Balance and Dizziness

Dr. Brittani Trapp, Doctor of Audiology at Colwood Hearing and Balance Clinic, transcripts from our 14th Annual Healthy Hearing Expo. Transcripts have been edited for clarity. 

Dr. Brittani Trapp speaking about balance, vertigo, diziness, and other vestibular issues.

Your Hearing and Cognition

Today we’re going to talk about our balance system. Vertigo and dizziness, what vestibular assessment is available, and treatment and management for vertigo and dizziness.

Our balance system is made up of our brain, our vestibular system, our ears, the visual system, our eyes, and the proprioceptive system, which is our skin, muscles, and joints. These all work together to provide our overall balance.

Information from the vestibular system, visual, and proprioceptive system is sent back to the brain. It’s combined at the brain stem, which also involves information from the cerebral cortex. The vestibular system gives us information about automatic movements, and the cerebral cortex gives information about what you’ve already learned.

If you walk down the hallway, we know to keep ourselves closer, with narrower feet if we have to walk through a narrow hallway area. The brain puts this information together, interprets it, and sends signals to the eyes and our body parts to react and keep us upright. The brain doesn’t need every little bit of information. It’s getting a lot of input and that can be redundant. The brain chooses what to focus on and what to ignore.

It also will heighten different areas and take more information from the ears, eyes, or proprioceptive systems depending on the environment. If we’re in a darker room where we don’t have our full vision, the brain takes over and says, let’s take more information from our inner ear and proprioceptive system to compensate for the lacking visual system.

The vestibular system is our inner ear structures. We have ten balance organs in our inner ears. We have three semicircular canals inside our ears – anterior, posterior, and horizontal canals. These are all filled with fluid. As we move, the canals move.

We also have the otolith origins, the utricle and saccule. These are our detection for up and down movement, as well as acceleration. For example, if we’re in a car it tells us if we are moving forward or backwards.

That information is sent to the brain through the vestibulocochlear nerve (VOR). Our vestibular system, this is sensing the direction and speed of head motion in relation to our environment. This keeps us steady as the head moves. It keeps our images steady as the head moves. As we walk, our head is bobbing, but we don’t see a bobbing sensation. It should be steady eyesight. This is the vestibulo-ocular reflex. This sends muscle commands from the brain to our eyes to stabilize that gaze.

If we have damage to the VOR, this sends faulty signals from the brain which causes motion related dizziness, unsteadiness or nausea.

The next part is the proprioceptive system. This is skin, muscles and joints. This senses ourselves in relation to world around us. It’s sensitive to stress or pressure and let’s our brain know how our feet or legs are positioned in relation to the ground, or how your head is positioned compared to your torso. This system is controlled by the vestibulospinal reflex. This is the reflex pathway that sends commands from the brain to the body parts. If we have issues with this reflex, we have imbalance or staggering problems.

Vertigo and dizziness, there’s a difference between these. Vertigo is the sensation that you or the room around you is moving. This happens when one or both ears may be out of sync, or there could be an underlying problem with the ear sensors. Dizziness, light-headedness, rocking and swaying, are common dizzy difficulties.

Vertigo and dizziness are not diseases. They’re symptoms, likely of an underlying vestibular disorder or condition. It’s important to tell your healthcare provider when it started, how frequently it happens, how long it lasts. All these details guide us to determine what it is, because patterns of dizziness follow specific disorders.

Along with vertigo and dizziness, we might have other symptoms such as fluctuating hearing, pressure in the ears, tinnitus.

We can have nausea, vomiting or cold sweats if we have hormonal responses to the dizziness. Some may experience headaches or motion sensitivity. We can also have vision problems, like blurred vision, light sensitivity, rapid eye movements that are involuntary, which we call nystagmus. Some experience screen sensitivity, difficulty tracking objects, visual lag, or dizziness when watching a moving object which is called visually induced dizziness.

There are many different vestibular disorders. I’ve highlighted the most common ones. One of the most common ones is age-related dizziness and imbalance. As we have wear and tear on our ear with hearing loss, we may also have wear and tear on the balance sensors in the inner ear, which can lead to imbalance.

Benign paroxysmal positional vertigo. This is a common one. Dizziness and imbalance after a traumatic brain injury, like a concussion.

Some of these can be an infection, which causes both vertigo and dizziness.

Meniere’s disease follows a pattern of fullness in the ears, fluctuating hearing loss, vertigo, and tinnitus. It follows very specific symptoms that way. Typically, with Meniere’s disease, we have vertigo that lasts a few hours. Motion and cyber sickness are another one, with screen sensitivity or sensitivity in a vehicle or in an elevator.

Persistent postural dizziness. This is constant dizziness, even though we don’t have triggers for dizziness. This typically follows a vestibular event, so it could be we had BPPV, or visually induced dizziness and the brain hasn’t compensated back to typical following the incident, and we’re left with a constant sense of dizziness.

Another form is vestibular migraine or migraine related dizziness. This is related to an inner ear virus. This only affects the balance sensors, our hearing isn’t comprised or changed.

