Challenges in Cochlear Balloon Decompression and Auditory Nerve Surgery - Otolaryngology

Dr. Ye Dawei reply Otolaryngology

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A Discussion on Dizziness: A Voice from a Dizziness Specialist
I often treat patients with dizziness in my clinic.
From my initial fear of the dizziness specialty clinic around 1982 to now being able to listen to their pain, the journey of my medical practice has been quite enlightening.
Dr.
Yang Yi-hsiang describes in his small book "Dizziness Reception" a chapter dedicated to this group of patients who can be both amusing and frustrating.
One of the biggest nightmares for any otolaryngology resident is receiving a new patient whose main complaint is dizziness, and I certainly felt the same way when I started.
I remember when Director Fan assigned me to the dizziness specialty clinic, I, who was usually docile, raised my voice in refusal (I respect the director, but I fear dizziness even more :-)).
Those who have followed the dizziness clinic must have a deep impression of how these patients often provide irrelevant answers; when asked how they feel dizzy, they might start discussing their ungrateful daughter-in-law or their harsh mother-in-law...
Thus, every Tuesday afternoon's dizziness specialty clinic became my headache time.
Once, a grandmother complained about her dizziness and how one side of her head felt like it was splitting, only to suddenly shift the conversation to how she was mistreated by her mother-in-law in her youth and how fortunate her daughter-in-law is now...
I always took these opportunities to practice translating their complaints in my head from Chinese to English or vice versa; otherwise, I wouldn't know how to get through those long afternoons.
I have forgotten the grandmother's face (they all look alike, even their walking and speaking tones), but I remember that she shed tears in front of me while saying, "I was so beautiful before I married into my husband's family.
When I was a conductor, so many young men would purposely take my bus; they tortured me, causing me migraines and 'dark dizziness'..." After her tears, I had to stop the mental gymnastics I was performing and found myself at a loss for how to comfort her.
However, after that experience, the time I spent on mental gymnastics in the clinic gradually decreased, and my sincere listening to their complaints unconsciously increased.
Behind every patient lies a significant history; what I once dreaded hearing—these non-academic complaints—seemed to transform into the most pleasant melodies.
The domestic grievances of these dizziness patients became the most intimate secrets shared between us.
Even after starting my practice, some dizziness patients still come to see me, needing long-term medication, so I often refer them to provincial hospitals.
Once, a woman recounted how she struggled to take her dizzy mother to a metropolitan medical center in the north, facing difficulties in getting leave from school.
After overcoming obstacles to make an appointment at the medical center, they ended up having to cancel due to the exhausting journey.
I didn't delve into her complaints about the unreasonable treatment at the hospital, but looking at the elderly woman sitting in front of me, unable to maintain an upright posture due to dizziness, I felt a deep emotional tug—was it excitement, compassion, or sympathy...?
When treating dizziness, no advanced technological instruments can replace a detailed medical history, thorough physical examination, and a compassionate attitude.
In general outpatient settings, asking questions can easily disrupt the flow of consultations, so I decided to allocate the first 20 minutes of each clinic session specifically for dizziness patients.
Although this meant adding nearly an hour to my daily schedule, it initially felt physically taxing (the comprehensive history taking, local ENT examinations, gaze-evoked nystagmus tests, positional nystagmus tests, head-shaking nystagmus tests, postural reflex tests, and stepping tests can be exhausting), it became a sweet burden.
If possible, and if there are enough patients, I hope to maintain this practice.
For colleagues who have referred dizziness patients to me, I always strive to treat them with respect and diligence.
Although I lack nystagmography, EEG, CT scans, and MRIs, I hope to provide dizziness patients with better care than they would receive at a medical center.
Physiology and Pathology of the Human Balance System
The human balance system relies on visual, proprioceptive, and vestibular functions to maintain equilibrium, with the inner ear referred to as the "labyrinth." Renowned writer Yu Qiuyu mentioned in the November 5th issue of the United Daily News that the labyrinth of Knossos, which caused dizziness, was home to a half-man, half-bull monster that required Athens to send seven pairs of young men and women as sacrifices each year.
A young man named Theseus resolved to abolish this evil practice and, after consulting with his father, disguised himself among the youths to infiltrate Crete and defeat the monster.
This endeavor was fraught with peril; his father promised to watch from a cliff, and if he saw a ship with a white sail, it would mean success; if a black sail appeared, it would mean his son had died.
After defeating the monster in the labyrinth, Theseus could not find his way out, and the daughter of King Minos fell in love with him and helped him escape.
Tragically, while at sea, the princess suddenly died, and in his grief, Theseus forgot to change the ship's black sail to white.
His father, anxiously watching from the cliff, saw the black sail and, believing his son had perished, jumped into the sea, thus earning the name Aegean Sea.
The labyrinth has a unique characteristic: once entered, one can only proceed along its spiral paths and never find an exit, which is why "labyrinth" in Latin means "pathway." Physicians studying the labyrinth (inner ear) often find its complex functions difficult to grasp, much like Theseus lost in the maze.
On the same day, another article titled "Understanding Vincent's Voice" discussed the story of the Impressionist painter Vincent van Gogh, who modern medical research suggests suffered from Meniere's disease.
