CONDITIONS TREATED

Benign Paroxysmal Positional Vertigo (BPPV) is a peripheral vestibular disorder involving the inner ear. The cause of BPPV is not well understood. Sometimes there is no apparent reason for the onset of symptoms or it may occur following a bout of viral labyrinthitis, after a whiplash injury, fall or head injury or high impact exercises.

BPPV is usually characterised by sudden onset of short and intense bursts of dizziness/vertigo (spinning sensation), related to certain changes of position (e.g. lying down, leaning forwards or turning over in bed). Symptoms tend to last for less than one minute and may be accompanied by nausea and nystagmus. Symptoms may resolve spontaneously or may be more persistent. Symptomatic episodes may occur in clusters and may last from a few days to a few months.

The inner ear contains otoconia which are small crystals of calcium carbonate. They occasionally become dislodged and float into the semicircular canals. The free floating crystals affect the movements of tiny hair cells which detect head position. This disrupts the normal signals to the brain and symptoms of imbalance, vertigo and dizziness result.

Diagnosis of BPPV is determined by clinical history and confirmed by positioning tests (e.g. the Hallpike manoeuvre). These tests are carried out by an experienced clinician and may cause a brief increase in dizziness because they move the otoconia. The positioning tests involve movements of the head and body in certain directions. If the tests are positive then nystagmus will occur (the direction of which will indicate which semicircular canal is involved).

Repositioning manoeuvres (e.g. the Epley manoeuvre) are used to treat the symptoms by moving the otoconia along the canal to an area where they can be reabsorbed. An exercise programme may also be recommended to help the brain to compensate and adjust to any residual motion sensitivity. Exercise programmes generally focus on carefully controlled and graded exposure to symptom-provoking stimuli so that the brain learns to adapt to these.

It is important to note that there are many causes of dizziness and symptoms should always be investigated by an experienced clinician so that an accurate diagnosis can be made. Treatment programmes are always individualised.

The inner ear is made up of very small and delicate balance and hearing apparatus.

3D anatomy images copyright of Primal Pictures Ltd www.primalpictures.com

There are two main parts:

The Labyrinth: The 3 semicircular canals and the otolith organs

The Cochlea: The hearing apparatus (other parts of the hearing apparatus are in the middle and outer ear.

Labyrinthitis is an infection or inflammation of the inner ear. The labyrinth provides us with sensory information about motion and assists the vision with gaze stability. If inflammation occurs in one labyrinth the sensory function is distorted and information altered when received in the brain. This inflammation of the labyrinth can cause acute vertigo and hearing loss.

Vestibular Neuritis is an inflammation (usually viral) of the vestibular nerve which can cause sever vertigo, nausea and vomiting. The main distinguishing feature between labyrinthitis and vestibular neuritis is hearing loss is most often only seen with labyrinthitis.

The symptoms are due to the affected ear not sending appropriate signals to the brain so the good ear increases signals. It is this discrepancy in information received by the brain that is thought to give rise to symptoms of vertigo. Often only one ear is affected, but occasionally one can have a bilateral vestibular involvement.

The symptoms usually lessen after several days and one is able to manage mobility easier. There may be some residual features of the initial onset that do not reduce with gradual return to normal activity.

Management: Medical advice is highly recommended at onset. Your consultant will review your case and direct necessary tests. You may also be referred for vestibular rehabilitation by a Balance Centre physiotherapist specializing in vestibular assessment and treatment.

Bilateral Vestibular Loss or Hypofunction is a vestibular problem involving both left and right inner ears structures. Symptoms of imbalance and visual disturbance called oscillopsia are the main features. It is a rare condition and most often caused by ototoxicity. Antibiotics such Gentimycin can be ototoxic and can give rise to a bilateral lesion although some bilateral vestibular problems are caused by viral infections or tumour.

Often people with a bilateral vestibular hypofunction find walking in the dark considerably more difficult. Since the vestibular system on both sides is not functioning optimally any activity that challenges the somatosensory system or the visual system such as walking on grass or busy traffic could cause further imbalance.

Careful history and review of onset as well as special test such as rotary chair testing have been found particularly helpful in identifying bilateral vestibular problems. Vestibular Rehabilitation by a physiotherapist

Acoustic neuroma or vestibular schwannoma are benign tumours of the brain that can affect the vestibularchochler nerve (8th cranial nerve). They are rare and often very slow growing but can cause significant balance and hearing problems as well as problems with the muscles of the face. If the tumour becomes large enough it can compress on other structures such as the brain stem and other cranial nerves. Onset of symptoms is usually gradual and not life threatening.

