| |
| Dizziness is a
symptom not a disease. It may be defined as a
sensation of unsteadiness, imbalance, or
disorientation in relation to an individual's
surroundings. The symptom of dizziness may vary
widely from person to person and be caused by many
difference diseases. It varies from a mild
unsteadiness to a severe whirling sensation known as
vertigo. As there is little representation of the
balance system in the conscious mind, it is not
unusual for it to be difficult for the patient to
describe his symptom of dizziness to the physician.
In addition, because the symptom of dizziness varies
so widely from patient to patient and may be caused
by many different diseases, the physician commonly
requires testing to be able to provide the patient
with some knowledge about the cause of his
dizziness. Dizziness may or may not be accompanied
by a hearing impairment |
| |
| |
| The ear is divided
into three parts: external ear, middle ear, and
inner ear. |
| |
| The external ear
structures gather sound and direct it toward the
eardrum. The middle ear chamber consists of an
eardrum and three small ear bones. These structures
transmit sound vibrations to the inner ear fluid. |
| |
| The inner ear
chamber (labyrinth) is encased in bone and filled
with fluid (endolymph and perilymph). This fluid
bathes the delicate nerve endings of the hearing and
the balance mechanism. |
| |
| Fluid waves in the
hearing chamber (cochlea) stimulate the hearing
nerve endings which generate an electrical impulse.
These impulses are transmitted to the brain for
interpretation as sound. Movement of fluid in the
balance chambers (vestibule and three semicircular
canals) also stimulates nerve endings, resulting in
electrical impulses to the brain, where they are
interpreted as motion. |
| |
| |
| The human balance
system is made up of four parts. The brain acts as a
central computer receiving information in the form
of nerve impulses (messages) from its three input
terminals: the eyes, the inner ear, and the muscles
and joints of the body. There is a constant stream
of impulses arriving at the brain from these input
terminals. All three systems work independently and
yet work together to keep the body in balance. |
| |
| The eyes receive
visual clues from light receptors that give the
brain information as to the position of the body
relative to its surroundings. The receptors in the
muscles and joints are called proprioceptors. The
most important ones are in the head and neck (head
position relative to the rest of the body) and the
ankles and joints (body sway relative to the
ground). |
| |
| The inner ear
balance mechanism has two main parts: the three
semicircular canals and the vestibule. Together they
are called the vestibular labyrinth and are filled
with fluid. When the head moves, fluid within the
labyrinth moves and stimulates nerve endings that
send impulses along the balance nerve to the brain.
Those impulses are sent to the brain in equal
amounts from both the right and left inner ear.
Nerve impulses may be started by the semicircular
canals when turning suddenly, or the impulses may
come from the vestibule, which responds to changes
of position, such as lying down, turning over or
getting out of bed. |
| |
| When one inner ear
is not functioning correctly the brain receives
nerve impulses that are no longer equal, causing it
to perceive this information as distorted or off
balance. The brain sends messages to the eyes,
causing them to move back and forth, making the
surroundings appear to spin. It is this eye movement
(called nystagmus) that creates a sensation of
things spinning. |
| |
| Remember to think of
the brain as a computer with three input terminals
feeding it constant up-to-date information from the
eye, inner ear and muscles and joints (proprioceptors).
The brain itself is divided into several different
parts. The most primitive area is known as the
brainstem, and it is here that processing of the
input from the three sensory terminals occurs. The
brainstem is affected by two other parts of the
brain, the cerebral cortex and the cerebellum. |
| |
| The cerebral cortex
is where past information and memories are stored.
