Welcome, everyone, to the webinar, Dizziness and Diseases of the Ear. We're so glad that you could be here today to learn more about identifying common diseases of the ear and how they can disrupt the body's balance system. Your moderators for today are me, Ted Annis, Senior Marketing Specialist, and Carrie Peterson, Member Services Supervisor. Our expert presenter today is Julie Purdy, Manager of Audiology at Rady Children's Hospital, San Diego. Julie has been part of the audiology team at Rady Children's Hospital since 2007 and became Manager of Audiology in 2014. Prior to joining Rady Children's Hospital, she was Director of Education for Starkey Labs Canada. We're very excited to have Julie as our presenter today, but before we get started, we have just a few housekeeping items. Please note that we're recording today's presentation so that we may offer it on demand through the IHS website in the future. This webinar is available for one continuing education credit through the International Hearing Society. We've uploaded the CE quiz to the handout section of the webinar dashboard, and you may download it at any time. You can also find out more about receiving continuing education credit at our website, IHSinfo.org. Click on the webinar banner on the homepage or choose webinars from the navigation menu. You'll find the CE quiz along with the information on how to submit your quiz to IHS for credit. If you'd like a copy of the slideshow from today's presentation, you can download it from the handout section of the webinar dashboard, or you can access it from the webinar page on the IHS website. Feel free to download the slides now. Tomorrow, you will receive an email with a link to a survey on this webinar. It is brief and your feedback will help us create valuable content for you moving forward. Today, we'll be covering the following topics. What is dizziness? Common non-ear causes of dizziness. Middle and inner ear disorders linked to dizziness. At the end, we'll move on to a Q&A session, and you can send us a question for Julie at any time by entering your question in the question box on your webinar dashboard, usually located to the right or the top of your webinar screen. We'll take as many questions as we can in the time we have available. Now I'm going to turn it over to Julie, who will guide you through today's presentation. Take it away, Julie. Thank you very much. So, it's a pleasure to be with you all today, even though I don't get to see your smiling faces and you don't get to see mine. We're going to talk today about dizziness, and we're going to talk today specifically about dizziness that's related to your hearing, so dizziness that's related to the inner ear. We're going to look at a few middle ear items as well. When we look at how we keep our balance or what causes us to be dizzy, we really have three different systems that tell us where we are in space and keep us upright. The first one are our eyes, and so our eyes will tell us where we are. They let us know if it's night, if it's day. We have our inner ear, which responds to gravity and looks at sort of back-and-forth types of motions. That's the piece that specifically we're going to talk about today. And then we also receive information from our prokaryoceptive system, so those would be, for example, if I'm standing, the soles of my feet are going to tell me I'm standing because I'm going to be receiving input from the soles of my feet. Right now, I'm seated, so I have my feet on the floor, so there's information coming from my feet. There's information coming from my back because I'm leaning up against my chair, and there's information coming from the posterior portion of my body because I'm sitting in my chair. So the combination of those three inputs tell me, hmm, I'm seated. Realistically, if we have problems with our balance, it can come from any of these issues or from any of these systems, but the system that we're specifically going to talk about today, of course, is the middle one, the one that deals with our hearing and with our balance, specifically to the inner ear. When a person says they're dizzy, they really typically mean many different things, and we kind of want to look at these next four things. We want to look at vertigo, we want to look at lightheadedness, we want to look at disequilibrium, and we want to look at the concept of anxiety. All of those things, for many people, mean dizziness. Now, vertigo is the one that specifically we're interested in today because that feeling of vertigo, that feeling that everything around you is spinning or moving, that is usually because the signals that are coming from your inner ear aren't consistent with the signals that are coming from other places. So we have something going on in the inner ear that's giving us faulty information that's not consistent with our eyes that are telling us, for example, that we're seated, or the sensory systems I told you that are telling me that I'm in my chair. So vertigo is the piece that we're really very specifically interested in today. We're not as interested in lightheadedness, and that kind of idea of lightheadedness is the feeling that you're about to faint, and this is something that many of us have had if we stand up very quickly or if we become agitated and we're breathing very quickly, you can kind of generate that feeling. So some people that have vertigo will also complain that they're lightheaded, but if you're just standing up too quickly, odds are you don't have an inner ear problem. Now, disequilibrium, the third thing on our list, that is something that can also be associated