Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo, also called BPPV, is an inner ear problem. The symptoms associated with BPPV are:

There are five main “triggers” involving changing head position that bring on the vertigo of BPPV

  1. Lying down flat in bed
  2. Rolling over in bed ( usually only in one direction)
  3. Getting up from lying down
  4. Looking up on a high shelf ( Top Shelf Syndrome)
  5. Bending over
  • Feelings of dizziness ( not vertigo) can persist once you are out of bed and moving around
  • Nausea when experiencing feelings of vertigo

Causes of BPPV

Tiny calcium particles within your inner ear called otoconia help you keep your balance. These particles are stuck in one part of the inner ear, the utricle. The calcium particles stimulate nerve cells inside the utricle when you move your head, and then send signals to your brain, telling it what direction your head is moving.

In some cases, the particles can break loose and accumulate in one of the canals, most commonly the posterior canal. When this happens, the nerve cells tell your brain that your head has moved and also causes a rotary movement of the eyes, called nystagmus

Evaluation and Treatment

  1. Your doctor will ask for a complete medical history and will perform a thorough physical examination. Deletion Tests will include:
    • Dix-Hallpike test, and possible an ENG/VNG
    • Deletion
  2. The most common treatment for BPPV is known as the Epley maneuver, in which the otoconia are allowed to move back into the Utricle where they normally reside.
  3. As always, you will discuss all treatment options with your doctor before making a final decision about what is best for you. Medicine may be prescribed to help the nausea and dizziness. Your doctor may also recommend a form of physical therapy for repeat Epley maneuvers..

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Labyrinthitis/vestibular neuronitis

Labyrinthitis is thought to be inflammation of the bony or membranous inner ear (labyrinth) or the nerve which takes the inner ear information to the brain. The symptoms associated with Labyrinthitis are:

  • Vertigo
  • Balance problems
  • Acute nausea and/or vomiting
  • Hearing loss, which can sometimes be permanent 

Causes of Labryinthitis

The inner ear can be damaged by viral infections or certain toxic substances. Depending on the kind of labyrinthitis you have, your treatment options will vary.

Evaluation and Treatment

  1. Your doctor will ask you for a thorough history and will perform a physical examination. Different diagnostic studies may be ordered, including imaging studies, lab tests and detailed physical examinations. Once the acute phase has subsided (2-3 weeks), an ENG/VNG is performed and usually shows a damaged inner ear balance system.
  2. Most cases are treated with medicine to reduce the acute vertigo with nausea and vomiting. Rest is prescribed for a few days until the acute vertigo begins to resolve. 

As always, you will discuss all treatment options with your doctor before making a final decision about what is best for you.

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Ménière's disease/Endolymphatic hydrops

Ménière's disease is a disorder of the inner ear. Symptoms include:

  • Intermittent episodes of vertigo
  • Ringing in the ears (tinnitus)
  • A feeling of fullness or pressure in the ear
  • Fluctuating hearing loss

Ménière's episodes may occur in clusters; several attacks may occur within a short period of time. However, years may pass between episodes. Between the acute attacks, most people are free of symptoms or may note mild imbalance and tinnitus.

Causes of Ménière's Disease

The symptoms of Ménière's Disease are caused by a build up of fluid in the inner ear. However, doctors are not certain of exactly why this happens.

Evaluation and Treatment

  1. Your doctor will ask for a complete medical history and will perform a thorough physical examination. Different diagnostic studies may be ordered, including imaging studies, lab tests and detailed physical examinations. These may include:
    • Examination of the ears
    • Comprehensive hearing test

Additional testing may include:

  • Electronystagmography, or balance test (ENG)
  • Electrocochleography (ECOG)
  • Magnetic Resonance Imaging (MRI)
  • Lab tests to exclude inner ear immune related infections or conditions

Once testing is completed, your doctor will evaluate the results and confirm the diagnosis of Ménière's Disease.

