Vertigo

[chen60]

In July 07 I woke up and the room was spinning my husband took me to the ER and the did a CT scan and told me it was vertigo and sent me to the ENT I had a hearing and balance test all negitive.  In August it happened again and once I was in the ER this time I had a MRI/MRA and ultrasound on the arteries in my neck all negitive and was sent to a neurologist.  Saw him he said I had a text book case of BPPV.  I have tried meclizine and it did not help so they gave me lorasapam which helps but I still get dizzy everyday.  Has anyone else had to deal with this and how long does it last I really would like to feel normal again.  I did try PT with the reposition of the crystals but it did not help that much.

[Joyce K Lee, MD]

Dear chen60,

Thank you for submitting your question.
I will answer your concerns to the best of my abilities, but please be informed that I am unable to offer a diagnosis based on your history and list of symptoms.
I am limited in not having the opportunity to perform a full neurologic examination on you, nor am I able to review the pertinent imaging.
This is solely for educational purposes and should in no way be a substitute for a formal evaluation by a certified physician.

As you can imagine, vertigo is a common complaint in the outpatient setting.

When we as neurologists evaluate dizziness either in our outpatient clinics or in the emergency department, we aim towards differentiating central versus peripheral causes and benign versus more serious causes of vertigo.

It is reassuring to me that you have had an MRI/A and carotid ultrasounds to assess for possible stroke or tumor and that these were all negative.

I am also glad to hear that you have seen an ENT physician and have had your hearing tested.

To begin, it is very important to determine if vertigo truly exists. Vertigo implies that there is a sensation of motion either of the person or the environment. This should not be confused with symptoms of lightheadedness or fainting.

To determine if true vertigo exists, you must describe a sensation of disorientation or motion. In addition, you may also have any or all of these symptoms:
Nausea or vomiting
Sweating
Abnormal eye movements

The duration can be from minutes to hours and can be constant or episodic. The onset may be due to movement or change in position. It is important to tell your doctor about any recent head trauma or whiplash injury as well as any new medications you may be taking.
You may have hearing loss and a ringing sensation in your ears.
You might have visual disturbances, weakness, difficulty speaking, decreased level of consciousness, and difficulty walking.
These details must be teased our by a trained neurologist to aid in managing the problem.

Vertigo can be caused by problems in the brain or the inner ear.
Benign paroxysmal positional vertigo (BPPV) is the most common form of vertigo and is characterized by the sensation of motion initiated by sudden head movements.
Vertigo may also be caused by inflammation within the inner ear. This is known as labyrinthitis. This condition is characterized by the sudden onset of vertigo and may be associated with hearing loss.
Meniere disease is composed of a triad of symptoms: episodes of vertigo, ringing in the ears, and hearing loss. People have the abrupt onset of severe vertigo, fluctuating hearing loss, as well as periods in which they are symptom-free.
Acoustic neuroma is a type of tumor causing vertigo. Symptoms include vertigo with one-sided ringing in the ear and hearing loss.
Vertigo can be caused by decreased blood flow to the brain and base of the brain. Bleeding into the back of the brain is known as cerebellar hemorrhage and is characterized by vertigo, headache, difficulty walking, and inability to look toward the side of the bleed. The result is that the person's eyes gaze away from the side with the problem. Walking is also extremely impaired.
Vertigo is often the presenting symptom in multiple sclerosis. The onset is usually abrupt, and examination of the eyes may reveal the inability of the eyes to move past the midline toward the nose.
Head trauma and neck injury may also result in vertigo, which usually goes away on its own.
Migraine, a severe form of headache, may also cause vertigo. The vertigo is usually followed by a headache. There is often a prior history of similar episodes but no lasting problems.

As stated above, based on your negative neuroimaging it doesn't sound like you have a tumor or stroke.

I agree, in the thought that you may either have BPPV or an inner or middle ear problem (usually as a result of a viral infection to the ear.)

Meclizine and Lorazapam are standard treatments for BPPV, in addition to vestibular PT.
Some other medications include the following:
Diphenhydramine (Benadryl)
Scopolamine transdermal patch
Promethazine hydrochloride (Phenergan)
Diazepam (Valium)
Please remember that all of these medications do have side effects and should be cafefully chosen by your physician.

Although I do not see cases like your on a daily basis, the patients I have seen often state that physical therapy is MORE helpful than the medications!
There are two types of PT that you should consider:
1)Vestibular rehabilitation exercises consist of having you sit on the edge of a table and lie down to one side until the vertigo resolves followed by sitting up and lying down on the other side, again until the vertigo ceases. This is repeated until the vertigo is no longer inducible.
2) Particle repositioning maneuver is a treatment based on the idea that the condition is caused by small stones in the inner ear. Your head is repositioned to move the stones to their normal position. This maneuver should be repeated until the abnormal eye movements are no longer visible.

Unfortunately, despite medications and PT some patients continue to have their symptoms.

I strongly recommend that you see a vestibular neurologist.
If I may, I would like to recommend Dr. Neil Cherian at the Cleveland Clinic.
He is very experienced in this field and has done some amazing things with his vestibular patients.

Hope this helps,
Best of luck,
JKL, MD

[Godofredo MD]

Hi.

There are basically two types of treatments available for benign paroxysmal positional vertigo (BPPV), conservative and surgical. Conservative treatment basically involves a series of movements or "exercises" known as canalith repositioning procedure with the goal of moving particles from the fluid-filled semicircular canals of your inner ear (vestibular labyrinth) into a tiny bag-like structure (utricle) where these particles would not cause symptoms. The success rate for these procedures can range from 80-95%. Sometimes it may necessitate repeating the procedures for it to be successful.

Surgical treatment should only be considered if conservative treatment fails. The procedure is called posterior canal plugging and basically involves blocking the part of the inner ear causing the dizziness with a bone plug.which prevents floating particles in your ear canal from moving. Success rates with this procedure can reach as high as 90% but has a less than 5% chance of long-term hearing loss as a complication.

It would be advisable to try and undergo canalith repositioning procedures once more before deciding on whether surgery may be a viable option.

Talk to your doctor about this.

Good luck.