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Vertigo is associated
with problems affecting the inner ear, including Meniere’s
disease and BPPV. Treatment options can range from a
simple office procedure, to medications like gentamicin,
to complex surgery.
For years, Sreeramulu
“Raj” Rajaram had chronic ear infections.
When his hearing wasn’t as good as usual, he went
to an ears, nose and throat (ENT) doctor, who told him
he had a large amount of wax build up and removed it.
But then, Mr. Rajaram experienced sudden, sharp pain
in his right ear. “I was out of the country at
the time, so all I could do was take Tylenol or aspirin
to help relieve the pain,” he says.
But pain wasn’t
Mr. Rajaram’s only symptom. Sometimes he would
get a spinning sensation and lose his balance. “I’d
be driving and turn my head to check a mirror, and I
would experience this strange sense of losing my balance,”
he said. These episodes, as he would later learn, are
symptoms of vertigo.
Back home, Mr. Rajaram’s
physician examined him, ordered a CT scan and advised
him to consult a specialist in otology, an ENT specialist
with expertise in treating problems of the ears. The
54-year-old satellite engineer, who lives in Mercer
County, called the office of Dr.
Robert Jyung, an assistant professor of surgery-division
of otolaryngology-head and neck surgery at New Jersey
Medical School and director of otology and neurotology
at the University Hospital.
After Dr. Jyung took
Mr. Rajaram’s medical history and examined him,
he made the diagnosis of a cholesteatoma, an abnormal
but benign growth of skin within the middle ear. Some
people are born with a cholesteatoma, but the condition
often occurs as a byproduct of chronic ear infection.
An untreated cholesteatoma can erode bone covering the
ear’s semicircular canals, causing vertigo, hearing
loss, and even pain. Mr. Rajaram had a cholesteatoma
in both ears, but the one in the left ear was not causing
active symptoms.
“Dr. Jyung recommended
that I have surgery to remove the cholesteatoma, and
I wanted to be sure this was the right thing to do,
so I told him I would like to have a second opinion.
He was happy to provide names of some doctors in the
Philly area closer to where I live,” says Mr.
Rajaram.
As it turns out, Mr.
Rajaram went home, did research on the Web, and decided
to have Dr. Jyung perform the surgery. The same-day
procedure involved enlarging the ear canal and removing
the skin growth. Two weeks later, he was able to go
back to work. “My ear pain and the vertigo are
gone. I haven’t had to take the medicines that
were prescribed for either problem,” says Mr.
Rajaram. “Although I had to drive a distance to
get to Dr. Jyung’s office and University Hospital,
it was well worth it. I have never had an ENT doctor
like Dr. Jyung before. He took the time to explain my
condition and what I could expect with the surgery.
I was also pleased with the professionalism of his staff
and the excellent operating room team.”
Verity
about Vertigo
Alfred Hitchcock had
it only partly right. For the most part, Jimmy Stewart’s
character in Vertigo had a fear of heights. “Vertigo
is an illusion of motion—usually spinning or turning—that
is often associated with problems affecting the inner
ear, which has a role in our sense of movement and maintaining
balance. In some conditions, a simple tilt of the head
can bring on an episode of vertigo,” says Dr.
Jyung, “People with vertigo describe a sensation
of their surroundings moving—the room ‘spins,’
for example.”
There are other symptoms
besides vertigo, such as lightheadedness, nausea, and
vomiting. While “dizziness” is a common
complaint, from a medical perspective, it’s a
vague term that could indicate a number of problems.
There are other conditions, such as stroke and heart
attack, that can cause some of the same symptoms as
vertigo, and it’s not uncommon for a first-time
vertigo patient to go to an emergency room believing
he or she is experiencing one of these life-threatening
conditions. “An emergency room visit could lead
to an extensive workup to rule out a heart attack or
stroke,” says Dr. Jyung. “If these problems
are ruled out, then the patient is often given the diagnosis
of ‘vertigo’ and prescribed a medicine called
Antivert and advised to see an ENT. However, vertigo
is a symptom, not a diagnosis by itself.”
Making
a Diagnosis
A detailed medical history
is an important part of the first visit to the otolaryngologist.
“It’s said that the patient’s history
is the most important diagnostic tool in evaluating
vertigo,” says Dr. Jyung. Indeed, something as
seemingly minor as the length of a vertigo episode can
provide the physician with valuable information. A person
who has what’s known as Benign Paroxysmal Positional
Vertigo (BPPV) typically has symptoms for less than
one minute at a time, while someone with the less common
Meniere’s Disease could have episodes that last
20 minutes to several hours. Among other questions,
the doctor will ask whether the patient has had a loss
of hearing, tinnitus (ringing in the ears), or recently
had a cold or head trauma. These are essential details
because, for example, people with BPPV typically retain
normal hearing, while those with Meniere’s Disease
often have hearing loss that fluctuates.
Following the history,
the physician will examine the patient’s ears,
looking for evidence of chronic infection or a cholesteatoma.
Most often, the eardrums will appear normal, and if
the patient’s history suggests BPPV, there is
a simple office test that the doctor can use to confirm
the diagnosis. With the Dix-Hallpike test, the patient
starts in a sitting position on the examination table.
The patient is brought quickly into the lying position,
with the head turned to the side of the ear being tested.