with vertigo. So if you're having vertigo and everything is spinning, you might have a difficult time walking. Disequilibrium is specifically that problem with walking, that problem with staying upright, and so if you're still a little bit uncertain what I mean by disequilibrium, if you see a person who has had too much to drink or if you've been one of those people yourself, and by this I do mean specifically alcoholic beverages, if you've ever overindulged or seen anybody that's overindulged and they're kind of staggering around and having a difficult time staying upright, that truly is a disequilibrium type of a feeling, but this would happen, of course, not in conjunction with alcohol. We would be interested in times when this is occurring that doesn't have as easy of an identifiable cause. And then the last thing that we really do need to look at, and we're going to look at this in a couple of different ways today, is the idea of anxiety, and when people become scared or worried or depressed, they sometimes will say that they feel dizzy, and what they mean is that they're feeling very off. They're not feeling like they're in control of their body. They're not really in control of their space, but this concept of anxiety is not really one that we're going to explore today, and it does sometimes accompany vertigo because if you know that you're going to get dizzy and perhaps become ill, you can become anxious about that, but there are many people where anxiety is truly the issue and they're calling it dizziness, but it's not going to also once again be an inner ear related type of an issue, so anxiety can seem as if you're dizzy, but it's not the thing that we're looking at today. So I told you we're going to talk about ear causes, and definitely we are, but there are some pretty major non-ear causes as well, and I wanted to spend a couple of seconds, maybe a minute, talking about these. People that have real sudden drops in their blood pressure, or people that have arthritis in their neck that puts pressure on the spinal cord, there are people that have tumors in the cerebellum, oftentimes people with diabetes will be dizzy, and people that have poor circulation can report dizziness. There are definitely neurological conditions, Parkinson's and multiple sclerosis are the two most common, but there are other neurological conditions that people can have that cause them to have disequilibrium or vertigo. There are plenty of medications that people can take, and if you ever watch the television when they're listing off the side effects, one of the things that you'll find is for pretty much every medication, dizziness is listed as a side effect. It doesn't really matter what it is, that just tends to be one that's often a side effect of medication, but we know that anti-seizure drugs, antidepressants, sedatives, tranquilizers, blood pressure medications, all of those kinds of things can cause a person to be dizzy. Anxiety, we've talked about, but it's important enough that we want to list it again. And then any of the kinds of things where you would have low iron levels or low blood sugar or you've become overheated or you're dehydrated, all of those things can cause dizziness. And so it's important if a person reports that they're dizzy that we shouldn't automatically assume that that is related to the ear. It could be related to any of these things that we've just talked about. And these are actually fairly common for a person to have dizziness associated with these things. So we're going to mostly talk about the inner ear. The inner ear is the one that gets the blame for the vertigo, but there are definitely a few conditions that people can have that are middle ear related, so we want to talk about those. And when I talk about the middle ear, I am talking about the place that's extending from that little blue piece, the tympanic membrane, through the ossicles into the base of the stapes where it enters into the inner ear. So that particular section has a few disorders associated with it that have been linked to dizziness and, of course, the hearing loss. So let's look at those kind of quickly. The first one is otitis media, and we know that people can have otitis media. It can be acute, and so it can be nasty looking like what you see in the pictures here where everything is red and inflamed and infected, so that's one type of otitis media. Another one is really sort of more that chronic middle ear fluid, something we see often in kids but certainly in adults as well, where the fluid isn't infected, it's just sitting there chronically and causing problems. People with otitis media, both the acute type as well as the chronic, will sometimes complain that they feel dizzy, that they feel off, that they feel unsteady. This is one that has been linked, since I work in a pediatric setting, I'm really aware of this, but this has been one that's been linked to children who have lots of these problems growing up, tend to not have as good of balance as some of their peers. I know in my own life, I'm a fairly clumsy person, and I love to blame it on my otitis media that I had as a child, because I had plenty of that as a kid. It could be that it is linked to what I had as a child, and it could be that I'm just not very coordinated, but otitis media certainly has been linked to sort of not developing as good of balance in children, and we know that many adults that continue to complain of this sort of thing will complain that they're dizzy. Linked to that, of course, is the condition that truly causes the issue for otitis media, and that's eustachian tube dysfunction. We