Then visually induced dizziness, which we mentioned earlier. This can occur from walking into a grocery store where the room is really big, or we’re downtown and the high-rises make us dizzy, or we’re standing still and a car drives by, which triggers dizziness.

Coming back to BPPV, this is a common one people have heard of. BPPV is the leading cause of vertigo. Calcium structures, called otoconia or crystals in the inner ear, get dislodged from a gel structure in the ear into the semicircular canals we were talking about. When they’re free floating in the canals, they’re not supposed to be, so the brain goes into overload and sends us into a spinning sensation. That lasts for a few seconds until the crystal falls onto the canal wall. Once the crystal stops moving, the vertigo subsides. However, every time we move in specific movements, it re-triggers that vertigo episode.

BPPV is treatable. There are movement maneuvers we can teach you to move the crystals into the gel-like structures they’re supposed to be in.

Getting to the vestibular assessment. Many professionals are typically involved in the vertigo and dizziness journey. Most commonly is your primary care physician. They are going to give you diagnosis and guide you on what’s going on and order tests. Ear, nose and throat specialists as well, or a neurologist or neuro-otologist. The neuro-otologist is a specialist who looks at inner ear disorders.

In B.C., audiologists trained in vestibular management have a specific certificate and year-long training in vestibular work. 

Support from counsellors can be beneficial. Some may benefit from registered massage therapists where we work on the neck and relaxing the neck can be helpful as well.

Speaker: What is happening with the neck?

Dr Trapp: For some people there could be cervicogenic dizziness which is usually dizziness or muscles – so if we relax those. A tight neck can lead to headaches, and we can relax the neck muscle area which can help to reduce symptoms.

Vestibular tests – there are lots out there. Your doctor might order a CT, MRI, ultrasound, eCG blood test or neurological test to rule out other underlying issues. Typically, the most common reason for people to go in with vertigo to the ER – these tests are done to rule out strokes and more.

Functional vision test. These are intensive. Typically, they tend to take a few hours. They tend to be triggering so it’s broken up over a few appointments. This involves looking at your eyeglass prescription, checking to see if you need a prism, looking at your eye health to see if dizziness or double vision are related to other issues.
They will map out the vision field to look for how your visual field is. This is also looking at loss or impingement of the optic nerve or the pathway along the optic nerve.

Hearing tests are a very important part of the vestibular evaluation. Many vestibular disorders affect the hearing portion of the inner ear. The hearing test tends to follow a specific configuration on the audiogram to lead into diagnosis.

There’s a vast array of vestibular function tests. One is the vestibular evoked myogenic test – VEMPS. These are for our senses back and forth, up and down.
There’s a head impulse test. That is doing quick movement along – back and forth and up and down to assess the VOR, the vestibular ocular reflex – testing its function and how the semicircular canals are functioning sending information to the brain and the eyes.
This test gives a lot of information, and we can isolate the semicircular canals. This test gives so much good information which goes back to your doctor for diagnosis.

Videonystagmography. We call it a VNG – it’s an ocular motor test, positional test and caloric test. Ocular motor shows problems with the brain stem or cerebellum. Positional shows signs for BBPV. If see an underlying BPPV in my assessment – we go right into the treatment in the appointment.

The vestibular testing has a bad rap for making you dizzy. One test typically causes a bit of dizziness for a few seconds as its performed, which is our caloric testing. We put water or air in the ear canal to warm or cool – transferring it into the vestibular system. This temperature change can cause dizziness. It’s about 30 seconds which doesn’t feel so great. But it’s short lived and gives us information about what’s going on.

Those are the most common vestibular tests. Test results – with the vestibular test and audiology look at problems with the balance structure in the inner ear, eyes, central nervous system etc. It gets sent back to your physician for further review or referrals to ear or neurology.

Now some people are discouraged when they get normal results. Normal results are fine. It just means the balance structures are doing what they are supposed to be doing. This lets us get into what we need to do. With specific disorders we expect normal results with some. It doesn’t mean there’s nothing wrong, just that the physical structures are good.

There’s lots of treatment and management that’s available for dizziness and vertigo. In particular, vestibular rehabilitation training helps with imbalance or dizziness, but not acute vertigo episodes. Vestibular rehabilitation strengthens the connection between body, eyes, brain and inner ear. It’s best if it is tailored to each specific individual as everyone is different. Some people do just a few sessions which solves the problem, others go on for longer.

If I’m working on a fall risk or general balance some people do stay on longer term because they enjoy it and know they are more confident after coming in for their vestibular training. Some of the exercises include adaptation, gaze stabilization, balance retraining with the eyes open and closed, and strengthening exercises. We have been talking about the proprioceptive system. Lots of exercises like squats to build up the legs. Range of motion, breathing and relaxation exercises and aerobic exercises.

There’s medication treatment which will come from your doctor. It must be individualized to you for specific situations. The most common is a vestibular suppressant which helps reduce symptom intensity and prevent frequent episodes of vertigo. This one is called Betahistine. Other medications can be prescribed for nausea, anxiety and depression. Surgical treatment is less common because there are effective medical management tools.

