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Hello, my name is Michael Seidman, I am an Otorhinolaryngologist (also known as an ENT surgeon). I received my BS degree in nutrition and my MD degree both from the University of Michigan. I did a 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 Florida.

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 and treat 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 and visual systems). These systems are all necessary to maintain proper balance, and disorders of any of these can cause balance problems. We know that people 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 year 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. Another common cause of balance disturbance is head trauma, i.e., hitting your head in a motor vehicle accident, falling off a ladder, etc. There are many chronic diseases 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 (chemical 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 tests (takes approx. 2 hours), an auditory brainstem response test (explain). Specific balance tests including an ENG...(explain) and rotational chair test (explain). On occasion I may also obtain a test called Platform posturography (explain) and electrocochleography (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 CT 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.

This particular video will discuss Meniere's disease in some detail. 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 is unknown but is thought to be because either too much fluid is made or too little absorption is occurring in the endolymphatic sac. On rare occasion we may see delayed endolymphatic hydrops. This occurs after someone has had a known hearing loss for years and rarely this problem can occur after head trauma. 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. One other test worth mentioning is electrocochleography. EcoG is a test used by some physicians while others do not give it much credence. The test may be abnormal or normal in the same patient at different times and it is a test that I do not routinely order. Sometimes a CT or MRI scan may be indicated to rule out other problems.

Patients with Meniere's disease typically tell us that their ear becomes full or blocked, then they get a roaring sound in the ear and their hearing goes out followed by severe vertigo. The spinning usually last from 15 minutes up to 12 hours, with the average being 1-3 hours. Following the attack, the symptoms resolve and 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. Dyazide is preferred because unlike other diuretics, dyazide does not waste potassium supplements. In general, while on a diuretic eating a banana or an orange a day is advisable to provide a good source of potassium, If the hearing dramatically goes down or if you are early on in your symptoms, I may recommend a 1 week trial of steroids. On occasion, steroids have made the attacks go away for quite some time. There are of course significant potential side effects with steroids, such as irritability, mood swings, stomach upset with the potential for stomach ulcers, increased appetite weight gain (usually not more than several pounds) and one of the more severe reactions is a drug reaction where the hip bone can become very weak and you can actually fracture the hip, this is extremely unusual but can happen. Most of these side effects are tolerated relatively well especially as I usually use the medicine for 7-10 days. Many other medications have been tried including histamines and a non-FDA approved drug called Serc (used frequently in Canada and Europe). Medical management may also include the use of antivert, Dramamine, scopalamine or valium for the vertigo when it is severe. Surgical management is usually reserved for people who continue to have problems despite medical management. There are many procedures described, but I will discuss the four most commonly used procedures.

Endolymphatic Sac Surgery: This is an outpatient procedure that takes 1-1.5 hours to do. Patients come in the morning and are home the same day. The operation is designed to uncover the endolymphatic sac. I will typically incise the sac and stent it open, while other surgeons just uncover the sac or decompress it. Some surgeons actually completely remove it. Although this operation has the lowest chance for major complications, it is also the least effective overall. The percentage of patients with significant vertigo control at 2-5 years is 50%. Overall, however, I find that approximately 75% of patients who have this operation do not feel the need to proceed with more aggressive surgical options. The most common complications with this procedure are bleeding, infection, hearing loss (5%), persistent balance problems (50%), facial nerve injury with resultant facial paralysis (1:1000), change or loss of sense of taste, cerebrospinal fluid leak and meningitis (both very rare) and no improvement in your vertigo attacks (50%). Typically the recovery period is short and I have had people back to work within several days but on average 1-2 weeks. Some have suggested that this operation is no better than a placebo procedure (Danish Sham Study) and that it should not be done. In the survey that I sent out to 600 neurotologists around the world, this was still the most commonly done procedure.

Vestibular Neurectomy: This is an operation that I do with a neurosurgeon. This procedure takes approximately 3-4 hours. It requires a stay in the intensive care unit (usually overnight) and then a 3-7 day hospital admission. Patients will usually experience a severe attack of vertigo that gradually improves. The quicker we can get you up and walking the faster you will recover. The percentage of patients with significant vertigo control at 2-5 years is 91-93%. Thus, from a vertigo control standpoint this is an excellent option. The risk of hearing loss is approximately 10%. The complications to consider are again bleeding, infection, hearing loss (10%), persistent vertigo (3-7%), facial nerve injury with resultant facial paralysis (1:1000), change or loss of sense of taste, cerebrospinal fluid leak and meningitis. The risk of CSF and meningitis are higher with this procedure than with other procedures because we are working in the brain. The recovery is usually 3-7 days in the hospital with return to work in 4-8 weeks. Typically the younger you are the more rapid is your recovery. I have performed this operation in patients as young as 25 years and as old as 96, although both extremes are unusual. Most patients tell me that even years after surgery they may still feel dizzy with a rapid head turn or if they step off a curb.

