- WHAT IS AN OTOLOGIST/NEUROTOLOGIST?
- DIZZINESS
VERTIGO- MENIERE’S DISEASE/ ENDOLYMPHATIC HYDROPS
- BPPV
- LABYRINTHITIS
- VESTIBULAR NEURONITIS
- WHAT CAN BE DONE ABOUT VERTIGO?
- ACOUSTIC NEUROMA/VESTIBULAR SCHWANNOMA
WHAT IS AN OTOLOGIST/NEUROTOLOGIST?
Otology/Neurotology are subspecialities, or subdivisions, within the field of otolaryngology (ENT) that focus on tertiary care disorders affecting the ears, balance system, temporal bone, and related functions. The diagnostic, medical and surgical skills of a fellowship-trained otologist/neurotolgist include expertise in the treatment of advanced hearing loss and tinnitus, hearing nerve, congenital malformations, infectious and inflammatory diseases of the ear, tumors of the ear, dizziness and vertigo.
Dizziness, Vertigo and Balance Disorders
What is “dizziness”?
Dizziness is a term often used by patients to relate a disturbance in their equilibrium. The term is very general and can include a wide array of symptoms such as fatigue, visual disturbance, lightheadedness, confusion, vertigo, and many others.
It is often difficult for the patient to adequately describe the symptoms. One of the goals of the physician specializing in dizziness is to gain an understanding as to what type of “dizziness” the patient has been experiencing.
What is “vertigo”?
Vertigo is a symptom, not a diagnosis. Vertigo is defined as the hallucination of motion. These motions can be “objective” — the patient perceives movement of the environment, or “subjective” — the patient perceives an internal sense of motion.
Objective vertigo is nearly always related to problems of the inner ear or the ear’s complex connections to the central nervous system. Subjective vertigo can be ear-related as well but can also have numerous other causes.
What are some of the common diagnoses that can cause vertigo?
Meniere’s disease/Endolymphatic hydrops
Meniere’s disease involves the combination of ear pressure, tinnitus, hearing loss, and vertigo, and is the result of excess pressure of endolymphatic fluid in the inner ear. However, atypical forms of Meniere’s disease may result in virtually any combination of the above symptoms. The disease typically persists for several months, and may then go into remission. The condition may then re-emerge after periods of stress, dehydration, or high salt intake. Both the hearing and balance function may diminish with such recurrences.Meniere’s disease usually occurs in only one ear, but may involve both ears in 10% of patients.
The first stage of treatment for Meniere’s disease involves diuretics, salt restriction, oral steroids, aggressive oral hydration, allergy treatment, and avoidance of caffeine, alcohol, and stress.
The second stage of treatment involves injections of steroids or gentamicin into the ear, the minimally invasive Meniett device, or endolymphatic sac-mastoid shunt surgery.
The third stage of treatment involves such measures as a labyrinthectomy or vestibular nerve section. Fortunately, the third stage of treatment is rarely necessary.
Of note, there is considerable overlap in symptoms between migraine-associated dizziness and Meniere’s disease, and the former should be considered in patients for whom treatments for presumed Meniere’s disease prove ineffective.
Benign Paroxysmal Positional Vertigo (“BPPV”)
Occasionally, particles form or settle in one of the semicircular canals of the inner ear. The particles tend to sink to the lowest point of the canal. Certain positional changes, such as rolling to one’s side in bed, can result in reorientation of the canal in space, causing the particles to sink to the new “bottom.” This typically results in a sensation of “room spinning” that lasts for less than one minute.Labyrinthitis
Inflammation in the inner ear can result from bacterial middle ear infections or, more commonly, from viral infections. Labyrinthitis can cause rapid progression of vertigo and possibly hearing loss. The term “labyrinthitis” is also occasionally used in a generic way — to indicate that a patient’s symptoms appear to be on the basis of an unspecified inner ear disorder.Vestibular Neuronitis
Viral infection of the vestibular (balance) nerve can result in vertigo lasting for several days, followed by more prolonged imbalance.Other
There are many less common causes of vertigo, some ear-related and some neurologic.
What can be done about my vertigo?
1. Diagnosis
The first step to solving the problem of vertigo is obtaining the correct diagnosis. This is often a complicated process. The history and physical examination remain the most important elements of the evaluation. Additionally, nearly all patients should undergo hearing testing to help evaluate inner ear function. Some patients may also require other audiological testing such as brainstem auditory evoked response testing (BAER), otoacoustic emissions (OAEs), electrocochleography (ECoG) and electro-or videonystagmography (ENG or VNG). Occasionally, radiological studies such as CT or MRI may be requested as well.Not every patient requires every test.
The specialist analyzes the information gathered from the history and physical examination as well as the various diagnostic studies in order to determine the diagnosis.
2. Treatment
The treatment options vary greatly with the specific diagnosis. Some available treatments include: dietary changes, oral medications, instillation of medication into the middle ear, positional maneuvers, vestibular rehabilitation (specialized physical therapy), and surgery.