His letters reveal that he frequently battled tinnitus and dizziness in daily life.
The famous painting "Starry Night" has even been interpreted by otolaryngologists as depicting the counterclockwise rotation caused by left ear pathology during a Meniere's attack, as seen in the swirling patterns of the painting.
His struggles with tinnitus, a sensation of ear fullness, and auditory hypersensitivity led him to famously sever his left ear, and frequent arguments with fellow painter Gauguin exacerbated his dizziness.
In the first year of college, I listened to Don McLean's "Vincent" in the dormitory, captivated by its beautiful melody, unaware of the tragic life of the song's protagonist.
The vestibular receptors in the inner ear consist of two types of structures: three ampullae (crista ampullaris) in the semicircular canals and the maculae (saccule and utricle) in the otolith organs.
The semicircular canals are responsible for detecting angular acceleration and deceleration, such as rotation, pitch, and roll movements; the saccule detects vertical linear acceleration, while the utricle detects horizontal linear acceleration.
Constant velocity does not stimulate the vestibular system.
The vestibular system transmits gravitational and acceleration stimuli to the central nervous system, first reaching the vestibular nuclei in the brainstem, which then integrates information from the eyes and proprioceptors and sends it to five areas: 1.
The cerebral cortex, which interprets head position and spatial orientation.
2.
The cerebellum, responsible for muscle coordination to maintain balance.
3.
The eye muscles, to maintain visual fields.
4.
The spinal cord, to maintain muscle tone for posture.
5.
The vagus nerve nuclei, to maintain normal gastrointestinal motility.
If there is a pathological change affecting the normal balance system, the vestibular nuclei will receive imbalanced signals, leading to the following conditions: 1.
The cerebral cortex interprets this as dizziness.
2.
The cerebellum may cause ataxia.
3.
Excitation of the ocular motor nuclei can lead to nystagmus.
4.
Excitation of the spinal cord can trigger righting reflexes.
5.
Excitation of the vagus nerve nuclei can cause retroperistalsis, leading to nausea and vomiting.
Additionally, the cerebellum sends signals to suppress the function of the normal side's vestibular system, reducing imbalance and promoting central nervous system compensation.
Dizziness Disorders Overview
Clinically, we often simply categorize dizziness into peripheral dizziness—indicating pathology limited to the inner ear—and central dizziness—indicating pathology in the brain, including motion sickness.
The central nervous system can compensate for inner ear imbalances, typically within one to two days, and at most within three weeks.
Therefore, symptoms of peripheral vestibular disorders should not persist for more than four weeks.
Peripheral vestibular imbalance is always accompanied by nystagmus and dizziness.
Nystagmus, derived from Greek, means "to nod off," as the head slowly tilts down during drowsiness, and at a certain point, it suddenly corrects itself, resembling the nystagmus seen in dizziness patients.
Nystagmus consists of a slow phase followed by a rapid phase; the slow phase is controlled by the inner ear, while the rapid phase is a reflex controlled by the brainstem.

The so-called visual fixation suppression refers to the ability of open eyes to diminish or eliminate nystagmus; losing this ability—where open eyes exacerbate nystagmus or nystagmus occurs with eyes open but not closed—indicates a central nervous system lesion.
Below are common dizziness disorders:
1.
Meniere's Disease: When the general public thinks of dizziness, they often think of "Meniere's," and even general practitioners tend to diagnose it as such.
However, there are not as many cases of Meniere's disease as one might think; many patients complaining of dizziness are often overdiagnosed by physicians.
Thus, if the number of Meniere's cases is disproportionately high in an otology clinic, the physician's competence may be questioned.
In simple terms, if a patient presents with dizziness, tinnitus, and hearing loss, the physician will consider this condition.
The renowned Japanese physician Ichiro Chikubai described it as "7 points disease," due to its following characteristics: 1) Severe dizziness: feels like the world is spinning and can last for several hours, with the first episode being the most intense.
2) Spontaneous dizziness: occurs without any apparent trigger and can strike suddenly.
3) Recurrent dizziness: Meniere's patients often experience repeated episodes, rarely just one.
4) Reversible dizziness: patients have completely normal periods between episodes and do not experience prolonged dizziness.
5) Dizziness accompanied by cochlear symptoms: Meniere's patients often have fluctuating hearing, severe tinnitus during acute episodes, and sometimes perceive sounds at different frequencies.
6) Hearing loss is often more pronounced at low frequencies.
7) Patients may experience "reverberation," often complaining of discomfort in noisy environments like markets or train stations.
To date, no laboratory tests can definitively diagnose Meniere's disease, making detailed medical history and basic physical examination crucial.
Patients often experience unforgettable spinning sensations accompanied by tinnitus, a feeling of ear fullness, and hearing loss; these episodes do not occur daily and last longer than the brief episodes seen in benign paroxysmal positional vertigo (BPPV) or the days-long episodes of vestibular neuritis.
Most patients experience dizziness for about 3 to 4 hours before gradually improving, only to have it recur weeks later.