The cerebellum, on the other hand, provides
automatic (involuntary) information from activities
which have been repeated often. |
| |
| The brainstem
receives all these nerve impulses: sensory from the
eyes, inner ear, muscles and joints; regulatory from
the cerebellum; and voluntary from the cerebral
cortex. The information is then processed and fed
back to the muscles of the body to help maintain a
sense of balance. |
| |
| Because the cortex,
cerebellum and brainstem can eventually become used
to (ignore) abnormal or unequal impulses from the
inner ear, exercise may be helpful. Exercise often
helps the brain to habituate to (get used to) the
dizziness problem so that is does not respond in an
abnormal way, does not result in the individual
feeling dizzy. An example of habituation is seen
with the ice skaters who twirl around, stop
suddenly, and do not apparently have any balance
disturbance. |
| |
| |
| Sensations of
unsteadiness, imbalance or disorientation in
relationship to one's surroundings may result from
disturbances in the ear, neck, muscles and joints,
the eyes, the nervous system connections of these
structures, or a combination of any of the above. |
| |
| |
| Ear dizziness, one
of the most common types of dizziness, results from
disturbances in the blood circulation or fluid
pressure in the inner ear chambers, from direct
pressure on the balance nerve, or physiologic
changes involving the balance nerve. Inflammation or
infection of the inner ear or balance nerve is also
a major cause of ear dizziness. |
| |
| The inner ear
mechanism is about the size of a pea, and is
extremely sensitive. There are two inner ear
chambers: One for hearing (cochlea), and one for
balance (vestibule and semicircular canals). These
chambers contain a fluid which bathes the delicate
nerve endings. These nerve endings are stimulated
when there is movement of the fluid. Nerve impulses
are then transmitted to the brain by the hearing and
balance nerves. The nerves pass through a small bony
canal (internal auditory canal), accompanied by the
facial nerve. |
| |
| Any disturbance in
pressure, consistency or circulation of the inner
ear fluids may result in acute, chronic, or
recurrent dizziness, with or without hearing loss
and head noise. Likewise, any disturbance in the
blood circulation to this area or infection of the
region may result in similar symptoms. Dizziness may
also be produced by over stimulation of the inner
ear fluids, such as one encounters when he spins
very fast and then stops suddenly. |
| |
| |
| Central dizziness is
usually an unsteadiness brought about by failure of
the brain to correctly coordinate or interpret the
nerve impulses which it receives. An example of this
is the "swimming feeling" or unsteadiness that may
accompany emotional stress, tension states, and
excessive alcohol intake. Circulatory inefficiency,
tumors, or injuries may produce this type of
unsteadiness, with or without hearing impairment. A
feeling of pressure or fullness in the head is
common. Occasionally true vertigo (spinning) may be
caused by central problems. |
| |
| |
| Neck Dizziness
(cervical vertigo) results from abnormal or
uncoordinated nerve impulses being sent to the brain
from the neck muscles. |
| The neck muscles are
constantly sending nerve impulses to the balance
centers of the brain to help maintain equilibrium.
Spasm (tenseness) of the muscles may result in an
abnormal nerve discharge, leading to unsteadiness or
dizziness. This spasm may result from injury,
arthritis of the spine, or from pressure on nerves
in the neck. |
| |
| |
| Muscle-joint
dizziness is relatively uncommon. Any disturbance of
sensation arising from the muscles and joints in the
limbs (such as occurs in the muscular dystrophies
and other abnormalities) produces this type of
unsteadiness. Such an example is the unsteadiness
experienced when one tries to walk on a leg that has
"gone to sleep." |
| |
| |
| Eye Muscle imbalance
or errors of refraction may produce unsteadiness. An
example of this is the unsteadiness which may result
when one attempts to walk while wearing glasses
belonging to another individual. |
| |
| Another example of
visual dizziness is that occasionally produced if
one is seated in a car looking out the side window
at passing objects. The eyes respond by sending a
rapid series of impulses to the brain indicating
that the body is rotating. On the other hand, the
ears and the muscle-joint systems send impulses to
the brain indicating that the body is not rotating,
only moving foreword. The brain, receiving these
confused impulses (from the eyes indicating
rotation, from the ears and muscle-joint systems
indicating forward motion) sends out equally
confusing orders to various muscles and glands that
may result in sweating, nausea and vomiting. When
one sits in the front seat looking forward, the
eyes, ears, and muscle- joint systems work more
uniformly and one is less likely to develop car
sickness. |
| |
| A visual disturbance
may be caused by dizziness from other sources.
Intermittent inability to focus the eyes, difficulty
reading or intermittent blurring of vision, although
at times the result of anxiety or tension may result
from small reflex movements of the eye called
nystagmus. This nystagmus is common during severe
dizziness. |
| |
| |
| Persons subject to
dizziness should exercise caution when swimming.