First signs:

• hearing loss
• imbalance
• vertigo
• Nausea and vomiting
• Tinnitus
• Pressure in the ear
• Facial weakness

There is no known cause for vestibular schwannoma. Medical advice is recommended for specific investigations and management.

A fistula is an opening or connection which is abnormal. The condition Perilymphatic fistula is an opening between the middle ear (air filled) and inner ear (fluid filled). This presents a ‘leak’ often due to a tear or defect. PLF is rare and most often follows an incident such as head injury or barotrama and to a lesser degree repeated infection, tumour or congenital in origin. Depending on were the ‘leak’ or fistula is it may cause a different set of symptoms. A fistula between the bone in the semi circular canals, specifically the superior canal is known as Superior Canal Dehiscence (described below). A perilymphatic fistula may also be present between the bone surrounding the inner ear and the brain allowing fluid to communicate.

Symptoms reported may be dizziness, vertigo, nausea or vomiting, imbalance or hearing loss. Symptoms may be induced by pressure changes cause during coughing, sneezing or blowing the nose. Symptoms may also be noise provoked. Often people with PLF find with rest, symptoms reduce.

Prompt medical advice is recommended for accurate diagnosis and specific treatment.

Semicircular canal dehiscence (SCD) is a rare and still a relatively unknown condition, first described by Lloyd Minor MD in 1998.

SCD is caused from an opening (dehiscence) within the bony shell of the superior semicircular canal. This poses the vestibular labyrinth sensitive to loud sounds and pressure changes. This hole can measure less than 1mm up to 5 mm in size.

SCD typically affects men more than women presenting with symptoms in their 30s to 40s. It is reported to be more common within the left ear, but can be seen in the right ear or both ears.

SCD can affect both hearing and balance to varying extents in individuals. It is recognised that in some cases, patients will experience the hearing changes without any dizziness.

Typical symptoms are:

• Fullness of the ear
• Autophony - patients often report they can hear their own voice as a disturbing and distorted sound as if relayed through a cracked speaker. They often hear creaking of their own joints, their heartbeat and sound of chewing. Additionally they can report hearing their own eye movements like sandpaper on wood.
• Conductive hearing loss
• Dizziness - often this is triggered by loud, low frequency noises, heavy lifting or straining.
• Oscillopsia - eyes that are jumping up and down
• Pulsatile tinnitus

Activities that may trigger the SCD dizziness, oscillopsia and imbalance are:

• Heavy lifting
• Straining
• Sneezing
• Blowing your nose
• Childbirth
• Running
• Exposure to low frequency sounds
• Exposure to loud sounds

Management

For some patients, avoiding triggers may be sufficient. Hearing aids can be used if low to mid frequency conductive hearing loss is present. For others surgical intervention may be required to repair the dehiscence.

A referral to the Wellington Balance Centre will enable a thorough investigation into your symptoms, completing all imaging and assessments. Onward referrals for surgical intervention and any rehabilitation will be facilitated as indicated.

Definition: Meniere’s disease is a disorder of the inner ear which is characterized by episodes of acute vertigo, tinnitus, hearing loss and aural fullness (pressure in the ear).

Symptoms: The most prominent feature of Meniere’s disease is vertigo, which may include dizziness, nausea, and vomiting. Other symptoms such as hearing loss or tinnitus are often noted latter. Meniere’s disease usually affects only one ear initially but can eventually affect both ears. The disease process is progressive with unpredictable attacks. Following an attack symptoms usually resolve. In the late stages of Meniere’s disease hearing loss is often more permanent as repeated pressure may cause irreversible damage to the delicate inner ear structures.

Causes: There is no known cause for Meniere’s disease, although there is some thought that increases pressure in the system may influence. It is most often attributed to a viral infection of the inner ear, allergy, heredity disposition or head injury.

Seeking medical advice: Medical advice should be sought for diagnosis and management.

Tests & Diagnosis: Your consultant may request you have special tests which may include a hearing test, vestibular function tests, blood tests or an MRI.

Treatment: Your Consultant will advise you on what course of treatment is best for you.