Many elderly patients report having recurrent dizziness since their youth, eventually leading to gradual hearing loss and persistent tinnitus.
This condition typically occurs between the ages of 20 and 40 and has a maternal inheritance pattern.
The cause is believed to be endolymphatic hydrops in the inner ear, leading to a sensation of ear fullness.
Treatment primarily involves medical management, including neuroprotective agents, vasodilators, and mild sedatives.
If episodes occur monthly, treatment should last at least four months; if they occur every two months, treatment should last at least five months, which is the interval between episodes plus three months.
If medical treatment is ineffective or the patient cannot tolerate long-term medication, endolymphatic sac decompression surgery may be considered.
2.
Vestibular Neuritis: The eighth cranial nerve, which innervates the inner ear, consists of the cochlear nerve for hearing and the vestibular nerve for balance.
The vestibular nerve is more susceptible to viral infections, which can lead to severe dizziness.
Its characteristics include: 1) Severe dizziness, often preventing the patient from getting out of bed, but without symptoms of auditory nerve involvement such as tinnitus or hearing loss.
2) Onset typically occurs between the ages of 20 and 50.
3) Dizziness often occurs just once but can last for several days, while the sensation of imbalance may persist for weeks or even months.
4) The affected ear may show a reduced response to water irrigation, without dizziness or central nervous system symptoms.
5) Patients usually recover within six months.
6) A recent history of upper respiratory infections within the last 1 to 3 weeks.
3.
Benign Paroxysmal Positional Vertigo (BPPV): As the name suggests, this is a benign, sudden-onset condition related to changes in head position, known in English as Benign Paroxysmal Positional Vertigo (BPPV).
Its characteristics include: 1) Dizziness occurs when the head is turned to a specific angle but resolves with a change in position.
For example, lying on one side may trigger dizziness, indicating that side is affected.
2) Dizziness typically lasts only seconds and does not exceed 30 seconds.
3) There is usually a latency period of about 5 to 10 seconds before dizziness and nystagmus occur when the head is turned to a specific angle, and if the position is maintained for about 5 to 45 seconds, it will gradually subside; repeated head movements can alleviate dizziness.
4) Dizziness episodes often come with autonomic symptoms such as nausea, vomiting, and cold sweats, but without symptoms of auditory nerve involvement like tinnitus or hearing loss.
5) When the head is in a hanging position, clockwise nystagmus is observed, while rapid sitting up results in counterclockwise nystagmus, a phenomenon unique to BPPV.
Regarding the pathophysiology of BPPV, Dix and Hallpike noted in 1952 that the pathology lies not in the brain but in the utricle of the inner ear; Harvard's Schuknecht further theorized that dislodged otoliths float into the endolymph of the semicircular canals, stimulating the sensory receptors and inducing dizziness.
Common causes for otolith dislodgment include: 1) Head trauma, the most common cause.
2) Noise-induced damage, such as from shooting.
3) Drug toxicity, such as from streptomycin or kanamycin.
4) Chronic otitis media affecting the otolith organs.
5) Surgical damage to the utricle.
6) Obstruction of the vestibular artery supplying the utricle.
7) Aging.
The utricle and saccule are both otolith organs in the inner ear, with the semicircular canals responsible for rotational sensations, while the otolith organs manage linear motion sensations.
The saccule detects vertical movements, while the utricle detects horizontal movements.
Even without treatment, the dislodged otoliths in the endolymph will eventually dissolve, leading to self-resolution within 3 to 6 months.
Medication can alleviate symptoms, and patients are encouraged to slowly turn their heads toward the affected side to reduce dizziness.
4.
Sudden Hearing Loss: "Sudden" means that the patient can clearly pinpoint a specific day or even moment when they suddenly lost hearing or experienced severe tinnitus.
This is considered an ENT emergency, and patients are generally advised to seek immediate hospitalization.
Some patients may also experience dizziness and vomiting, necessitating differentiation from Meniere's disease.
Typically, dizziness occurs only once, lasting a day or several days, but does not recur, although hearing loss and tinnitus may persist.
Meniere's disease, on the other hand, often involves recurrent dizziness, but hearing usually recovers more quickly after episodes.
A small number of acoustic neuroma cases may also present with sudden hearing loss, requiring CT scans for differential diagnosis.
The causes are widely accepted to include inner ear circulatory disturbances, viral infections, and autoimmune diseases.
Current treatment approaches have moved away from a "shotgun" approach to targeting specific potential causes.
1) Inner ear circulatory disturbances: Blockage or spasm of the blood vessels supplying the inner ear can lead to hypoxia and hearing loss.
This is more common in patients with systemic vascular diseases such as diabetes, hypertension, or hyperlipidemia.
Therefore, treatment primarily involves plasma expanders (e.g., Dextran), which is a glucose polymer with a molecular weight of 40,000 that reduces blood viscosity and prevents thrombosis.
2) Viral infections: Many viruses can infect the inner ear, such as the rubella virus and cytomegalovirus, which can cause congenital deafness in fetuses; mumps virus, measles virus, herpes zoster virus, and the recently prevalent influenza virus can lead to acquired deafness.