Buoyancy of the water results in an essentially
weightless condition, and visual orientation is
greatly impaired if one's head is under water. As a
result, orientation depends almost entirely on the
inner ear balance canals. An attack of dizziness at
this time could be very dangerous. Similarly,
individuals who have lost both inner ear balance
canals should avoid underwater swimming. |
| |
| |
| Any disturbance
affecting the function of the inner ear or its
central connections may result in dizziness, hearing
loss or tinnitus (head noise). These symptoms may
occur singly or in combination, depending upon which
functions of the inner ear are disturbed. |
| |
| Ear dizziness may
appear as a whirling or spinning sensation
(vertigo), unsteadiness, or giddiness and
lightheadedness. It may be constant, but is more
often intermittent, and is frequently aggravated by
head motion or sudden positional changes, nausea and
vomiting may occur, but one does not lose
consciousness as a result of inner ear dizziness. |
| |
| |
| Dizziness may be
caused by any disturbance in the inner ear, the
balance nerve or its central connections. This can
be due to a disturbance in circulation, fluid
pressure or metabolism, infections, neuritis, drugs,
injury, or growths. |
| |
| At times an
extensive evaluation is required to determine the
cause of dizziness. The tests necessary are
determined at the time of examination and may
include detailed hearing and balance tests, x-rays,
and blood tests. A general physical examination and
neurological tests may be advised. |
| |
| The object of this
evaluation is to be certain that there is no serious
or life-threatening disease, and to pinpoint the
location of the problem. This lays the groundwork
for effective medical or surgical treatment. |
| |
| |
| Any interference
with the circulation to the delicate inner ear
structures or their central connections may result
in dizziness and, at times, hearing loss and
tinnitus. These circulatory changes may be the
result of blood vessel spasm, partial or total
occlusion (blockage), or rupture with hemorrhage. |
| |
| |
| Inner ear dizziness
due to blood vessel spasm is usually sudden in onset
and intermittent in character. It may occur as an
isolated event in the patient's life or repeatedly
in association with other symptoms. If it is
recurrent it usually is associated with migraine
headache-type symptoms. Predisposing causes include
fatigue and emotional stress. Certain drugs such as
caffeine (coffee) and nicotine (cigarettes) tend to
produce blood vessel spasm or constriction and
should be avoided. Blood vessel spasm has been noted
to occasionally begin after head injury. Although
there may have been no direct injury to the inner
ear by the trauma, the spasm may begin to damage the
ear. |
| |
| |
| As one gets older,
blood vessel walls tend to thicken due to an aging
process known as arteriosclerosis. This thickening
results in partial occlusion, with a gradual
decrease of blood flow to the inner ear structures.
The balance mechanism usually adjusts to this, but
at times persistent unsteadiness develops. This may
be aggravated by sudden position changes such as
that encountered when one gets up quickly or turns
suddenly. |
| |
| Complete occlusion
of an inner ear blood vessel (thrombosis) results in
acute dizziness often associated with nausea and
vomiting. Symptoms may persist for several days,
followed by a gradual decrease of dizziness over a
period of weeks or months as the central nervous
system and uninvolved ear compensates for the loss
of the involved ear. |
| |
| |
| Occasionally one of
the small blood vessels of the balance mechanism
ruptures. This may occur spontaneously, for no
apparent reason, or it may be the result of high
blood pressure or head injury. Symptoms are the same
as those of occlusion. |
| |
| |
| Treatment of
dizziness due to changes in circulation consists of
anti-dizziness medications to suppress the symptoms.
They also stimulate the circulation and enhance the
effectiveness of the brain centers in controlling
the symptoms. An individual with this type of
dizziness should avoid drugs that constrict the
blood vessels, such as caffeine (coffee) and
nicotine (tobacco). Emotional stress, anxiety and
excessive fatigue should be avoided as much as
possible. Often, increased exercise will aid in the
suppression of dizziness in many patients by
stimulating the remaining function to be more
effective. |
| |
| |
| Postural or
positional dizziness is a common form of balance
disturbance due to circulatory changes or to loose
calcium deposits in the inner ear. It is
characterized by sudden, brief episodes of imbalance
when moving or changing head position. Commonly it
is noticed when lying down or arising or when
turning over in bed. This type of dizziness is
rarely progressive and usually responds to
treatment, but it may recur. Treatment usually
consists of exercises designed to provoke the
dizziness until it fatigues. This type of exercise
may be recommended by your physician to cause the
positional dizziness to run its course more quickly.
