Meniere's
Disease
Dizziness
Why Do We Fall?
Meniere's Disease: What is Meniere's
Disease?
Meniere's disease, also called idiopathic endolymphatic
hydrops, is a disorder of the inner ear. Although the cause
is unknown, it probably results from an abnormality in the fluids
of the inner ear. Meniere's disease is one of the most common
causes of dizziness originating in the inner ear. In most cases
only one ear is involved, but both ears may be affected in about
15% of patients. Meniere's disease typically starts between
the ages of 20 and 50 years. Men and women are affected in equal
numbers.
What are the Symptoms?
The symptoms of the Meniere's disease are episodic rotational
vertigo (attacks of a spinning sensation), hearing loss, tinnitus,
(a roaring, buzzing, or ringing sound in the ear), and a sensation
of fullness in the affected ear. Vertigo is usually the most
troublesome symptom of Meniere's disease. It is defined as a
sensation of movement when no movement is occurring. Vertigo
is commonly produced by disorders of the inner ear, but may
also occur in central nervous system disorders. The vertigo
of Meniere's disease occurs in attacks of a spinning sensation
and is accompanied by disequilibrium (an off- balance sensation),
nausea, and sometimes vomiting. The vertigo lasts for 20 minutes
to two hours or longer. During attacks, patients are usually
unable to perform activities normal to their work or home life.
Sleepiness may follow for several hours, and the off-balance
sensation may last for days.
There may be an intermittent hearing loss early
in the disease, especially in the low pitches, but a fixed hearing
loss involving tones of all pitches commonly develops in time.
Loud sounds may be uncomfortable and appear distorted in the
affected ear.
The tinnitus and fullness of the ear in Meniere's
disease may come and go with changes in hearing, occur during
or just before attacks, or be constant.
The symptoms of Meniere's disease may be only
a minor nuisance, or can become disabling, especially if the
attacks of vertigo are severe, frequent, and occur without warning.
How is a Diagnosis Made?
The physician will take a history of the frequency, duration,
severity, and character of your attacks, the duration of hearing
loss or whether it has been changing, and whether you have had
tinnitus or fullness in either or both ears. You may be asked
whether there is history of syphilis, mumps, or other serious
infections in the past, inflammations of the eye, an autoimmune
disorder or allergy, or ear surgery in the past. You may be
asked questions about your general health, such as whether you
have diabetes, high blood pressure, high blood cholesterol,
thyroid, and neurologic or emotional disorders. Tests may be
ordered to look for these problems in certain cases. The physical
examination of the ears and other structures of the head and
neck are usually normal, except during an attack.
An audiometric examination (hearing test) typically
indicates a sensory type of hearing loss in affected ear. Speech
discrimination (the patient's ability to distinguish between
words like "sit" and "fit") is often diminished
in the affected ear. An ENG (electronystagmograph) may be performed
to evaluate balance function. This is done in a darkened room.
Recording electrodes are placed near the eyes. Wires from the
electrodes are attached to a machine similar to a heart monitor.
Warm and cool water or air is gently introduced into each ear
canal. Since the eyes and ears work in a coordinated manner
through the nervous system, measurement of eye movements can
be used to test the balance system. In about 50% of patients,
the balance function is reduced in the affected ear. Other balance
tests, such as rotational testing or balance platform, may also
be performed to evaluate the balance system.
Other tests may be done. Electrocochleography
(ECoG) may indicate increased inner ear fluid pressure in some
cases of Meniere's disease. The auditory brain stem response
(ABR), a computerized test of the hearing nerves and brain pathways,
computed tomography (CT) or, magnetic resonance imaging (MRI)
might be needed to rule out a tumor occurring on the hearing
and balance nerve. Such tumors are rare, but they can cause
symptoms similar to Meniere's disease.
What Treatment Will the Physician Recommend?