Treatment typically involves corticosteroids, starting with 60 mg per day for six days, then tapering over two weeks.
3) Autoimmune diseases: Patients often have systemic autoimmune diseases, such as systemic lupus erythematosus or rheumatoid arthritis, and may experience bilateral hearing loss.
Diagnosis is based on medical history, physical examination, and nystagmography (ENG) to determine if the lesion is central or peripheral.
Patients are generally advised to be hospitalized for at least a week; if hearing does not improve, they are discharged; if there is improvement, they may stay for another week.
During hospitalization, daily hearing tests and monitoring of nystagmus changes are conducted, and follow-up appointments are scheduled every two weeks for three months to track hearing recovery.
Several indicators affect prognosis: 1) The earlier treatment is initiated, the better the prognosis.
2) High-frequency hearing loss indicates a poorer prognosis.
3) Patients with dizziness have a worse prognosis, while those with tinnitus still have cochlear nerve function, indicating a better prognosis.
4) Older age correlates with a poorer prognosis.
5.
Cervical Dizziness: Each side of the neck has a vertebral artery connected to the basilar artery of the brainstem.
If cervical spine deformities, bone spurs, or foraminal stenosis compress the vertebral artery, it can lead to poor blood flow to the inner ear, resulting in dizziness.
This condition must be differentiated from BPPV; generally, cervical dizziness is shorter in duration, milder in symptoms, occurs at an older age, and lacks counter-rolling nystagmus.
Patients may also experience neck or shoulder stiffness and pain.
6.
Tumarkin's Catastrophe: Patients may suddenly collapse without warning, yet remain fully conscious throughout the episode, which can occur several times a week.
The cause remains unclear but may involve sudden loss of muscle tone in the affected side due to dysfunction of the otolith organs in the inner ear.
7.
Acoustic Neuroma: The acoustic nerve runs from the inner ear to the brainstem, with tumors most commonly appearing at the opening of the internal auditory canal, known as the cerebellopontine angle (CP angle).
Initially, patients may only experience gradual unilateral hearing loss or tinnitus.
This tumor grows very slowly, so even if it compresses the vestibular nerve, central compensation may prevent dizziness.
As the tumor enlarges and compresses blood vessels, it can lead to sudden hearing loss or dizziness, with symptoms becoming increasingly diverse over time.
Acoustic neuromas smaller than 1 cm confined to the internal auditory canal are often difficult to detect on CT scans; thus, some have performed lumbar punctures to introduce air into the ventricles, allowing patients to lie on their sides so that air enters the internal auditory canal.
If an acoustic neuroma is present, the air will not fill the internal auditory canal, known as "air CT." However, this method can cause patients to experience headaches for about a week due to the air in the cranial cavity.
With the advent of MRI, tumors smaller than 1 cm can now be easily diagnosed.
If the tumor grows larger and extends toward the cerebellum or brainstem, it poses a life-threatening risk.
Clinically, patients may present with water irrigation without dizziness and normal hearing, but absent responses in auditory brainstem responses must be considered.
8.
Labyrinthine Dysfunction: I frequently use this diagnosis in my clinic because I often encounter patients whose symptoms do not fully meet the definitions of the individual diseases, and I lack specialized instruments for differential diagnosis.
However, it can still be determined that the pathology is limited to the inner ear and does not involve the central nervous system, providing reassurance to both patients and their families.
Although this condition can resolve spontaneously (remember that the central nervous system has compensatory mechanisms), medication can shorten the duration of the illness and alleviate suffering.
Central Dizziness: As the name suggests, central dizziness is caused by brain disorders.
The most common type is "vertebrobasilar insufficiency," which begins with the two vertebral arteries in the neck merging into the basilar artery at the brainstem, branching into the posterior inferior cerebellar artery, anterior inferior cerebellar artery, and superior cerebellar artery.
The anterior inferior cerebellar artery further branches into the internal auditory artery supplying the inner ear, making it sometimes difficult to distinguish from peripheral lesions.
Clinically, peripheral lesions often present with sudden and intermittent episodes lasting seconds to days, with dizziness characterized by intense spinning sensations, and head position changes exacerbating dizziness, while the affected ear facing up tends to be less dizzy; central lesions, conversely, typically present with gradual and persistent episodes lasting months, with less intense spinning sensations, and head position changes do not worsen dizziness, with the affected ear facing down being less dizzy.
These are basic principles, but further evaluation of medical history, physical examination, blood tests, and imaging studies is necessary for accurate diagnosis.
Vertebrobasilar Insufficiency: This condition often initially presents as lightheadedness, with occasional dizziness lasting several minutes, accompanied by nausea, vomiting, or bilateral tinnitus.
Another characteristic is the emergence of symptoms specific to brain lesions, such as dysarthria, difficulty speaking, swallowing difficulties, diplopia, sensory disturbances, and limb weakness or numbness.
Elderly patients with hypertension, diabetes, hyperlipidemia, or cervical spondylosis are more likely to develop this condition, while younger patients often have a family history and genetic predisposition.
Basilar Artery Migraine: This is a type of migraine where arterial dilation causes headaches, while constriction leads to dizziness, primarily affecting the basilar artery, which supplies the cerebellum and inner ear.
