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Dizziness and Balance Testing

*Please note that a Doctor’s Prescription Referral is required for all testing.

What is Inner Ear/Vestibular Testing (Info for patients)

We are testing different parts of the inner ear to determine what is causing your dizziness. Over 80% of dizziness id from the inner ear- however, there may be different causes also.

The testing is non invasive and does not hurt. It usually takes about two hours

The testing includes:

  • Hearing
  • Inner ear sensory cell function, an automatic test with tones
  • pressure test for middle ear
  • Auditory brainstem response (ABR)- an automatic test that measure the pathway to brain, listening to clicking sounds
  • positional test where you lie in different positions to see if you get dizzy
  • Oculomotor tests to test your eye muscles by looking at target
  • air into ear canal to test inner ear function, no pain lasts a few seconds.

Balance & Dizziness

Acoustic Neuroma

Acoustic neuromas (also known as vestibular schwannomas) are slow growing non-malignant tumors of the 8th cranial nerve (hearing nerve). Most commonly, they occur on the covering cells (Schwannoma cells) of vestibular nerve. These cells provide the insulation of the nerves, much like the insulation around an electrical wire. Acoustic neuromas usually cause hearing loss and may or may not cause dizziness or imbalance. The most common symptoms of acoustic neuroma slow, progressive, sensorineural hearing loss in the affected ear. Typically, the hearing loss occurs over months or years associated with poor speech recognition and tinnitus. About 20% of patients will have dizziness or imbalance.


Anxiety and Panic Syndrome Vertigo

Panic attacks are usually characterized by sudden bursts of unexpected fear or stress. The symptoms can include palpitations (racing heart), lightheadedness, dizziness, vertigo or lack of balance and an overwhelming need to escape. Commonly, patients experience hyperventilation, tightness in the chest as though the lungs cannot be adequately filled with air. The attacks typically last 1 0-20 minutes. The dizziness can take several forms from a lightheaded sensation to a progressing near-faint dizziness due to hyperventilation. Dizziness associated with Anxiety is usually a vague sensation of floating or lightheadedness along with fatigue. These symptoms often occur when the patient is alone, sitting quietly. They may feel nauseated, lose their balance or fall. The symptoms may be intermittent or last for years, varying in intensity from day to day. Anxiety attacks are often associated with having to make major decisions.


Benign Positional Vertigo (BPV)

Benign Positional Vertigo (BPV) is caused by loose particles which have been displaced in the inner ear. These particles are formally called "Otoconia". The Otoconia are small crystals of calcium carbonate usually located in the "utricle" of the inner ear, however, they become displaced into one of the semi-circular canals. The symptoms of Benign Positional Vertigo are almost always provoked by changes in the head or body position. The most common positions include: lying flat in bed, getting up from bed, rolling over in bed, looking up or bending over. The vertigo typically lasts only a few seconds. In between episodes patients may feel off-balance or lightheaded.


Bilateral Vestibular Lesion

Bilateral vestibular lesion results in a loss of balance typically due to ototoxic medications. Both vestibular organs are damaged. Symptoms include a loss of sure footedness, the necessity of touching walls or objects to help keep balance, and trouble changing surfaces, e.g., tile to carpeting.

Treatment Options Include:

  • Balance Retraining
  • Vestibular Therapy

Cervical Vertigo

Vertigo or dizziness due to a neck injury or is provoked by a neck posture no matter what the orientation of the head is to gravity. When cervical vertigo is diagnosed, the usual symptoms are dizziness associated with neck movement, stiff neck, pain in the head, neck or arms. There is usually no hearing loss but there may be ear pain (otalgia).

Demylinating Disease/Multiple Sclerosis

Dizziness and/or Imbalance is the initial symptom in 5-15% of patients with Multiple Sclerosis. Almost 50% of patient's with MS experience dizziness or imbalance at some time during the course of the illness. The dizziness is typically transient. Nystagmus may be present. Other symptoms include blurry vision, weakness, numbness and ataxia. A typical bout of dizziness associated with MS lasts from hours to days and positional dizziness or head motion dizziness (Oscillopsia) may be present, lasting a few seconds. Patients may be unsteady and fall when they close their eyes.


Enlarged Vestibular Aqueducts (EVA) in Children and Hearing Loss

What are Vestibular Aqueducts?

Vestibular aqueducts are narrow, bony canals which are "J-shaped" in adults. In young children, they are short and straight and continue to develop up to the age of 3 or 4. The aqueducts are one of the last parts of the inner ear to develop and are vulnerable to developmental damage.

Recent research indicates the vestibular aqueduct contains fluid that contains certain chemicals
needed to help start the nerve signals that send both sound and balance information to the brain. The correct fluid content and levels appear to be extremely important during the development of the inner ear by influencing the shape of the bony structure.

What are enlarged Vestibular Aqueducts?

Enlarged vestibular aqueducts (EVA) are estimated to occur in up to 20% of cases of sensorineural hearing loss in young children. They are caused by minor head injuries, change in barometric pressure and physical exertion. Excessive noise exposure has also been reported as a cause. An enlarged vestibular aqueduct is defined as a diameter of 1.5mm or greater (normal is defined as .8mm) and are identified by CT scanning or MRI.