have many people whose eustachian tubes, the tube from the back of the throat that leads into the nasopharynx, just does not open and equalize pressure the way that people would like it to, and so we will see folks that have eustachian tube dysfunction that don't end up with middle ear fluid, but end up with negative or positive middle ear pressure will also complain that they feel dizzy, and where you will sometimes see this in a very dangerous way will be for somebody, say for example, that's scuba diving, and they're not able to clear their ears, and they become very disoriented and dizzy underwater, so that's a case where this particular issue could be quite detrimental to the person's life, but hopefully they have a buddy, but that's one of the cases that you will find that people will complain that they flew on an airplane, they weren't able to equalize, and when they come off the airplane, not only is their ear sore, but they also are feeling very dizzy and very disoriented, and so eustachian tube dysfunction is another one of the middle ear sorts of issues. Otosclerosis is a third, and otosclerosis is a fairly well-known condition. We know that most people, when they have it, are likely to be women. One of the ways that we diagnose otosclerosis is looking at kind of this bluish or reddish eardrum called the Schwartz sign, and so there's a good picture of that here on your screen. We know that the audiogram often will be conductive, and it will have a 2K Carhartt notch, so the bone will be not as good at 2,000 hertz, and so otosclerosis is one of those ones where we know it's linked to hearing loss, but I want to kind of talk a little bit about just a case, and as we go through, I have a few cases here or there to show you. This is the audiogram from our clinic, and you can see that the person has a unilateral conductive hearing loss on the left side. Their bone is slightly dropped. It's not a complete Carhartt notch, but it does dip a little there at 2,000 hertz. This person had reported that they had tinnitus on that side for five years. They have a familial history for otosclerosis, but they were never diagnosed with it because they had had otitis media during those five years, so they were constantly having middle-ear fluid, and we were constantly struggling with the middle-ear issues, and so they were never diagnosed with otosclerosis, and that often can happen. People will have more than one thing going on, and it makes it difficult to really sort it out. At the time of this particular audio, this person is 11. That's a fairly young age to have otosclerosis, but it happens at any age. They did have a SPART sign. They do have that kind of bluish eardrum that you can see here, so they ended up having a CT, and the diagnosis did come back that they had otosclerosis. Now, this particular person had been reporting dizziness. They didn't find that the dizziness was debilitating, but they did feel a little unsteady and off, and they had felt that way for the past five years, so they were feeling as if they had a very good handle on it, so although they were given a surgical option to have the audiogram hopefully improved and hopefully to do away with the dizziness, as well as being provided with hearing aid options, they chose just to monitor. They know that down the road, they're going to have to do something about this, but they're going to do it at a time that's convenient for them because this particular condition, this particular dizziness isn't enough that it's really affecting their life, and that's usually pretty common for these middle-earth sorts of things that people will have some dizziness, but it's not going to be so debilitating that they feel like they can't get through it. And then we have cholesteatoma. Hopefully no one's having lunch there on the East Coast. For us on the West, it's a little early, but those are kind of nasty-looking pictures, but we know that cholesteatoma, which is not really a tumor, but it's a destructive, expanding growth, and it can extend into sections of the head that are going to also cause dizziness. So those are sort of the most common middle-ear kinds of things. The real major things that we need to talk about today, and we have the most of our time to do so, are things that happen in the inner ear, and specifically in the vestibular system. I think we're all, all of us, much more familiar with what goes on in the cochlea. It's a more straightforward kind of end organ, but what we have here on the screen on the left, you'll see our cochlea, but you'll also see our three semicircular canals, and you can see how closely these two pieces are related, and you can see some structures there that are identified. They're utricles and saccules, and we're going to look at some of those as we go along. We're going to have another little anatomy picture here in just a second, but we know that these particular structures are very closely related, so oftentimes something that happens to one can cause a problem with the other and vice versa, which is why hearing loss is really closely associated with dizziness and dizziness with hearing loss. If we look inside one of the little ampules, one of the little kind of raised portions of the semicircular canals, you'll see that we have fluid, just like we have in the cochlea, and you'll also see that we have some hair cell structures that look pretty similar to the hair cell structures we would be used to seeing when we look at anatomy pictures of the cochlea. So, fairly similar looking kinds of structures. We have supporting cells and type 1 hair cells, just like we do in