Migraine affects approximately 15% of the UK population, typically between 20 and 50 years old. There are two main types of migraine; Migraine without aura (previously known as Common Migraine) and Migraine with aura (previously known as Classic Migraine).

Migraine with aura can be further subdivided into three classifications:

• Migraine with prolonged aura – where 1 of the aura symptoms last more than 1 hour but less than 7 days
• Basilar migraine - where the aura may include vertigo, tinnitus, decreased hearing, ataxia, visual symptoms, dysarthria, double vision, bilateral sensory changes or weakness and decreased consciousness
• Migraine aura without headache – where no headache evolves

Aura symptoms are associated with transient neurological symptoms consisting of sensory, motor or cognitive changes. They typically last between 5-20 minutes but can persist up to 1 hour. Common aura symptoms are visual disturbances i.e. flashing lights, zigzag lines and areas of blindness, numbness, tingling sensations and slurred speech. Partial paralysis, weakness down one side of the body, confusion, a stiff neck and fainting can also be signs of aura in certain types of migraine.

Associated with the migraine phase, feelings of nausea, vomiting and a sensitivity to light, sound and movement may occur in conjunction with a one sided, throbbing headache. An episode usually lasts between four and 72 hours but you can feel tired for several days afterwards.

Vestibular migraine is a term used to describe a headache with vertigo presenting at some time before, during or after the headache phase. Other features of an aura mentioned above may still present along with vertigo, tinnitus or decreased hearing.

Treatment of Vestibular Migraine is the same as with Migraine with/without aura – specifically reduction of risk factors and prescription of either prophylactic medications and/or abortive medications.

Associated risk factors are stress, nicotine, hypoglycaemia from irregular eating, irregular sleeping patterns, imbalance in Oestrogen levels and dietary triggers. Some food products are claimed to cause a migraine almost immediately for example red wine or MSG (mono sodium glutamate), whereas others can cause migraines as late as the next day for example chocolate, nuts and cheese.

It is strongly recommended that medical advice is sought if any of the above symptoms present themselves, as some of the symptoms may be due to other causes than migraine. A referral to the Wellington Balance Clinic will enable accurate diagnosis and management with the identification and provision of any associated rehabilitation needs.

Traumatic Brain Injury (TBI) can cause a multitude of physical, sensory and cognitive problems that can all impact on an individual’s balance, mobility and independence. Specialist Neurological Rehabilitation typically manages this population. However, specific vestibular pathologies can also occur as a result of the TBI and can have an additional impact on regaining efficient balance, postural control and functional independence.

There are many conditions that may present themselves affecting the vestibular system, the vestibular nerve or areas of the brain such as the cortex or cerebellum. The main causes of these conditions are inner ear concussion, temporal bone fractures and central haemorrhage or contusions, which will be discussed further. In addition to these causes cervical trauma or ‘whiplash’ and psychological factors may be involved.

Inner Ear Concussion

This is claimed to be the most common result of TBI causing symptoms ranging from BPPV, sensorineural hearing loss, imbalance, walking difficulties and poor control of posture.

Subsequent changes in intracranial pressure following the TBI can cause ruptures to the membranes causing a Perilymphatic Fistula. This can cause fluctuating hearing changes, intermittent vertigo, balance and walking difficulties.

Temporal bone Fractures

A Transverse Fracture, which accounts for 20% of temporal bone fractures, poses the most significant impact on the Vestibular system and balance. It is associated with blows to the back of the head (occipital) and causes one sided loss of vestibular function either partially or completely in nature. If the blow to the head causes one sided problems only, typical symptoms would include spontaneous problems stabilising gaze, vertigo and problems maintaining balance and posture in sitting, standing and walking. With bilateral trauma, severe imbalance is likely in all positions with additional Oscillopsia (bouncing vision).

The remaining 80% of temporal bone fractures are longitudinal in nature and are associated with blows to the side of the head (parietal and temporal regions). They cause middle ear trauma and thus hearing loss is the key symptom.

Central Vestibular Lesions

As a result of the TBI, contusions and haemorrhages occur in many areas of the brain and brainstem. In addition to the impairments that these areas may be involved in for example speech, memory and movement, specific areas that process and integrate the peripheral vestibular information may also be damaged. This could affect the brains ability to compensate and regain postural control and efficient balance.