Symptoms of Enlarged Vestibular Aqueducts:

  • sudden drop in hearing
  • fluctuating sensorineural hearing loss
  • a progressive hearing loss
  • sudden decrease in speech recognition
  • sudden decline in school performance with no explanation
  • complaint of dizziness

Any or all of the above following a mild head trauma. pressure change or physical exertion

Treatment for Enlarged Vestibular Aqueduct:

There are no accepted medical or surgical treatments for hearing loss resulting from enlarged
vestibular aqueduct syndrome. There has been no scientific research showing that steroids are
effective in treating the sudden hearing loss associated with EVA and studies have shown that
surgery to either drain the liquid or remove the duct can be harmful in destroying the residual
hearing.

Early identification is a key in maintaining the auditory skills to develop speech in younger children. Patients with EVA should be advised to avoid the known triggers such as mild head trauma by limiting contact sports or factors that may trigger sudden drops in hearing.


Labyrinthitis

Labyrinthitis is an inflammation or damage to the inner ear often due to a viral or bacterial infection. The virus typically affects both the hearing and balance portions of the inner ear creating symptoms of both hearing loss and dizziness. Labyrinthitis differs from Neuritis as Neuritis affects the vestibular nerve and patients with Neuritis suffer from dizziness without hearing loss. The syndrome of Labyrinthitis include sudden onset of vertigo, commonly associated with head or body movement, diminished hearing - usually in one ear, nausea, vomiting, or malaise. Tinnitus may also be present. The initial episode is typically the worst, lasting several hours. The vertigo usually becomes better over time and the episodes may only last a few minutes.

Damage to one inner ear.

Treatment Options Include:

  • Vestibular Therapy
  • Anti dizziness medication while acute

Mal Debarquement

Mal de Debarquement Syndrome (or MdDS) is an imbalance or rocking sensation that occurs after exposure to motion (most commonly after a sea cruise or a flight). After alighting or "debarking" (debarquement) the traveller continues to feel "at sea", unable to get their land legs back. Although most travellers can identify with this feeling and do actually experience it temporarily after disembarking, in the case of MdDS sufferers it can persist for many weeks, months, even years afterwards. The symptoms are with person constantly, they never leave, nor can they be alleviated by any anti-motion drugs. "Like trying to constantly walk on a mattress or trampoline" is a good description of the main symptom, which is usually most pronounced when the patient is sitting still; in fact, the sensations are usually minimized by actual motion such as walking or driving. Symptoms include rocking, swaying, bobbing, floating, imbalance.


Menieres Disease

Meniere's Disease is caused by excessive fluid I pressure buildup in the inner ear causing episodic vertigo attacks, fluctuating hearing loss, tinnitus, and a feeling of pressure or fullness in the involved ear. The attacks are characterized by dizziness with nausea and vomiting lasting hours or days in duration.

Treatment Options Include:

Dietary changes

Modifying the diet can reduce the body's fluid retention and help decrease fluid buildup in the inner ear.

Middle ear injections

In this approach, the doctor injects gentamicin (Garamycin), an antibiotic through the eardrum and into the inner ear, where it's absorbed.

Surgery

If the vertigo attacks associated with Meniere's disease are severe and debilitating and medical treatments don't help, surgery may be an option. Procedures may include:

  • Endolymphatic sac procedures.
  • Labyrinthectomy
  • Vestibular neurectomy
  • Rehabilitation

*If there are problems between attacks, patients may benefit from Vestibular therapy. The goal of Vestibular therapy is to help the body and brain regain the ability to process balance information correctly.


Neuritis

In vestibular neuritis, dizziness is attributed to a viral infection of the vestibular nerve. Symptoms include sudden onset of vertigo (without hearing loss), nausea and vomiting. The attacks often occur seasonally in spring or early summer and maybe associated with an upper respiratory infection. The initial attack typically is the worst, lasting from several hours to two or three days. The dizziness improves over time, may only last a few seconds/minutes and is usually provoked by motion.

Treatment Options Include:

  • Anti dizziness medications during acute episode
  • Vestibular Therapy

Oscillopsia

Oscillopsia is a visual disturbance in which objects in the environment appear to move or bounce when the head is turned or when the patient tries to look at objects while walking. Oscillopsia is caused by a miscommunication between the eyes and the inner ear. Symptoms include: motion sickness, dizziness when looking at busy patterns on walls or walking down grocery aisles, difficulty reading in a car, imbalance and nausea. The symptoms may last a few minutes or longer. Patients often feel better when they remain still.


Perilymphatic Fistula

A perilymphatic fistula occurs when there is a break/tear in the inner ear allowing perilymph fluid to leak out. The tear usually occurs at the round or oval window. The most common symptoms include brief episodes of vertigo (lasting a few seconds up to a couple of minutes) associated with change in pressure such as coughing, sneezing, going to the bathroom, exercising or straining. Hearing loss and tinnitus may also be present. The causes of perilymphatic fistulas include trauma, surgery, scuba diving or ear infections.