This condition often occurs in young women and is related to menstruation, with a maternal family history.
Symptoms include dizziness, tinnitus, blurred vision, unsteady gait, occipital pain, and even altered consciousness.
Careful inquiry into dietary habits often reveals a preference for cheese, chocolate, tomatoes, and orange juice, as these foods contain amino acids that can cause abnormal vascular constriction.
Patients must take calcium channel blockers continuously for three months and avoid the aforementioned foods.
Benign Recurrent Vertigo (BRV): This condition occurs in children who experience unexplained recurrent episodes of dizziness lasting about 20 minutes, occurring several times a month.
Symptoms often arise in the morning due to changes in posture, such as nausea, vomiting, pallor, or cold sweats, sometimes accompanied by headaches but without tinnitus.
Due to the sudden and severe nature of these symptoms, parents often worry.
It is now believed to be caused by vasospasm of the basilar artery, leading to insufficient blood supply to the inner ear.
Family histories often reveal multiple instances of migraines or dizziness.
Treatment primarily involves calcium channel blockers, which are highly effective, with over 90% of children showing improvement within two weeks of treatment, although they should continue for three months.
If children do not receive continuous treatment for three months, they are more likely to develop basilar artery migraines in adulthood.
Orthostatic Dysregulation (OD): This is a common dizziness condition in children caused by autonomic nervous system dysregulation.
Sudden standing can lead to lightheadedness, pallor, cold sweats, or even inability to stand.
Many schoolchildren complain of discomfort upon waking in the morning, which gradually improves by the afternoon.
Patients experience decreased blood pressure and increased heart rate when standing, and the opposite when lying down.
Cerebellar Hemorrhage or Infarction: Early cerebellar lesions are challenging to diagnose, often presenting solely with dizziness.
In addition to detailed medical history and physical examination, nystagmography can reveal specific abnormal eye movements in the early stages of the disease.
The cerebellum can be anatomically divided into three parts: the "primitive cerebellum," which refers to the lower vermis and nodulus, primarily responsible for maintaining posture (also known as the vestibulocerebellum); the "old cerebellum," which includes the anterior and posterior vermis, connected to the spinal cord and responsible for higher-level continuous movements; and the "new cerebellum," which comprises the two hemispheres and coordinates movements of the body's trunk muscles.
If there are lesions in the cerebellum or its connecting fibers, symptoms of motor system disorders may arise, such as unsteady gait, headaches, dizziness, and vomiting.
Cerebellar Tumors: Commonly, "cerebellar meningiomas" occur in women aged 40 to 50 during menopause.
Initially, there may be no specific symptoms, and women at this age often report nonspecific complaints such as headaches, depression, or anxiety, a phenomenon referred to as "indeterminate complaints" by Japanese doctors.
Clinicians must rule out the possibility of cerebellar meningiomas in middle-aged women with such complaints.
Cerebellar or Brainstem Infarction or Hemorrhage: In the dizziness clinic, the greatest fear is misdiagnosing this condition as a typical peripheral disorder and delaying treatment, which can be fatal.
Its characteristics include persistent and severe dizziness, intense headaches, altered consciousness, and specific changes in nystagmus.
If this condition is suspected, CT or MRI scans should be performed.
Motion Sickness: Dizziness arises from an imbalance in the balance system, while motion sickness is distinct from the previously mentioned peripheral and central disorders.
It can be described as a reflexive dizziness caused by the rocking and shaking of various modes of transportation, leading to abnormal impulses from the semicircular canals and otolith organs, resulting in dizziness and nausea.
Numerous triggers can be categorized into internal factors (such as fatigue, colds, alcohol consumption, sleep deprivation, or gastrointestinal discomfort) and external factors (excessive movement of transportation vehicles stimulating the semicircular canals and otolith organs; visual stimuli causing "perceptual conflict," such as looking at the wavy sea while on a boat; and sensory stimuli such as smelling oil, seeing someone vomit, or hearing engine noises).
These factors collectively create a predisposition for motion sickness, triggering autonomic nervous system dysregulation, resulting in symptoms such as nausea, vomiting, gastrointestinal discomfort, cold sweats, unsteady gait, rapid heartbeat, elevated blood pressure, and dizziness.
To prevent motion sickness, it is essential to avoid the aforementioned internal and external factors.
If necessary, Bonamine can be taken 30 minutes before travel; taking it after symptoms have developed is ineffective.
If nausea persists during travel, focusing on an object one meter ahead can help suppress symptoms through central visual fixation suppression.
Common medications include antihistamines and anticholinergics to calm the autonomic nervous system, with each treatment course lasting three months.
Motion sickness can improve through training, as fishermen, astronauts, and pilots have adapted well to it.
What Dizziness Doctors Want to Know
As mentioned earlier, dizziness patients often provide irrelevant answers during consultations, making it crucial for physicians to guide the questioning process.
I often use a "Dizziness, Tinnitus, and Headache Specialty Clinic Questionnaire" to ensure I do not miss any important information.
