by Lance E. Jackson, MD, FACS
Dizziness,
a common and difficult condition
The field of Otology/Neurotology specializes in the treatment of all disorders related to the ear, hearing and vestibular system, including dizziness disorders. Dizziness is an extremely common complaint, causing 40 percent of Americans to seek medical treatment at some point in their lives. Dizziness and balance disorders can be very debilitating and life-altering.
Diagnosing and treating dizziness can be very difficult. Frequently, patients are treated with prolonged use of vestibular suppressant medications (such as Meclizine), which in some patients are contraindicated because they worsen balance function and can delay central compensation and overall recovery. Yet other patients may not receive treatment for their dizziness, such as in elderly patients with many potential factors contributing.
Dizziness is a vague term that can be used by patients to describe various symptoms, such as vertigo (feeling of spinning or other movement), imbalance, lightheadedness, near-syncope, syncope or difficulties focusing vision (e.g. after rapid movements of the head or body).
While history is extremely important in making an accurate diagnosis, specialized testing (including videonystamography, vestibulo-ocular reflex testing and platform balance testing) can assess vestibular system function and balance function as a whole. A diagnostic approach utilizing such testing helps to identify whether the cause of the dizziness is peripheral vestibular in origin, related to another organ system (e.g. the central, visual, and/or somatosensory systems which are all important in balance) or multifactorial.
Fortunately, there are improved therapeutic alternatives currently available for treating dizziness. When accurately diagnosed, treatment of course can be more directed and successful. In an Otology/Neurotology practice, we find that the majority of causes of dizziness respond to conservative management with use of specialized physical therapy termed Vestibular and Balance Rehabilitation Therapy (VBRT). Although such a specialization of PT is less than 20 years old, the literature repeatedly has demonstrated its success, and it has become a mainstay in the treatment of vertigo and imbalance.
This form of therapy takes advantage of the elasticity of the central nervous system by facilitating central compensation for peripheral vestibular dysfunction and allowing adaptation for other sensory organ or central impairments.
Dizziness disorders treated with physical therapy
Many dizziness disorders improve with VBRT, sometimes as the sole therapy and sometimes in combination with other interventions such as lifestyle modifications, medications and/or surgery. Disorders treated with VBRT include:
Benign Paroxysmal Positional Vertigo (BPPV) – This is the most common cause of vertigo attributable to the inner ear.
It is caused by displaced calcium carbonate crystals (otoconia) from the otolithic organ into one of the semicircular canals. The displaced crystal can be free-floating (canalithiasis) or adherent to the cupula of the canal (cupulolithiasis). Although the posterior semicircular canal is most commonly involved, it was more recently appreciated that the lateral or anterior canals also can be involved. Dix-Hallpike and positional testing maneuvers performed while using goggles to track eye movements (videonystagmography) provides a means to make an accurate diagnosis of the presence/absence of BPPV, side involved, canal involved and whether canalithiasis or cupulolithiasis is present.
Once the diagnosis is made, a directed repositioning maneuver is completed by a trained PT. When performed correctly, such maneuvers are more than 90 percent successful with 1-2 office visits, completely resolving the vertigo within minutes to achieve what many patients describe as a “miraculous” cure to their life-altering vertigo symptoms.
In a study published earlier this year regarding 260 BPPV patients treated in our practice, we found that anterior semicircular canal involvement is much more common than previously appreciated (21.2 percent of patients), trauma was a prominent cause, and it responded with high success to repositioning maneuvers.
Vestibular Neuritis – This is thought to typically be viral in origin. The 2-3 days of acute and severe vertigo is treated with vestibular suppressant medications as needed. After the continuous vertigo dissipates, patients are typically left with an imbalance and movement-induced dizziness related to a permanent vestibular deficit. Such a vestibular deficit is ideally treated with a customized progressive VBRT program to induce central compensation (i.e. train the brain to accept that it is receiving asymmetric signals from the two ears). Care must be taken not to over-stimulate the vestibular system, as this can delay compensation. Therefore, individuality is critically important. The therapy reduces the overall recovery time.
