Hearing Specialist | Clermont FL


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Multiple Causes

Inner Ear Problems

Multiple Causes

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  • Introduction of Desert Sounds, number of years, convenient locations, latest technology, etc. Member of the American Institute of Balance Affiliate Network of vestibular specialists. This means that we use proven ways to not only identify dizziness and balance problems but also treat these problems.
  • Dizziness is a general word that people use to describe lots of different things that they feel. If I asked 20 of you to explain what dizziness means to them, I would get 20 different answers. It could be a lightheaded sensation. This could be caused by blood pressure medication, but it could also be related to those three glasses of wine last night (May or may not use that one). You might describe dizziness as a spinning sensation that only lasts for seconds and occurs when you get in your bed. You may describe dizziness as a fear of falling that you experience when you are walking outside or going up or down a curbside. The point is that there are many causes of dizziness and it takes someone with special knowledge to determine the exact cause. For example, let me tell you about that spinning type of dizziness – it’s called vertigo
  • Define Vertigo for them Explain that a lot of physicians don’t know this, but 85% of the time, vertigo is caused by an inner ear problem. Explain that doesn’t come from you, that’s Johns Hopkins University School of Medicine that reported that data.
  • Let me show you what we’re talking about when I say inner ear. Here is the hearing part of the inner ear, but some people don’t know that the primary function of the inner ear is to help you maintain balance. When there is a problem here, you may become off-balance or experience vertigo. You may even have other types of dizziness. Extra Info: Overview of Auditory & Vestibular System Depiction of outer ear , middle ear , and inner ear . Note that the vestibular structures are located posterior to the hearing structure ( cochlea ).
  • Here are three common types of inner ear problems that are known to cause vertigo. Explain in brief because you are going into more detail on next few slides.
  • Menieres disease is only the cause of vertigo in about 20-400/100,000 people. It is not very common. Basically, there is too much fluid in the inner ear. I don’t have to tell you what happens if you fill up a balloon with air and keep on filling and filling. That’s similar to what can happen in the inner ear from too much of this fluid.
  • Vestibular Neuritis is caused by a virus. The virus causes inflammation of the nerve going from the balance part of the inner ear to the brain. This is the second most common cause of vertigo. People with this may have lightheadedness after the vertigo stops. They may also develop the most common caused of vertigo that I will tell you about in a minute.
  • People with Meniere’s disease need medicine during their worst symptoms. Some of these people need surgery to fix the problem in the inner ear. Either way, once the attacks of vertigo are stopped these folks usually need vestibular rehabilitation. People with vestibular neuritis do need medicine during the worst part, but then they need to get off the medicine. That’s another thing that most doctors don’t understand. Some of these medications for MD or VN actually make people more likely to fall.
  • Here is one example of a gentleman who experienced VN. Now, when he moves his head, his vision gets blurred. He has trouble walking when it is dark or if he is outside (grass, uneven sidewalks, etc.). This first video clip shows part of the way that this can be treated. The gentleman is having therapy to re-train his brain to deal with the sick ear. Now, he will be able to keep his vision clear, not only when he is moving his head, but driving, walking, etc.
  • This is another example to help the patient re-learn how to deal with walking on tough surfaces. We are adapting his brain to the sick ear. We are helping him not feel nauseated with head movement while walking and getting him to use information from his feet and lower legs to help him with his balance.
  • Now, this is a big one. BPPV is the number one cause of vertigo. 50% of people 70 and older will have BPPV at least once. Doctors often tell their patients with BPPV that it will go away on its own or even worse they tell the person, “well, you’ve had a few birthdays so you will just need to learn to live with it.” That’s a horrible thing to say—you do not have to learn to live with positional vertigo because we know how to treat it.
