Table of Contents

1. Q: What is the difference between "dizziness" and "vertigo"?
2. Q: What treatment is available for vertigo?
3. Q: What is the cause of benign paroxysmal positional vertigo (or BPPV)?
4. Q: What is happening to produce the vertigo in BPPV?
5. Q: How is the diagnosis of BPPV made?
6. Q: Can BPPV be cured?
7. Q: How are the Epley Maneuvers carried out?
8. Q: How can I get treated with the Epley Maneuvers?
9. Q: Can you explain "inner ear concussion"?
10. Q: What is Meniere's Disease?
11. Q: What causes Meniere’s Disease?
12. Q: Is definitive treatment available for Meniere's disease?
13. Q: If conservative treatment of Meniere’s disease with dietary control and medications has failed, what else can be done?
14. Q: What place does physical therapy have in the treatment of vertigo?

Q: What is the difference between "dizziness" and "vertigo"?

A: Dizziness is a vague term, and can be roughly separated into four basic categories:

1. "True vertigo": An illusion of movement: either you feel that you’re moving, or that the room is moving.

2. "Imbalance": A tendency to fall, especially in darkness.

3. "Lightheadedness, giddiness, queasiness, sea-sickness or nausea": These are a person’s reactions to vertigo or imbalance. They are sometimes referred to as vegetative symptoms.

4. "Faintness", or weakness.

The term "vertigo" is often used loosely to refer to 1,2 and 3 above, as opposed to 4.

Q: What treatment is available for vertigo?

A: It is important to differentiate between "symptomatic" and "definitive" treatment.

"Symptomatic" treatment may make you feel better, but does nothing to correct the underlying condition causing the symptoms. Unfortunately, this is the way most vertigo is treated. Examples of symptomatic treatment for vertigo in common use: Antivert (meclizine), Valium (diazepam) and Xanax,

"Definitive" treatment first identifies and localizes the underlying cause of the condition, then is directed toward correcting it. For conditions with true vertigo symptoms, the underlying cause is within the inner ear over 95% of the time.

Definitive treatment is generally our recommended approach, and will be discussed separately for each condition.

Q: What is the cause of benign paroxysmal positional vertigo (or BPPV)?

A: BPPV is usually a complication of the aging process, but can also be brought about by an injury to the head or by a disease process like the flu or other viral illness. A particular episode is precipitated by placing the head in a certain position, such as lying down, rolling over, getting up or looking up.

Q: What is happening to produce the vertigo in BPPV?

A: Canaliths (calcium carbonate crystals) are normally attached atop a membrane in the otolith organ (or balance center) of the inner ear. These crystals can break off for various reasons and migrate into a semicircular canal. Then, when the head position is changed, the canaliths shift and abnormally stimulate the nerve sensors (cupula) of the semicircular canal, creating a sensation of movement (vertigo).

Q: How is the diagnosis of BPPV made?

A: A diagnostic maneuver (Hallpike test) is carried out and the eyes are observed for a characteristic pattern of movement.

Q: Can BPPV be cured?

A: In most cases, yes! The former method was to surgically destroy the function of the balance system in the involved ear, and let the opposite side take over. Then Dr. Epley demonstrated that the problem could also be cured by repositioning the canaliths. This treatment has been validated by several institutional studies. Now known around the world as "The Epley Maneuvers", this procedure is low risk, non-invasive and highly effective. Dr. Epley named it "Canalith Repositioning".

Q: How are the Epley Maneuvers carried out?

A: The head is maneuvered so as to guide the canaliths back though the labyrinth to where they originated. To facilitate this process, the canaliths can be tracked by observing the eye movements they cause, and by applying an oscillator to the skull. In most medical facilities, this maneuvering is done by hand with the patient lying on a table. The Portland Otologic Clinic uses special automated equipment that positions the patient and allows observation of eye movement via miniature video cameras. This provides an advantage in diagnosing and treating difficult or complicated cases.

Q: How can I get treated with the Epley Maneuvers?

A: If you can’t find a local physician who knows how to carry out this treatment, consider giving your primary physician or local otolaryngologist the information for ordering the professional videotape course regarding "The Epley Maneuvers". This course covers diagnosis and treatment in detail.

Q: Can you explain "inner ear concussion"?