- What is your occupation? Is there potential exposure to chemical pollutants? Is your work environment noisy? Painters, gas station attendants, drivers, or aircraft engine technicians may be exposed to organic solvents like toluene or styrene, causing dizziness; noise exposure or acoustic trauma can lead to tinnitus and dizziness.
- Is there a family history? Some conditions, such as Meniere's disease and basilar artery migraines, have a maternal inheritance tendency.
- Are you taking any long-term medications? Many medications can cause dizziness, including contraceptives, antihypertensives, and anticonvulsants.
In the past, children often received kanamycin injections, or tuberculosis patients received streptomycin, which could also lead to dizziness and tinnitus.
- Have you had a recent cold? Have you been hiking or diving? Have you flown recently? A recent cold may lead to vestibular neuritis, while sudden pressure changes from hiking or diving can cause serous otitis media or inner ear window rupture, resulting in dizziness.
- What is the nature of your dizziness? Is it spinning, floating, rolling, or swaying? If the dizziness is "clockwise or counterclockwise," it is often due to inner ear pathology, but cerebellar or brainstem hemorrhage or infarction can also cause it; "back-and-forth rolling" should raise suspicion for central lesions in the cerebellum or brainstem; "floating" dizziness, where walking feels heavy-headed, suggests vascular issues in the cerebellum; "swaying dizziness," akin to an earthquake, indicates potential cerebellar, brainstem, or vermis tumors.
- Do you lean to one side while walking? Do you fall to one side? Have you collapsed suddenly? Generally, falling forward or backward suggests a central lesion, likely cerebellar; falling to the left or right indicates a peripheral lesion, such as inner ear pathology, which would cause a fall toward the affected side.
"Tumarkin's catastrophe" may cause sudden collapse while remaining conscious.
- How long does the dizziness last? How often does it occur? During the day or night? Dizziness from BPPV lasts only seconds, while Meniere's disease can last several hours, and vestibular neuritis can last several days; central lesions typically last seconds to minutes, so other symptoms must be considered for differential diagnosis.
Meniere's disease often occurs shortly after waking, while vertebrobasilar insufficiency may occur at night, especially during bathroom visits.
- Is the dizziness related to a specific posture? Does it worsen or improve with certain positions? Meniere's patients prefer to keep the affected ear facing up, while cerebellar hemorrhage patients may keep the affected ear facing down to relieve pressure on brain tissue.
BPPV patients experience dizziness when turning their heads to specific angles, but repeated movements can desensitize them; malignant paroxysmal positional vertigo patients can hardly move their heads.
- Are there symptoms of nausea, vomiting, cold sweats, pallor or flushing, shoulder pain, neck stiffness, headaches, or heaviness? Dizziness patients may exhibit autonomic symptoms due to the connection between the vestibular nuclei in the brainstem and the vagus nerve nuclei.
"Headaches and heaviness" must rule out central tumors, while "occipital pain and heaviness" may suggest toluene poisoning or inhalation of strong adhesives; "neck stiffness, shoulder pain, and headaches" may indicate vertebrobasilar insufficiency.
- Is there any hearing loss, tinnitus, a sensation of ear fullness, sensitivity to loud sounds, ear pain, or ear discharge? BPPV and vestibular neuritis do not typically present with tinnitus, while Meniere's disease does.
- Are there any numbness in the limbs or around the mouth? Blurred vision or temporary blindness? Difficulty speaking or swallowing? "Numbness in the limbs" may indicate vertebrobasilar insufficiency or a stroke warning; "blurred vision or blindness" may suggest central vascular lesions; "difficulty speaking or swallowing" may indicate blockage of the posterior inferior cerebellar artery.
Dizziness Evaluation
With the rapid advancements in modern medicine, sophisticated instruments are constantly evolving, but when it comes to diagnosing and treating dizziness, the importance of medical history and basic physical examination cannot be overlooked.
I personally believe that these aspects are far more critical than advanced technologies like nystagmography, CT scans, or MRIs; often, these tests merely confirm whether our hypotheses are correct.
What evaluations should we perform for dizziness?
1.
Detailed Medical History: Many clues can be found in the questionnaire; experienced physicians can often preliminarily distinguish between central and peripheral lesions based solely on the questionnaire.
Is there an immediate life-threatening risk?
2.
Local ENT Examination: This can rule out various ENT conditions and issues such as earwax, otitis media, cholesteatoma, sinusitis, or nasopharyngeal carcinoma.
3.
Gaze-Evoked Nystagmus Test: Position yourself about 50 cm from the patient, instructing them to focus on your fingertip while moving it up, down, left, and right by 30 degrees to observe for nystagmus.
A special concave lens (Frenzel glasses) can magnify the eye and eliminate external burdens or stimuli, facilitating better observation of nystagmus changes.
4.
Head-Shaking Nystagmus Test: This method has the highest induction rate, and any nystagmus that appears is likely to be clinically significant, making it the most commonly used screening test for follow-up patients.
5.
Positional Nystagmus Test: Have the patient lie flat and turn their head left and right while hanging down to observe for nystagmus; BPPV patients can often be induced to show nystagmus during this test.
6.
