

MAV

MD

22
6
8 12
4 22 1 0 1
1 2 1
1 1 0
0 2
2

psychogenic

41

BPPV

34

TOTAL NO.

100
80
60
40
20
0

MEN
WOMEN

Figure 6 : Distribution of cases according to sex : BPPV; Benign Paroxysmal Positional Vertigo, MD;
Meniere's Disease, MAV; Migraine ,Associated Vertigo, VN; Vestibular Neuronitis, PF; Perilymphatic
Fistula, DEH; Delayed Endolymphatic Hydrops, AN; Acoustic Neuroma, AICA; Anterior Inferior
Cerebellar Artery, MS; Multiple Sclerosis

30
J T U Med Sc 2011; 6(1)

Shami and Al Sanosi

Discussion

covered. Patients with central vertigo

usually had complaints of other significant
symptoms and signs of central nervous
system pathology.
Taking a complete history of a patient with
vertigo is the most important for making a
diagnosis.
Most of our patients recorded an average
duration of episode of vertiginous attacks in
seconds(46.8%) followed by those who had
an average duration of minutes (31.5%),
oppose the result reported by Somefun
Although, the patients number in this study
is smaller compared to other studies but, it
is the first study to look at the common
pattern of vertigo related to Saudi
patients7,10,12.
Since less than half of the total cases had
more than one visit, a prospective study
with extended follow-up periods will
provide more reliable data on remission.

Vertigo mostly affected patients aged

between 40 to 50 years and more often in
women(male :female ratio 1:2.6).
The mean age at presentation was (45.1)
years, which is less than that reported from
North America (50 years) and Europe(57.6
years)1,5-6.
In the otology clinic, peripheral vestibular
disorder is the main diagnostic category
similar to that reported in North America,
Europe and Japan. However, with difference
in percentage1,5-7.
The percentage of patients with a definitive
diagnosis being ascertained in this study
was 90.3% (112 of 124 cases), higher than
that reported by Katsarkas (79.4%), Yin M
(77.8%) and Isaradisaikul (73.9%)2,7-8. Some
studies reported 94.999% of cases
diagnosed with definitive etiology of
vertigo, which included motion sickness,
glaucoma, renal insufficiency, diabetes,
fibromyalgias,
orthostatic
syncope,
presyncope, unspecified cardiovascular, or
Costens syndrome6.
The two most common etiologies were
BPPV and Menieres disease, similar to that
reported in china and Nigeria9-10.
The number of patients with psychogenic
vertigo in this study was substantially lower
(1.6%) than the previously reported (5.1
11.5%)1,5-6. The Psychiatric disorder was
reported, either as a primary or a
contributing factor in 40% of the cases with
persistent dizziness, but was considered
primary in only 16%11.
Patients with normal physical examination
and normal vestibular tests are encouraged
to undergo a psychiatric evaluation.
Clinicians may lack awareness to encourage
them to have further evaluation, possibly
through explaining the small number of
psychogenic etiology.
Central vestibular disorders were diagnosed
in 19 cases (15.3%), similar to other studies
(7.817.2%)1,5,7. Broad varieties of central
pathology causing vertigo have been
reported. Although this study included a
variety of central nervous system disorder,
not all disorders causing vertigo were

Conclusion
Peripheral vestibular disorder remains the
main diagnostic category in our cases and
the two most common etiologies were BPPV
and Menieres disease.
Information obtained from this study may
serve as a reference guide in diagnosing
vertigo for other ENT clinics in Saudi
Arabia.
Acknowledgment
The authors thank Prince Sultan Research Chair
for Hearing Disability at King Saud University
for its support.

References
1.

2.

Bath AP, Walsh RM, Ranalli P, Tyndel

F, Bance ML, Mai R, Rutka JA.
Experience from a multidisciplinary
"dizzy" clinic. Am J Otol. 2000; 21(1):
92-97.
Isaradisaikul S, Navacharoen N,
Hanprasertpong C, Kangsanarak J,
Panyathong R.Causes and time-course
of vertigo in an ear, nose, and throat
clinic. Eur Arch Otorhinolaryngol.
2010; 267(12): 1837-1841.

31
J T U Med Sc 2011; 6(1)

Causes of vertigo in Saudi patients seen at tertiary teaching hospital

3.

4.

5.

6.

7.

8.

Otolaryngol Head Neck Surg. 1994

;110(3): 296-301.
9. Zhao Z, Mu Z, Fu Z, Liang J, Lin J, Ou
Y, Kong W. Clinical features of 168
patients with vertigo. Lin Chung Er Bi
Yan Hou Tou Jing Wai Ke Za Zhi.
2010; 24(19): 880-882.
10. Somefun OA, Giwa OS, Bamgboye BA,
Okeke-Igbokwe
II,
Azeez
AA.
Vestibular disorders among adults in a
tertiary hospital in Lagos, Nigeria. Eur
Arch Otorhinolaryngol. 2010; 267(10):
1515-1521.
11. Kroenke K, Lucas CA, Rosenberg ML,
Scherokman B, Herbers JE Jr, Wehrle
PA, Boggi JO. Causes of persistent
dizziness. A prospective study of 100
patients in ambulatory care. Ann
Intern Med. 19921; 117(11): 898-904.
12. Liu B, Liu C, Chen XW, Duan JP, Zhao
XY, Guan JZ, Zuo LJ. Investigation and
analysis of the baseline data of 3432
patients with vertigo. Zhongguo Yi Xue
Ke Xue Yuan Xue Bao. 2008; 30(6): 647650.

Hannaford PC, Simpson JA, Bisset AF,

Davis A, McKerrow W, Mills R. The
prevalence of ear, nose and throat
problems in the community: results
from a national cross-sectional postal
survey in Scotland. Fam Pract. 2005
22(3): 227-233. Epub 2005 Mar 16.
Neuhauser HK. Epidemiology of
vertigo. Curr Opin Neurol. 2007; 20(1):
404-6.
Heaton JM, Barton J, Ranalli P, Tyndel
F, Mai R, Rutka JA. Evaluation of the
dizzy patient: experience from a
multidisciplinary neurotology clinic. J
Laryngol Otol. 1991; 113(1): 19-23.
Guilemany JM, Martnez P, Prades E,
Saudo I, De Espaa R, Cuchi A.
Clinical and epidemiological study of
vertigo at an outpatient clinic. Acta
Otolaryngol. 2004; 124(1): 49-52.
Yin M, Ishikawa K, Wong WH, Shibata
Y. A clinical epidemiological study in
2169 patients with vertigo. Auris Nasus
Larynx. 2009; 36(1): 30-35.
Katsarkas A. Dizziness in aging: a
retrospective study of 1194 cases.

32
J T U Med Sc 2011; 6(1)