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Balance Disorders (Vertigo, lightheadedness, dizziness and dysequilibrium) Copyrighted to Michael Seidman,MD., FACS
Hi. My name is Michael Seidman, I am an Otorhinolaryngologist (also known as an ENT Surgeon). I received my BS degree in nutrition and MD degree both from the University of Michigan. I did residency training in Otolaryngology and then did a fellowship in hearing, balance, facial nerve, skull base, acoustic neuroma and cochlear implant surgery at the Ear Research Foundation in Fla.
Vertigo is a term that describes a sensation of motion. Often people who suffer with vertigo tell me that they are "dizzy". Dizziness can also refer to such feelings as lightheadedness, unsteadiness, wooziness, confusion, giddiness, a sensation of being pulled, a sensation of walking on a waterbed, a floating sensation, a feeling of being on a boat or just getting off a roller coaster, etc. Typically, describing the sensation that they are experiencing is very difficult for most people with balance problems.
Balance problems are extremely common with more than 40% of patients over the age of 75 experiencing balance symptoms. Although more than 70% of patients with true vertigo have an inner ear source for their balance problem, the feeling of imbalance without a turning or spinning sensation is not usually due to an inner ear problem. There are literally thousands of causes for balance disturbances many of which have nothing to do with your ears or brain. Neurotologists are otolaryngologist -head and neck surgeons who have a particular interest in hearing and balance disorders and have taken a fellowship, beyond residency, to study these types of problems.
A complex interaction of the inner ear coupled with two other sensory systems maintains balance (we have three semicircular canals in the left ear and three in the right), the somatosensory system (brain and spinal cord, including muscles and joints), and the visual system. One way to understand this is to think of the three systems as legs of a tripod (Inner ear, central nervous system and visual systems). These systems are all necessary to maintain proper balance, and can function relatively well with two of the three systems but when you develop a problem in one of the remaining two systems, serious balance problems occur. For example, people who have had diabetes for years may develop an inability to feel the floor with their feet (this is a somatosensory problem). By day they may have little trouble with maintaining their balance. However if they get up in the middle of the night to use the restroom, they often find that they are very unsteady. What has happened is that normally they are living with two of the legs of the tripod intact, namely the inner ear-vestibular system and vision. Since the somatosensory component is not functioning well because of the diabetes when you turn out the lights you are removing the second of three systems or legs necessary for good balance, thus leaving only the vestibular system. Therefore, the balance is off. Even people with severe back or neck problems, such as arthritis can have problems with balance, again having nothing to do with the inner ear.
One very important aspect in trying to sort out the causes of balance problems includes finding if there are any ear symptoms. Specifically, we are interested in whether there is any unexplained hearing loss or fluctuation of hearing, does it affect one or both ears. Is there any fullness, blockage or pressure sensations in the ears that is not related to allergic problems, being on an airplane or in the mountains? Is there any ringing, buzzing or roaring in the ears? Typically, all patients have experienced these symptoms to some degree, but the primary concern is if there is any relation to the balance problems. It is also important for us to know if there are any specific neurologic symptoms. That is symptoms that may point to a brain cause rather than an ear cause. For example, is there any history of loss of consciousness, confusion, unexplained headaches, migraine symptoms, changes in vision, weakness or numbness to name a few. Your past medical history is also very important. Knowing whether there were any preceding bacterial or viral illness is important, such as the flu or the common cold for example. These infections can localize to the inner ear and potentially cause vestibular dysfunction. Other common cause of balance disturbance is head trauma, ie hitting your head in a motor vehicle accident, falling off a ladder etc. There are many chronic disease that can cause disequilibrium such as Diabetes, low blood sugar, severe allergy disorders, thyroid abnormalities, cardiac disease, and blood pressure alterations (both high and low) smoking and alcohol use. Medications are probably one of the most common causes of balance problems and you should consult your pharmacist or primary care physician regarding medications that may cause dizziness.