Occasionally, postural dizziness may be permanent
and surgery may be required. |
| |
| |
| Some individuals
develop imbalance as a result of the aging process.
In many cases this is due to circulatory changes in
the very small blood vessels supplying the inner ear
and balance nerve mechanism. Fortunately, these
disturbances, although they may persist, rarely
become worse. |
| |
| Postural or
positional vertigo (see above) is the most common
balance disturbance of aging. This may develop in
younger individuals as a result of head injuries or
circulatory disturbances. Dizziness on change of
head position is a distressing symptom, which is
often helped by vestibular exercises. |
| |
| Temporary
unsteadiness upon arising from bed in the morning is
not uncommon in older individuals. At times this
feeling of imbalance may persist for an hour or two.
Arising from bed slowly usually minimized the
disturbance. Unsteadiness when walking, particularly
on stepping up or down, or walking on uneven
surfaces, develops in some individuals as they
progress in age. Using a cane and learning to use
the eyes to help the balance is often helpful. |
| |
| |
| Imbalance due to ear
infection is usually insidious and mild in onset.
Such imbalance may occur with or without hearing
impairment. As the infection gets closer to the
vital balance mechanism in the inner ear, the
dizziness becomes more constant and severe in
nature, and is often associated with nausea and
vomiting. |
| |
| |
| Control of an ear
infection is imperative in this type of dizziness in
order to prevent spread of the infection directly
into the balance center of the inner ear. Should
this develop, serious complications including total
loss of hearing in the involved ear may result. If
the infection cannot be eliminated by medical
treatment, surgery is indicated to remove the
infection. |
| |
| |
| Neuritis is a
physiological change which occurs in the nerve after
injury by trauma, a virus, autoimmune disease, or
vascular compression. When this occurs, the balance
function is impaired, resulting in a severe, and at
times prolonged, episode of dizziness, often
followed by some unsteadiness or motion for weeks to
years. Fortunately, this balance disturbance usually
subsides in time and usually does not recur in the
majority of cases. It may be, however, very chronic
at a moderate to mild level. Medical treatment is
helpful in eliminating symptoms until the central
nervous system can compensate for the injured nerve.
This usually consists of dizziness- suppressing
drugs. On occasion, the central nervous system
cannot compensate and surgery may be necessary |
| |
| |
| Occasionally
metabolic disturbances produce dizziness with or
without associated hearing loss by interfering with
the function of the inner ear or the central nervous
system. Occasionally hearing loss may occur without
the presence of dizziness. |
| |
| A change of thyroid
function or abnormalities in the blood sugar are the
most common metabolic disturbances resulting in
dizziness. Rarely, fat metabolism abnormalities may
also cause problems resulting in hearing loss and/or
dizziness. Thyroid dysfunction is diagnosed by blood
tests and treatment consists of taking a thyroid
hormone. Abnormalities in the blood sugar are
diagnosed, again by blood studies, and treatment
usually consists of diet control and/or drug
therapy. Fat metabolism problems and diagnosed by
studies of the fatty acids and cholesterol in the
blood. Treatment of these may consist of diet
control with or without drug therapy. |
| |
| |
| Rarely, allergies
may cause dizziness and/or vertigo. Allergies are
usually diagnosed by obtaining a careful history and
occasionally performing a series of skin tests with
inhalants and food, and/or blood tests. Treatment
usually consists of elimination of the offending
agents when possible, or, if this is not possible,
by allergy shots to stimulate immunity. |
| |
| |
| Injury to the head
occasionally results in dizziness of long-standing
origin. If the trauma is severe, it is usually due
to the combined damage to the inner ear, balance
nerve, and central nervous system. Lesser injury may
damage any one, or a combination of these
components. The unsteadiness is at times prolonged,
and may or may not be associated with hearing loss
and head noise as well as other symptoms. |
| |
| |
| In head trauma the
inner ear structures may be damaged by the severe
sudden shaking that occurs. The pressure in the
inner ear often begins to rise or calcium crystals
may be dislodged. There may also be bleeding into
the inner ear. This is called inner ear concussion.