Head Position Change Nystagmus Test: Observe for nystagmus when the patient quickly lies down from a sitting position to a hanging head position; patients with central lesions like vertebrobasilar insufficiency often exhibit downward nystagmus.
7.
Stepping Test: Normal individuals can maintain balance with their eyes closed, with a deviation angle not exceeding 30 degrees and a distance of no more than 1 meter.
Those with poor inner ear function will lean toward the affected side, while cerebellar lesion patients may struggle to maintain balance even with their eyes open.
8.
Postural Reflex Test: This includes the Romberg test, assessing the patient's ability to maintain an upright position; tandem walking, where the patient walks in a straight line with their heel touching their toe.
Cerebellar lesion patients often cannot perform this test.
9.
Vertical Writing Test: Have the patient write a line of text with their elbow suspended vertically, comparing the slant of the writing with eyes open and closed; patients with inner ear lesions will show a bias toward the affected side when writing with their eyes closed, while cerebellar lesion patients may struggle to recognize their writing.
10.
Eustachian Tube Test: Using a Politzer bag, apply it to the external auditory canal while having the patient tilt their head back 60 degrees and alternately squeeze and release the bag; if there is a Eustachian tube issue (such as syphilis, cholesteatoma, or rupture of the inner ear window), dizziness and nystagmus will occur.
11.
Temperature Response Test: Have the patient lie flat with their head flexed forward 30 degrees, then irrigate with water at 30°C and 44°C.
Normal patients will exhibit nystagmus approximately 15 seconds after irrigation, lasting 2 to 3 minutes; less than 1 minute indicates that the affected side's inner ear function is impaired, typically due to peripheral lesions; more than 3 minutes suggests loss of cerebellar control over the inner ear, indicating central lesions.
12.
X-ray Examination: X-rays of the middle ear, mastoid, inner ear canal, and cervical spine can reveal conditions such as otitis media, tumors invading the inner ear canal, or bony spurs or deformities in the neck.
13.
Blood Tests: Complete blood count, blood glucose, cholesterol, triglycerides, syphilis serology, and thyroid function tests, as related systemic diseases can also cause dizziness.
14.
Hearing Tests: 1) Pure Tone Audiometry (PTA) can screen for conductive or sensorineural hearing loss.
2) Tympanometry can assess for middle ear effusion, Eustachian tube obstruction, and stapes reflex.
3) Auditory Brainstem Responses (ABR) can identify lesions along the auditory nerve pathway from the inner ear to the brainstem, where five waves are present; if a wave is absent or delayed, it indicates a lesion.
If PTA is normal but ABR is abnormal, acoustic neuroma must be considered.
4) Otoacoustic Emissions (OAE) can assess cochlear function, as the cochlear cells can emit sound.
This is commonly used for newborn hearing screening.
15.
Nystagmography (ENG): This can reveal specific abnormal eye movements in the early stages of the disease, with electrodes placed on either side of the patient's eyes to record the electrical potential difference between the retina and cornea.
Observing changes in nystagmus can lead to early diagnosis of many neurotological conditions before physical symptoms manifest.
16.
Center of Gravity Oscillation: ENG assesses the "vestibulo-ocular reflex," while center of gravity oscillation measures the "vestibulo-spinal reflex," allowing for quantitative assessment of postural reflexes via computer analysis.
Common Medications for Treating Dizziness
Common medications used by physicians to treat dizziness can be categorized as follows: 1) Vasodilators: Many dizziness patients experience symptoms due to poor vascular circulation, so vasodilators are often used.
Since microvessels have a diameter of about 3 micrometers while red blood cells are about 7 micrometers, merely dilating blood vessels is insufficient; ideal medications should also enhance red blood cell deformability and reduce blood viscosity.
Common vasodilators include: a) Tebonin, commonly known as ginkgo biloba, which promotes cerebral circulation, has antiplatelet effects, and scavenges free radicals.
b) Euclidan, a well-known peripheral dizziness vasodilator.
c) Cephadol, an antihistamine and anticholinergic anti-dizziness medication.
d) Sibelium, a calcium channel blocker that prevents calcium ions from entering vascular smooth muscle, inhibiting vasoconstriction and promoting vasodilation.
2) Neuroprotective Agents: a) Alinamin F: an active form of vitamin B1 with anti-neuritis effects.
b) Methycobal: an active form of vitamin B12 that accelerates nerve cell metabolism and repairs damaged nerve fibers.
c) Vitamin E: promotes peripheral blood circulation.
3) Sedatives: including Valium, Librium, and Serenal.
4) Antidizziness Agents: the most famous being Bonamine.
5) 7% Sodium Bicarbonate 60cc IV Injection: commonly used for acute dizziness episodes, this injection can rapidly alleviate symptoms and can be administered multiple times a day until dizziness subsides.
It is safe for pregnant women, hypertensive patients, or diabetics, with no side effects.
In the clinic, patients often ask why they need to take medication continuously for three months.
This is because continuous medication for three months reduces the recurrence rate, and the central nervous system's compensatory mechanisms typically take about three months to stabilize.