Surgical treatment can have two options. Restorative or destructive. Restorative surgery – if there’s a specific vestibular disorder that may have a windowing effect that needs a patch on the inner ear. Destructive is for severe vertigo and dizziness that impact lifestyle. This would be the last case scenario. A surgeon would ablate the inner ear system which stops it from impacting the brain. We need a lot of vestibular after to work on our balance because we are missing balance sensors on one side.

A lot of people benefit from mindfulness, meditation and relaxation strategies. Therapeutic massage, chiropractor treatments like with the neck. Some find aromatherapy or acupuncture to be helpful as well.

One of the most common reasons why I see a lot of vestibular patients is for fall risk concerns. Falls are the leading cause of hospitalization and injury in Canadian adults. People with hearing loss fall 2.5 times more often than people with normal hearing. As our hearing loss progresses, we are at an even higher risk of a fall.

The correlation with hearing loss and fall risk is assumed to be because we are less aware of our surroundings when we can’t hear what is going on. We typically tend to have more difficulty with spatial awareness. When we have hearing loss, we use more listening effort and have less resources for balance and walking especially at the end of the day.

Some of the most common ways to prevent falls are to wear both hearing aids and glasses if you need them. This gives your brain more input because they are two out of the three most important areas for balance. We want to make sure we have access to eyes and sight. We want to reduce tripping hazards at home. If we have rugs, we want to make sure they aren’t slippery. Grips on our slippers so we don’t slide across hardwood. If you have stairs, make sure there’s a railing. These can go a long way to reduce falls.

Beware of sensations in feet and legs. If there are pins and needles, consult your physician about it so we aren’t at risk for falls. Manage your health and medication – make sure your medication list is accurate and dosage is as it should be.

We can also look at fall risk vestibular exercises. A lot of what we do is tailor fall risk exercises to those that are coming into the clinic.

Thank you so much for listening. If you have any vestibular concerns,  questions or would like to book at appointment, you can find me at Colwood Hearing and Balance Clinic. 

Resources

One of my favourite resources is balanceanddizziness.org. It’s a Canadian website with great information about exactly what vertigo and dizziness are, common disorders, assessment, where to go. It has great information there. Then we have Speech and Audiology Canada. And additionally balance disorders on the American speech and hearing website.

Q&A

Speaker: Do you need a referral to the clinic?
Dr. Trapp: No, you don’t need a referral. Call in, Gillian will answer the phone and ask questions about what you’re looking for and guide you to what’s best.

Speaker: If you’ve had COVID, have you noticed your patient’s ears being affected by COVID?
Dr. Trapp: For some people, it has. As we’ve seen with everything, COVID has a unique way of hitting everyone and everyone may be different. We have seen some people that it has affected the inner ear or balance, or both, or tinnitus.

Speaker: In your clinical assessment, do you do movement testing such as . . . Convergence testing, VOR, etc.?
Dr. Trapp: Yes, that’s what my vestibular test does. You have goggles on and I’m tracking eye movements to see what’s going on. It is testing VOR.

Speaker: Do you do balance testing?
Dr. Trapp: Yes, we do that.

Speaker: Is this testing covered by extended health or some other insurance?
Dr. Trapp: We can’t bill MSP. They don’t cover audiology related services at this point, so it is private pay. With extended services, it falls under reimbursement often. If the evaluation is too much out of pocket, your physician can refer you to a public health option, but the waitlist is extensive.

Speaker: Does your training focus on issues caused by Meniere’s?
Dr. Trapp: Yes, my testing would guide us to whether it’s Meniere’s or not. I have training on that side, as well as the physician.

Speaker: Do patients come directly to you or through the doctor and neurologist?
Dr. Trapp: Either or. Some people come to me before seeing their doctor. I do take referrals from doctors, but you don’t need a referral to come in.

Speaker: So, you diagnose and treat?
Dr. Trapp: I don’t officially diagnose, your doctor does that, but I navigate what it is and the treatment. After your doctor gives a diagnosis, we reconvene.

Speaker: But you are treating?
Dr. Trapp: Yes. I’m not prescribing medications, but I am giving treatment options. I do repositioning maneuvers. We do that with goggles, and I make sure everything is back to typical.

Speaker: You said you do testing. Does that go back to the physician?
Dr. Trapp: I don’t diagnose. The test results go back to the doctor. It’s not within the scope for audiologist to officially give a diagnosis. It must come from a medical physician. I know what’s going on, but I can’t officially give a diagnosis. It must come from the physician.

Speaker: But you can’t diagnose?
Dr. Trapp: They’re usually coming to me because they need treatment so regardless, I’m guiding the appropriate treatment. The physician gives the label, but it doesn’t change the outcome because we’re working on things. I stay within my scope. If we need medical intervention before that, we do that and then work on management after.

Speaker: Are you talking about a general practitioner or a specialist?
Dr. Trapp: Either a general practitioner or an ear nose and throat (ENT) or neurologist.

Speaker: So, you say it’s either directly or through a practitioner. Which is longer?
Dr. Trapp: So, we’re talking about getting referred by your doctor or coming in. Going through additional avenues is going to be longer due to the nature of meeting with the physician.

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