Diet and Medication
A low salt diet and a diuretic (water pill)
may reduce the frequency of attacks of Meniere's disease in
some patients. In order to receive the full benefit of the diuretic,
it is important that you restrict your intake of salt and take
the medication regularly as directed. Anti-vertigo medications,
e.g., Antivert® (meclizine generic), or Valium® (diazepam generic),
may provide temporary relief. Anti-nausea medication is sometimes
prescribed. Anti-vertigo and anti-nausea medications may cause
drowsiness.
Life Style
Avoid caffeine, smoking, and alcohol. Get regular
sleep and eat properly. Remain physically active, but avoid
excessive fatigue. Stress may aggravate the vertigo and tinnitus
of Meniere's disease. Stress avoidance or counseling may be
advised.
Precautions
If you have vertigo without warning, you should
not drive, because failure to control the vehicle may be hazardous
to yourself and others. Safety may require you to forego ladders,
scaffolds, and swimming.
When is Surgery Recommended?
If vertigo attacks are not controlled by conservative measures
and are disabling, one of the following surgical procedures
might be recommended:
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Dizziness
What You Can Do for Dizziness and Motion
Sickness
Each year more than two million people visit
a doctor for dizziness, and an untold number suffer with motion
sickness, which is the most common medical problem associated
with travel.
What Is Dizziness?
Some people describe a balance problem by saying they feel dizzy,
lightheaded, unsteady, or giddy. This feeling of imbalance or
dysequilibrium, without a sensation of turning or spinning,
is sometimes due to an inner ear problem.
What Is Vertigo?
A few people describe their balance problem by using the word
vertigo, which comes from the Latin verb "to turn".
They often say that they or their surroundings are turning or
spinning. Vertigo is frequently due to an inner ear problem.
What Is Motion Sickness and Sea Sickness?
Some people experience nausea and even vomiting when riding
in an airplane, automobile, or amusement park ride, and this
is called motion sickness. Many people experience motion sickness
when riding on a boat or ship, and this is called seasickness
even though it is the same disorder.
Motion sickness or seasickness is usually just
a minor annoyance and does not signify any serious medical illness,
but some travelers are incapacitated by it, and a few even suffer
symptoms for a few days after the trip.
The Anatomy of Balance
Dizziness, vertigo, and motion sickness all relate to the sense
of balance and equilibrium. Researchers in space and aeronautical
medicine call this sense spatial orientation, because it tells
the brain where the body is "in space:" what direction
it is pointing, what direction it is moving, and if it is turning
or standing still.
Your sense of balance is maintained by a complex
interaction of the following parts of the nervous system:
The inner ears (also called the labyrinth),
which monitor the directions of motion, such as turning, or
forward-backward, side-to-side, and up-and-down motions.
The
eyes, which monitor where the body is in space (i.e.
upside down, rightside up, etc.) and also directions of motion.
The
skin pressure receptors such as in the joints and spine,
which tell what part of the body is down and touching the ground.
The muscle
and joint sensory receptors, which tell what parts
of the body are moving.
The central
nervous system (the brain and spinal cord), which processes
all the bits of information from the four other systems to make
some coordinated sense out of it all.
The symptoms of motion sickness and dizziness appear when the
central nervous system receives conflicting messages from the
other four systems.
For example, suppose you are riding through
a storm, and your airplane is being tossed about by air turbulence.
But your eyes do not detect all this motion because all you
see is the inside of the airplane. Then your brain receives
messages that do not match with each other. You might become
"air sick."
Or suppose you are sitting in the back seat
of a moving car reading a book. Your inner ears and skin receptors
will detect the motion of your travel, but your eyes see only
the pages of your book. You could become "car sick."
Or, to use a true medical condition as an example,
suppose you suffer inner ear damage on only one side from a
head injury or an infection. The damaged inner ear does not
send the same signals as the healthy ear. This gives conflicting
signals to the brain about the sensation of rotation, and you
could suffer a sense of spinning, vertigo, and nausea.
What Medical Conditions Cause Dizziness?
