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New Treatments for Dizziness, Tinnitus and Hearing Loss

If the patient is saying dizziness, we have to learn to divide it like this and then our questioning will become more appropriate and then you will come to a diagnosis, in terms of deciding which system is involved. So now one of the visual causes of dizziness. Some of the common causes are recent correction of refractive errors.

Proprioceptive defects; peripheral neuropathy, diabetic, alcoholic, infections, leprosy - you donít see - dietary deficiencies, trauma. Now how many of you believe that neck trauma causes dizziness? Okay, only a minority. What do the majority think? You donít think that neck trauma can cause dizziness? Have you ever seen a patient after being rear-ended in an auto accident? What do they complain of? They are complaining of dizziness.

Labyrinthine causes of dizziness: now labyrinthine causes, first of all they can be developmental and you donít have to worry about that. But trauma, vestibular concussion. Now if you get a head injury and you donít get a fracture line going through the labyrinth like you are seeing over here - I know you donít know how to interpret these x-rays - but weíll tell you that there is a fracture line which is going through the labyrinth and it has destroyed the labyrinth. Then that is a separate thing from vestibular concussion. Now vestibular concussion and auditory concussion.

Now ablation. The ear ablation has destroyed the labyrinth. Now infections. There can be bacterial infections of the inner ear, syphilitic infection is on the rise now. And syphilitic infections can cause symptoms that are just like MťniŤre's disease. The patient has a fluctuating hearing loss, so one day he is better and three weeks later he is worse. You treat them with steroids and they get better, then they get more down. So syphilitic infections you should keep in mind.

Now there are some inner ear - we talked about infection - and I donít know if all of you look inside the ear and can appreciate what is happening in the ear. But if you look in the ear and you find a little hole above the short process of the malleus like this, this is called a cholesteatoma. And this cholesteatoma has got a capacity for eroding into the inner ear.

Then there are intracranial causes. These intracranial causes can be intra-axial. This is the pons, here is the fourth ventricle. Or they can be extra-axial in the posterior fossa. They can be pre-pontine, at the cerebellar pontine angle, and so on. I want to show you some examples. So extra-axial congenital lesions. This here is a epidermoid in the cerebellar pontine angle.

Then vascular malformations. In the angle you can have a vascular malformation, and this lady was very interesting. She came into the emergency room with acute vertigo. So she was admitted into the neurological service and they did all the tests and everything was normal, so they sent the patient over to me to find out if the ear was responsible.

Now there can be intra-axial congenital causes. Here is a Dandy-Walker cyst. This man was complaining of slight imbalance. And then you can have a Chiari malformation causing imbalance. Then you can have an epidermoid between the cerebellar hemispheres which can cause dizziness. Of course you can have extra-axial acquired lesions, tumors.

Then infarcts. Here is a patient with an infarct. I always have a argument with the neurologists. They say, "Oh, we see all those kind of little things all the time. Bright objects, donít mean anything." But if the patient is symptomatic and if certain tests indicate that the problem is in the brain, then I think they become significant. So far we have not had the technology.

Demyelination of course. And then I donít know if you all pay attention to the vermis but the vermis is an important structure, having connections with the vestibular system. And if you see a vermis which has got so much CSF around it, and this begins to look like a Christmas tree, then this is atrophy which is significant.

In the output system. What can be the problem in the output system? There can be skeletal anomalies following joint surgery and you know that if you have a joint replacement, you may have - the orthopedic surgeon may measure everything very well - but one limb may turn out to be a little longer than the other.

So we come down to this wonderful scheme, and we have now excluded all these others from our history. Talking to the patient you can, for the most part, exclude that. Now we focus on this system, and this is the tough one for you. Because youíve never heard this before. Okay, now this is what this organ looks like.

Okay, how do they do this? I wonít talk so much about these two because we donít evaluate these in our clinical evaluations. I just want to show you a little bit of anatomy, and this may be a little bit too complicated for you, but bear with me. This is the cochlea that I just showed you, the cochlea and this is the semicircular canal.

Notice the ampullated end of the canal. You know there is a dilated end, an ampullated end and there is a non-ampullated end. The ampullated end has got a ridge in its middle. Thatís not too difficult to understand. You can see that ridge. Now we are just going to talk about the horizontal canal. Donít get confused about the vertical canals. Just the horizontal canals. So here it is, this is the horizontal canal.

Now letís see what happens when you get a labyrinthine ablation. Are you called in to see head injuries in your hospitals? Yes. Okay. Now supposing the patient is brought into the hospital, head injury, and he has blood coming out of this ear and heís got some clear fluid also coming out of the ear. What you do is put it on some blotting paper of some kind and then you will see that there will be the halo sign. All of you know about that, right?

So here is the effect of unilateral vestibular loss. There is a horizontal spontaneous nystagmus toward the good ear, the head and body tilt is towards the lesion and if you do past-pointing, which is difficult in the patient who just had a crack on his head, but if you were to sit him down like this and have him point with his index finger like so and you stand opposite the

Now of course there is compensation. So after this organ has been destroyed there will be compensations. Now some diseases will only destroy it to that extent where recovery is possible. For example, an acute attack of MťniŤre's, the diseased organ will be restored to health and everything will be fine for awhile, until he gets the next attack.

Now if a patient has had a unilateral loss of vestibular function and he has to get up in the middle of the night to go to the bathroom, and there is not enough light, he is going to say, "I am even more dizzy." Why? Because I told you that we maintain our balance because we have input from the visual system, the vestibular system and the proprioceptive system. Now one vestibular system is not working. If the eyes arenít seeing, then two are not working.

So you have to characterize the dizziness then you have to ask about the time course. Is it episodic? Is it constant? If it is episodic, how long does it last? How often does it occur? Is it getting more frequent? Is it getting less frequent? Are you feeling better? Is it more intense? Is it less intense? All those questions have to be entered in because the whole thing.

Before all this started, you know that in the 70ís it was very hard to decide which patients to Ö in the first place, it was hard to diagnose a Chiari malformation. And secondly, it was hard to know which one to decompress. So in my earlier years working with the Chiari malformation, when I showed my very first case - the one I showed you the decompression of, that lady - the neurosurgeon was not prepared to do anything.

There are patients who are asymptomatic Chiari. Iíve had patients come to me, and in my series there were a number of patients who are symptomatic. He came to me, not entirely asymptomatic, he said heís got a hearing loss. Another one came with a facial paralysis. Headaches are a very common thing.