Medical and Surgical Treatments
Medical Treatment of Dizziness
In this section:
Treatment varies with the individual patient according to the suspected cause and the magnitude and frequency of the symptoms. During an acute spell, suppressant medications such as Antivert or Valium can provide symptomatic relief. These drugs, however, do nothing to cure the problem. But, like treating seasickness, getting symptomatic relief and waiting for the spell to pass may be all that is needed. All of these suppressants can cause drowsiness. Thus, you must be extremely careful with driving and other risky activities because the combination of dizziness with drowsiness can be hazardous. These medications can also slow down natural recovery or impair rehabilitation.
Some patients, who have a particularly stubborn type of dizziness such as the unsteadiness that occurs following a stroke, require physical therapy (vestibular rehabilitation) in order to see improvement.
Reduction of Inner Ear Fluid Build-up
Ménière’s disease can often be improved by decreasing the amount of sodium in the inner ear. A very low salt (sodium) diet combined with a water pill (diuretic) that eliminates sodium from the body is usually very effective. If you take water pills, make sure to have blood tests to assure your potassium does not get too low.
Inner Ear Injections
For Ménière’s disease and a few other uncommon ear disorders, “transtympanic injections” of medications may be of some benefit. These medications can include steroids to decrease inflammation, or medications, like Gentamicin, which can selectively affect the inner ear. Gentamicin has been used as a way of destroying the inner ear without surgery. In progressive treatments, it can destroy the balance portion of the inner ear, leading to fewer dizzy spells. Gentamicin treatments require several visits in which the medication is placed through a small hole created in the ear drum. Careful monitoring is necessary regarding the amount of medication used because the best dose for each person can vary greatly. However, these treatments can lead to persistent unsteadiness and hearing loss. Thus, these treatments are more often recommended for the elderly or those who already have a significant hearing loss. Also, there is a small risk that the intentional perforation of the eardrum will not heal or may become infected.
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Surgical Treatment of Dizziness
Surgery may be needed to treat dizziness if other medical treatment fails. Several types of operations are available depending on the cause of the dizziness. Not all procedures are options for every patient. Some can only be offered in severe situations.
You and your otologist, or ear nose and throat (ENT) surgeon, will need to decide which approach is best for you. This is always a matter of weighing the pros and cons of each option whether it is medical or surgical. Factors include your hearing, age, health and the severity of the disease.
In this section:
- Surgical treatments:
- General recommendations after surgery
- Risks and complications
Surgical treatments include:
Endolymphatic Sac Decompression
In Ménière’s disease, the inner ear is under excess pressure. One portion of the inner ear, called the endolymphatic sac, is surrounded by bone. By removing the bone surrounding this area, pressure in the inner ear may be reduced, greatly improving symptoms of Ménière’s disease. Inner ear fluid undergoes a natural recycling every day. It is made from the brain’s spinal fluid and is absorbed by the endolymphatic sac. In Ménière’s disease, the sac may fail to absorb enough fluid. This increases inner ear pressure resulting in dizziness, tinnitus and hearing loss. In the past, a small tube (shunt) was placed into the sac to drain fluid, but we have found that the surgery is just as successful without a tube and has less chance of hearing loss. Since the sac is found partially embedded in bone between the ear and the thick lining of the brain, a very slight risk of spinal fluid leak is possible. Although it is successful for most patients, some people do not improve. This procedure has a low risk of hearing loss, so it may be recommended as the first choice for surgically treating Ménière’s disease. An overnight hospital stay may be needed.
When dizziness is severe, but hearing is still good, cutting the balance nerve between the inner ear and the brain may eliminate vertigo while preserving hearing. This procedure requires general anaesthesia and 4 to 5 days hospitalization. Since access to this area is through a craniotomy (skull opening), hair must be shaved for several inches behind the ear, and a small piece of fat from the belly must be harvested to place into the incision to decrease the chance of spinal fluid leak. There is always some vertigo for a few days following the surgery. Although the attacks are usually completely eliminated, there may be persistent dizziness, visual blurring and unsteadiness. Usually the opposite inner ear will compensate for this but a balance exercise program is essential. Occasionally, some people may get headaches following the surgery. As with any craniotomy, there is a small risk of infection (meningitis), leak of spinal fluid, or stroke.
If a patient has useful hearing, then there is a choice between the nerve-clipping operation (vestibular nerve section) or an endolymphatic sac decompression.
The sac operation is a more minor procedure, the goal of which is to relieve pressure within the inner ear rather than removing the balance function as cutting the nerve does. Although it is not as effective as vestibular nerve section, it avoids many potential risks because it is not necessary to work within the brain’s cavity. Furthermore, it is the only surgery that improves hearing in some patients – especially if it is done early in the course of the disease.
