Disequilibrium, Dizziness, Vertigo

Disequilibrium, dizziness or vertigo are common complaints and these are things that do require attention of an Otolaryngologist for complete evaluation. Usually a dizziness questionnaire is filled out which will provide significant information from the patient's recollection, and can be also filled out at the time an episode is occurring for a more complete assessment.

The most common reason for disequilibrium, dizziness or vertigo is probably related to viral etiologies causing inflammation around the labyrinthene nerve, which is called neuronitis, or involving the labyrinth itself, called labyrinthitis. This is usually short-lived, anywhere from 3 weeks to 3 months, and usually more effectively treated by steroids for decreasing inflammation and with Meclizine or Antivert to decrease the subjective sensation of dizziness.

People who have chronic recurring disequilibrium, dizziness or vertigo find that this needs a little bit more evaluation. This is usually as audiogram to evaluate the pure tone hearing, speech reception, movement of the tympanic membrane and reflexes. If there is any abnormalities in the ABR, which is an evaluation of the nerve and it's conduction, an MRI to rule out an intracranial lesion would be appropriate. An MRI is always used as a last resort, final evaluation, for ruling out an intracranial lesion which can be causing these symptoms as well.

A metabolic screen is appropriate to rule out metabolic abnormalities which may be contributing to these episodes. The most common type of abnormality is either hyperactivity or hypoactivity of the thyroid. There are autoimmune type processes that can cause dizziness and that's why anti-nuclear antibody testing, rheumatoid factor, ESR, are also done. A complete metabolic profile and CBC, because anemia, diabetes, abnormalities of electrolytes, can also be contributing factors. It is uncommon, but has been reported and is found occasionally, that neuro-syphilis is also a cause. Most of these require identification and then treatment resulting in resolution of the dizziness, disequilibrium or vertigo.

One of the more common types of dizziness that is commonly seen and treated by an otolaryngologist, or neurotologist, is Meniere's syndrome. This is classically described as fluctuating episodes of dizziness. These last anywhere from 20 minutes to several hours, where they are quite severe, associated with ringing in the ear,  or ears, fullness sensation, hearing loss, nausea and vomiting. The fluctuation of the hearing loss, tinnitus and fullness can wax and wane at the initial presentation and for several months or years, but is usually results in a progressive increase in episodes with sensorineural hearing loss. Most of the treatments regarding Meniere's syndrome are addressed to decrease or eliminate at lease the dizziness and have an effect on the progression of sensorineural hearing loss as well. In the past the most common treatment was symptomatic treatment with Maclizine or Antivert to decrease subjective sensation of dizziness. Also Valium or Diazepine, for doing the same objective. Anticholinergics, steroids, antibiotics, elimination of salt intake are also treatment in some individuals. These are all things that are offered to all patients with Meniere's syndrome, whether the patient requires or elects surgical treatment. The most common surgical treatment done is an "endolymphatic sac decompression" or "endolymphatic shunt procedure." This provides significant  improvement in 75% of patients and this usually last for 2-7 years, with most patients having some element of recurrence of their symptoms to some degree. Of course, patient's who have had this procedure done have severe dizziness, which is incapacitating. Nerve sectioning can be done to the vestibular nerve and usually this is intended to preserve hearing, at the time of surgery, but sensorineural hearing loss is always a possible risk in doing any types of ear surgery. Of particular note, is a new interest in using chemicals which help to destroy the cells in the inner ear that usually precipitate dizziness, input into the brain. New delivery systems have been developed, either using a pump or using a hole in the eardrum with a sponge wick, which provides access to the oval window.

The procedure in the past had to do with placement of Gentamicin into the middle ear space that usually come out quite rapidly with swallowing and there is a question how much has been put in. With the recent onset of pumps and sponge type apparatuses, which go into the round window, we have been able to deliver either antibiotics which are ototoxic for decreasing dizziness and this is primarily through a method of the variable sensitivity of the hearing hair cells and the balance hair cells with regards to their sensitivity. The balance hair cells are much more sensitive and elimination of the dizziness with significantly   effecting the hearing is entirely possible, but as mentioned above, hearing loss, which is sensorineural in nature, is always a risk and complication associated with any type of ear procedures.

Also, autoimmune type of inner ear disease has also been found to be able to be treated using the same methods or a pump or wick and drops through the ear canal by the patient. Treatment is usually short-lived but does require a considerable amount of monitoring prior to initiating the procedure and placement of the wick, as well as placing the wick while medication is being applied on a daily basis by the patient. Weekly hearing tests and balance testing is recommended, and that discontinuing of medications as soon as there is any detection by the patient on increasing ringing in their ear, tinnitus or hearing loss. Once this is noted the antibiotic therapy in discontinued and steroids are applied, both through the wick as well as the oral intake to preserve and decrease as much inflammation as possible to preserve the hearing. Reapplication can be done if dizziness persists. Appropriate testing to be sure which ear needed to be addressed is essential and constant follow up with a physician is appropriate. This last method is available in Cheyenne, Wyoming by myself and is appropriate for patients with new diagnosis of Meniere's syndrome or endolymphatic high drops, as well as patients who have previously been diagnosed with this, have had endolymphatic sac procedures and having recurrence of those symptoms. It is always best to come in and see your physician with regards to this treatment, or any treatment, relating to Meniere's syndrome.