Mechanism

Benign paroxysmal positional vertigo, or BPPV, is a common condition that affects the balance mechanism.  Sometimes we do not know the cause.  It may reflect a viral infection or it can occur after trauma.  Acute attacks of vertigo take place, associated with head movement.  The mechanism by which this disorder occurs is the presence of otoconial debris (calcium crystals) that become displaced into one, or occasionally more, of the semi-circular canals.  The movement of the head causes this debris to move within the canal and this generates an abnormal stimulus of the ampullary crest on one side compared to the other.  The person will perceive a feeling of movement (vertigo) when in fact they remain stationary. 

Symptoms

BPPV Vertigo (spinning sensation), light-headedness, imbalance, nausea, headache.

Symptoms of BPPV are almost always caused by movement or change in head position.  The most common motions that trigger the BPPV-related dizziness are laying down, rolling over in bed and getting out of bed.  Others may experience vertigo when tipping their head to look up or rapidly moving their head sideways.  The symptoms are usually consistent, occurring every time the person is exposed to certain head motion, although intermittent and episodic reactions are also common.

People with BPPV report prolonged feelings of loss of equilibrium or just “not being right” between the more acute episodes.  It is increasingly being recognised that postural control is also impaired outside acute episodes.  The older the patient, the worse the postural control and this has been shown by comparison to normal people without a balance disorder at different ages.

Diagnosis
Comprehensive history of symptoms
Physical examination
Dix-Hallpike manoeuvre

Treatment
Highly specialised vestibular rehabilitation therapy.  The “Epley” manoeuvre is used to manipulate the “calcium crystals” out of the semi-circular canals, and effectively rid the patient from vertigo and dizziness symptoms.  The key message for all people who have suffered BPPV from whatever cause including trauma is that the more one treats the condition with specialised therapists, then the more likely the better outcome with a good prognosis. 

Mechanism

Both vestibular neuritis and labyrinthitis are caused by viral or bacterial infection of the vestibulo-cochlear nerve that carries information about the hearing and balance from the inner ear to the brain.  Neuritis affects the vestibular (balance) part of the nerve, whereas labyrinthitis usually affect both the vestibular and cochlear (hearing) parts of the nerve. 

The infection can cause nerve inflammation either on one or both sides, inhibiting the normal conduction of signals to the brain.  If one side gets inflamed, then it will conduct impulses at a reduced rate and amplitude.  This in turn creates a mismatch in signals coming from both sides, causing brain to perceive a weakness on the inflamed side.  Thus, the person will perceive a feeling of movement (vertigo) when in fact they remain stationary.  The spinning can either be clock-wise or anti-clock wise, depending which side is affected.

The inner ear infection if different to the middle ear infection – a common bacterial infection affecting the eardrum that is prevalent in children (“glue-ear”). 

Symptoms

Vestibular neuritis normally causes symptoms of vertigo, dizziness, imbalance (walking, standing, and posture), nausea and headache.
Labyrinthitis normally causes symptoms of vertigo, dizziness, imbalance, nausea and headaches and is also associated with hearing loss and/or ringing in the ears (tinnitus).

Symptoms can range in severity, from general light-headedness to severe vertigo.  The initial attack is normally more acute than the subsequent ones, can occur suddenly and last for many hours.  It can also be associated with nausea and vomiting, lack of concentration, imbalance, and severe fatigue.  Most people are unable to get out of bed or move during the duration of the initial attack. In the case of labyrinthitis, vertigo and dizziness may also be associated with hearing loss and tinnitus.  The acute stage is normally followed by a recovery stage, during which one may still feel “muzzy” and unbalanced.  The recovery stage may take several weeks, months and even a year.  In rare cases, some will present with chronic symptoms of dizziness.

Diagnosis

Comprehensive history of symptoms
Physical examination
Specialised vestibular function tests

Treatment

Following the acute stage, the recovery from vestibular neuritis and labyrinthitis can be facilitated with the highly specialised and customised vestibular rehabilitation therapy.

Mechanism

Meniere’s Diasease, is a vestibular disorder that occurs due to an increased fluid (endolymph) build-up in the inner ear.  The exact cause of this is not known, but theories focus around circulation problems, auto-immune reaction, allergies, viral infection, and genetic factors. 

