Practice What You Preach

Last Sunday, I had an up close and personal encounter with Vestibular Neuritis. It hit suddenly, somewhere between buttering the toast and sitting down to breakfast. I was completely symptom free 2 minutes earlier, buzzing around my kitchen making eggs and pouring coffee. I noticed a little lightheaded feeling and blurred vision as I carried my plate to the table, but when I put the plate down, I noticed the round table was spinning in a clockwise direction. I was in full blown vertigo within 20 to 30 seconds.

The irony here is that I am the director of the Balance Disorders Program at Wake Forest University Medical Center, and I teach young doctors how to evaluate patients complaining of vertigo. Irony only gets you so far when the world is spinning, but my training and experience did allow me to practice what I preach. I have seen hundreds of patients over the years with various stages of Vestibular Neuritis, the vast majority having undergone numerous expensive medical tests, Ct Scans, and/or Cranial MRI’s which I have preached are typically unnecessary if you know what to look for.

I was completely incapacitated, couldn’t walk, and had a decision to make: have my wife call an ambulance and go to the Emergency Room, or get to my bedroom and do a self examination. I chose the latter, knowing that a focused examination is more sensitive than a CT Scan or MRI at separating stroke from a more benign inner ear attack. My wife helped me to the bedroom, got me a bucket for the anticipated and ever so pleasant nausea and vomiting, and videotaped my eye movements with my iPhone.

Using the HINTS technique, within about 15 minutes of the onset of my symptoms, I was comfortable that I did not need imaging, therefore, no trip to the ER. How did I do this?

HI  for Head Impulse

I sat on my bed and tried to find something to visually fixate on. This tends to slow down the sensation of vertigo. I locked onto to the doorknob of the closet door. Once I established how stable my vision was with my head still, I started doing small head turns (impulses) to the left and right. It was very clear that when I moved to the left, I could keep my eye on the doorknob, but when I moved to the right, there was no way. My eyes just went with my head and I consistently lost the doorknob target. That alone made me over 90% confident I was not having a stroke, which by the way, is a higher confidence level than a cranial MRI.

N for Nystagmus

Since I knew that vertigo is generated by involuntary, jerking eye movement called nystagmus, I asked my wife “Are my eyes bouncing back and forth?” Certain patterns of nystagmus suggest stroke, others suggest a benign inner ear disorder. In Vestibular Neuritis, the eye movements always beat in the same direction, but speed up when you look away from the culprit ear, and slow down when you look toward the culprit ear. Since the intensity of the vertigo is directly related to eye speed, I could feel this difference immediately. Watching the video of my eye movements confirmed for me that I had “direction fixed left beating nystagmus following Alexander’s law” which is highly indicative of an acute inner ear disorder on the right side. If the nystagmus had changed direction when I moved my eyes, I would have been on the way to the hospital.

TS for Test of Skew

This is basically a check to see if I was having double vision (diplopia).  So again, I tried to fixate on something and alternately closed my right eye, then left, then right, and so on. This was not easy because my eyes were bouncing around, but I could not detect any double vision.

This all took about three or four minutes, but the test pattern was highly suggestive of vestibular neuritis on the right. I checked a few other things. I made sure I had no trouble speaking or swallowing. I noted I had no headache, and I had no deficit in some simple motor control tests like “finger to nose pointing” and “rapid alternating hand movements.” For several hours I could not walk unassisted, but I was comfortable this was due to the intensity of the vertigo, and should improve, rather than worsen, as the day progressed. Which it did.

I did learn one important lesson about managing the acute, intense vertigo phase. For years, I have told people to try to visually fixate on an object, looking out of the corner of their eye to slow down the vertigo. This worked, but I was much more comfortable with my eyes closed. Who knew?

Today, I am one week out from the incident; this computer screen is still a bit of a challenge but I am back at work. I won’t be driving for a while. And I have given up ballroom dancing for now.

In my next post, I will show you what all this looks like with some video and testing results.

 

 

 

 

 

 

 

A few years ago, I did a post here discussing patients that continued to complain of imbalance and “fleeting disorientation” after successful treatment using the Epley maneuver or some other form of canalith repositioning. So let’s revisit that and explore some related newer reports, as well as talk about people that do not improve after repositioning for BPPV.

Repositioning Failure

Some patients continue to complain of positional vertigo after undergoing treatment with the Epley maneuver. First, no treatment works on everybody, but repositioning for BPPV has a very high success rate. In fact, success rate is so high that if the treatment fails, it is more likely that the diagnosis is wrong than it is that the repositioning procedure failed to move otoconia out of the posterior canal. Numerous studies put the success rate for BPPV of the posterior canal in the high 90% range. There are other forms of BPPV where the otoconia enter the horizontal canal, and very rarely the anterior canal. The Epley maneuver is specifically for posterior canal BPPV and would not help BPPV of the horizontal canal. There are procedures for horizontal canal BPPV, but with lower success rates. One particular form of horizontal canal BPPV, where the otoconia is believed to be in the long arm of the canal, close to the ampulla, is particularly resistant to repositioning. This form of BPPV is characterized by ageotropic horizontal nystagmus where the nystagmus beat to the  left after rolling onto the right side, and then change to right beating horizontal nystagmus after rolling onto the left side. There is a recommended treatment for this, known as the Gufoni maneuver, but it does not enjoy nearly the same success rate as the Epley maneuver for posterior canal BPPV.

Residual Non-Vertigo Dizziness Following the Epley Manuever

A high percentage of patients will report resolution of positional vertigo after undergoing a repositioning treatment, but more than one in three will continue to describe more vague symptoms of imbalance and movement related visual disorientation and instability in the days to weeks following treatment.

There are two schools of thought regarding these residual symptoms. One theory involves utricular dysfunction. A damaged utricle is the source of BPPV (that is where the otoconia debris comes from). I can’t add much to that discussion, but a review of available literature can be found here.

A second theory is that there is a neural dampening or “cerebellar clamp” process. We know that the brain has the ability to reduce the gain of the vestibular ocular reflex (VOR) in the healthy ear following an acute unilateral vestibular loss. It is also possible, but currently unproven, that the brain’s response to intermittent bursts of increased unilateral discharge (which occurs with BPPV) is to dampen it’s connection to the affected ear, or maybe just the affected canal.

With canalith repositioning, there is not a gradual recovery, but rather an immediate repair. It is plausible that it takes some time for the brain to readjust to a newly healthy labyrinth. This theory has been explored by Faralli et al:

“According to Faralli et al. point of view, the genesis of residual dizziness (RD) could reside in the inability of the vestibular system to readapt quickly to a new functional state: in detail the persistence of debris in the semicircular canal could alter the tonic discharge from the affected labyrinth and could induce a new central adaptation rebalancing the vestibular nuclei activity, in order to minimize the peripheral asymmetry. This new equilibrium tends to stabilize the perturbation produced by the otoconia that is free to float in the semicircular canals. After successful maneuvers, the brain adapted to the new condition is unable to quickly readjust to the old pattern and this could be the cause of RD”

The Bottom Line

Residual non-vertigo dizziness is a common complaint after successful canalith repositioning for BPPV. It generally goes away in a week or two with normal activity, but recovery may be accelerated by performing VOR exercises.