Although present over a period of months, the dizzy
symptoms will often subside, but at times a mild
persistent dizziness occurs. In other patients a
post-traumatic endolymphatic hydrops (Meniere's
disease) begin to develop some months to years after
the injury. In these cases continual medicine may be
required, or surgery may be necessary. |
| |
| |
| In more severe
trauma, the balance and hearing nerve may be
sheared. This occurs when the skull suddenly stops
and the brain continues to move for a fraction of a
second. The nerve is damaged at the entrance to the
temporal (ear) bone. Symptoms are usually
unresponsive to medical treatment and require
surgery. |
| |
| |
| Again in severe
trauma the base of the brain and/or the cerebellum
may be injured. These structures are slow to heal
and there is often a residual dizziness that is
severely resistant to any treatment. Fortunately,
the symptoms are usually relatively mild and do not
preclude some type of work. However, occasionally
they may be quite incapacitating. Medication is not
often beneficial, but rehabilitation therapy can be
quite helpful. |
| |
| A perilymphatic
fistula is a leak of inner ear fluid into the middle
ear. Relatively minor closed head injuries may cause
a fistula, the fistula occurs at either the oval
window (window where the stapes bone fits) or the
round window membrane (an opening from the cochlea
to the middle ear). Fistulas change the pressure in
the inner ear and lead to a variety of symptoms,
some of which can be incapacitating. Persistent
daily low grade dizziness is often associated with
fistulas, but the patient may also experience severe
episodes of vertigo similar to those seen in
Meniere's disease. Surgery is usually required to
close a fistula and stop the symptoms. If the
fistula is large, or has been present for some time,
there may be permanent damage to the inner ear and
symptoms may persist even after closure of the
fistula. In these cases a vestibular nerve section
is necessary to stop the persistent dizziness. |
| |
| |
| A noncancerous tumor
occasionally develops on the balance nerve between
the ear and the brain. When this occurs,
unsteadiness, hearing loss and head noise may
develop. Extensive hearing tests, balance tests, and
x-rays are necessary to diagnose such tumors. |
| |
| If the diagnosis of
a tumor is established, surgical removal is
imperative. Continued growth of the tumor would lead
to complications by producing pressure on vital
adjacent nerves and the brain. An operation has been
developed which allows the removal of these tumors
at an early stage. Best results can be obtained if
the tumor is diagnosed early and removed while the
only symptoms are hearing loss, dizziness, and
tinnitus (head noise). |
| |
| |
| A total loss of
inner ear balance function in both ears is rare. It
results in a condition called Dandy's syndrome. This
may result from infections, injuries or tumor
removal. There may be serious dizziness at the time
the individual first loses the balance mechanism.
Other portions of the balance mechanism (eyes,
muscles and joints) help the individual to
compensate for the loss of inner ear function. Most
do quite well except in the dark or when swimming.
Many notice oscillopsia, a tendency for objects to
appear to move up and down while in motion. |
| |
| There is no
treatment for Dandy's syndrome. Most patients
compensate well and lead normal lives. One should
avoid movement in total darkness and avoid
underwater swimming. |
| |
| |
| The vestibular
(balance) nerve is located in a very complex part of
the skull called the posterior fossa. A number of
blood vessels are in close proximity to the nerve.
If a blood vessel happens to compress or pulsate
against the vestibular nerve, dizziness may result. |
| |
| The diagnosis of
this syndrome is difficult. A careful history and
the results of specialized auditory and balance
tests provide the physician with the suspicion of a
vascular compression syndrome. The treatment is
microvascular vestibular nerve decompression. |
| |
| |
| Labyrinthine
dysfunction describes one of the non-specific
conditions where the inner ear is not functioning
properly. Although the cause is often unknown, viral
illnesses, medication, and trauma are known at times
to cause this condition. In order to reach this
diagnosis definitively, hearing and balance testing
must be done. |
| |
| Symptoms may be
highly variable. They can range from occasional
unsteadiness to episodic vertigo or constant
unsteadiness. Hearing loss is occasionally present. |
| Initially, treatment
is medical and a wide variety of medications may be
used. Occasionally, vertigo exercises are helpful.
