What IS dizziness?
Audiologists don’t simply treat hearing loss, they also provide solutions for a number of hearing and balance disorders, from symptoms of dizziness to conditions like Meniere’s disease. The following is an overview of several ways an issue with your auditory system can impact your inner balance.
Dizziness is a symptom not a disease. It is a broad term that 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 or conditions. 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 their symptom of dizziness to a medical provider. In addition, because the symptom of dizziness varies so widely from patient to patient and may be caused by many different diseases, diagnosis commonly requires testing to be able to provide the patient with some knowledge about the cause of their dizziness. Dizziness may or may not be accompanied by a hearing impairment.
Maintenance of balance
The human balance system is made up of four parts, the eye, inner ear, muscles and central nervous system. 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. With a constant stream of impulses arriving at the brain from these input terminals, all three systems must function well independently and 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: three semicircular canals and two otolith organs (saccule and utricle). Together they are called the vestibular labyrinth and are filled with fluid similar to the 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, which is once reason why we have two ears! Nerve impulses may be started by the semicircular canals when turning suddenly, or come from the otolith organs, which responds to changes of position, such as lying down, turning over or getting out of bed.
When the inner ear is not functioning correctly the brain receives nerve impulses that are confusing and conflicting with the environment. 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 also known as vertigo.
TYPES OF DIZZINESS
Ear dizziness, one of the most common types of dizziness, results from a number of issues: positional stimulation of otolith "crystals," disturbances in the blood circulation or fluid pressure in the inner ear chambers, inflammation of the balance nerve, or infection in any portion of the ear.
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 an over stimulation of the inner ear fluids with "crystals," which may be encountered if you spin very fast and then stops suddenly.
Symptoms of ear dizziness
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 alone 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 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 you should not lose consciousness as a result of inner ear dizziness
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 with multiple sclerosis or concussions being an example.
Related to central dizziness is also loss of proprioceptive input. For example, some people are unsteady or likely to fall/have high fall risk because of neuropathy (i.e. Diabetes, spinal surgery), poor circulation to extremities, need for hip and/or knee replacements, central nervous system disorders, etc. This type of dizziness presents similar to central dizziness and will correlate with various chronic illness and medical history.
Eye muscle imbalance or errors of refraction may produce unsteadiness. An example of this is the unsteadiness, which may result when you attempt to walk while wearing glasses belonging to another individual. Blurred vision is a common symptoms of both visual and ear disturbances.
Causes and symptoms of INNER EAR dizziness
As discussed, dizziness may be caused by any disturbance in a number of systems. In the world of Audiology, it may be caused by 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, which may involve multiple specialists. At our clinic, the Audiology tests necessary are determined at the initial evaluation and may include a comprehensive hearing evaluation, balance function tests, MRI and other imagining, and blood tests. A general physical examination and neurological tests may be advised as well. 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.
Benign Positional Paroxysmal Vertigo (BPPV)
BPPV is a common form of balance disturbance due to circulatory changes or to loose calcium deposits (otoliths) in the inner ear. It is characterized by sudden, brief episodes of spinning sensation when moving or changing head position. Commonly it is noticed when lying down or turning over in bed, or bending over to pick something off the floor. This type of dizziness as its names suggests is benign, related to positional changes and is short-lived. The vertigo brought on by the movement rarely lasts more than a a minute with a feeling of being "off" following the episode and possibly for the remainder of the day. This type of vertigo occasionally resolves itself or responds very well to treatment. It may reoccur in some patients, however.
Treatment is typically provided by a physical therapist and involves attempts to reposition the loose particles back where they belong in the inner ear (Canalith Repositioning Procedure). If this isn’t successful, additional exercises may be recommended. Physical therapist treatment is highly recommended due to ample time spent with the patient to ensure the vertigo is completely resolved. We work with various therapy groups in Fairbanks and beyond who are trained in this form of treatment. Occasionally, postural dizziness may be permanent and surgery may be required, which is very rare.
Neuritis is a physiological change that occurs in the nerve after injury by trauma, a virus, autoimmune disease or vascular compression. When this occurs, the balance function is impaired (and hearing is suddenly impaired in labyrinthitis), 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 (i.e. Meclizine) that should be used for a maximum of 3-5 days until the initial severity subsides. Following use of the medication, balance function testing with an Audiologist along combined with physical therapy exercises will often lead to a full recovery.
Meniere’s disease and endolymphatic hydrops
Meniere's disease is thought to be due to (in most cases) 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 or under-absorption of the fluid. This leads to an increase in the fluid pressure (hydrops) that may, in turn, produce dizziness that may or may not be associated with the above symptoms. A thorough evaluation is necessary to determine the cause of Meniere's disease, ruling out all other possible diagnoses. Circulatory, metabolic, toxic and allergic factors may play a part in any individual. Emotional stress, while making the disease worse, does not cause Meniere’s disease.
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 episode of vertigo has stopped. 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.
Endolymphatic hydrops is a term that 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. All patients with Meniere's disease have endolymphatic hydrops, but not all patients with hydrops have Meniere's disease. 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).
Treatment of Meniere's disease and endolymphatic 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).
Treatment is aimed at improving the inner ear circulation and controlling the fluid pressure changes of the inner ear chambers. 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. Vaso-constricting 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, gentamycin injections may be used to 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.
Atypical migraine or basilar migraine
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. This may occur more frequently during times of increased 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 balance system.
Imbalance related to aging
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 minimizes 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.
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 (i.e. Diabetes) 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 are 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 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. Concussion is an area of great research these days involving unique forms of vertigo and dizziness. 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.
A noncancerous tumor occasionally develops on the balance nerve between the ear and the brain. When this occurs, unsteadiness, hearing loss and head noise in the effected ear may develop. Extensive hearing tests, balance tests and imaging are necessary to diagnose such tumors.
If the diagnosis of a tumor is established, surgical removal is often recommended although because it is usually benign, "watch and wait" may be recommended at first. 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).
Nonsurgical dizziness treatments
Typically, a a physical therapist evaluation may be recommended when inner ear dizziness is of concern. For most patients with vestibular or balance disorders, the initial work-up takes approximately 60-90 minutes. The evaluation begins with a history of the patient's symptoms. Following the evaluation, a treatment plan is developed. The treatment plan may consist 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. The length and intensity of the 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.
There are many causes of dizziness and some may include hearing loss and/or tinnitus (sound in the ears). Your managing Audiologist may recommend hearing aids or sound therapy devices to manage both of these conditions.
Surgical treatment options for dizziness
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 and usually a "last resort." 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. Audiologists work closely with Ear, Nose, and Throat physicians to determine if surgical intervention is necessary.