If the patient has BPPV, the eyes move in a characteristic
repeating manner known as nystagmus, and there is a
simultaneous sensation of vertigo. If the patient does
not have these responses, the opposite ear is tested.
Typically the condition affects only one ear, but rarely,
it can occur in both ears.
The otolaryngologist
will usually recommend an audiogram, or hearing test,
since the affected ear could have impaired hearing.
Depending on the patient’s symptoms, the physician
might recommend other tests, including an MRI of the
brain with contrast dye. This can help rule out the
possibility of a benign brain tumor known as a vestibular
schwannoma, which can mimic conditions such as BPPV
or Meniere’s Disease. Another test, an electronystagmography,
or ENG, is used to determine if the balance system on
one side is weaker than the other, which can pinpoint
the problem ear.
A
Crystal-Clear Solution
BPPV is the most common
cause of vertigo when the problem lies in the inner
ear. While “benign” indicates a less serious
condition, the brief but intense episodes of vertigo
can be alarming. Fortunately, otolaryngologists have
had considerable success treating BPPV with a maneuver
named after the man who developed it, Dr. John Epley.
To understand why the
Epley maneuver works, it’s essential to know what
doctors believe causes BPPV. When tiny calcium carbonate
crystals known as otoconia are dislodged within the
inner ear, some of them dissolve naturally, but others
become trapped within one of the semicircular canals
of the inner ear. A quick turn of the head can cause
the cluster of crystals to shift, stimulating the nerve
endings at the end of a semicircular canal. That’s
when the symptoms of vertigo can begin.
The Epley maneuver, in
which the patient’s head is turned in certain
positions, uses the force of gravity to draw the crystals
out of the semicircular canal and into another part
of the inner ear where they may be absorbed. “The
results can be immediate and quite dramatic,”
says Dr. Jyung. “However, while the Epley maneuver
is very effective, once a patient has had BPPV, he or
she is at risk for future episodes. If that happens,
an office visit for another Epley maneuver can be all
that’s needed.”
Another
Cause of Vertigo
About two million Americans
have Meniere’s Disease, a progressive inner ear
condition that can cause vertigo and result in hearing
loss. The exact cause is unknown, but some researchers
speculate that a breakdown in the circulation of potassium
ions could lead to fluid buildup in one compartment
of the inner ear. A person can have Meniere’s
Disease in one ear or both, and the accompanying vertigo
can be very severe, long lasting, and come without warning.
The patient also can experience ringing and/or a feeling
of pressure in the ear, as well as a fluctuation in
hearing.
Treating vertigo in a
patient with Meniere’s Disease is quite different
than the approach for someone with BPPV. Some patients
benefit from a low-salt diet and a diuretic (water pill),
which could influence fluid buildup in the inner ear.
If that fails, a useful first-line treatment that Dr.
Jyung tries for Meniere’s patients is gentamicin,
a potent antibiotic. “Gentamicin is injected through
the ear drum and penetrates the inner ear, where it
shuts down the balance part of the inner ear,”
he says. “Gentamicin can work very well, but it
can also damage hearing, so it is given in a series
of small doses to avoid hearing loss.”
In Dr. Jyung’s
experience, gentamicin injections are effective between
80 percent and 90 percent of the time, but there are
also surgical options. Endolymphatic sac decompression
is a procedure where the surgeon opens the mastoid bone
to access the endolymphatic sac, which is exposed. “We
don’t know exactly why this procedure is helpful—possibly
by quieting down the inner ear—but it carries
relatively low risks to the patient,” says Dr.
Jyung. Another surgical option, vestibular nerve section,
severs the nerve to the ear that controls balance. A
labryinthectomy, which Dr. Jyung considers the surgical
procedure of last resort, removes the inner ear’s
semicircular canals. By doing so, he says, the vertigo
is almost always controlled, but the patient’s
remaining hearing is also destroyed.
Recovering from vertigo
treatments such as gentamicin injections or a labyrinthectomy
often requires physical therapy to help the patient
adjust. This is called vestibular rehabilitation therapy,
which relies on the brain and the balance system in
the healthy ear to compensate.
Fortunately, most people
with vertigo do not need surgery. And, there are medications
that can relieve some of the side effects of a vertigo
attack. “Lorazepam, a drug related to valium,
can be given in a small dose, under the tongue or swallowed,”
says Dr. Jyung. “One of lorazepam’s benefits
is that it acts rapidly to help the patient withstand
the nausea and vomiting associated with vertigo. But
it cannot stop an attack from occurring.” As for
Antivert, the drug many patients are given by the emergency
room physicians, he says the drug could help a few patients,
but the drug’s drawbacks are its sedating effect
and its slowness in onset. Researchers are taking a
look at other drugs, such as calcium channel blockers,
that could also help people with vertigo.
“Vertigo is a symptom
that should always be investigated,” says Dr.
Jyung. “Not only can vertigo impair function,
its unpredictability in conditions like Meniere’s
Disease can put someone in a dangerous situation. Once
vertigo is properly diagnosed, the treatment can bring
dramatic, beneficial results.”
To arrange
for a consultation with Dr. Robert Jyung, please call
973-972-2548. To learn more about vertigo and its treatment,
listen
to Dr. Jyung's recent appearance on HealthLink Radio.
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