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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:

  1. The endolymphatic shunt or decompression procedure is an ear operation that usually preserves hearing. Attacks of vertigo are controlled in one-half to two-thirds of cases, but control is not permanent in all cases. Recovery time after this procedure is short compared to the other procedures.
  2. Selective vestibular neurectomy is a procedure in which the balance nerve is cut as it leaves the inner ear and goes to the brain. Vertigo attacks are permanently cured in a high percentage of cases, and hearing is preserved in most cases.
  3. Labryrinthectomy and eighth nerve section are procedures in which the balance and hearing mechanism in the inner ear are destroyed on one side. This is considered when the patient with Meniere's disease has poor hearing in the affected ear. Labryrinthectomy and eighth nerve section result in the highest rates for control of vertigo attacks.

    Other operations or treatments may be advised in some cases. If surgical treatment seems to be needed, the risks and benefits should be thoroughly discussed with your surgeon. Although there is no cure for Meniere's disease, the attacks of vertigo can be controlled in nearly all cases.

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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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