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Dizziness (Vertigo) and Balance Problems: Diagnostic Tests
 
Inner Ear Problems:
Causes of Dizziness (Vertigo)
  
Managing Balance Problems: Vestibular Rehabilitation Therapy
  
Managing Dizziness (Vertigo) with Medications
 
What Is Meniere's Disease?
 
Coping with Meniere's Disease
 
Coping with Meniere's Disease:
Other Things You Can Do 
  
Treating Meniere's Disease:
Eating a Low-Salt Diet
  
Treating Meniere's Disease:
Finding Low-Salt Foods
  
Treating Meniere's Disease:
Lifestyle Changes
  
Treating Meniere's Disease: Medications
  
Treating Meniere's Disease:
Reducing Your Stress
  
Treating Meniere's Disease: Surgery
 

Dizziness

Benign Paroxysmal Postional Vertigo
Meniere’s disease
Labyrinthitis
Vestibular Neuronitis
Vestibular Migraine

 

Benign Paroxysmal Positional Vertigo (BPPV)

What is Benign Paroxysmal Positional Vertigo?
BPPV is the most common cause of vertigo or dizziness. Symptoms consist of brief episodes of spinning lasting less than 30 seconds that occur when an individual lies down in bed, sits up from bed, rolls over in bed, or tilts the head forward or backward. 
What are the symptoms of Benigh Paroxysmal Positional Vertigo?
The movement of calcium crystals, called otoliths within the semicircular canals of the inner ear causes this sensation. Otoliths are a normal part of the utricle, an organ of the inner ear balance system found in an area called the vestibule. Inner ear infection, head trauma, ear surgery or (most commonly) unknown causes can cause the otoliths to detach from the utricle. Certain head motions cause these detached crystals to tumble and stimulate other motion detecting nerves in the semicircular canals. This movement within the semicircular canals erroneously tells the brain that the head is moving and triggers the sensation of vertigo.
 
Usually, BPPV is a self-limiting condition. Over time, the otoliths can fall into an area within the inner ear where they become immobile. Once this happens, the symptoms disappear. 
How is Benign Paroxysmal Positional Vertigo diagnosed? 
If the condition is not resolving spontaneously, treatment can include a procedure to reposition the otoliths within the inner ear, called an Epley maneuver. This procedure can be done in the otolaryngologist’s office. The calcium deposits are repositioned in the inner ear through a series of head movements. This allows the otoliths to settle into an inert position in the inner ear. Occasionally the Epley maneuver may need to be repeated in order to be fully effective.
 
Although BPPV is a benign condition, other types of vertigo can represent more serious underlying inner ear or neurological conditions. All vertigo should be evaluated by a physician to differentiate between benign and more serious causes of dizziness.
 

Menieres Disease

What is Endolymphatic Hydrops (Meniere’s Disease)?
Endolymphatic hydrops is a condition in which the fluid balance in the inner ear is disturbed. This can occurs as a results of inner ear inflammation, trauma, or for unclear reasons. Endolymphatic hydrops resulting from unclear reasons is called Meniere’s disease.
 
What are the symptoms of Meniere’s Disease?
Most patients with Meniere’s Disease will have several or all of the following symptoms: vertigo (dizziness characterized by an abnormal sense of motion such as spinning), hearing loss on one side that may increase and decrease over time, fullness of the ears, and tinnitus (ringing, buzzing, roaring, or other abnormal internal sound sensations). Symptoms may resolve for weeks, months, or even years, but they tend to be recurrent. Symptoms can be triggered by various factors such as stress, allergy attacks, and salt ingestion.
 
How is Meniere’s Disease diagnosed?
Patients with dizziness and hearing loss undergo a full ear nose & throat physical examination and obtain an audiogram (hearing test). In addition, your physician may order specialized balance testing such as electronystagmography (ENG), auditory brainstem response (ABR) and vestibular evoked myogenic potential (VEMP) studies. Frequently, imaging such as MRI or CT is needed. Based on the medical evaluation, the diagnosis and treatment options for the dizziness and hearing loss will be presented to you.
 
How is Meniere’s Disease treated?
Hearing loss associated with Meniere’s Disease is nerve hearing loss, which cannot be corrected surgically. Hearing aids are typically the main treatment option. These devices now employ modern programmable electronics that make them function much better than older aids that are not programmable. Hearing aids typically allow patients to hear better and reduces the sensation of tinnitus. Patients whose hearing is so severe that hearing aids are not useful may be candidates for a cochlear implant.
 