Before your consultation with me or my colleagues, it is helpful and highly recommended that you have had an extensive evaluation by your primary care doctor to rule out other possible causes of balance disorders. It is important that they give particular attention to the cardiac and neurologic systems. It is also helpful if they have done a metabolic evaluation that might include a blood sugar test, blood pressure, electrolytes (chemicals in your blood) +/- thyroid studies for example.
After you have had an extensive evaluation by your primary medicine doctor, you will have an evaluation by me or one of my associates. This includes a complete otolaryngologic head and neck examination and a directed neurotologic exam that will include tests of your cranial nerves (nerves that let you smile, move your tongue, shrug your shoulders etc), eye movements, balance testing such as walking straight lines and stepping tests. Other objective tests that may be done are a comprehensive hearing test, an auditory brain stem response test (explain). Specific balance tests including an ENG
explain and rotational chair test (explain). On occasion I may also obtain a test called a Platform posturography (explain) and electrococholeography (explain). These tests help in the localization of your particular problem and can possibly affect treatment recommendations. Often after completing the extensive evaluation we may still not be able to learn the source of your balance problem and may recommend either a CAT scan or MRI (explain). From time to time it may be indicated to send you to a neurologist for further evaluation. Once we have ruled out potential dangerous causes of balance disturbances we can talk about treatment options that may exist.
I would like to talk about some common treatable balance disorders. One of the most common balance problems that we see is called benign positional paroxysmal vertigo (BPPV-BPV). BPV is characterized by position provoked sensation of vertigo. Most patients tell me that if they roll left or right in bed or if they look up on a top shelf or turn their head rapidly, or bend over rapidly and spring back up that they become very dizzy Typically, we see short-lived spells of vertigo lasting 15-60 seconds. The most common cause of this problem is from either head trauma, infection or unknown causes. This is a self-limited problem and if you do nothing, over time this will go away, often it can come back at a later date. In the olden days, Drs. would recommend cervical spine collars to limit any position that would make you dizzy. Today we have been recommending Cawthorne exercises or a particle repositioning maneuver.
Another very common problem is Meniere's disease. In the late 1800's Prosper Meniere recognized a disorder characterized by four symptoms: 1) Vertigo 2) Fluctuating hearing loss 3) Aural fullness (ear pressure) and 4) Roaring tinnitus. This problem is caused by a build up of inner ear fluid called endolymph (endolymphatic hydrops). The exact cause for this build up of fluid unknown but is thought to b because either too much fluid is made or too little absorption is occurring in the endolymphatic sac. The diagnosis of Meniere's disease is a clinical one. That is, the diagnosis is made from the history we obtain from you. There are some classic findings with objective tests, namely a low frequency hearing loss seen on a hearing test. Balance testing (ENG) may range from normal to abnormal. It is helpful if we find a weakness in one of the inner ears but this is not always the case. Sometimes a CT or MRI scan may be indicated to rule out other problems.
Patients having Meniere's disease typically tell us that their ear becomes full or blocked, then they get a roaring sound in the ear and the hearing goes out followed by severe vertigo. The spinning usually lasts from 15 minutes up to 12 hours, with the average being 1-3 hours. Following the attack the symptoms resolve the patients often feel normal. Some patients still feel "off" for a day or so. The primary treatment options are to restrict your salt caffeine, alcohol, fatty foods and simple sugars. This serves to reduce the overall fluid volume in your body and thus reduce the endolymph. Often we will prescribe a diuretic, a water pill, which serves to reduce the amount of fluid in your body. Typically, I prescribe Dyazide one pill per day.
An option in the treatment for dizziness is vestibular rehabilitation. Specifically, we give you exercises designed to strengthen the balance system, and we encourage general exercise provided your medical Dr. has cleared you from a health standpoint. Exercises do not help immediately. They take time possibly as short as 6 weeks but usually many months. Performing the exercise program twice daily is typically recommended. Over time, the dizziness usually subsides. On rare occasion some people may continue to have episodic spells of vertigo. If the hearing is good a vestibular neurectomy may help. If the hearing is poor then a labyrinthectomy may be indicated. Some patients complain of persistent light-headedness and wooziness, which are not likely to be improved with surgery and may even become worse.