Balance Disorders
Balance problems are extremely common, particularly in senior citizens. Falls are among the leading causes of fatal and non-fatal injuries in the elderly.
Our balance depends mostly on the function of 3 systems:
1. Vision
Our eyes give us important information in reference to our orientation, position, and movement relative to our environment.2. Proprioception (position sense)
Provides information regarding our orientation relative to gravity. When a person leans, he should be able to feel the shift in pressure of his feet against the floor. Similarly, there should be some detection of leaning in the muscles of the trunk.3. Vestibular
The inner ear balance system is responsible for maintaining balance and equilibrium, particularly during motion.
In general, if there is weakness in one of these systems, the remaining 2 systems should allow the individual to compensate and to maintain balance under most conditions. If the weakness in one system is overwhelming, or if there is weakness in more than one system, imbalance may result. There are numerous other health, fitness and environmental factors that can that can contribute to balance disorders.
The primary goals of the balance evaluation are to determine which of these systems is contributing to the imbalance and to determine if there is an underlying disorder that requires treatment.
In nearly all cases, measures can be taken to help improve balance and to reduce the risks of falls and injury.
Acoustic neuroma/Vestibular schwannoma
Acoustic neuromas or, more properly, vestibular schwannomas are benign growths of the balance nerves from the inner ear. They typically grow quite slowly, on the order of 1-2mm per year, and damage both hearing and balance as they do so. An MRI of the internal auditory canals and brain with and without contrast is required for definitive diagnosis.
Smaller, less symptomatic tumors may often be observed with serial MRI scans, especially in patients with limited life expectancy. Otherwise, vestibular schwannomas are treated with either stereotactic radiosurgery or formal surgical removal. The likelihoods of tumor control, facial nerve injury, hearing preservation, and functional balance vary considerably with the size and location of the individual tumor, as well as the treatment approach, and so should be discussed with a qualified neurotologist or skull base surgeon.
Bone Anchored Hearing Aids
Bone anchored hearing aids offer hearing rehabilitation for individuals with single sided deafness or conductive hearing loss who are unable to use traditional hearing aids (chronic mastoiditis, otitis externa, or atresia/microtia). Unlike with cochlear implants, at least one cochlea must have relatively intact nerve function for these devices to work well.
These devices transmit amplified sound energy through the bone of the skull directly to the cochlea, bypassing the tympanic membrane and ossicles. As a result, patients generally report excellent clarity with these devices.
Bone anchored hearing aids are placed as an outpatient procedure, under either intravenous sedation or general anesthesia. The surgery usually takes less than an hour. The discomfort is usually minimal, and the risks of the procedure are quite low. However, patients considering the procedure should discuss the details further with their physician.
Cholesteatoma
A cholesteatoma is an epithelial (skin-based) cyst originating from the tympanic membrane, and is usually associated with eustachian tube dysfunction. Chronic negative pressure in the middle ear space pulls the tympanic membrane inward, creating a pocket or cyst that accumulates epithelial debris. The pocket then grows slowly, and can erode surrounding structures such as the ossicles (middle ear bones), the facial nerve, the inner ear, or even the bone against the brain. The pocket also becomes a source of chronic infection, which usually does not resolve until the cyst is removed. As such, cholesteatomas can cause conductive (mechanical) and/or sensorineural (nerve-damage) hearing loss, facial paralysis, or even meningitis. Cholesteatomas may affect all age groups, and as a fundamentally mechanical problem, usually must be treated surgically with a procedure called a tympanomastoidectomy. A tympanostomy tube may also be inserted to address the underlying eustachian tube dysfunction. A second surgery is often required 6 months after the first to check for regrowth and to correct any ossicular (ear bone) damage. A significant amount of hearing loss can usually be recovered at the second surgery. The recovery from surgery is usually relatively benign, and the risks are usually quite low.
Rarely, children may be born with a so-called congenital cholesteatoma, which is the result of an error of development. These are not usually detected until about 3-6 years of age, and may be mistaken for years as a chronic ear infection. Congenital cholesteatomas generally behave similarly to the more common acquired cholesteatomas described above, with the exception that they are infected less frequently.
Cochlear Implants
Cochlear implants offer hearing rehabilitation for individuals with severe-to-profound nerve damage (sensorineural) hearing loss for whom hearing aids are not effective. Candidates for the procedure must have developed speech and language previously (postlingual), or must be of an age that will allow for the development of these skills (perilingual). Individuals considering the procedure must undergo extensive testing to determine whether they are better served with a cochlear implant or more traditional hearing aids or other technologies. The surgery usually takes about 1 hour, and is performed under general anesthesia. Postoperative discomfort is usually mild. Young children require an overnight stay in the hospital, but otherwise the surgery is performed as an outpatient procedure. The risks of the procedure for properly selected patients are low. However, patients considering the procedure should discuss the details further with their physician.