Labyrinthectomy: This operation takes about 1-2 hours and is considered the "gold standard" of procedures for vertigo as it controls symptoms in 95% of patients at 2-5 years. The major downside is that you are guaranteed to be deaf in the operated ear as it essentially wipes out the inner ear. The complications to consider are again bleeding, infection, hearing loss (100% everyone), persistent vertigo (5%), facial nerve injury with resultant facial paralysis (1:1000), change or loss of sense of taste, cerebrospinal fluid leak and meningitis. The hospital stay is usually 1-3 days with return to work in 4-8 weeks. After surgery patients will usually experience severe vertigo for several days. Again like the other operations, the quicker one can force themselves to get up and move about, the faster they will recover.

Gentamicin into the middle ear: This is a procedure that takes 30 minutes. There are several ways to do this: one is in the office but usually has to be repeated 3-10 times. Essentially, we inject gentamicin or streptomycin through your eardrum towards your inner ear. Gentamicin is an antibiotic that is toxic to the vestibular system. Versions of this procedure have been in existence for many years. The percentage of complete vertigo control at 2-5 years is approximately 75-80%. Approximately half the patients lose some hearing and 10-20% may become dear. The primary complications include bleeding, infection, ear drum perforation with need for later repair, hearing loss (50%), change or loss of sense of taste. Theoretically it would be possible to have facial nerve injury but of all the procedures this is the least likely to result in facial paralysis. Persistent balance problems can also occur. The recovery is similar to the vestibular neurectomy and labyrinthectomy, specifically gradual improvement over 4-8 weeks. There are two newer methods of doing this, one is the Silverstein Microwick and the other is via a RW microcatheter. Currently, I prefer the RW catheter technique if we elect to inject the gentamicin. This is done in the OR and takes approximately 1 hour of total time. A small catheter is inserted into your round window (a window into the inner ear) and the medicine is given directly to the inner ear. Very low doses can be used which appears to reduce the risk, but not guarantee, for hearing loss. You are then hooked to a pump for 7-21 days while the medicine is going into the inner ear. The catheter is then easily removed while in the office. Typically, you will feel off balance for weeks to months with gradual improvement.

I used to only recommend the vestibular neurectomy, as it had one of the highest rates of reduced vertigo and a low incidence of hearing loss. However, since 1992, I have been offering endolymphatic sac surgery (when hearing is good) or the gentamicin, if hearing is down a bit as first choice primarily because both have relatively low risks and there is some suggestion that there may be an improvement in some of the other symptom's associated with Meniere's disease such as ear fullness, hearing loss, and tinnitus. However, improving these latter symptoms is still relatively unlikely and the primary reason for surgery is to help with the vertigo. If you have no hearing in the affected ear, a labyrinthectomy is probably the best option. There are other procedures that can be recommended but on a much less frequent basis.

In summary of the surgical procedures, I would like you to know that I understand that you are probably nervous about this particular problem and that it is normal to be scared or nervous about any type of surgery. These particular types of surgeries are ones that I have performed many times, I teach residents, medical students and other doctors to do this type of surgery. I lecture around the world and publish articles related to these subjects. So all in all, you are in very god hands, I know you will do well and I will take the best possible care of you. Our anesthesia and nursing personnel are some of the best and I have a great deal of faith and trust in all of them. They will also take wonderful care of you. Please tell me of any concerns or questions so I can address them.

Some people may get Meniere's disease in the opposite ear, that is, both ears may be involved. Studies have shown a range of 5-80% chance of having both ears involved. In 996 I sent a survey out to all surgeons who care for patients with Meniere's disease throughout the world and found that most doctors say approximately 10% of people get the disease in both ears.

Another 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 doctor 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.

Other common causes of dizziness include Benign Positional Vertigo, which is essentially dizziness that is position related and lasts for 20-60 seconds at a time. Vestibular neuronitis is where you have a 24-72 hour spell of continuous vertigo with nausea and vomiting and gradual recovery over weeks to months. Interestingly, this only affects your balance and does not cause any hearing symptoms. This is in contrast to labyrinthitis which causes severe vertigo with N and V and hearing loss. The recovery from labyrinthitis takes months to even years.

There are hundreds of other possible causes for balance disorders. Perilymphatic fistula is an entity that can mimic Meniere's disease and is a relatively uncommon disorder. I was invited to the Massachusetts Eye and Ear / Harvard Medical school in 1988 to discuss how PLF can mimic Meniere's, but again this is a fairly uncommon problem. There is also a disorder called a vascular loop. This is where a loop of a blood vessel pulses on the hearing and balance nerve.

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 a very frustrating problem for you. I am eager to help.

Sometimes, standard therapies are not effective. Since I am the Co-Chair of HFHS Complementary and Alternative medicine (which I abbreviate as CAM) Center, I am very interested in alternatives when reasonable. 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, acupuncturists, St. John's 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 John's Neuromuscular therapy, message therapy, homeopathy and herbal therapy, there are many others. For Meniere's disease in specific, we as traditional MD's do a very good job at alleviating many of the symptoms with medicine or surgery. Nonetheless, it is always wise to consider options.

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)
Lipoflavonoids
B vitamins
Multivitamin supplements (including Body Language Vitamin Co. MVI and antioxidant, Advances Medical Ntrn and Optivite)
Kimmelman CP; Seidman MD; Seidel SJ, Shambaugh GE

Herbals to help vertigo
Ginkgo biloba
Ginseng
Blessed thistle
Hawthorn
Gotu Kola
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)
Primary ingredients:
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)

Di-vertigo
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

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