A: Your inner ear structures are very delicate, and although they are protected by bone (the skull), they are particularly susceptible to even minor head blows, or to severe g-forces as occur in a "whip-lash" injury. Symptoms of light-headedness, imbalance, nausea and short-term memory problems tend to develop and progress in the weeks and months afterward. These symptoms frequently persist for years, or even indefinitely, if not properly treated.

Definitive treatment is available for this condition.

Q: What is Meniere's Disease?

A: It is a chronic condition of the inner ear with the classic triad of 1) vertigo attacks, 2) one-sided hearing loss, and 3) tinnitus and fullness in the ear.

The typical attack involves a spinning sensation, nausea and vomiting. The acute phase usually lasts 15 minutes to an hour, followed by a "post-dromal" phase lasting hours to days with light-headedness and dizziness provoked by head movement.

The time between attacks can be anywhere between days and years. In the early stages of the disease there is usually complete recovery between attacks, including return of hearing, but if the condition is allowed to progress it can cause a permanent severe hearing loss and tinnitus. In 10 - 20% of cases the disease later involves the opposite ear.

Q: What causes Meniere’s Disease?

A: We know that it involves an abnormal production of endolymph, one of the inner ear fluids. But the etiology is often elusive. Immune mechanisms, and the after-effects of trauma or infectious disease have been implicated.

Q: Is definitive treatment available for Meniere's disease?

A: Yes. In fact, early definitive treatment is strongly recommended so as to avoid progression of the hearing loss, notwithstanding the elimination of vertigo spells. Do not accept being told that "nothing can be done".

We will discuss the more conservative approach first:

Diet control, consisting mostly of an avoidance of excessive salt, caffeine and alcohol, may be helpful. The principle effective type of medication has been diuretics, but certain vasodilators and vitamins have also been recommended.

Q: If conservative treatment of Meniere’s disease with dietary control and medications has failed, what else can be done?

A: A new "transtympanic" (through the ear drum) method of medication delivery is rapidly gaining favor. This involves injecting medications into the round window area, whence they diffuse into the inner ear in much higher concentration than can be attained by the systemic route. Sometimes this is done via a small plastic tube passed through a small opening in the ear drum, whereupon the medication is slowly infused with a pump. The medications most commonly used include gentamicin, streptomycin, and dexamethasone (a corticosteroid).

If surgery is indicated, we recommended an endolymphatic sac procedure, also called an "endolymphatic shunt". This is a conservative, non-destructive procedure designed to drain off the excess fluid. Its short-term effectiveness rate is about 80-90%, but many cases recur within the next few years and need to be re-operated.

Destructive surgery includes labyrinthectomy (destruction of the inner ear) and vestibular nerve section (cut the nerve). They provide a high success rate but unfortunately have a higher risk factor as well. In our opinion, destructive procedures of any kind should be considered a last resort.

Q: What place does physical therapy have in the treatment of vertigo?

A: PT can be helpful if the condition is "stable', i.e. no abnormal short-term change in the input going to the brain from the labyrinth. Thus, PT will do no good if there are recurring attacks of Meniere’s Disease, where the input from one ear is episodically turned off.

With chronic, persistent labyrinthitis, as occurs after a whiplash injury, there is probably a constant irritation of the labyrinth that is aggravated by minor physical activity. PT usually only aggravates the symptoms.

PT is helpful in speeding up central nervous system compensation after destructive ear surgery or a stable injury. It is helpful in patients suffering from inactivity, particularly the elderly. And it can be helpful in Mal d' Debarquement Syndrome, where the person’s balance system has accommodated to the rhythmic rocking of a ship, but won't re-accommodate to being back on terra firma.

PT is misused when it delays the early determination of a definitive diagnosis. Thus, avoid the attitude of, "Let's try PT first, and if the dizziness doesn't get better, then we'll investigate further."

Home  |  Balance System 101  |  Common Syndromes  |  Dizziness from A to Z
Dizziness Q & A  |  EarInfo Column  |  New Advances  |  Other Vertigo Resources
Hearing Loss Q & A  |  Tinnitus  |  Other Hearing Resources
Related Books  |  The Portland Otologic Clinic
About Dr. Epley  |  The "Epley Maneuvers"

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