Dizziness associated with Meniere’s Disease responds well to treatment with low salt diet, avoidance of triggering factors (e.g. stress) or treatment of triggering factors (e.g. allergy), and a diuretic medication. The few patients who do not respond well to these conservative treatments may undergo additional treatments. These include office procedures such as intratympanic steroid or gentamicin injection, and surgical treatments such as endolymphatic sac surgery, labyrinthectomy, and vestibular nerve section. Very few patients currently require surgical treatment due to the success of the office procedures.

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Labyrinthitis and Vestibular Neuronitis

What are labyrinthitis and vestibular neuronitis?

Labrynthitis and vestibular neuronitis are conditions of true vertigo. The patient experiences a sensation that the surrounding environment is spinning. The onset is usually sudden. Half of the cases are preceded by an upper respiratory tract infection or cold. The sensation of vertigo usually lasts for several hours or several days. It is unusual for this phase to last more than 48 hours.  This is caused by a viral infection of the inner ear (labrynthitis) or the nerve going to the inner ear (vestibular neuritis). Many people will seek immediate attention in the emergency room or with their primary care physician because the symptoms are so extreme.

After the powerful symptoms of vertigo have passed (usually within 48 hours), patients are usually left with a feeling of disequilibrium (unsteadiness) that can last for days to months. The viral infection weakens the inner ear on one side, which creates an asymmetry within the balance centers of the brainstem. This creates a constant sense of unsteadiness. The disequilibrium is tolerable at rest but sudden movements of the head or body will trigger vertigo or light-headedness. As the affected inner ear recovers, the sensation of balance gradually returns.


How are these conditions treated?

The treatment of this condition is usually supportive. Medications, such as Meclizine, Antivert or Valium, can be given to help with the acute vertigo. These medications will help the patient if they are having symptoms of vertigo or nausea. These medications essentially cut off communication between the inner ear and the brain, so that the patient can have temporary relief of the vertigo.

It is important to keep in mind that these medications are not therapeutic; meaning they do not cure the problem. They are prescribed to make the patient comfortable in the short-term until the inner ear recovers. In fact, if these medications are taking too regularly, they will delay recovery. The brain and the inner ear have to interface in order for the natural function of the inner ear to recover.  If these medications are constantly cutting off this interface, recovery will occur much more slowly.

 Unfortunately, patients have to go through a period of compensation, where they will experience some dizziness, before the inner ear will recover. This period of compensation can be seen as a time when the inner ear is returning to full strength and getting back “on-line” with the brain so that balance function can be re-established. This process usually takes several weeks, but it can take months.

Patients who do not recover with several weeks of observation will require more intervention and investigation. This can include vestibular physical therapy to help strengthen the inner ear. It may also include a CT or MRI scan of the brain and an ENG (Electronystagmogram). An ENG is a specialized test that evaluates the strength and function of the inner ear’s balance function. Sometimes, something that was believed to be labrynthitis when it initially presented, turns out to be a completely different medical problem. This is why it is important to follow up with the ENT doctor until the symptoms are resolved or controlled.

By Joseph Chang, MD
 

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Vestibular Migraine

What is a vestibular migraine?

People who suffer from chronic dizziness may be suffering from Vestibular Migraine. This condition involves a sense of disequilibrium rather than vertigo. Disequilibrium is a feeling that either the patient or the environment is swaying. Most patients describe it as “unsteadiness.” It is a sense of slow, rotational movement of one’s surrounding which can be mild or debilitating. The sensation can last from seconds to weeks and has a wide variety of manifestations. The exact neurological pathways responsible for a vestibular migraine are not completely understood.


Who gets vestibular migraine?

Most people with this condition have a personal or family history of migraine headaches. The dizziness does not have to occur with the headaches. Most patients also have a strong history of motion sickness. The dizziness can be associated with nausea, vomiting, sensitivity to light, sensitivity to sound, visual changes, and inability to continue normal activities. Stress, anxiety, hypoglycemia, fluctuating estrogen, certain foods, smoking, and other factors can trigger migraine.


How is vestibular migraine diagnosed?

The diagnosis of vestibular migraine is largely established by the patient’s history, but the workup may include an audiogram, a CT or MRI scan of the brain and an ENG (Electronystagmogram). An ENG is a specialized test that evaluates the strength and function of the inner ear’s balance function.


How is vestibular migraine treated?

Treatments include observation, vestibular physical therapy or medical therapy. The medical therapies designed to treat vestibular migraine are the same medications used as prophylactic therapy for migraine headaches.

By Joseph Chang, MD

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