  • To understand BPPV, we need to look at how the ear works. You basically have some tiny rocks in a certain part of the inner ear. This is your gravity detector area.
  • Here’s another look at the gravity detector. See how the rocks are all over the top and embedded in this membrane. This is the way it is supposed to be. Otolith Sensory Structure Otoconia Otolithic Membrane Macula
  • Here is an actual picture of some of these crystals. Otoconia
  • Now, everything’s fine when the rocks stay where they belong but they can move into a different part of the ear. That’s when the person gets positional vertigo. Why does this happen? Go through reasons. So, if these rocks are in the wrong place, when you move your head, the rocks move and you feel an intense spinning dizziness—vertigo.
  • These are some of the specific symptoms that people have with BPPV.
  • It is also interesting to see that people who have BPPV have greater difficulty with daily activities, have twice the depression as people without BPPV, and experience twice the falls of people without BPPV You do not need to wait for this to go away on its own. You do not need to learn to live with it. Desert Sounds can fix this.
  • Let me tell you about how this can be fixed. Medicine does not work. There are surgery options but they go into your skull to cut the nerve to the inner ear—most people do not want to have this done. Some treatments have the person causing the dizziness over and over again until they get used to it—ridiculous. Repositioning maneuvers are the best treatment. With one 20 minute therapy, we can fix BPPV 80% of the time. We can fix BPPV 96% of the time with a second treatment. The point is that you do not have to learn to live with it.
  • Here is basically how the treatment works. We move you through a specific sequence of head and body positions to get the rocks back into the place where they belong—the gravity detector part of the inner ear.
  • Here is a patient who has BPPV affecting the left ear. I want you to watch the eyes of the patient and the treatment.
  • Here’s another example of a person with BPPV.
  • This is a different treatment than you just saw, but it works just as well. Again, watch the eyes and the positions of the patient. Gans Repositioning Maneuver Data if you want it. On average, 1.25 treatments needed to clear the 207 patients 80% of 207 patients clear after one treatment, 95.6% cleared after two GRM treatments
  • Goal with treatment of BPPV is to get rid of the positional vertigo.
  • What about patients who feel that they are off-balance or maybe have experienced a fall? We maintain balance by using information from our inner ears, our eyes, and our feet and lower legs. The brain puts all this together to keep us from falling. A problem with any of these areas may cause falls. You need to be evaluated by a specialist in inner ear and balance issues to determine where the problem is—that’s the only way to get the person appropriate treatment.
  • Balance problems and falls are such a huge problem that Congress has even created an Act to deal with it. In 2005, the Keeping Seniors Safe From Falls Act was introduced. This is important because balance problems and falling may lead to (explain problems) Look at the number of hospital admissions just due to hip fractures. This is a very big problem. Many of you may have experienced or no someone who has experienced a fall. Evaluation by a specialist in balance is the only way to ensure that you will get appropriate treatment to help avoid falls.
  • These are some of the things that we recommend after we’ve determined why a person is having a balance problem or falling.
  • Here is some video of a person who could not stand on her own when she came in for evaluation. She had a stroke a several months before she came in and also had vertigo. Now, she was having falls a couple of times a week. It was only a matter of time before she became seriously injured. It was determined that she actually had BPPV and a balance problem. The BPPV was fixed immediately like how I showed you in the other videos. Next, she worked with a physical therapist to improve her balance. They worked on strength and balance to get her to a point that she could walk on her own, even outside.
  • Here she is outside. The therapist is right there with her because you see they are coming to a handicap entrance with a slope—a very tough place for someone with a balance problem.
  • Now, look at the patient. She is actually able to walk unassisted. – This from a person who had vertigo whenever she would lay down to go to sleep and could not stand up from a chair by herself.
  • Regardless of your dizziness or balance problem, you do not have to learn to live with it. Hear At Last can determine what the problem is and how to fix it.
  • Hearing Specialist | Clermont FL