the cochlea, and then we have endolymph, as I mentioned to you, we have fluid as well, so pretty similar kinds of structures. One of the biggest concerns that we see for dizziness when we look at it from an early-on standpoint is going to be a syndrome called enlarged vestibular aqueduct, and enlarged vestibular aqueduct is something that a person is, of course, born with because it's actually a structural abnormality. It's most commonly associated with a genetic chromosome abnormality, and you can see that listed there, SLC26A4, it's that particular gene, and so there are a couple of different disorders that have that particular genetic abnormality. Now, not everybody that has an enlarged vestibular aqueduct has one of these two syndromes, but most of them do have this particular gene, and we know that this is something that goes haywire at the fifth week of gestation, so we know that this is something that happens really early on, and we know that people that have an enlarged vestibular aqueduct can often have conductive mixed or sensorineural hearing loss, and the hearing loss can be stable or it can be fluctuating, and certainly we also see the same kinds of things happening with vertigo as well. Oh, I went a little bit too fast. What we see with enlarged vestibular aqueduct is these kiddos will be born with this, and many of the adults that we see have not had a very good diagnosis, and when they start to see a diagnosis is after they've had some kind of a head injury usually. Maybe if they're a child, they've been playing touch football and they got hit, or if they're an adult, they got struck or they fell, and all of a sudden the hearing drops and the balance becomes bad, and so we'll oftentimes see with this these big jumps or these big changes, and it's very easy to diagnose if a person has had a CT or an MRI, but realistically those are not things that were common when many of our adults were growing up, and so adults kind of had this issue and not even really known that they have enlarged vestibular aqueduct, so that's one that we can pretty easily clear-cutly say, oh, yep, your dizziness and your hearing loss are related to an anatomical abnormality. So the second big issue that we know happens with vertigo related to the ear is BPPV, or benign paroxysmal positioning vertigo, and this particular problem is one with otoconia, these little crystals that are supposed to be in gel in the utricle become dislodged and they migrate around, so they float around to a place where they're not supposed to be, and they basically cause a traffic jam. And so now all of a sudden the free-flowing fluid that's supposed to be able to circulate through the semicircular canals is not so free-flowing and it's not circulating the way that it's supposed to. And so people that have BPPV have a very kind of clear-cut pattern. They move their head suddenly or they sit up suddenly and all of a sudden they're dizzy and that goes away after just a few minutes and so it's just very much I move and then I'm dizzy, then I move again, and then I'm dizzy. The nice thing about BPPV is unlike many of these disorders, there's actually something that we can do about it and a very smart gentleman, John Epley in Oregon, developed the Epley procedure and there's multiple procedures and people can go online. You can go on YouTube and see how to do them. I have here the pictures for you, but people will typically not do this on their own, although we do have patients that do it on their own or do it with their family. You put yourself through a series of head movements that are specifically designed to get those little otoconia to float back to where they're supposed to be. Once they're back in their proper location, then the person doesn't have the vertigo anymore, the dizziness anymore. The bad thing about this particular disorder is that those little otoconia, once they become loose, they're not in the gel like they're supposed to be, you can get them back to the right place, but they don't really always like to stay there. A typical person who truly has BPPV, who truly has found relief through the Epley procedure or one of these canalith repositioning procedures, will oftentimes have to have this done again. It might last for a year, six months, eight months, two years, and then they end up doing it again. The nice thing about it is it's not overly time consuming. People will usually spend roughly a half an hour or so in the procedure and like I said, people will do it at home and it's not unsafe to do it at home. If any of you are interested, go on YouTube and you can do it yourself. It's not going to harm you to do it, but it gives you the idea that you're just really placing your head in some very specific procedures in order to get those otoconia to float back to their proper location. The nice thing about BPPV, like I mentioned to you, is it is one where we really have something that we can offer that's pretty non-invasive. The other real big one that's very well known and certainly affects a lot of people is Meniere's disease. With Meniere's disease, you can see we have a couple of pictures here. You can see there's a healthy inner ear and then you can see that the end of the lymphatic sac is bulged out on the Meniere's patient. What we see with Meniere's disease is that we have this overabundance of fluid and it's typically characterized by these very sudden episodes of vertigo. They can last as long as several hours. I've had patients that they've lasted several days. Some people they last just a few minutes. When a person is dizzy with Meniere's, most of the time they're very, very