Dizziness & Vertigo

Doctor, Please Explain Dizziness and Motion Sickness

Insight into causes and treatment options

• What is the difference between dizziness, vertigo, and motion sickness?
• How does the body maintain its equilibrium?
• How can I reduce dizzy spells?  

Yearly more than two million people visit a doctor for dizziness, and an untold number suffer from motion sickness. Although patients complain of similar symptoms, there are different treatments available. An otolaryngologist will explore the causes behind the balance discomfort by examining the ears, nose, and throat to make a diagnosis. Often times, cases of dizziness and motion sickness are mild and self-treatable disorders, but severe cases deserve medical attention.

What is the difference between dizziness, vertigo, and motion sickness?

Some people describe a balance problem by saying they feel dizzy, lightheaded, unsteady, or giddy. This feeling of imbalance or disequilibrium is sometimes caused by an inner ear problem. Others describe their balance problem by using the word vertigo, which comes from the Latin verb "to turn". They often say that they or their surroundings are turning or spinning. Vertigo can also be triggered by problems in the inner ear.

Motion sickness is a common medical problem associated with travel. Some people experience nausea and even vomiting when riding in an airplane, automobile, boat, or amusement park ride. Motion sickness is usually just a minor annoyance and does not signify any serious medical illness, but some travelers are incapacitated by it. A few even suffer symptoms for a few days after the trip.

How does the body maintain its equilibrium?

Dizziness, vertigo, and motion sickness all relate to the sense of balance and equilibrium. Researchers in space and aeronautical medicine call this sense spatial orientation, because it tells the brain where the body is "in space:" what direction it is pointing, what direction it is moving, and if it is turning or standing still.

Your sense of balance is maintained by a complex interaction of the following parts of the nervous system:

• The inner ears (also called the labyrinth), which monitor the directions of motion, such as turning, or forward-backward, side-to-side, and up-and-down motions.
• The eyes, which monitor where the body is in space (i.e. upside down, rightside up, etc.) and also directions of motion.
• The skin pressure receptors such as in the joints and spine, which tell what part of the body is down and touching the ground.
• The muscle and joint sensory receptors, which tell what parts of the body are moving.
• The central nervous system (the brain and spinal cord), which processes all the bits of information from the four other systems to make some coordinated sense out of it all.

The symptoms of motion sickness and dizziness appear when the central nervous system receives conflicting messages from the other four systems. For example, suppose you are riding through a storm, and your airplane is being tossed about by air turbulence. But your eyes do not detect all this motion because all you see is the inside of the airplane. Then your brain receives messages that do not match with each other. You might become "air sick." Or, to use a true medical condition as an example, suppose you suffer inner ear damage on only one side from a head injury or an infection. The damaged inner ear does not send the same signals as the healthy ear. This gives conflicting signals to the brain about the sensation of rotation, and you could suffer a sense of spinning, vertigo, and nausea.

What medical conditions cause dizziness?

Circulation— If your brain does not get enough blood flow, you feel light headed. Almost everyone has experienced this on occasion when standing up quickly from a lying down position. But some people have light headedness from poor circulation on a frequent or chronic basis. This could be caused by arteriosclerosis or hardening of the arteries, and it is commonly seen in patients who have high blood pressure, diabetes, or high levels of blood fats (cholesterol). It is sometimes seen in patients with inadequate cardiac (heart) function or with anemia.

Certain drugs also decrease the blood flow to the brain, especially stimulants such as nicotine and caffeine. Excess salt in the diet also leads to poor circulation. Sometimes circulation is impaired by spasms in the arteries caused by emotional stress, anxiety, and tension.

If the inner earfalls to receive enough blood flow, the more specific type of dizziness occurs-that is-vertigo. The inner ear is very sensitive to minor alterations of blood flow and all of the causes mentioned for poor circulation to the brain also apply specifically to the inner ear.

Injury— A skull fracture that damages the inner ear produces a profound and incapacitating vertigo with nausea and hearing loss. The dizziness will last for several weeks, then slowly improve as the normal (other) side takes over.

Infection: Viruses, such as those causing the common "cold" or "flu," can attack the inner ear and its nerve connections to the brain. This can result in severe vertigo, but hearing is usually spared. However, a bacterial infection such as mastoiditis that extends into the inner ear will completely destroy both the hearing and the equilibrium function of that ear. The severity of dizziness and recovery time will be similar to that of skull fracture.

Allergy— Some people experience dizziness and/or vertigo attacks when they are exposed to foods or airborne particles (such as dust, molds, pollens, danders, etc.) to which they are allergic.

Neurological diseases— A number of diseases of the nerves can affect balance, such as multiple sclerosis, syphilis, tumors, etc. These are uncommon causes, but your physician will think about them during the examination.

What kind of a medical examination can I expect?

