Vestibular Assessment

It is estimated that over 85% of dizziness is ear related. 

How can an audiologist help in the assessment and/or treatment of the dizzy patient?  For most dizzy patients, their otologist or physician will use medical history combined diagnostic tests to rule out non-ear related types of dizziness.  Once other medical or emergency type causes have been excluded, an audiologist can help.  Audiologists, specializing in the diagnosis and treatment of the dizzy patient, perform special tests to determine the cause of dizziness and the treatment needed.  It is estimated that over 85% of dizziness is ear related, most of which is easily diagnosed with the help of advanced technology and a highly trained staff, like that found at Heuser Hearing Institute.  Once a proper diagnosis has been made, a treatment plan follows.  Treatment is typically managed at Heuser Hearing Institute, but in cases where other professionals are needed, we have an extensive referral source as well as on-site multidisciplinary management.

After the exam and once a diagnosis have been determined, there may be multiple treatment options available.  Treatment for dizziness has been proven effective for most ear related dizziness.  Other treatments and management systems have been proven to manage most disorders of balance.  Recommendations may include physical or vestibular therapy, medication, diet management and occasionally surgical intervention.

Tests to determine the cause or source of dizziness may include hearing tests, balance tests, Electronystagmography (ENG), rotational tests, electrocochleography (Ecog) and others. The exam may include several tests including hearing tests, balance function tests, brainstem response evaluation and tests for dizziness. 

Audiometric evaluation or hearing tests:  a hearing test is often critical to determine the type and location of the vestibular problem, regardless of the presence or absence of hearing loss.  The hearing and balance systems share a common location as well as nerve position and fluids, so hearing or ear problems can often provide good information concerning dizziness.

Electronystagmogram (ENG) or Videonystagmogram (VNG) evaluates the function of the vestibular or balance portion of the inner ear.  Eye movements are measured while the inner ear is stimulated.  Stimulation may be produced by eye movement, head movement, body position changes or the presentation of cool and warm air or water into the inner ear.  Heuser Hearing Institute uses air.

Balance function tests include a series of progressive balance challenges to determine the relationships of vision, Somatosensory (skin, joints and muscles) and the vestibular system and their affects on balance. 

Rotational tests evaluate the inner ear and central nervous system function in response to rotational stimulation that is either active or passive.

Vestibular rehabilitation is a series of exercises or maneuvers designed to improve balance and reduce complaints of dizziness.

Auditory Brainstem Response evaluation measured the nerve of hearing into the brainstem area.  This test is used as needed for patients who may have not previously completed another site of lesion test such as a CT scan or MRI.  The test evaluates the function of the auditory system including the inner ear and auditory nerve.  The ABR is frequently used with children and infants.  Electrodes will be taped to the infant’s ears and forehead and electrical activity from the auditory nerve will be measured.  The test is performed while the child is sleeping and does not require the infant to respond in any way.  The test should be scheduled at a time when the infant will be sleepy or the test can be completed using sedation.  Heuser Hearing Institute does not use sedation; if the infant does not sleep, the test will be rescheduled or we will recommend another facility where the infant can be sedated for the test.  Immediately prior to testing, a bottle may be given in order to help the infant sleep.  The test usually takes 30 minutes once the infant is sleeping, but you should allow 2 hours for the entire procedure.

Otoacoustic Emissions:  Otoacoustic Emissions evaluates the function of the inner ear; the test simply identifies if there is inner ear function but does not measure the amount of hearing.  The test can be performed while the infant is awake but he/she has to be quiet and still.  This test may be used if the infant is not sleeping for the ABR.  However, if the OAE is the only test completed, the evaluation will be inconclusive and additional testing will be scheduled.

Electrocochleography:  An electrocochleogram measures and records electrical responses from the cochlea.  This test is often used in conjunction with history and other tests to make a diagnosis of endolymphatic hydrops.

A complete vestibular, or dizzy, assessment will take about two hours.  The test is painless but you may feel dizzy or nauseated for some time after the appointment.  It is recommended that you arrange for someone to drive you home following your appointment. 

Frequently asked questions

Can I still take medication prior to the exam?  Medication prescribed for dizziness should not be taken.  A patient is encouraged to follow the provided instructions which basically prohibit any medication other than life sustaining medication.  If a patient is still in doubt, they should contact the prescribing doctor. 

Will the test make me sick?

The testing procedures cause some patients to become nauseated.  For this reason, patients are instructed not to ear three hours prior to the exam?

What is the exam?