sick and by that I mean they're vomiting to the point that they're that type of sick. It's a really debilitating, disabling condition when it occurs. Some people it comes on suddenly, others will have precursors and they will kind of know that it's eminent. The other thing about Meniere's disease is that we do include these sort of four symptoms for Meniere's disease. Not everybody has all four and certainly at the very beginning when people are having attacks they will not often have all four, but there's kind of this little group of symptoms that you have a fluctuating hearing loss, which is a sensorineural, predominantly low frequency hearing loss, ringing in the ear, the vertigo, which we've already mentioned, and then this feeling of what's called oral fullness or feeling like your ears are plugged up. People will oftentimes say they think they have an ear infection, but they won't. It's those four things that will go along that will typically give a diagnosis of Meniere's disease. In addition, of course, there's some testing that's done for that. People do find that there are triggers for Meniere's disease, so stress, overwork, fatigue, emotional distress, illnesses, pressure changes, certain types of foods, salt are things that can sometimes trigger Meniere's for people. So here's a case of a nine-year-old girl. She'd been dizzy every other week since she was four. She didn't have any other auditory issues or headaches, so really no hearing loss. When you look at her audiogram you can see that there's not a low, well there is at 250, but it's not that really common low-frequency hearing loss, and she has some high-frequency hearing loss as well. So that's not a real typical Meniere's type of a pattern. They thought that initially it was BPPV because her symptoms did not last long, and they did somewhat seem to be related to movement, but the EPLI procedure did not resolve the problems whatsoever. So it usually does. So based on the history, she was given a Meniere's disease diagnosis. She was not tested. She didn't have any other information, but she was given that. Eight months later, the dizziness returned, and this time you can see she has hearing loss. Now this is much more of a, not clear-cut, but certainly much more of a potential for Meniere's disease, and she was given diuretics, and so that's one of the things that's tried, and certainly after the use of diuretics, her hearing returned to the pre-medicated levels and the dizziness went away. These two things coupled together typically will then give you a Meniere's disease diagnosis. So the patient has continued to use diuretics daily, and she has not been dizzy for the past 17 months, and you can see her audiogram is still not completely as good as the right side, but she came in already with that high-frequency loss on the left side, and she's not been dizzy, and she's not had any other changes in her hearing. So here's a case where diuretics being used as kind of a prophylactic type of a procedure where she's using them daily has really done a good job of resolving the dizziness for her, and that's a lucky patient because they don't all have complete relief. So the underlying condition for Meniere's disease is something called endolymphatic hydrops, and so that's the case where you have this extra fluid, and it can be associated with something primary, like Meniere's disease, or it can occur as related to an event or an underlying condition. So sometimes people will get a head trauma, or they'll have some kind of inner ear surgery, and then they will develop endolymphatic hydrops, but endolymphatic hydrops is sort of the big condition, Meniere's disease being one of the things that can give you endolymphatic hydrops, and other things can give it to you as well. And so people can be treated, for example, with diuretics following a head trauma, and their dizziness and hearing loss will go away, but that does not mean that they have Meniere's disease, which is why I wanted to be sure and talk also about endolymphatic hydrops. So another thing that can happen is you can just have an infection or swelling of your vestibular nerve, and if it happens in the cochlea we call it labyrinthitis, if it happens on the vestibular side we call it vestibular neuritis, but this is just where the nerve becomes inflamed, and sometimes this is viral, sometimes it's bacterial, it's most often viral and less likely bacterial, but physicians will usually try different types of medications to get the swelling to go down, and so that's another thing that can cause vertigo and hearing loss. The real, I think probably biggest part of information that we've gathered or garnered in the last few years is about the whole idea of having autoimmune disease, and we know that autoimmune diseases can affect large portions of our body, and they certainly can affect the inner ear, and this is an inflammatory condition, it attacks the ear and it can attack the vestibular system as well, and it's rare, but we know that there are a variety of different syndromes and I've listed many of them up there for you, but there are others, a variety of different kinds of syndromes that have autoimmune disorder that affects the ear associated with it. Autoimmune is a really tricky one, because it tends to be very debilitating, so this is a comic that isn't very funny if you had autoimmune disorder, and it says you want to do something today and it says I can't, I did a thing yesterday, and that's really I think how most patients feel is they're maybe going to be up to doing one thing, but this is so debilitating that then they really just