Circulation: If your brain does not get enough
blood flow, you feel light headed. Almost everyone has experienced
this on occasion when standing up quickly from a lying down
position. But some people have light headedness from poor circulation
on a frequent or chronic basis. This could be caused by arteriosclerosis
or hardening of the arteries, and it is commonly seen in patients
who have high blood pressure, diabetes, or high levels of blood
fats (cholesterol). It is sometimes seen in patients with inadequate
cardiac (heart) function or with anemia.
Certain drugs also decrease the blood flow to
the brain, especially stimulants such as nicotine and caffeine.
Excess salt in the diet also leads to poor circulation. Sometimes
circulation is impaired by spasms in the arteries caused by
emotional stress, anxiety, and tension.
If the inner ear fails to receive enough blood
flow, the more specific type of dizziness occurs-that is-vertigo.
The inner ear is very sensitive to minor alterations of blood
flow and all of the causes mentioned for poor circulation to
the brain also apply specifically to the inner ear.
Injury: A skull fracture that
damages the inner ear produces a profound and incapacitating
vertigo with nausea and hearing loss. The dizziness will last
for several weeks, then slowly improve as the normal (other)
side takes over.
Infection: Viruses, such as
those causing the common "cold" or "flu,"
can attack the inner ear and its nerve connections to the brain.
This can result in severe vertigo, but hearing is usually spared.
However, a bacterial infection such as mastoiditis that extends
into the inner ear will completely destroy both the hearing
and the equilibrium function of that ear. The severity of dizziness
and recovery time will be similar to that of skull fracture.
Allergy: Some people experience
dizziness and/or vertigo attacks when they are exposed to foods
or airborne particles (such as dust, molds, pollens, danders,
etc.) to which they are allergic.
Neurological diseases: A number
of diseases of the nerves can affect balance, such as multiple
sclerosis, syphilis, tumors, etc. These are uncommon causes,
but your physician will think about them during the examination.
What Will the Physician Do for My Dizziness?
The doctor will ask you to describe your dizziness, whether
it is light headedness or a sensation of motion, how long and
how often the dizziness has troubled you, how long a dizzy episode
lasts, and whether it is associated with hearing loss or nausea
and vomiting. You might be asked for circumstances that might
bring on a dizzy spell. You will need to answer questions about
your general health, any medicines, you are taking, head injuries,
recent infections, and other questions about your ear and neurological
system.
Your physician will examine your ears, nose,
and throat and do tests of nerve and balance function. Because
the inner ear controls both balance and hearing, disorders of
balance often affect hearing and vice versa. Therefore, your
physician will probably recommend hearing tests (audiograms).
The physician might order skull X-rays, a CT or MRI scan of
your head, or special tests of eye motion after warm or cold
water is used to stimulate the inner ear (ENG - electronystagmography).
In some cases, blood tests or a cardiology (heart) evaluation
might be recommended.
Not every patient will require every test. The
physician's judgement will be based on each particular patient.
Similarly, the treatments recommended by your physician will
depend on the diagnosis.
What Can I Do to Reduce Dizziness?
Avoid
rapid changes in position, especially from lying
down to standing up or turning around from one side to the other.
Avoid
extremes of head motion (especially looking
up) or rapid head motion (especially turning or twisting).
Eliminate
or decrease use of products that impair circulation,
e.g. nicotine, caffeine, and salt.
Minimize
your exposure to circumstances that precipitate your dizziness,
such as stress and anxiety or substances to which you are allergic.
Avoid
hazardous activities when you are dizzy, such
as driving an automobile or operating dangerous equipment, or
climbing a step ladder, etc.
What Can I Do for Motion Sickness?
Always ride where your eyes will see the same motion that your
body and inner ears feel, e.g. sit in the front seat of the
car and look at the distant scenery; go up on the deck of the
ship and watch the horizon; sit by the window of the airplane
and look outside. In an airplane choose a seat over the wings
where the motion is the least.
Do
not read while traveling if you
are subject to motion sickness, and do not sit in a seat facing
backward.