The doctor will ask you to describe your symptoms, whether it is light headedness or a sensation of motion, how long and how often the dizziness has troubled you, how long a dizzy episode lasts, and whether it is associated with hearing loss or nausea and vomiting. You might be asked to cite specific circumstances that induce a dizzy spell. You will also be questioned about your general health, medicines you are taking, head injuries, recent infections, etc.

The physician will examine your ears, nose, and throat and do tests of nerve and balance function. Because the inner ear controls both balance and hearing, disorders of balance often affect hearing and vice versa. Therefore, your physician might recommend hearing tests or audiograms. Depending on your diagnosis, the physician might order skull X rays, a CT or MRI scan of your head, or special tests of eye motion after warm or cold water is used to stimulate the inner ear (ENG - electronystagmography). In some cases, blood tests or a heart evaluation might be recommended.

Tips to reduce dizzy spells

• Avoid rapid changes in position, especially from lying down to standing up or turning around from one side to the other.
• Avoid extremes of head motion (especially looking up) or rapid head motion (especially turning or twisting).
• Eliminate or decrease use of products that impair circulation, e.g. nicotine, caffeine, and salt.
• Minimize your exposure to circumstances that precipitate your dizziness, such as stress and anxiety or substances to which you are allergic.
• Avoid hazardous activities when you are dizzy, such as driving an automobile or operating dangerous equipment, or climbing a step ladder, etc.

Tips to alleviate motion sickness

• Always ride where your eyes will see the same motion that your body and inner ears feel, e.g. sit in the front seat of the car and look at the distant scenery; go up on the deck of the ship and watch the horizon; sit by the window of the airplane and look outside. In an airplane, choose a seat over the wings where the motion is the least.
• Do not read while traveling if you are subject to motion sickness, and do not sit in a seat facing backward.
• Do not watch or talk to another traveler who is having motion sickness.
• Avoid strong odors and spicy or greasy foods immediately before and during your travel. Medical research has not yet investigated the effectiveness of popular folk remedies such as soda crackers and Seven Up® or cola syrup over ice.
• Take one of the varieties of motion sickness medicines before your travel begins, as recommended by your physician. Some of these medications can be purchased without a prescription (i.e., Dramamine®, Bonine®, Marezine®, etc.) Stronger medicines such as tranquilizers and nervous system depressants will require a prescription from your physician. Some are used in pill or suppository form.

Reprinted with permission of the American Academy of Otolaryngology-Head and Neck Surgery Foundation, copyright © 2006. All rights reserved.

BPPV & The Epley Maneuver

Approximately 25% of patients reporting problems with dizziness may have a condition referred to as Benign Paroxysmal Positional Vertigo (BPPV). This is a troublesome position-related dizziness persisting months after an original attack.

This problem arises from dysfunction within the semi-circular canals of the inner ear, and results in "attacks" of vertigo... a spinning sensation. Typically, symptoms occur upon lying down, turning the head to the right or left, arising from bed, leaning forward, and looking upward. The problem appears to be loose particles that float in the inner ear, stimulating the dizziness. These attacks are usually of 30-90 seconds in duration and occur with positional body changes.

Dr. John Epley of the University of Oregon has introduced a form of physical therapy that has proven to be successful in treating BPPV.  The Canalith Repositioning Procedure (CRP) is designed to treat (BPPV) by causing the repositioning of loose particles in the semicircular canal, using timed head maneuvers and applied vibration.

Commonly known as the Epley Maneuver, this treatment is carried out in our office, often under videonystagmography control. With proper application, success is greater than 80%.  It is an effective, painless, inexpensive and non invasive method for treating BPPV.

Doctor, Please Explain Ménière’s Disease

Insight into the diagnosis and management

• What are the symptoms?
• How is a diagnosis made?
• What treatments are available?
• and more…

Ménière’s disease, also called idiopathic endolymphatic hydrops, is a disorder of the inner ear. Although the cause is unknown, it probably results from an abnormality in the fluids of the inner ear. In most cases only one ear is involved, but both ears may be affected in about 15 percent of patients. Ménière’s disease typically starts between the ages of 20 and 50 years. Men and women are affected in equal numbers.

What are the symptoms?

The symptoms of Ménière’s disease may be only a minor nuisance, or can become disabling, especially if the attacks of vertigo are severe, frequent, and occur without warning. Among them are:

• Attacks of a spinning sensation or episodic rotational vertigo;
• Roaring, buzzing or ringing sound in the ear or tinnitus;
• Sensation of fullness in the affected ear;
• Intermittent hearing loss, especially in the low pitches during the early development stage;
• Fixed hearing loss involving all pitches in the advanced stage of the disease;
• Uncomfortable and distorted sounds.