can't get around to doing anything else. Now about 50% of the people that have this that affect their hearing also have it that affect their dizziness or cause them to have unsteadiness or disequilibrium, and so it is one that is super tricky to both diagnose and also very tricky for us to do anything about. So I'm going to give you a case, this is an athlete who had a sudden hearing loss after having an upper respiratory infection. She had oral herpes at the time of the visit, and that only plays a role because we know that herpes can affect different parts of the body, right? She started on steroids, they tested her for several of the most common autoimmune disorders and all of that came back normal. Six months later, you'll see this audiogram, we did audios in between times, but six months later this is the audiogram, there's no real improvement, the person had an MRI and they didn't see MS or lesions or anything like that, and they were told to come back in six months if there wasn't a change, so really no real clear cut diagnosis at this point. The person had a sudden drop in their hearing, you can see that here, they were given a hearing aid but they decided, excuse me, they were given the hearing aid information but chose not to get it, and you can see that there's potentially why because they're still doing fairly well on the right hand side. They were given another round of steroids, no improvement. Three months after that, there was another drop in the hearing and now they had roaring tinnitus, they were offered medication again but they chose not to take it. Another three months later, the tinnitus has gone away, the hearing continues to fluctuate 10-15 dB, you can see the word rec is now 12%, they did decide to finally try a hearing aid and they weren't successful, and obviously there's other things that could be tried with this particular person, there's cross-types of hearing aids and bi-cross-types of hearing aids, so there's a variety of different hearing aid options but frankly, the piece for them that's the most difficult is the fact that they just don't really know what's going to happen and they get these sudden drops of hearing and then they have vertigo associated with it as well. So this is a really tricky one because the problem with autoimmune is that seldom is there a really good way of preventing these drops, so kind of a sad one. Paralympic fistula, on the other hand, typically does have something that we can do, it's always nice if there's a cure, so paralympic fistula is when we have an abnormal connection, usually it's a tear in one of the, either the oval or the round windows and so what that allows to happen is air to get into the inner ear and fluid to get out into the middle ear and we don't really want those things to occur, and so a person who will have a paralympic fistula, they'll find if they have any change in the middle ear or if they have any change in air pressure that they will then get dizzy and this can also cause problems with hearing. So let's look at a nice fun case. So if you look at this audiogram, I would immediately think Meniere's disease, that is a great Meniere's disease audiogram, that looks like a Meniere's disease audiogram to me. They had a sudden onset of hearing loss with tinnitus while they were weight lifting. Now see, weight lifting kind of puts it back into the paralympic fistula category because it would be sort of a sudden onset and this did not go away, so if it were Meniere's we would expect the person to have a relief after a few hours or a few days. They couldn't do an MRI but all the lab work came back, they were put on a diet of no nicotine, no caffeine or salt and they found that our loud noise and they were put on prednisone. So they were put on all kind of a standard sorts of things just to see what was going on. A little bit later the patient's hearing had come back somewhat but not to pre-zoomed pre-hearing loss levels. We don't have a pre-hearing loss test but we were told that the hearing was normal. The physician decided to go ahead and go in and do an exploratory surgery and found that there was fluid pooling in the oval window so they did an oval window fistula repair and ta-da, ta-da, ta-da, this is one month post audio. Audio is back, we don't always get that but yay for this one and the person most importantly is not busy and is able to go back and do all of their regular activities. So that's a nice case. So we know and I know that this is a really long slide and it has a lot on it and I want to look at just kind of the main categories but you can download this so if this is something that you would like more on or be able to refer back to, I put this on so you'd have that. But ototoxicity is something that when we expose ourselves to drugs or chemicals or something that can damage the inner ear and we know that anything that we're doing that's ototoxic is going to also damage or most likely damage the vestibular system as well because we're really damaging the vestibulocochlear nerve and it can be one or the other but often times it's both and we probably know more about the damage that we do to our hearing because that's much more easy to document the changes where if we're looking at damage to the vestibular system unless we do pre and post testing which is a little bit more rare testing and typically not done as frequently as pre and post audiograms if you're getting chemotherapy for example so we don't tend to see that we have as good of documentation on what happens with the vestibular system but we know these things affect it as well. So we know that environmental