Do
not watch or talk to another traveler who is having motion sickness.
Avoid
strong odors and spicy or greasy foods immediately
before and during your travel. Medical research has not yet
investigated the effectiveness of popular folk remedies such
as soda crackers and Seven Up® or cola syrup over ice.
Take
one of the varieties of motion sickness medicines
before your travel begins, as recommended by your physician.
Some of these medications can be purchased without a prescription
(i.e., Dramamine®, Bonine®, Marezine®, etc.) Stronger medicines
such as tranquilizers and nervous system depressants will require
a prescription from your physician. Some are used in pill or
suppository form.
Remember:
Most cases of dizziness and motion sickness are mild and self-treatable
disorders. But, severe cases and those that become progressively
worse, deserve the attention of a physician with specialized
skills in diseases of the ear, nose, throat, equilibrium, and
neurological systems.
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Why Do We Fall?
Every year more than two million Americans fall and sustain
serious injury, costing in excess of 3 billion dollars. Hidden
costs include pain, disability, lawsuits, deterioration in general
well-being, and the impact on other family members. Falls and
the resulting injuries have become one of the elderly's most
serious health issues. As our senior population continues to
grow, falls and their consequences will increase in the future.
Causes
The
accumulation of injuries throughout life change or damage the
central nervous system (CNS) and the body as a whole, and our
bodies deteriorate through inactivity. Vision diminishes with
advancing age, and this directly effects the sensory systems
involved with movement. The sensory cells in the ears' balance
system change, gradually decrease and cannot be replaced. The
nerves that carry sensory information to the brain from the
muscles, joints and skin can also deteriorate with age, and
the complex brain interconnections lose connecting fibers and
nerve cells. The ability of nerve endings to generate the chemicals
responsible for the transmission of information also seem to
be affected by aging. This process accelerates after the age
of 50.
Many diseases affect the CNS and sense organs.
Hardening of the arteries (atherosclerosis) is probably the
worst; it is accelerated by hypertension, smoking, and diabetes.
Although it gradually increases during middle age, there is
a point at which a slight additional decrease in blood flow
causes serious vascular impairment such as a stroke.
Head injuries, sometimes caused by falls, can
damage the sense organs in the inner ears, or the brain itself.
The worst disability occurs when both sense organs and CNS structures
are damaged simultaneously. Physical activity is very important
for recovery from injury to the sensory systems. The general
debility of aging can negatively affect recovery if it results
in a decreased level of activity.
Diseases of the eyes, such as glaucoma and cataracts,
decrease visual sensory function and are a common problem in
old age. Injuries to the knees, hips, and back often do not
completely heal, leaving some limitation of motion. Arthritis
can cause permanent crippling, nonreversible effects. Osteoporosis
leads to bone weakness and increases the probability of serious
injury from a fall, or might cause a spontaneous fracture and
lead to a fall. Muscle strength gradually decreases with age.
Joint tendons and ligaments lose their flexibility and limit
motion. The combined ravages of bone and joint injury, arthritis,
and inactivity can result in a body which cannot carry out motion
commands initiated by the brain.
Prevention
As many of the problems responsible for falling develop during
early and middle
age, initial efforts to prevent injuries must be aimed at younger
age groups. Many of the changes in muscle, bone and the central
nervous system are not inevitable results of aging, but are
brought on by inactive lifestyles and self-inflicted damage
from smoking, poor diet, and lack of exercise. Although hardening
of the arteries is occasionally hereditary, in most cases it
can be reduced by diets low in cholesterol and saturated fatty
acids, as well as regular physical exercise. This stimulates
the muscles as well as the cardiovascular system and could greatly
reduce this problem. If there is a family history of hardening
of the arteries, medications to lower cholesterol are available.
Early diagnosis and treatment of diabetes mellitus and hypertension
can make a difference in the progression of arthrosclerosis.
Smoking cessation might also help reduce this disorder.