From all the Ménière’s disease’s symptoms, vertigo is usually the most troublesome. It is commonly produced by disorders of the inner ear, but may also occur in central nervous system disorders. Vertigo may last for 20 minutes to two hours or longer. During attacks, patients are usually unable to perform activities normal to their work or home life. Sleepiness may follow for several hours, and the off-balance sensation may last for days.

How is a diagnosis made?

The physician will take a history of the frequency, duration, severity, and character of your attacks, the duration of hearing loss or whether it has been changing, and whether you have had tinnitus or fullness in either or both ears. You may be asked whether there is history of syphilis, mumps, or other serious infections in the past, inflammations of the eye, an autoimmune disorder or allergy, or ear surgery in the past. You may be asked questions about your general health, such as whether you have diabetes, high blood pressure, high blood cholesterol, thyroid, neurologic or emotional disorders. Tests may be ordered to look for these problems in certain cases.

When the history has been completed, diagnostic tests will check your hearing
and balance functions. They may include:

For hearing

• An audiometric examination (hearing test) typically indicates a sensory type of hearing loss in the affected ear. Speech discrimination (the patient’s ability to distinguish between words like “sit” and “fit”) is often diminished in the affected ear.

For balance

• An ENG (electronystagmograph) may be performed to evaluate balance function. In a dark room, recording electrodes are placed near the eyes. Warm and cool water or air is gently introduced into each ear canal. Since the eyes and ears work simultaneously through the nervous system, measurement of eye movements can be used to test the balance system. In about 50 percent of patients, the balance function is reduced in the affected ear.
• Rotational testing or balance platform, may also be performed to evaluate the balance system.

Other tests

• Electrocochleography (ECoG) may indicate increased inner ear fluid pressure in some cases of Ménière’s disease.
• The auditory brain stem response (ABR), a computerized test of the hearing nerves and brain pathways, computed tomography (CT) or, magnetic resonance imaging (MRI) may be needed to rule out a tumor occurring on the hearing and balance nerve. Such tumors are rare, but they can cause symptoms similar to Ménière’s disease.

How is Ménière’s Disease medically managed?

Aside from lifestyle changes, your doctor may advice you to take a diuretic (water pill) to reduce the frequency of attacks. Anti-nausea and anti-vertigo medications may also be prescribed to provide temporary relief. However, a side-effect of the medications may be drowsiness.

Another medication that may be used is gentamicin. It is an antibiotic, commonly administered in the form of drops or injections, which causes a partial loss of balance function in the treated ear, controlling vertigo in about three fourths of cases and usually preserving hearing. Apart from a period of disequilibrium that can occur as the patient adjusts to the new level of balance, this treatment is usually very well tolerated. It is also significantly simpler and less invasive than other surgical treatments.

In addition, stress management counseling may be recommended, as stress tends to aggravate the symptoms of vertigo and tinnitus. If you have vertigo without warning, you should not drive, because failure to control the vehicle may be hazardous to yourself and others. Safety may require you to forego ladders, scaffolds, and swimming.

When is surgery recommended?

If vertigo attacks are not controlled by conservative measures and are disabling, one of the following surgical procedures might be recommended:

• Intratympanic treatment, also known as chemical labyrinthotomy, is an office procedure in which a medicine, such as gentamicin, is injected into the middle ear. The endolymphatic shunt or decompression procedure is an ear operation that is usually preserves hearing. Attacks of vertigo are controlled in one-half to two-thirds of cases, but control is not permanent in all cases. Recovery time after this procedure is short compared to the other procedures.
• Selective vestibular neurectomy is a procedure in which the balance nerve is cut as it leaves the inner ear and goes to the brain. Vertigo attacks are permanently cured in a high percentage of cases, and hearing is preserved in most cases.
• Labryrinthectomy and eighth nerve section are procedures in which the balance and hearing mechanism in the inner ear are destroyed on one side. This is considered when the patient with Ménière’s disease has poor hearing in the affected ear. Labryrinthectomy and eighth nerve section result in the highest rates for control of vertigo attacks.

Tips to reduce the frequency of Ménière’s Disease episodes

• Avoid caffeine, smoking, alcohol.
• Restrict your salt intake.
• Eat properly.
• Get plenty of sleep.
• Remain physically active, but avoid excessive fatigue.
• Avert stress and anxiety, as it may aggravate vertigo and tinnitus.
• Consider incorporating stress management techniques into your lifestyle.

Reprinted with permission of the American Academy of Otolaryngology-Head and Neck Surgery Foundation, copyright © 2006. All rights reserved.

	Head & Neck Surgery		Pediatric Otolaryngology		ENT Facial Surgery Center
	Sinus Surgery		Sleep Disorders & Snoring		Tinnitus
	Allergy & Asthma		Vertigo		Thyroid Gland
	Hearing Loss		Acid Reflux (GERD) (LPR)		Parotid Gland

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