  1. Your course of treatment will include medicines to treat the dizziness and vertigo. A diuretic, which decreases fluid levels in the body, may be prescribed. Certain dietary restrictions will be ordered to reduce your salt intake, as salt increases the amount of fluid in your body, and therefore will increase fluid build up within your ear.
  2. If medicine and diet do not give you relief from the symptoms, your doctor may recommend surgery. There are three surgical treatments for Ménière's Disease.
    • Endolymphatic sac surgery/shunt- This surgery is performed by making an incision behind the ear and exposing the mastoid bone. The mastoid is opened, and the facial nerve is identified in the mastoid. The bone over the endolymphatic sac is exposed and the sac is opened. A non-reactive sheet/tube of silastic or a valve is inserted into the sac for future drainage, so fluid will no longer build up.
    • Vestibular neurectomy- This surgery involves sectioning the nerve of balance, near where it comes out of the brain. The hearing portion of the nerve is preserved so that most patients maintain their hearing.
    • Labyrinthectomy- This surgery is performed by making an incision behind the ear and exposing the mastoid bone. Then the labyrinth or inner ear balance organ is exposed. The semicircular canals within the labyrinth are carefully drilled away. This surgery results in complete loss of hearing.
  3. Another recent option for patients suffering from severe vertigo due to Ménière's Disease, are injections referred to as Intratympanic gentamicin treatments. These injections deaden the inner ear and are given through the ear drum by a small needle. This procedure allows treatment of one side, without affecting the other. Injections are usually administered once a month. The procedure is not painful -- a local anesthetic is used to numb the ear drum.

As always, you will discuss all treatment options with your doctor before making a final decision.

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Perilymphatic fistula

A perilymphatic fistula is an abnormal opening in the fluid-filled inner ear. Symptoms may include:

  • Dizziness
  • Vertigo
  • Imbalance
  • Nausea, and vomiting
  • Ringing or fullness in the ears
  • Hearing loss

Causes of Perilymphatic Fistulas

A perilymphatic fistula is caused by an abnormal opening of the fluid-filled inner ear. This produces a leak of a microscopic amount of inner ear fluid (perilymph) in the area of the round and oval windows.

Evaluation and Treatment

  1. Your doctor will ask for a complete medical history and will perform a thorough physical examination. Different diagnostic studies may be ordered, including imaging studies and detailed physical examinations. These may include:
    • Fistula test
    • Audiometry
    • Electronystagmography, or balance test (ENG/VNG)
    • Electrocochleogram (ECOG)
    • VEMP (Vestibular evoked myogenic potentials
    • Temporal bone CT scan
    • MRI scan with contrast
  2. Treatment may include bed rest, as fistulas sometimes heal without any intervention. Usually bed rest is prescribed for one to two weeks, to determine if it helps with symptoms and hearing loss.
  3. Medicines like diazepam can be used to reduce acute vertigo, if present.
  4. Depending on the kind of fistula you have, different surgical options will be considered. Oval and round window fistula surgery involves placing a soft-tissue graft over the fistula defect in the oval and round window.

As always, you will discuss all treatment options with your doctor before making a final decision.

Superior Semicircular Dehiscence (SSCD)

This disorder was first reported in 1998. A dehiscence is an abnormal opening in an otherwise intact bone . In SSCD, the opening is in the bone overlying the top of the superior semicircular canal. This opening allows pressures from the intracranial cavity to be transmitted to the inner ear. This circumstance is called a “third window effect”. This effect also exists in Perilymphatic Fistulas. Symptoms may include:

  • Dizziness or bouncing of the horizon with walking (oscillopsia)
  • Vertigo with loud noises (Tullio’s Phenomenon)
  • Imbalance
  • Nausea, and vomiting
  • Hearing loss which can be a low-tone conductive type. Other patients have an increased hearing of their own body noises.

Causes of SSCD

Most causes are due to an inherent thin covering of bone over the superior semicircular canal and a gradual wearing away of this bone with time.

Evaluation and Treatment

  • Audiometry
  • Fistula test (Tullio’s Test)
  • Electronystagmography, or balance test (ENG/VNG)
  • Electrocochleogram (ECOG)
  • VEMP (Vestibular evoked myogenic potentials)
  • Temporal bone CT scan

Treatment

Many patient’s symptoms are relatively mild and need no intervention. In some cases, surgery may be required for severe or refractor symptoms. The surgical approaches are:

  1. Middle fossa craniotomy and either plugging or re-surfacing the superior semicircular canal.
  2. Trans-mastoid approach to plug the superior semicircular canal
  3. Reinforcing the round and oval window areas in a similar fashion to a perilymphatic fistula repair.

As always, you will discuss all treatment options with your doctor before making a final decision.

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