Many of the medications used to treat hypertension,
heart disease, allergy, insomnia, stomach acidity, and depression
have side effects which influence brain function and can increase
the likelihood of falling. In this time of specialization it
is possible for one patient to receive prescriptions from several
physicians that might have additive side effects on brain and
sensory function. Patients should keep a complete list of all
their medications and dosages, and make this list available
to each physician they consult. Coordination of all medications
through a single primary care physician would help avoid adverse
drug reactions. Many pharmacies use computer systems to warn
the pharmacist about potential drug interactions. This requires
that the patient purchase all medications from the same pharmacy
or list all medications with each pharmacy. Unfortunately some
over-the-counter medications such as antihistamines, sleeping
medications, analgesics, and cough suppressants can add to the
side effects of prescription medications. Alcohol also affects
movement and judgement and adversely interacts with many medications.
Prevention Tips:
Health
Have your vision and hearing checked regularly. If your vision
and hearing are impaired, you may lose important cues that help
you maintain your balance.
Get up slowly.
A momentary drop in blood pressure, due to drugs or aging, can
cause dizziness if you stand up too quickly.
Maintain balance
and footing. If you sometimes feel dizzy, use a cane or walker
to help you to keep your balance on uneven ground or slippery
surfaces. Wear sturdy, low-heeled shoes with wide, nonslip soles.
Exercise regularly.
Regular exercise improves your strength, muscle tone, and coordination.
This can not only help prevent falls, it can reduce the severity
of injury if you do fall. Walking is a good form of exercise.
Home
Remove raised
doorway thresholds in all rooms. Rearrange furniture, if necessary,
to keep electrical cords and furniture out of walking paths.
Fasten area carpets to the floor with tape or tacks, and don't
use throw rugs.
Don't use difficult
to reach shelves. Never stand on a chair. Use nonskid floor
wax and wipe up spills immediately.
Be sure stairways
are well lighted and have sturdy hand rails. If you have a vision
problem apply brightly colored tape to the first and last steps.
Install grab
handles and nonskid mats inside and just outside your shower
and tub, and near the toilet. Shower chairs and bath benches
minimize the risk of falling.
Put a light
switch by the bedroom door and by your bed so you don't have
to walk across the room to turn on a light. Night lights in
your bedrooms, halls, and bathrooms are a good idea.
Rehabilitation
What about patients who have already fallen? Although rehabilitation
is not perfected, much can be done.
The first task is a thorough and complete evaluation of the
patient's sensory, CNS, and muscle/joint function.
A careful
evaluation of the balance function should be performed. This
includes a search for causes of dizziness, such as inner ear
diseases that cause imbalance: an evaluation of the inner
ear balance system which might be adversely affected by certain
drugs (such as a class of antibiotics known as aminoglycosides);
trauma; and the aging process.
Tests of higher
mental function are important since falling may be a sign
of serious mental deterioration.
A careful
review of all medications (both prescription and over-the-counter)
used by the patient is very important. If the patient needs
medication for anxiety or depression, switching from a long-acting
drug to one which is more quickly passed from the body seems
to decrease the risk of falling.
All correctable problems should be treated. Visual correction
with proper eyeglasses, improvement of hearing by hearing
aids, adjustment or elimination of medications, and correction
of hypertension or any other disease that could impair balance
must be accomplished.
Rehabilitation includes increasing the range
of motion as well as physical strength. A very important part
of rehabilitation is helping patients overcome their fear of
falling and thus avoid further injury. Walkers and canes can
aid stability, and adaptations in the home are important. Simple
changes such as installing hand holds in bathrooms or along
walls could decrease the likelihood of falling and increase
patient confidence. Removing the patient from a familiar environment,
or drastically changing it, often hampers recovery.
As soon as possible, rehabilitation should be
moved to an outpatient setting with participation of family
members and home support groups. Rapid return to physical activity
and social interaction with family and community can often stop
the vicious spiral into inactivity, reclusiveness, and progressive
deterioration.
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