Dear Patient:

Thank you for choosing our clinic.  Please read and complete all of the information in this packet prior to your appointment scheduled for ________________________ at ______________________. 

You have been scheduled for dizziness and/or balance testing.  The testing will take about two hours.  Testing is painless, but you may feel dizzy or nauseated for some time after the appointment.  For this reason, we recommend that you arrange for someone to drive you home following your appointment.

Dizziness and balance testing is generally divided into three parts.  For all of the procedures, you will have electrodes taped to our face; so that eye movements can be measured.  First, you will be asked to watch a series of lights on the wall.  Second, you will be asked to move your head and body into several different positions.  Finally, we will introduce warm and cool air into your ear canal. 

Please note, certain medications may change the finding of the examination.  We ask that you do not take any nonessential medications for a period of 48 hours before your appointment time, and that you avoid the following:

Anti-dizzy pills
Sleeping pills
Tranquilizers
Antihistamines
Narcotics
Over the counter cold or allergy medication
Medications which contain any of the above
Alcoholic beverages

Do not discontinue medications for blood pressure control, cardiac or circulatory problems, diabetes or other medications for similar medical disorders.  If you have any concerns about medications, please callus at 502-584-3573.

Also,

Do not eat or drink anything for a period of three hours before the time of the test
Do not drink any caffeinated beverages on the day of the test
Do not use any tobacco products on the day of the test
Do not wear make-up or face cream the day of the test.

Again, thank you for choosing Heuser Hearing Institute/Home of the Louisville Deaf Oral School.  If you have any further questions or need further instructions, please call us at 502-584-3573.

How does the inner ear work?

The inner ear is divided into three main parts.  One part, the cochlea, is the hearing organ.  The other two parts, the vestibule and semi-circular canals, play a role in balance maintenance. The vestibule is a domed shaped area between the cochlea and semi-circular canals.  Its primary role is to let you know how much you are moving forward and backward.  The semi-circular canals tell you where your head is in space and provides information relative to angular acceleration.  The ear combined with vision, muscles and touch help you to maintain your balance.  Misleading information from any of these areas can cause a patient to be dizzy or off balance.  A vestibular and balance assessment is designed to identify the weakest part or parts of the system so that correction can follow. 

Common diagnoses include:

Benign Paroxysmal Positioning Vertigo
Inner ear infections
Neuronitis
Labyrinthitis
Meniere’s Disease
Mal de Debarquement

There are many other common causes of dizziness.  More information on causes and more detail for the listed diagnoses can be found at the Vestibular Disorders Association website,  www.vestibular.org


Benign Paroxysmal Positioning Vertigo (BPPV)

Benign Paroxysmal Positioning Vertigo (BPPV) is a condition of the inner ear that causes episodic vertigo (spinning) and/or a pitching sensation.  Symptoms often occur when a patient looks up, down or lies on their side.  If BPPV is left untreated, it can lead to a constant sensation of light headedness or imbalance.  This sensation is a result of desynchronization of eye and head movement.

What it means:

Benign:  you can live with it forever
Paroxysmal:  it may show up more or less intensely from one month or week to the next.
Positional:  triggered by certain positions of the head
Vertigo:  short spinning or pitching sensation.

Anatomy of BPPV:

If you could walk into the inner ear, you would walk into an area called the vestibule.  Off of that vestibule, you will find the cochlear that helps you hear and the semicircular canals that help you maintain your balance and know where your head is in space.  The whole apparatus is filled with the same fluid.  The difference however, is that the cochlea and the semi-circular canals are tube shaped, so the fluid just flows through easily to let you know what you are hearing or where your head is in space.  The vestibule is a dome shaped area, so if there wasn’t something on top of the fluid; it would slosh around in your head.  On top of the fluid, you have a layer of jello-like material with a layer of crystals or rocks imbedded in it.  The rocks or crystals help you to know how much you are moving forward and backward.  In cases of BPPV, some of the crystals or debris have become dislodged and fall into an area that causes you to feel dizzy.  Typically, the debris falls into one of the front two canals of balance.  When they do, the patient will experience debilitating vertigo.  The debris will go back on its own and the patient will be fine.  In some case of BPPV, the debris has fall into the posterior or back canal for balance.  The debris will get stuck in that area resulting in episodic vertigo (dizziness).

Common causes of BPPV:

BPPV is commonly caused by head injury, a history of allergy and sinus trouble, a history or ear related surgery and gravity or head position.  There are many other causes of BPPV.  Because BPPV is often a result of gravity, people who are prone to developing a case of BPPV include people who have experienced long surgeries and people who have a vocation that requires their head to be in the same position for many hours.  Vocations most commonly affected include painters, mechanics and electricians.

