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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 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, 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 otolaryngology 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 the 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 symptoms are all necessary to maintain proper balance, and disorders of any of these can cause balance problems. We know that many 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 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 if 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 ear 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 illnesses 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, 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 my colleagues or me, 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 (takes approx. 2 hours), an auditory brainstem test (explain). Specific balance tests including an ENG, (explain) and rotational chair testing (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 a CAT scan or MRI (explain). For 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 primarily about benign positional paroxysmal vertigo (BPV-BPV). I will also briefly mention some other common treatable balance disorders. BPV is by far the most common balance disorder that we see. It is characterized by a 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. The problem stems from tiny stones or crystals in our inner ear called otoconia that may become dislodged from their normal position or particulate matter floating in the wrong position in one of your semicircular canals.
If this is the problem that you have, there are several treatment options. 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, doctors would recommend cervical spine collars to limit any position that would make you dizzy. Today we have been recommending Cawthrone exercises which are designed to stress or tax the balance system by bringing on the dizziness, in addition, we suggest that you do what makes you dizzy in a controlled setting at home so that you do not injure yourself. I will often have patients turn their head to the affected side and position themselves in bed with that side down to bring on the dizziness. After the dizziness is gone, and you are done cursing at me!! I have you sit back up (often the dizziness occurs again when assuming the upright position) and repeat until the dizziness is gone. In some it will take three or four times of this maneuver, in others it may take twenty to thirty times. Typically, these exercises will eradicate the problem in about half the time of doing nothing.
Another option is to do a particle repositioning maneuver. This is considered the latest and greatest and I have been doing this since 1992. This is performed in the office, but on occasion I may have you repeat it at home. The idea is to put the particles or otoconia back to their original position. This takes approximately five minutes in the office or at home. In my hands, this treatment works for about 90% of my patients. The only downside is that you should (after this maneuver is performed) sleep upright for 48 hours and then you cannot assume any position that made you dizzy for seven additional days. There are others who argue that this is not important, but I believe it to be. People will ask me, how do they not roll on their right or left side, my response is: I don't care how you do it, just do it. Put a 2 x 4 or a cactus next to you, so if you roll, it will stop you quickly! If you dizziness is not gone after 2-3 months, I may recommend extensive balance testing if you have not already had it.
For the very rare person who is incapacitated by this problem and for the person who has had this for more than a year despite medical treatment, you may be a candidate for one of the two surgical procedures. Singular neurectomy is a procedure where the nerve to the posterior semicircular canal is cut. This procedure works in 90% of the patients, besides the usual risk of any ear surgery the risk of hearing loss/deafness is 10%. The other surgical option is a semicircular canal occlusion. This operation is also 90% successful but has a higher risk or hearing loss on the range from 10-30%. Most patients are significantly improved without surgery and this should only be considered as a last option.
There are many other fairly common causes for balance problems and I will briefly discuss several of the most important ones.
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 is unknown but is thought to be 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.
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 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. Lasix, a more powerful diuretic requires that you also take 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. Surgical management is usually reserved for people who continue to have problems despite medical management.
Vestibular Neuronitis. Another common problem resulting in balance disturbance is vestibular neuronitis. This is characterized by severe vertigo with nausea and usually vomiting. The spinning usually lasts for 1-3 days with gradual improvement over the next several weeks to months. Interestingly there is no associated hearing loss or other ear symptoms. The lack of other ear symptoms is what differentiates this problem from labyrinthitis, which also causes hearing loss in association with the dizziness. Labyrinthitis usually causes vertigo and imbalance for 3-7 days with a slower recovery. Both problems are initially treated with medications such as antivert, dramamine, scopolamine and valium, to make symptoms more tolerable. If there is associated hearing loss we often give a trial of steroids to see if any of the hearing will come back. The most common causes of vestibular neuronitis and labyrinthitis are viral or bacterial infection that may occur anywhere in the body and then possibly spread to the inner ear. Reduction of blood supply to the inner ear may also be a cause of the above mentioned symptoms and often we never find out the true cause.
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 headiness 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 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.
There are hundreds of other possible causes for balance disorders. There is an entity called a vascular loop. This is where a loop of a blood vessel pulses on the hearing and balance nerve. On rare occasion, vascular loops may cause hearing loss, vertigo and tinnitus.
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. Sometimes, standard therapies are not effective. Since I am the Co-Chair of HFHS Complementary and Alternative Medicine (which I abbreviate CAM) Center, I am very interested in alternative 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. Johns Neuromuscular therapy, massage therapy, homeopathy and herbal therapy, and there are many others. For Benign Positional vertigo 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.
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, Advances 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