Labyrinthitis – This causes vertigo symptoms similar to vestibular neuritis, with or without associated hearing loss. It is similarly treated with a customized VBRT program.
Meniere’s Disease – This is treated in a graded fashion depending on the severity of symptoms and response to more conservative treatments. Lifestyle/dietary modifications, use of maintenance diuretics, allergy treatment and symptomatic use of vestibular suppressant medications (e.g. Meclizine, Valium) or steroids as needed are usually effective treatment. If the vertigo remains disabling with maximal medical therapy, surgical alternatives exist, including inner ear perfusion with gentamicin, vestibular neurectomy and labyrinthectomy. Perfusion of the inner ear with gentamicin is usually a good first-line surgical treatment for Meniere's disease because it is minimally invasive, but it is designed to cause a vestibular deficit and also carries with it the risk of hearing loss. When a vestibular weakness has been surgically induced, VBRT is used to accelerate a patient's return to normal daily activities. Due to the permanence of an iatrogenically-induced therapeutic vestibular deficit, it is also important for maintenance of a long-term vestibular exercise program.
Other Vestibular Deficits–Vestibular weakness can be induced by many conditions including inner ear ischemia, skull base tumors (such as acoustic neuromas and meningiomas), infectious etiologies, concussive head trauma and autoimmune inner ear disease. Although initially these patients may exhibit severe vertigo, in the long-term they are most bothered by imbalance and movement-induced dizziness.VBRT is again the best treatment.
Migraine Associated Dizziness – Migraine disease is a frequent cause of dizziness of markedly variable quality. Patient complaints can include short periods of vertigo lasting seconds, prolonged periods of dizziness lasting up to several days, feelings of lightheadedness, imbalance, motion intolerance and/or troubles focusing vision after rapid movements of the head. With vestibular testing, migraine sufferers often demonstrate a hyperactive vestibular response, which would explain their hypersensitivity to motion (similarly, they can also suffer hypersensitivity to other external stimuli including bright lights and loud noises). Dietary/lifestyle changes combined with a customized VBRT program are often beneficial treatments. Due to the vestibular hyperactivity, it is important in this population to be regular and slowly progressive in the vestibular exercise program.
Multifactorial Dizziness of Aging – Frequently, elderly patients, and sometimes younger patients, complain of a chronic feeling of imbalance without true vertigo. Possible contributing factors include cerebrovascular ischemia, stroke, demyelinating conditions, vestibular dysfunction, cataracts, macular degeneration, lower extremity weakness, joint disease or replacements, neuropathy and spinal disease. Through adaptation, patients gain improved stability in confidence and during ambulation when they undergo appropriate VBRT. The improved balance achieved reduces the risk of falls, which can be particularly dangerous and potentially life-threatening in elderly patients.
Help is available
An Otologist/Neurotologist working closely with a physical therapist specializing in VBRT creates an environment ideal for treating dizziness disorders. This allows both the physician and PT to review test results and to discuss difficult patients directly. With the help of modern VBRT techniques, patients with all forms of dizziness and imbalance no longer need to simply “live with it.” Often, medicines such as vestibular suppressant drugs can be avoided, and actually should be avoided, since they can worsen balance function, increase the chance of falls, and reduce the rate of central compensation. An organized scientific approach for the diagnosis and treatment improves patient care and also can reduce the cost of care. Nearly all dizziness patients can be helped, even when the inner ear is not the direct etiology, such as in elderly patients with central causes for their dizziness.
Lance E. Jackson, MD completed medical school at Washington University in St. Louis, his Otolaryngology residency at Stanford University and his Otology/ Neurotology fellowship at the Ear Research Foundation in Florida. He has written many papers, chapters and co-authored a text on minimally invasive otologic surgery. He presently directs the Ear Institute of Texas, located in San Antonio.