Treatment:

Benign Paroxysmal Positioning Vertigo is treatable in 98% of cases.  There are multiple treatment options that are dictated by patient symptoms and needs.

Instructions following the Canalith Repositioning Procedure (CRP)

For the first 48 hours:

Do not tip your head up or down or bend at the waist.  Pretend there is a book balanced on top of your head and do not let it fall off.  Use of the cervical collar will help prevent you from tipping your chin down.  Sides to side turns are OK.
Do not go to appointments that require you to lie down or tilt your head (barber, dentist, chiropractor).
When brushing your teeth, rinse your mouth with a cup to avoid bending over.
You may shower or wash your hair but avoid tipping your head up or down.
Avoid repetitive motions, such as weeding the garden, ironing or sweeping.

Sleeping:  For the first 48 hours, sleep tilted back slightly at no more than a 45 degree angle.  It is easiest to sleep in a recliner if available.  Otherwise, use several pillows to prop yourself.  It is a good idea to put pillows at your feet to avoid scooting down in the night.  Do not rollover.  On the third night, you may sleep flat but not on the treated side.

It is best to avoid sleeping on your treated side (right/left) for the remainder of the week.

Post-treatment symptoms:

Many people experience an immediate change in head or ear pressure.  Most people experience total relief after the three day waiting period.
Headaches are common.  Typically, a patient who experiences headaches with episodes will also experience headaches post treatment.
Patients sometimes feel different, but not better, following a maneuver.  If symptoms persist the maneuver may need to be repeated or a different type of maneuver may be chosen.  Be patient.  Two to three procedures are typically required for those who do not respond to the first procedure.

These are general guidelines and may not apply in cases of head injury or multiple vestibular dysfunctions.

Meniere’s disease may also be called endolymphatic hydrops.  People who have Meniere’s are thought to have the symptom pattern associated with endolymphatic hydrops.  A person who has endolymphatic hydrops does not necessarily have Meniere’s disease. It is a disorder of the vestibular system of the inner ear.  It results from fluctuations of the amount or consistency of the inner ear fluid called endolymph.  Symptoms include dizziness, imbalance, fullness, pressure and tinnitus (ringing in the ears).  Other forms of this disease and/or names include cochlear hydrops, endolymphatic hydrops, Meniere’s disease, traumatic Meniere’s disease.  Sometimes the presentation of symptoms may vary slightly.  If that’s the case, a patient may have a diagnosis of atypical Meniere’s disease.  Symptom management should be physician directed.  Some patients with Meniere’s disease report benefit from traditional vestibular therapy programs.  It is also important to note that a person with know Meniere’s disease may be susceptible to other forms of dizziness that can be treated rather than managed.

Labyrinthitis and neuronitis are viral infections of the inner ear labyrinth (labyrinthitis) or vestibular nerve (neuronitis).  Bacterial infections may also spread from the middle ear resulting in infection of the inner ear.  Treatment is dependent upon early and appropriate diagnosis and is typically medically managed.  Once treated and if dizzy symptoms persist, an uncompensated lesion may be present.  Uncompensated vestibular lesions typically respond well to vestibular management.  A vestibular assessment to be followed by appropriate therapy is typical. 

Mal de Debarquement results from prolonged exposure to motion in some people.  It typically occurs after long sea cruises or airplane flights.  Patients typically complain of a constant rocking sensation.  Symptoms typically last for up to a year but can last for many years in rare cases.  A person with Mal de Debarquement should be medically managed until their symptoms subside.  They will have a normal vestibular assessment or dizzy test.

Perilymph Fistula is a small hole or tear in the membranes of the inner ear that separate the inner ear from the middle ear.  If a fistula is present, changes in middle ear pressure will directly affect the inner ear resulting in possible dizziness, vertigo, imbalance, nausea, vomiting, ringing, ear fullness and dizziness or nausea with sound stimulations.  Changes in altitude, air pressure or physical exertion may exacerbate symptoms.  Fistulas, or holes, may occur in other parts of the inner ear resulting in similar symptoms.  Fistulas should be medically managed.  Audiologic and vestibular evaluation can help to determine the likelihood of a fistula.  If tests indicate fistula presence, a surgery to explore the suspect area may be scheduled.  Repair may be scheduled as needed.  Other fistulas in bony material of the inner ear and its surroundings may be visible using CT scans.