Rehabilitation

Within this population, recognising the possibility of both peripheral and central causes within an individual physical presentation with balance problems is essential. Other injuries or factors may complicate the rehabilitation process, for example pain and joint restrictions, cognitive and behavioural problems, damage to the visual and musculoskeletal systems and damage to the neural structures responsible for vestibular compensation. As a result of all these co-existing features from the TBI, recovery of any peripheral symptom is likely to take significantly longer with a prolonged rehabilitation period.

Multiple Sclerosis (MS) is an autoimmune condition, meaning your own immune system attacks your own body’s tissue by mistaking it for a foreign body. Within MS, the tissue that is attacked is the protective cover on nerves (myelin sheath) within the central nervous system. This damage to the myelin causes the messages travelling down the nerves to be stopped, slowed down or interfered with. In addition to the myelin damage, the nerves themselves can be damaged, which leads to disability over time.

Nerves connect all areas of the body and are involved in all conscious and sub-conscious bodily functions. Therefore the range of symptoms can be diverse including movement, sensation, thinking, continence, vision, balance, speech and dizziness to name a few.

Image courtesy of MS Society

Balance requires messages to travel up to the brain, be integrated and a message be sent out from the brain to the body to react or move.

If the input messages are affected, this will provide unreliable information regarding the body’s position and balance. With damage to the Cerebellum or Brainstem the balance messages would be interpreted inaccurately and create an unreliable or slow response. Finally if the nerves involved in transporting the output message are affected, then the resulting movement will be ineffective and inaccurate, potentially affecting balance further.

Input problems with MS

A common symptom for MS sufferers is visual disturbances, typically double vision, blurring or the appearance that items are bouncing around. Altered sensation, tingling and numbness can be a confusing symptom to deal with as it can be variable in side and intensity. Possible vertigo or dizziness can also be a problem from the inner ear (Vestibular system) affecting balance.

Processing problems in MS

Many areas of the brain are involved in the process of balancing, particularly the Cerebellum and Brainstem. The Cerebellum is involved in the re-learning and compensation for inaccurate/missing input messages and in modulating the output responses. Additionally vertigo and nausea may present due to these areas of the brain being affected.

Output problems in MS

MS can affect the muscles in many ways which can all have an effect on the ability to balance and react to any perturbations to balance. Muscles may become stiff, weak, tremor and spasm or have difficulty with coordinated movements.

In the presence of problems in more than one aspect of balance, it will be harder to remain balanced with a greater risk of falling resulting. Other symptoms attributed to MS such as altered cognition and fatigue will also compound the ability to balance.

Rehabilitation

Recognising peripheral signs within a presentation of MS will enable accurate management of any coincidental peripheral vestibular pathology. Rehabilitation requires a holistic approach to manage all potential aggravators to balance and address underlying postural control and substitution strategies.

The body changes to varying degrees as we get older. Trends are shown with delayed reaction times and diminishing sensory acuity. The response patterns can be disordered increasing one’s risk of falling and injury. Listed below are some of processes we all may go through eventually.

Visual changes:

Age-related changes in vision usually begin in midlife, then tend to stabilize until around age 70 or 80, when further visual changes occur. About 95% of individuals over 70 years of age develop cataracts or some other form of vision loss.

Hearing changes:

Changes in one’s ability to hear, usually begins at midlife. Often only very mild changes happen until 60 or 70 years of age. Reduced ability to hear low intensity and high frequency sounds pose significant problems for over a third of older individuals.

Vestibular changes:

The vestibular system is delicate and with age looses some of the sensory hair cells. It is not know exactly why, but there in a higher incidence of BPPV in older adults.

Mobility:

One’s ability to move about and be active is interrelated between the functions of several body systems: musculoskeletal, respiratory and cardiovascular systems. Major illness or diseases in the systems mentioned are often the causes of difficulty and impact balance.

How one manages imbalance through use of strategies such as using the ankles, hip or stepping tends to change with age. A reliance more on hip strategy is seen and reduced use of ankle strategy. Weakness in the lower limbs and particularly the ankles may play a significant role in balance problems. Sensory changes in the feet and joint receptors can account for reduce reaction times increasing one’s risk of falling.

Attention:

Ones ability to multitask during balance tasks changes with the aging process. Older adults were found to have more difficulty with balance tasks during whilst at the same time performing simple cognitive tasks.

Staying fit is an important part of being healthy as we age. If you are having problems in any of these areas it could be useful explore the expert advice available at the Wellington Balance Centre. It is important to remember age is not a factor in recovery from peripheral vestibular injury.