When vertigo cannot be controlled with medication or
exercises, surgery is sometimes indicated. |
| |
| |
| Endolymphatic
hydrops is a term which describes increased fluid
pressure in the inner ear. In this respect it is
similar but not related to glaucoma of the eye
fluids. A special clinical form of endolymphatic
hydrops is called Meniere's disease, described
elsewhere in this book. All patients with Meniere's
disease have endolymphatic hydrops, but not all
patients with hydrops have Meniere's disease. |
| |
| There may be many
causes of endolymphatic hydrops. It occurs widely in
people of European decent and rarely in oriental or
black people. It may be caused or aggravated by
excessive salt intake or certain mediations. The
symptoms are highly variable. The patient may have
one symptom or a combination. Often there is a
combination of hearing changes, disequilibrium,
motion intolerance, or short dizzy episodes. There
may be tinnitus and/or a pressure feeling in the
head or ears. The patient does not have the well
defined attacks of Meniere's disease (fluctuating
hearing loss, tinnitus and episodes of spinning
lasting minutes to hours). Often the division
between the two diagnoses may be blurred and
difficult to separate, even for the patient.
Endolymphatic hydrops may progress to Meniere's
disease in some patients. |
| |
| The treatment of
endolymphatic hydrops is similar to that for
Meniere's disease. Medications are first used.
Diuretics (water pills) are almost always used.
Their purpose is to decrease the fluid pressure in
the inner ear. In addition to diuretics, other
medications may be indicated, depending on the cause
of symptoms in each patient's case. If these fail,
surgery is sometimes indicated. (See Surgery for
vertigo elsewhere in this document). |
| |
| |
| Meniere's disease is
a common cause of repeated attacks of dizziness, and
is thought to be due (in most cases) to increased
pressure of the inner ear fluids due to impaired
metabolism of the inner ear. Fluids in the inner ear
chamber are constantly being produced and absorbed
by the circulatory system. Any disturbance of this
delicate relationship results in overproduction of
underabsorption of the fluid. This leads to an
increase in the fluid pressure (hydrops) that may,
in turn, produce dizziness which may or may not be
associated with fluctuating hearing loss and
tinnitus. |
| |
| A thorough
evaluation is necessary to determine the cause of
Meniere's disease, if possible. Circulatory,
metabolic, toxic and allergic factors may play a
part in any individual. Emotional stress, while
making the disease worse, does not cause it. |
| |
| |
| Meniere's disease is
usually characterized by attacks consisting of
vertigo (spinning) that varies in duration from a
few minutes to several hours. Hearing loss and head
noise, usually accompanying the attacks, may occur
suddenly. Violent spinning, whirling, and falling
associated with nausea and vomiting are common
symptoms. Sensations of pressure and fullness in the
ear or head are usually present during the attacks.
The individual may be very tired for several hours
after the overt spinning stops. |
| |
| Attacks of dizziness
may recur at irregular intervals and the individual
may be free of symptoms for years at a time, only to
have them recur again. In between major attacks, the
individual may have minor episodes occurring more
frequently and consisting of unsteadiness lasting
for a few seconds to minutes. |
| |
| Occasionally hearing
impairment, head noise, and ear pressure occur
without dizziness. This type of Meniere's disease is
called cochlear hydrops. Similarly episodic
dizziness and ear pressure may occur without hearing
loss or tinnitus, and this is called vestibular
hydrops. |
| |
| |
| Treatment of
cochlear and vestibular hydrops is the same as for
classic Meniere's disease. The treatment of
Meniere's disease may be medical or surgical,
depending upon the patient's stage of the disease,
life circumstances, and the condition of the ears.
The purpose of the treatment is to prevent the
hearing loss, and stop the vertigo (spinning). |
| |
| It is aimed at
improving the inner ear circulation and controlling
the fluid pressure changes of the inner ear
chambers. At times it is necessary to cut the
balance nerve or remove the inner ear structures. |
| |
| Medical treatment of
Meniere's disease varies with the individual patient
according to suspected cause and magnitude and
frequency of symptoms. It is effective in decreasing
the frequency and severity of attacks in 80% of
patients. Treatment may consist of medication to
decrease the inner ear fluid pressure or prevent
inner ear allergic reactions. Various drugs are used
as anti-dizziness medication. Vasoconstricting
substances have an opposite effect and, therefore,
should be avoided. Such substances are caffeine
(coffee) and nicotine (cigarettes). |
| |
| Diuretics ("water
pills") may be prescribed to decrease the inner ear
fluid pressure. |
| |
| Meniere's disease
may be caused or aggravated by metabolic or allergic
disorders. Special diets or drug therapy are
indicated at times to control these problems. |
| |
| On rare occasions we
may use gentamycin injections which selectively
destroy balance function. This treatment is reserved
for patients with Meniere's disease in their only
hearing ear or with Meniere's disease in both ears. |
| |
| Surgery is indicated
when medical treatment fails to control the vertigo.