The criteria for determining whether dizziness has resolved are based on the patient's subjective experience: if there are no episodes for over three months, all previous discomfort has disappeared, and objective examinations show no abnormal nystagmus, the patient can be considered cured.
Generally, peripheral dizziness can be successfully treated with three months of continuous medication; however, about 30% of patients may require treatment for six months or longer.
In addition to medication, patients can also perform simple balance exercises at home.
First, have the patient stand with their eyes open, arms extended, and step in place for fifty steps; then, have them close their eyes and repeat the exercise.
This can be done twice daily, morning and evening, to observe any tilting during stepping, which can help assess progress.
Some People and Events Related to Dizziness
Records of dizziness date back to ancient Greece during the time of Hippocrates, although the connection to nystagmus or the inner ear was not understood.
In 1820, Czech physiologist Purkinje (the discoverer of Purkinje cells in the brain) observed that rotation could induce dizziness and rapid eye movements, but he believed this was due to brain stimulation.
In 1824, French anatomist Flourens first discovered that damaging the anterior semicircular canals in pigeons caused them to fall forward, while damage to the posterior canals caused them to fall backward, and damage to the horizontal canals caused them to spin in place and exhibit nystagmus.
Thus, the famous "Flourens' Law" was established—each semicircular canal only induces nystagmus in its plane, meaning the horizontal canal induces horizontal nystagmus, the anterior canal induces rotational nystagmus, and the posterior canal induces vertical nystagmus.
He also observed that removing the brain eliminated sensory function, while removing the cerebellum resulted in loss of balance, and removing the medulla oblongata was fatal.
In 1861, French physician Meniere published the famous "young girl case," where a 17-year-old girl experienced sudden dizziness accompanied by unilateral tinnitus and hearing loss, developed pneumonia on the third day, and died suddenly on the fifth day.
Meniere noted blood-like effusion in the girl's semicircular canals, suggesting that dizziness might be caused by inner ear pathology.
From a modern medical perspective, the girl likely suffered from leukemia, leading to inner ear hemorrhage, causing dizziness and hearing loss, rather than what we now refer to as "Meniere's disease." German physician Politzer, who attended Meniere's lecture in Paris, returned home and presented a similar case in 1867, attributing it to inner ear hemorrhage and naming it "Meniere's disease," thus ensuring Meniere's place in the history of neurotology.
In 1870, German physician Goltz published findings that damaging the semicircular canals would induce dizziness.
In 1892, German Ewald published that the direction of endolymph flow is closely related to head and eye movements, proposing the famous Ewald's Law.
In 1906, Austrian Barany discovered that cold or hot stimulation of the ear canal could produce nystagmus, leading to the well-known COWS (Cold Opposite Warm Same) principle, which refers to the temperature response test—"irrigating cold water into the ear causes nystagmus toward the opposite side, while irrigating warm water causes nystagmus toward the same side." The Nobel Prize in Physiology or Medicine in 1915 was awarded to Dr.
Robert Barany for his theory of convection caused by cold water rising and warm water sinking, making him the first otolaryngologist to receive this honor.
Retzius (1842–1919) was a Swedish tissue professor who used optical microscopy to observe inner ear tissues and created detailed illustrations of their structures.
In 1938, Professor Yamakawa Kyoshi of Osaka University published a pathological report on a Meniere's disease patient, a gynecologist at the same university named Ogata.
Yamakawa discovered endolymphatic hydrops during the autopsy, concluding that excessive endolymph production increased pressure in the endolymphatic space, leading to dizziness, tinnitus, and hearing loss.
That same year, British Hallpike published two similar pathological reports on endolymphatic hydrops, commemorating Meniere's initial proposal that dizziness arises from inner ear pathology, thus naming endolymphatic hydrops "Meniere's disease."
In 1942, Hallpike and Fitzgerald introduced the concept of alternating cold and hot stimulation and proposed the concepts of canal paresis and directional preponderance.
In 1944, Cawthorne first published the labyrinth training method, although it was not widely adopted.
In the 1950s, Glorig invented ENG to record eye movement patterns.
In 1970, McCabe refined the labyrinth training method, establishing it as an effective vestibular rehabilitation approach.
In 1974, the visual suppression test was introduced, incorporating information from the vestibulocerebellum.
In 1978, changes in head position induced the second phase of nystagmus, highlighting the involvement of the otolith organs.
In 1983, experiments aboard the European Space Agency's Spacelab 1 disproved Barany's convection theory, suggesting that volume changes due to thermal expansion and contraction caused dizziness and nystagmus.
In Chinese history, figures such as Emperor Gaozong of the Tang Dynasty suffered from dizziness, which even allowed Wu Zetian to seize power.
The "Records of the Three Kingdoms" notes: "Emperor Taizu suffered from dizziness, and whenever it occurred, he became disoriented." The "Romance of the Three Kingdoms" mentions that Cao Cao experienced dizziness two days before his death, stating, "I felt dizzy and heavy-headed, so I got up and lay down on the table." Ming Dynasty Emperor Shenzong refrained from attending court for 25 years due to dizziness, and Qing Dynasty figures such as Zeng Guofan and Li Hongzhang also struggled with dizziness.

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Reply Date: 2005/05/28