Trying to decide between these two operations is a common problem. The nerve clipping operation is one of the most successful treatments for Ménière’s disease but there are surgical risks related to working along the nerve’s root at the brainstem. Also, after cutting one balance nerve, it takes a while for the other ear to take over. Vestibular exercises are important to help overcome unsteadiness.
Unfortunately, Ménière’s can sometimes affect not one but both ears. In that case, sac decompression is preferred.
In severe cases of dizziness, labyrinthectomy can eliminate symptoms by removing the inner ear structures. It is very successful in stopping attacks. However, the surgery results in total loss of hearing in the operated ear, and therefore is generally performed when there is already poor hearing in that ear. Following the surgery, there is usually a period of several days of vertigo. Although the attacks are usually completely eliminated, there may be persistent dizziness, blurred vision and unsteadiness. Usually, the opposite inner ear will compensate for this but a balance exercise program is essential.
This procedure is only performed for severe cases of benign paroxysmal positional vertigo (BPPV). In this procedure, the portion of the inner ear which is causing the vertigo is blocked off by plugging its canal with tissue or bone. This prevents the abnormal motion of inner ear crystals; it is very effective in relieving vertigo and has a very low risk of hearing loss.
In patients with a perilymph fistula, the inner ear fluid leak may need to be patched. The eardrum is lifted and the likely areas of leakage are patched with tissue from behind the ear. Often the leak is microscopic, so the likely areas of leakage are patched, even if no fluid is seen. Symptoms usually improve over the next several weeks.
After any ear surgery, ask your physician when you can return to work or driving. This varies from days to weeks based on the severity of your dizziness/imbalance, your job, and the type of surgery you had. Stuffiness can also occur with any ear operation. This will usually improve slowly as your body absorbs the healing fluids. Discuss with your physician if you need physical therapy or occupational therapy to assist you as you return to your daily activities, work, or sports/leisure activities.
Surgical risks vary according to the procedure and by a person’s age and health. Most inner ear operations require a general anaesthetic and an incision behind the ear after shaving away some hair. Any surgery in or around the ear can put at risk many of the structures that reside in this area.
Surgery performed adjacent to the brain adds additional risk to life, brain and the surrounding nerves. In order to prevent a leakage of spinal fluid, patients who undergo clipping of the balance nerve often have a small amount of belly fat taken as a graft to seal the area underneath the incision.
Risks and complications typically include:
Further hearing impairment in the operated ear may occur following any of the procedures described above and is always expected after labyrinthectomy. Perforation of the eardrum can cause some hearing loss.
Tinnitus (head noise) usually remains the same as before surgery. If the hearing is worse following surgery, tinnitus may likewise be more noticeable. Sometimes tinnitus can be improved with rehabilitation programmes and specific strategies.
Taste Disturbance and Mouth Dryness
Taste disturbances and mouth dryness are not uncommon for a few weeks following surgery. In some instances this disturbance is prolonged or permanent.
Weakness of the Face Muscles
The facial nerve travels through the ear bone in close association with the hearing and balance nerves. Temporary weakness of one side of the face is an uncommon postoperative complication of ear surgery. It may occur as the result of the surgery, an abnormality or swelling of the nerve. Permanent paralysis of the face is rare. Should it occur, however, eye complications could develop, requiring treatment by an eye specialist (for your eye health) and a rehabilitation specialist (for treatment of the facial muscle weakness). It is very important to seek guidance on facial retraining exercises as over-use can lead to permanent problems with how your facial muscles coordinate and move.
Spinal Fluid Leak
Some of the operations described above result in a temporary leak of spinal fluid (fluid surrounding the brain). This leak is always closed prior to the completion of the surgery. On occasion, however, the leak reopens and further surgery may be required to stop it.
Infection is a rare occurrence following dizziness surgery. Should it develop, however, it could lead to Meningitis (an infection in the spinal fluid) and might require IV antibiotics. Fortunately, this complication is very rare.
A hematoma (collection of blood under the skin incision) develops in a very small percentage of cases, prolonging hospitalization and healing. Reoperation to remove the clot may be necessary if this occurs.
For vestibular neurectomies, a craniotomy (opening the skull) is required. Although unlikely, leakage of spinal fluid is possible; however, it is minimized by placing a plug of belly fat into the area. Also, there is a slight risk of long-term headaches (which may be treated with anti-inflammatory medication). Other rare complications include meningitis, bleeding, stroke, or even loss of life.
Imbalance, Dizziness and Blurred Vision
Certain medical and surgical procedures can cause permanent destruction of the inner ear vestibular function. This may lead to chronic dizziness, blurred vision and imbalance. Usually this is improved with physical therapy, but the imbalance and dizziness may be permanent. This is especially challenging when both ears have vestibular disorders. Labyrinthectomy, vestibular nerve section and Gentamicin treatments usually have at least some period of time when imbalance, dizziness and blurred vision occur. Discuss with your physician if these symptoms are expected to be temporary or permanent and if you need vestibular rehabilitation to improve your recovery.
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