Another cause of dizziness is a perilymphatic fistula (PLF) which is the result of an abnormal communication between the inner ear and the middle ear spaces. The most common cause of a fistula is from a surgical procedure called a stapedotomy. Other causes are head trauma, pressure changes caused by scuba diving, weight lifting and rarely airplane travel. The symptoms can be diverse but may be similar to Meniere's disease. In 1988, I presented a paper to the International Symposium of Meniere's Disease in Boston on PLF and how it may mimic Meniere's disease. The symptoms usually are hearing loss, tinnitus fullness and vertigo. Although many of the standard audiologic and balance tests will usually be performed, the only true way to diagnose a PLF is through an exploration of the middle ear. Whether a fistula is identified or not at the time of surgery patching both the oval and round windows is routine (primary sites for leak of fluid). This patching is done whether the leak is present or not as a microscopic leak can be present that cannot be seen.
There are hundreds of other possible causes for balance disorders. There is an entity called a vascular loop. This is where a loop of blood vessel pulses on the hearing and balance nerve. On rare occasion, vascular loops may cause hearing loss, vertigo and tinnitus. This problem can occasionally be diagnosed with an MRI scan but sometimes requires an angiogram. The primary problem is that more than 75% of all people have a vessel loop that is very close to the hearing and balance nerve yet they do not have any problem.
When we age there is a reduction of blood supply to many parts of our bodies. Sometimes we can document reduction of flow to the brain with ultrasound studies carotid/vertebral or other blood flow studies such as MRA or angiograms. When there is reduction of flow to the vessels in the back of the neck and head this is often called vertebrobasillar insufficiency. Sometimes these studies are not diagnostic or helpful and I may often begin treatment with medications such as aspirin, persantine, trental or cyclospasmol. All these medications improve blood flow by one of several different mechanisms. They all have the potential side effects of stomach irritation.
Migraine was first described by Hippocrates 25 centuries ago. It is a common disorder and it can on occasion cause balance problems. There is also an entity called cervical vertigo where patients have severe neck problems and this alone can cause balance problems. This is very difficult to prove as a cause and often it is a diagnosis of exclusion.
There are many other causes for balance disturbance. The most common metabolic cause is probably high blood sugar or hypoglycemia (low blood sugar). Other associated laboratory disturbances would be high cholesterol, high lipids (fats), low or high thyroid, drugs, and allergies. As you can see from this detailed discussion, there are many causes of balance disorders. Some are easy to sort out while other causes are elusive.
In closing, I would like to tell you that I understand that this is a very frustrating problem for you. I am eager to help. Having said this, you must also realize that even after a detailed history and examination is performed and testing when appropriate, we often cannot tell you precisely what is wrong. So as physicians, and health care providers, it is frustrating for me to not be able to tell you absolutely what is wrong. Out of 100 patients with dizziness, after a careful search we can come up with a diagnosis in about half of the patients. The other half we often shrug our shoulders, apologize and tell you we simply do not know why you have this problem. This has caused a significant amount of frustration for me, and this has probably been a major impetus for me to understand non-western medical options. What I mean by this is Complementary and Alternative Medicine (which I abbreviate as CAM). We must realize that medicine as you and I understand it does not have all the answers, we need to learn from our colleagues in Asia, Germany, Pakistan and India for example. With this in mind and with my BS degree in nutrition and the fact that I have studied herbs since 1981, I very much think of alternative options. I have several chiropractors, acupuncturist, St. Johns neuromuscular therapists and herbalists that I work with. I have had many patients achieve improvement when traditional medical ways have failed. To me this is a teamwork approach, I want to make sure you do not have anything dangerous, I then want to find out (if possible) what you have and then treat you appropriately.