Although trigger factors are also not clear, it is thought that stress, fatigue, diet pressure changes, and other illnesses contribute significantly provoking the symptoms.

Symptoms

Meniere’s disease is a collection of symptoms.  These include severe vertigo, hearing loss, tinnitus (ringing in the ears), and ear fullness/pressure.  Other symptoms may include nausea, headache and post-episodic fatigue.  The attacks are spontaneous and can last up to 24 hours.  They can also be consistent – happen a few time per day/week/months; or irregular – often separated by a symptom-free period.  Meniere’s disease does not follow a particular pattern, and it is hard to predict how it will develop over time. 

Diagnosis
Comprehensive history of symptoms
Physical examination
Hearing test
Specialised vestibular function tests

Treatment
People with diagnosed Meniere’s disease should be under the care of an ENT specialist and their GP.

Highly specialised and customised vestibular rehabilitation therapy is very effective in helping people with Meniere’s disease to manage and control their balance symptoms (vertigo, unsteadiness).

Migraine is a common disorder affecting between 10 and 20% of the population. Balance disorders are also common so it is likely that an individual may have both conditions. Recently however it as been identified that in some people the vertigo is part of the migraine process a little like what is known as migraine aura. This means migraine treatments may be helpful. Usually a specialist neurological opinion is needed.

Motion sickness is an intriguing phenomenon. It is caused by the balance mechanism telling us that we are moving whereas the visual mechanism gets the perception that there is not such movement.  Different people will get more or less motion sickness according to many factors including a genetic predisposition and what would be regarded as a less trained interaction between the balance mechanism and the visual pathway.  For instance the best way to avoid motion sickness when on a boat is to go out on deck and let the visual pathway focus on the horizon so that the visual impulses are picking up the same message as the vestibular mechanism itself. 

Perilymph fistula – a rupture in one of the inner ear structures, which causes a leakage of the inner ear fluid into the middle ear cavity.  Symptoms include short spells of vertigo, dizziness, nausea, hearing loss and tinnitus.  Triggers include changes in atmospheric pressure, altitude, going into a lift or a plane, and weather changes.  Perilymph fistula normally heals by itself with time, however surgical interventions are also common.

Ototoxicity – a damage caused to the inner ear or the vestibule-cochlear nerve due to drugs or chemicals.  It can results in permanent or temporary damage to hearing and/or balance.

Acoustic Neuroma – a non-malignant and slow-growing tumour of the vestibulo-cochlear nerve.  As it grows, it puts pressure on the surrounding nerves, inhibiting their function.  Symptoms include vertigo, dizziness, hearing loss and tinnitus.  Often it causes facial weakness and numbness on the same side, and in some cases, facial paralysis. Diagnosis includes regular hearing tests, specialised audiometric procedures (ABR, ASSR), MRI and CT scans.  Treatments include radiotherapy and surgery.  Following the surgery, there may be long-standing effects on the balance system, resulting in disequilibrium and imbalance.  Highly specialised and customised vestibular rehabilitation therapy is very effective in helping people to manage and control their balance symptoms following an acoustic neuroma surgery.

Superior Canal Dehiscence – better known as a Tulio phenomenon, is a very rare medical condition that is caused by the thinning of the bone that surrounds the inner ear.  The thinning may be due to gradual erosion, head trauma, or congenital factors.  Because the bone surround both the cochlear (hearing) and vestibular (balance) parts of the inner ear, SCD can lead to both hearing and balance problems.  Hearing symptoms may include hearing loss, tinnitus (subjective perception of noise, when the actual noise is absent), unusual sensitivity to normal sounds (hyperacusis), fatigue, and headaches.  Balance symptoms include noise-induced vertigo (Tulio phenomenon), dizziness, chronic imbalance, disequilibrium, motion sickness and nausea.  SCD is treated by surgical intervention used to repair the thinning bone.  Alternative techniques, such as plugging og the superior semi-circular canal, are also common.  Highly specialised and customised vestibular rehabilitation therapy is very effective in helping people to manage and control their balance symptoms following caused by SCD, both prior and after the surgery.