The type of operation selected depends on the degree
of hearing impairment in the affected ear, the life
circumstances of the individual, and the status of
the individual's disease. In some operations the
hearing may be occasionally improved following
surgery, and in others it may become worse. In most
cases it remains the same. Head noise may or may not
be relieved, and in some cases may become even more
marked. In most cases it is not relieved. |
| |
| Surgery is most
successful in relieving acute attacks of dizziness
in the majority of patients. Some unsteadiness may
persist over a period of several months until the
opposite ear and the central nervous system are able
to compensate and stabilize the balance system. |
| |
| |
| |
| This operation
drains excess endolymph from the inner ear. It is
usually performed under general anesthesia and
requires hospitalization for one to two days. |
| |
| An incision is made
behind the ear. A mastoid operation is performed and
a tube is inserted into the endolymphatic sac of the
inner ear to control the abnormal fluid pressure. |
| |
| A shunt operation
usually is advised when hearing is relatively good
in the involved ear. Further loss of hearing may
occur in 25% of cases due to progression of the
disease. Total loss of hearing in the operated ear
following surgery is uncommon, but does occur in
about 3% of operations. |
| |
| |
| The operation is
performed under general anesthesia and requires
hospitalization for approximately five to seven
days. Through an incision behind the ear, a
mastoidectomy is performed, the inner ear balance
chambers are removed, and the balance nerve is cut.
In order to fill in the cavity where bone was
removed, a superficial incision made on the abdomen
and a small amount of fat is obtained and placed in
the mastoid. |
| |
| In cases selected
for labyrinthectomy and section of the vestibular
nerve, hearing is severely impaired. The operation
results in total loss of hearing in the operated
ear, and frequently, a temporary increase in
dizziness. Fortunately, the attacks of dizziness are
eliminated in nearly every instance. Persistent
unsteadiness, however, may continue for a period of
weeks or months until the central nervous system
stabilizes the balance system. When necessary, this
operation can be performed if other surgery is not
successful. |
| |
| |
| This procedure is
performed under general anesthesia, and usually
requires five to seven days of hospitalization.
Through an incision above the ear, the balance nerve
is cut before it enters the inner ear chamber. |
| |
| Middle fossa section
of the vestibular nerve may be advised when hearing
is good in the involved ear. Up to 5% of patients
may develop a severe hearing impairment in the
operated ear. Fortunately, the attacks of dizziness
are eliminated in nearly every instance. Persistent
unsteadiness, however, may continue for a period of
weeks or months until the central nervous system
stabilizes the balance system. Temporary paralysis
of half the body has occurred following a middle
fossa nerve section, due to brain swelling. This
complication is, however, extremely rare. |
| |
| |
| This operation is
performed in the hospital under general anesthesia
and requires hospitalization for about five to seven
days. Through an incision well behind the ear, the
balance nerve is cut before it enters the inner ear.
In order to fill in the cavity where bone was
removed, a superficial incision is made on the
abdomen and a small amount of fat is obtained and
placed in the space where the bone was removed. |
| |
| This procedure
allows examination of the anatomy between the inner
ear and the brain, particularly the vessels. This
operation may be advised when the hearing is good in
the involved ear, and the patient is somewhat older.
Up to 15% of patients may develop a severe hearing
impairment in the operated ear after surgery.
Fortunately, the attacks of dizziness are eliminated
in nearly every instance (90% - 95%). Persistent
unsteadiness may continue for several weeks to
months until the central nervous system has
stabilized the balance system. Temporary paralysis
of half the body has occurred following a surgery
due to brain swelling. Fortunately, this
complication is extremely rare. |
| |
| |
| |
| Further hearing
impairment in the operated ear may occur following
any of the procedures, and is the expected result
following some. This has been commented on for each
procedure. |
| |
| |
| Tinnitus (head
noise) usually remains the same as before surgery.