Several alternative options include: Chiropractic medicine, Acupuncture, St. Johns Neuromuscular therapy, massage therapy, homeopathy and herbal therapy, and there are many others.
Specific nutrients that may be beneficial are:
Nutrients to help vertigo:
Magnesium 400 mg/day (Grain, nuts, beans, green vegetables and bananas)
Calcium 1000 mg/day (Yogurt, milk and cheese)
Potassium 3500 mg/day (Fresh fruits and vegetables)
Multivitamin supplements (including Body Language Vitamin Co. MVI and antioxidant, Advanced Medical Ntrn and Optivite)
Kimmelman CP; Seidman MD; Seidel SJ, Shambaugh GE
Herbals to help vertigo
Cocculus compositum (Vertigoheel)
Ginkgo (ginkgo biloba)
Claims: Improves circulation, Alzheimer's, cognition, tinnitus and vertigo
Actions: Vasodilator, adaptogen, stimulant, antioxidant
CI: Careful with patients on anticoagulants, (ginkgolides antag PAF)
Side effects: Rare GI upset (particularly with off brands)
Interactions: (Coumadin, heparin and other anticoagulants, no real concern with ASA)
Dosage: 40-60 mg TID, Commission E 240mg BID
Lebars PL et al JAMA 1997; Kanowski S et al Pharmacopsychiatry 1996
Ginseng (panax ginseng)
Claims: Fatigue, depression, stress, general well being, sexual energy and digestion
Actions: Adaptogenic (and promotes secretion of ACTH-causing release of endorphins and enkephalins) stimulant, lowers RBS, inhibits platelet aggregation
CI: Avoid in HTN, DM and pregnancy; may interfere with anticoagulant tx
Side effects: High doses-insomnia, anxiety, GI upset
Interactions: Do not use with other anticoag, stim (i.e., caffeine), MAOI, antipsychotics
Dosage: 100-300mg 103X / d
Blessed Thistle (cnicus benedictus)
Claims: Stimulates appetite, digestion, relieves dyspepsia, anti URI, ? antibacterial
Actions: Galactagogue-stimulates lactation
CI: None noted
Side effects: Large doses - GI upset of immune suppression
Interactions: Mugwort and cornflower - sensitization
Dosage: 2-3 drpfl 2-3x / d or up to 4-6 gm/d
Hawthorn (crataegus oxycantus)
Claims: Atherosclerosis, arrhythmia, HTN improves CO and coronary blood flow
Actions: Cardiac and sedative
CI: None noted (d o not use with other inotropes)
Side effects: Mildly sedative
Interactions: Avoid digitalis or foxglove
Dosage: 2-3 drpfl 2-3 x /d or 160-900 mg ext/d
Gotu Kola (centella asiatica)
Claims: Improves memory, hypothyroidism
Actions: Restorative, vulnerary-stops bleeding and promotes wound healing
CI: None noted
Side effects: None noted (rarely may cause skin irritation)
Interactions: None noted
Dosage: 50-600 mg 1-3x /d
Cocculus compositum (vertigoheel)
Cocculus indicus 4x 210 mg
Conium masculatum 3x 300 mg
Ambra grisea 6X 30 mg
Petroleum 8X 30 mg; Mg stearate (inactive ingred)
Activates vestibular regulatory sx brainstem (PDR); Claussen Bio Ther 1987; Claussen et al Arxneimittel F 1984)
Dbl-bl PC study showed to be as effective as Serc; both sig better than placebo (Weiser et al Arch Oto 1998)
No CI or adverse reactions (Heel/BHI Inc. 800-621-7644)
A combination of 7 highly concentrated oils, rubbed on behind each ear they claim 80% of people using product have resolution of their vertigo.
Either me or one of my colleagues will be in to talk with you to answer any additional questions or concerns. Additionally, we have this text written down so that you can review it at your leisure or refer back to. Also, I am here to help you to the best of my ability, and I look forward to working with you.
Thank you so much for taking the time to watch this video.
Copyrighted to Michael Seidman,MD., FACS