    1. 1. Dizziness & Vertigo: Evaluation and Treatment Options Al Turri Au.D Hearing and Dizziness Wellness Center Orlando, Clermont and BELLEVIEW www.fixmyhearing.com [email_address]    
    2. 2. Overview <ul><li>Dizziness </li></ul><ul><ul><li>Multiple Causes </li></ul></ul><ul><li>Vertigo </li></ul><ul><ul><li>Inner Ear Problems </li></ul></ul><ul><li>Imbalance </li></ul><ul><ul><li>Multiple Causes </li></ul></ul>
    3. 3. Vertigo <ul><li>Vertigo – hallucination of spinning </li></ul><ul><li>85% of all vertigo is caused by an inner ear problem – Johns Hopkins University </li></ul>
    4. 5. Inner Ear Problems and Vertigo <ul><li>Meniere’s Disease </li></ul><ul><ul><li>Vertigo lasting 30 minutes – 24 hours </li></ul></ul><ul><ul><li>Hearing Loss & Tinnitus </li></ul></ul><ul><li>Vestibular Neuritis </li></ul><ul><ul><li>Vertigo lasting 24-72 hours </li></ul></ul><ul><ul><li>Nausea & Vomiting </li></ul></ul><ul><li>Benign Paroxysmal Positional Vertigo (BPPV) </li></ul><ul><ul><li>Vertigo lasting seconds </li></ul></ul><ul><ul><li>Provoked by change in head position </li></ul></ul>
    5. 6. Meniere’s Disease Too much inner ear fluid
    6. 7. Vestibular Neuritis
    7. 8. Vestibular Rehabilitation <ul><li>Meniere’s Disease </li></ul><ul><ul><li>Medicine during worst symptoms </li></ul></ul><ul><ul><li>Possibly surgery </li></ul></ul><ul><ul><li>Vestibular Rehabilitation </li></ul></ul><ul><li>Vestibular Neuritis </li></ul><ul><ul><li>Medicine during worst symptoms </li></ul></ul><ul><ul><li>Vestibular Rehabilitation </li></ul></ul>
    8. 9. Vestibular Rehabilitation: Gaze Stabilization
    9. 10. Vestibular Rehabilitation: Adaptation/Habituation & Substitution
    10. 11. Benign Paroxysmal Positional Vertigo (BPPV) <ul><li>Positional Vertigo: </li></ul><ul><li>Most common cause of vertigo </li></ul><ul><li>#1 cause of vertigo in individuals 50 years and older </li></ul><ul><li>50% of patients > 70 will experience BPPV </li></ul><ul><li>May trouble patient for years </li></ul><ul><li>May contribute to imbalance </li></ul>
    11. 12. Calcium Carbonate Crystals -- Stones Positional Vertigo
    12. 13. Utricle – Gravity Detector (Stones are supposed to be here)
    13. 14. Stones from Utricle show both small and large crystals Close-up of crystals showing cylindrical forms Electron Micrograph (Lim, 1969)
    14. 15. Stones in the Wrong Place <ul><li>Stones move from correct part of inner ear to the wrong part </li></ul><ul><li>Why does this happen? </li></ul><ul><ul><li>Inner ear infection </li></ul></ul><ul><ul><li>Head Trauma </li></ul></ul><ul><ul><li>Multiple Medications </li></ul></ul><ul><ul><li>Cardiovascular Problems </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul>©2007 American Institute of Balance Education Foundation
    15. 16. Symptoms: <ul><li>Change in head position </li></ul><ul><ul><li>Looking up </li></ul></ul><ul><ul><li>Lying down </li></ul></ul><ul><ul><li>Getting hair washed </li></ul></ul><ul><li>Short duration (less than 1 minute) </li></ul><ul><li>May be accompanied by imbalance </li></ul>
    16. 17. Oghalai, J., Manolidis, S., Barth, J., Stewart, M., & Jenkins, H. (2000). Otolaryngology – Head and Neck Surgery , 122, 630-634.
    17. 18. BPPV Treatment <ul><li>BPPV does not respond to medicine </li></ul><ul><li>Surgical management includes singular neurectomy or posterior canal occlusion </li></ul><ul><li>Habituation - (Brandt & Daroff, 1980) </li></ul><ul><li>Repositioning Maneuvers - (Semont et al, 1988; Epley, 1992; Roberts, Gans, & Montaudo, 2006) </li></ul>
    18. 19. Progression of Stones through Posterior Canal Step 1. Posterior Canal Vertical Step 2. Posterior Canal Horizontal Step 3. Posterior Canal Rotated Step 4. Posterior Canal Returned to Vertical
    19. 20. Canalith Repositioning (left ear) Patient kept in each position for 1-3 minutes
    20. 21. Case Study <ul><li>76 Year Old Male </li></ul><ul><li>Initial event followed by 2-3 months of dizziness turning to Right </li></ul><ul><li>Nausea & disturbance of balance in the A.M. </li></ul><ul><li>Hearing Loss, Tinnitus </li></ul>
    21. 22. Case Study
    22. 23. Treatment Outcomes <ul><li>Goal: Extinguish Positional Vertigo </li></ul><ul><li>80-96% + success with all types of treatments </li></ul>
    23. 24. Imbalance <ul><li>Problem at any point may create tendency to fall </li></ul>
    24. 25. Keeping Seniors Safe From Falls Act <ul><li>Balance problems may lead to: </li></ul><ul><ul><li>Hip and Limb Fracture </li></ul></ul><ul><ul><li>Head Trauma </li></ul></ul><ul><ul><li>Reduced Mobility </li></ul></ul><ul><ul><li>Decreased Independence </li></ul></ul><ul><li>Falls leading cause of injury deaths among individuals who are over 65 years of age </li></ul>110 th Session of Congress, 2006 Hospital Admissions for Hip Fractures among the Elderly 1988 1999 2040 231,000 332,000 >500,000
    25. 26. Balance Intervention Program <ul><li>Balance Retraining Therapy </li></ul><ul><li>Weight Training </li></ul><ul><li>Fall Prevention </li></ul>
    26. 27. Balance Board
    27. 28. Walking Outside
    28. 29. Walking Without Help
    29. 30. You Do Not have to “Learn to Live With It” www.fixmyhearing.com Hearing and Dizziness Wellness Center