If the hearing is worse following surgery, tinnitus
may likewise be more noticeable. |
| |
| |
| Taste disturbance
and mouth dryness are not uncommon for a few weeks
following surgery. In 5% if the patients this
disturbance is prolonged. |
| |
| |
| The facial nerve
travels through the ear bone in close association
with the hearing and balance nerves, the inner ear
and mastoid (refer to the diagram). Temporary
weakness of one side of the face is an uncommon
postoperative complication of ear surgery. It may
occur as the result of an abnormality or swelling of
the nerve. Permanent paralysis of the face is
extremely rare. Should it occur, however, eye
complications could develop requiring treatment by
an eye specialist. |
| |
| |
| All of the
operations described above can result in a leak of
cerebrospinal fluid (fluid surrounding the brain).
Further surgery may be necessary to stop it. |
| |
| |
| Infection is a rare
occurrence following surgery for dizziness. Should
it develop, however, it could lead to meningitis (an
infection of the fluid surrounding the brain) and
may require prolonged hospital treatment.
Fortunately, this complication is very rare. |
| |
| |
| A hematoma
(collection of blood under the skin incision)
develops in a small percentage of cases, prolonging
hospitalization and healing. Reoperation to remove
the clot may be necessary if this complication
occurs. |
| |
| |
| Current
retrospective studies indicate that 85% of patients
with chronic vestibular dysfunction gain at least
partial relief of their symptoms after undergoing
vestibular rehabilitation. |
| |
| Typically, a
physical therapist evaluation of patients with
vestibular or balance disorders take approximately
60-90 minutes. The evaluation begins with a history
of the patient's symptoms. This includes how long
the patient has been symptomatic, how long the
symptoms last, general activity level and
medications that the patient is currently taking.
Range of motion, strength, coordination, balance and
various sensory systems are also assessed. Patients
are asked to perform; transitional movements such as
rolling, supine to sit and sit to stand. This is to
determine whether these motions produce or increase
symptoms. One of the most difficult things for
patients with vestibular disorders to do is walk and
move the head. Different combinations of head and
neck movements are performed during gait to provoke
symptoms. Balance is also tested on a firm surface
and again on a compressible surface with eyes open
and closed. Time tests of balance are performed with
eyes open and closed, while standing on one foot and
with feet aligned as if on a tightrope. |
| |
| Following the
evaluation, a treatment plan is developed. The
treatment consists of habitual exercises, balance
retraining exercise, and usually a general
conditioning program. The goal of habituation
exercises is to decrease the patient's symptoms of
motion provoked dizziness or lightheadedness. The
exercises are chosen to address the patient's
particular problems that were discovered during the
evaluation. These exercises use repetitive movements
or positional stimuli to physiologically fatigue the
response of the vestibular system. This, in turn,
increases the patient's tolerance for these
movements. Controlled provocation of symptoms with
the home program "desensitizes" the patient's
response to movements that previously stimulated
dizziness. Patients that have non-reproducible or
spontaneous symptoms (ones that appear unexpectedly
and independently of whether the patient is moving);
do not respond as well to these exercises as a means
to control their symptoms. Balance retraining
exercises are also given when appropriate and
consist of activities directed towards improving the
patient's balance. Exercises are chosen according to
the problem areas discovered in the evaluation and
often involve interaction among the three sensory
inputs involved in balance: vision, somatosensory
cues and vestibular inputs. Thus the patient may be
asked to perform exercises with eyes closed or
standing on a compressible surface. A general
conditioning program usually consists of a walking
program or another fitness program that the patient
is interested in. The length and intensity of the
general conditioning program depends upon the
patient's previous activity level and how easily
their symptoms are provoked. The patient must
consistently perform all the exercises as described
in their treatment program to achieve the goals of
improving their balance and decreasing their
dizziness. Typically the exercises are performed
twice a day. Patients are advised not to avoid
positions that provoke symptoms unless they are
unsafe. |
| |
| Usually the patient
is given a home exercise program to perform, and
asked to return to the office in two to four weeks
for a follow-up visit to monitor their progress and
modify their home program as necessary. If the
patient lives very far way, this can sometimes be
done over the phone. Occasionally, if the patient's
problems are significant enough, he or she may be
asked to come into to office for balance/vestibular
training that can be supervised by the physical
therapist. |
| |
| |
| There are many
causes of dizziness. This dizziness may or may not
be associated with hearing loss. In most instances
the distressing symptoms of dizziness can be greatly
benefited or eliminated by medical or surgical
management. |
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