Treatment Options Include:

  • Surgery
  • Site of Lesion Testing

Sudden Hearing Loss

Symptoms: Sudden Hearing Loss is defined as a sudden decrease or loss of hearing in one or both ears. This may be followed or accompanied by tinnitus in the ears. Dizziness may also occur prior to or during the hearing loss.

Causes: As there is no clear cause, however there are many probable causes.

  1. Viral and infections
  2. Autoimmune
  3. Labyrinthine membrane rupture/traumatic
  4. Vascular
  5. Neurologic
  6. Neoplastic

Treatment

Treatment is assessed upon severity, time elapsed and audiometric criteria. A patient who experiences a sudden hearing loss should seek rapid medical attention. Every case varies, depending on the suspected cause. The patient may be given medicine to increase circulation of the inner ear and to reduce excessive fluid build up in the middle ear or inner ear. The patients' diet may be modified to decrease the intake of certain substances. Most patients will undergo imagining to rule out certain pathologies. High doses of steroids are often used to restore hearing. Outcomes vary with steroid use and patients may have anywhere from no improvement to almost complete restoration of hearing.


Superior Canal Dehiscence

Superior Canal Dehiscence Syndrome is a balance disorder resulting from a hole in the bone overlying the superior semicircular canal within the inner ear. This abnormal opening affects the vestibula-ocular reflex and can cause dizziness, nausea and Tullios syndrome (vertigo and imbalance triggered by sound). Patients with SCD syndrome often present with dizziness that is worsened by loud noises or pressure.

Treatment options include:


Surgical treatment involves patching the bone from inside the skull. According to the Laboratory of Vestibular Neurophysiology at Johns Hopkins University School of Medicine, this treatment, which is sometimes coupled with physical therapy, has been successful in relieving symptoms.


Tinnitus (Ear/Head Noise)

Tinnitus has been described as "ringing" or "sound" that is heard in the ears or head. The sound could be a buzzing, cricket sound, hiss, roaring or tone. It may be a result of damage to the inner ear or other sources. Recent research suggests tinnitus from the inner ear may be a result of damage at the cell level. It is theorized the other hair cells in the cochlear (or inner ear) are damaged. This damage to the hair cells may occur from noise exposure, aging, medications such as Chemotherapy or ear infections. Tinnitus may be related to hearing loss, however having tinnitus does not mean you are loosing your hearing. Non-inner ear causes of tinnitus include: systemic disease such as Lyme disease, cardiovascular problems, benign tumors, head trauma and medications. Non inner ear sources of tinnitus may need medical intervention.

What may make tinnitus worse?

  • Caffeine
  • Smoking
  • Alcohol
  • Salty foods
  • Aspirin
  • Loud Noises
  • Stress
  • Sugar
  • Cough Medications

Treatment options for Inner Ear related tinnitus include:

  • Tinnitus Maskers
  • Hearing aids if hearing loss is present
  • Alternative Medicine such as Acupuncture and Hypnosis
  • Bedside white noise generators: ocean/rainfall sounds

National Associations:
American Tinnitus Association
P.O. Box 5
Portland, Oregon 97207
800-634-8978


Vestibular Migraines

Vestibular Migraines is a disorder associated with headaches and can cause several vestibular syndromes. Migraine is extremely common. Dizziness can occur before, during, or separately from the episodes of migraine headaches. Migraine with aura, or classic migraine, is associated with short symptoms (sensitivity to sounds and light, tingling, numbness, dizziness or lightheadedness). These symptoms, known as aura, precedes the headache and lasts 5 to 20 minutes. Stress, anxiety, hypoglycemia, fluctuating estrogen, certain foods, smoking, and other factors can trigger migraine. Vertigo and imbalance secondary to migraine usually respond to the same treatment used for migraine headaches.

Treatment options include:

Treatment of vestibular migraine includes eliminating from the diet substances known to trigger migraine attacks, such as chocolate, nuts, cheese, red wine, and other foods. Medications may also be prescribed.


Whiplash Vertigo

Whiplash is described as hyperextension of the neck following an accidentmost commonly a car accident. Dizziness and vertigo are reported to be the most frequent symptoms following a whiplash injury. Damage to the soft tissue of the neck is the source of cervical-vestibular disturbance. With this type of injury, the patient becomes dizzy when he turns his head or extends the neck muscle. Benign positional vertigo (BPV) is also common with whiplash and creates position induced vertigo often when the patient lies flat, looks up or bends over. The positional vertigo (BPV) is caused by calcium crystals being displaced into one of the semi-circular canals as a result of the whiplash. Other symptoms with whiplash injury include headaches, neck pain, back pain and spontaneous nystagmus.

Treatment Options:

  • Cervical vestibular symptoms are typically treated with physical therapy for the treatment of the soft tissue of the neck.
  • Benign Positional Vertigo is typically treated with Canalith repositioning.