Intended for healthcare professionals

Rapid response to:

On The Case

The emergence of ringing vertigo

BMJ 2005; 331 doi: (Published 22 December 2005) Cite this as: BMJ 2005;331:1502

Rapid Response:

Ringing vertigo: symptoms of VAD?

The campanologist who describes a possible connection between loud
sound vibrations and an imbalance of the inner ear mechanism exhibits
particular insight into her condition. It would be prudent to listen to
this patient and maintain a high index of suspicion for an organic
condition. Many of the other campanologist afflicted by 'ringing
vertigo' stated that they were not nervous people. They developed
feelings of lightheadedness, loss of feeling in their hands, and vertigo
exacerbated over time after repeated sessions. One campanologist states,
'I was feeling increasingly uncomfortable ringing up'. Another patient
was unable to do anything for a week, except lie in bed with his eyes shut
after the symptoms developed. The differential diagnosis clearly
includes a psychiatric condition such as anxiety disorder. The
differential should also include another condition namely vibroacoustic

Vibroacoustic disease (VAD) can occur due to chronic exposure to Low
frequency noise, <500Hz, and large pressure amplitude, >90 dB,
frequently as an occupational exposure.
One of the most frequent complaints in patients with VAD is balance
disturbances. Audiograms, tympanograms, and electronystagmograms are
frequently normal in these patients. MRI may present with hyperintense
foci in T2 of the cerebral white matter, brainstem, and/or basal nuclei,
suggesting ischemia, in 50% of patients with VAD. Echocardiograms of
patients with VAD have demonstrated a thickened pericardium in a small
series of patients, and may help identify the condition.
Mood and behavioural changes are the most common early findings in VAD.
Later changes include cognitive impairment, vertigo and auditory changes,
visual impairment, epilepsy, and cerebrovascular disease. Symptoms of
depression, including suicide attempts, irritability, aggressiveness, a
tendency for isolation and decreased cognitive skills have been described
as part of the clinical picture of VAD.
Physical exam frequently reveals an upper motor lesion, specifically the
palmo-mental reflex.

Specific populations that have been identified as at risk for VAD
include: aircraft technitians, military pilots and cabin crew members,
ship machinists, restaurant workers, and disk jockeys.

The cause of 'ringing vertigo' needs to be further elucidated by
clinicians treating these patients. As physicians we must consider that
many of these patients may have a serious psychiatric component to their
illness, the possibility of suicide, that needs to be addressed. An
underlying organic codition is a possibility that should also be
entertained in these patients.

1. Branco NA, Alves-Pereira M. Related Articles, Links

Vibroacoustic disease.
Noise Health. 2004 Apr-Jun;6(23):3-20. Review

2. Castelo Branco NA, Rodriguez E, Alves-Pereira M, Jones DR.
Related Articles, Links

Vibroacoustic disease: some forensic aspects.
Aviat Space Environ Med. 1999 Mar;70(3 Pt 2):A145-51.

3. Martinho Pimenta AJ, Castelo Branco MS, Castelo Branco NA.
Related Articles, Links

Balance disturbances in individuals with vibroacoustic disease.
Aviat Space Environ Med. 1999 Mar;70(3 Pt 2):A96-9.

4. Martinho Pimenta AJ, Castelo Branco NA. Related Articles, Links

Neurological aspects of vibroacoustic disease.
Aviat Space Environ Med. 1999 Mar;70(3 Pt 2):A91-5.

Competing interests:
None declared

Competing interests: No competing interests

24 December 2005
Alexis J Bayo-McGrath, MD, FACEP
Emergency Physician
Trauma Center, SJ, PR 00927