Ear, Nose and Throat - U.S.A.  (ENT USA) Dizziness - Positional Vertigo and Meniere's Disease
Dizziness and Vertigo
Positional Vertigo & Meniere Disease   
  
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Dizziness,
Vertigo and Meniere's Disease
 
Balance: 
Balance is determined by a complex combination
of inputs into the brain.  These inputs are:

  •   Vision
  •   Proprioception (sensation of position of joints
  •   Inner ear

 Search PubMed for Particle Repositioning Maneuver
 Search PubMed for Meniere's Disease

   

       

     

      

   
  


  
Dysfunction in more than one of these systems or in the brain itself may cause loss of balance or dizziness.  The elderly often have dizziness due to poor blood flow to the brain, hypotension (low blood pressure often from high blood pressure medications), poor proprioception and poor vision.  

Dizziness:  There are many types of dizziness, and only a few of these actually come from the inner ear.  When patients state they are dizzy, they usually are referring to one of three different types of symptoms:

  • A loss of control or staggering like being drunk, but the room orientation is normal.  The patient just cannot control his body.
  • A light-headedness or fainting.
  • A sensation of motion or spinning.

Of these symptoms, only the sensation of motion or spinning is characteristic of inner ear disease.  This type of dizziness is called vertigo.  A loss of control or staggering with normal room orientation can be found with some brain tumors and also drug use.  A light-headedness or fainting is usually found in nervous conditions but can also be a symptom of cardiovascular conditions or even a brain tumor.
 
Unfortunately, many patients have a difficult time describing their dizziness.  Up to 33% of patients with nystagmus (eyes spinning or jerking back and forward) use the terms "swimmy head" and "light-headedness" to describe vertigo or a spinning sensation.  An electronystagmogram is helpful in determining if a patient has vertigo or dizziness from the
inner ear.  

     
  

The two most important features of vertigo is its duration and if it is caused by a change in body position.  Vertigo which is caused by a change in position usually lasting less than one minute.  If caused by the inner ear, it may be treated by a particle repositioning maneuver.  The dizziness is felt to be caused by bone debris (otoconia which is dislodged from the macula of the utricle and saccule) entering the posterior semicircular canal.  A maneuver can be used to reposition this debris and relieve the patient's symptoms.  In one study 76% of patients with benign positional vertigo improved as compared to 48% of the untreated group.  View Abstract

 

The posterior canal is the most dependent, thus, otoconia usually enter it and cause the dizziness.  rarely, otoconia can fall into the horizontal canal.  If this happens a different maneuver may have to be performed. View Abstract   View Abstract

Positional vertigo may also be caused by brain abnormalities or tumors.  This is particularly true if it lasts a long time after the eliciting motion.

Vertigo lasting from 30 min. to 24 hrs. is often caused by Meniere's Disease.  This is a triad of ear ringing, hearing loss and vertigo.  Often there is pressure in the ear with the spell.  It usually affects only one ear but in 5% of cases may be bilateral.  70% of patients can be controlled with a low salt diet and diuretic (water pill).  Meniere's Disease is caused by too much pressure in the fluids (endolymph) of the inner ear--see temporal bone anatomy section.   There are many possible causes of Meniere's Disease but none are universally accepted.  Theses causes include:  Autoimmune,  genetic, vascular, allergy viral, head trauma and exposure to toxins.  There is now creditable evidence that loud sounds or acoustic trauma does NOT cause Meniere's disease -- read more..  

A variety of different treatments are available for
Meniere's Disease.  Initially, a low salt (Sodium Chloride) diet with avoidance of caffeine alcohol and tobacco may be tried.  If this fails diuretic therapy will help most patients.  Patients who still have severe vertigo despite these conservative measures, may be offered one of a number of surgical procedures.  Results are hard to judge because any treatment for Meniere's Disease even placebo has a 60% chance of improvement.  One of the newer treatments is intratympanic injection of gentamicin. View Abstract of Review Article    In this procedure an ototoxic drug (a drug which damages the inner ear), gentamicin, is injected through the eardrum, into the middle ear.  This treatment has been gaining wider acceptance and can be performed in the surgeon's office.  Complete control of vertigo has been reported in up to 90% of patients with worsening of hearing in about 25% of patients.  View Abstract   Perez et. al. reported control of vertigo in 83% of patients View Abstract and hearing loss (two years after treatment) due to gentamicin in 15.5% of the treated patients. View Abstract    Intratympanic ( middle ear )  injection of steroids for the treatment of Meniere's disease is controversial with some studies showing no long term benefit of the treatment.  View Abstract  View Abstract  Another technique is the use of transtympanic micropressure.  This is a new techinque which has not been extensively studied but initial results appear promising (Gates 2004) View Abstract

Vertigo lasting from 24 hrs. to one week is often caused by viral labrynthitis.  The patient seldom has hearing loss and recovers slowly over the course of one week.  Although sometimes it may take up to one month to recover.

Vertigo lasting greater than one week is often caused by a dysfunction in the central nervous system, or a brain condition, such as a tumor.

  Hearing Loss Length of
Major Spells
Caused by Changes in Position
Benign Paroxysmal Positional Vertigo No < 5 mins Yes
Meniere's Disease Yes 20 mins to
24 hours
No
Labrynthitis No 24 hours to
one week
No
Central Nervous System Disease Yes/No > one week Yes/No

Many cases of vertigo can be diagnosed by the above table.  However, there are many causes of vertigo and all can mimic central or a brain condition, many of which are serious.  A consultation with a doctor is important to properly diagnosis and treat dizziness.

Homeopathic Treatments:  Cocculus Indicus 6CH is a climbing flowering plant which has been purported to help vertigo.   The fruit of the plat produces picrotoxin a poisonous crystalline plant alkaloid which has a neurotransmitter stimulatory effect.   The only study regarding Cocculus Indicus 6CH on Pub Med (as of 2/1/2008) was a study by Lucertini M et al.   The report was unable to demonstrate in a double-blind study that Cocculus Indicus helped in reducing flight simulator sickness.    Buyer Beware - View Abstract 
  

   

 
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