chemicals can affect your hearing in your vestibular system so there's kind of a list there. We know that loop diuretics can affect the system depending on how they're being prescribed and how much they're being prescribed. We know that the aminoglycoside antibiotics can affect the vestibular and the balance and the hearing system and these are going to be done in sort of larger doses that we would only be doing or physicians would only be prescribing if they were really life saving types of measures. They're not the kinds of things you're going to get if you have a small ear infection. We know that aspirin in large quantities can do that as well and we know that the biggest culprit but once again it's the life saving kinds of things are any of the kinds of anti-cancer medications that people can be put on and particularly if they're coupled with radiation as well. So that kind of is like a two punch, the punch with the anti-cancer drug and the punch with the radiation. So those are all things that we know can affect both systems and can damage both systems. So here's an example. This is a 3-year-old, 8-month-old child that had headache, vomiting, ataxia, so they were having difficult walking and vertigo. You can see a big whopping tumor there where the arrow is pointing. The person had the tumor, was given chemotherapy over a 14-month period of time and radiation and we have some audios to look at. We have the first audio after the fourth session and the person didn't have a hearing aid but they were complaining of hyperacusis. So here are our audiograms. Number one is after the fourth session of chemo and you can see that what we have here is a real drop in hearing. In this particular case, even though I told you that the person could easily have more vertigo from having had chemo, and the reason for that is we have to assume that these symptoms of headache, vomiting, ataxia, and vertigo were related to the tumor and so once we were able to shrink the tumor and the tumor was not putting pressure on those structures that although we probably have done some damage to the vestibular system, it's still an improvement over where they were before. So now I want to talk a little bit about vestibular migraine. We know that about 40% of all patients that have chronic migraine that have been diagnosed with true migraine tend to also have some vestibular symptoms as well. And so at some point during their migraine, sometimes before, during, or after, they will feel that they are dizzy. These things can happen with the migraine, without the migraine, but there does tend to be a link between the concept of migraine and the concept of vestibular symptoms and many of the same triggers, so many of the things that you would be told not to do if you were having migraines are going to be the same kinds of things that we're going to tell you not to do if you're having vestibular issues, so cutting down on salt and some of those kinds of things. And the same sorts of triggers like stress or certain foods, weather changes, all of those kinds of things will exacerbate both symptoms. So there are certainly a connection there. Now this one isn't really truly a vestibular problem, but it is related to a change within the vestibular system, and it lets us highlight something kind of important, and this is the case if you ever go on a boat, particularly if you go on a long cruise or something like that, but you could go if you went ocean fishing or out on a boat for a few hours, you can find that when you come off the boat that you feel dizzy, that you feel unsteady. And I gave you a nice quote by Darwin, he wrote this in 1796, and he talks about the fact that this has happened to him, and what you're seeing here is that your vestibular system adapted. So it was on a boat, it realized that everything was swaying, it didn't want you to get sick, so it made that your new norm, and so your vestibular system coped, it adapted, and now when you get off the boat, your vestibular system has to cope and adapt again, because now you feel dizzy because now you're not on the boat anymore. So that's called mal debarquement, my French is fabulous, or MDD, I can say that one better. So in the whole concept of vestibular issues, there are a couple that are probably a little newer, and this is one, and it's called superior semicircular canal dehiscence, and in this particular condition, what we have is a breakdown in the bone around one place within the semicircular canal. It has some very interesting findings, one is that people will experience vertigo and also opsilopsia, which is the fact that you feel like objects that you know are stationary, like right now I have a Diet Coke on my desk, if it started to seem like it was spinning around, I would have to either assume that my office was haunted, or that I was having opsilopsia, and then the other thing that we know is that this can often be triggered by loud noises or any kind of maneuvers where a person is coughing or changing the inner cranial pressure. Then in terms of the auditory symptoms, people will often say that their own voice sounds like it's louder, and they tend to have hypersensitivity to bone-conducted sounds, and it looks like they have a really large conductive hearing loss, but if you look at the admittance, the admittance is normal. So this is not a super clear-cut case, but you can see we have a conductive hearing loss, but they had a normal tympanogram and normal acoustic reflexes, which you wouldn't expect. We felt that this person was not lying to us, they had chronic disequilibrium, it made it impossible for them to work, and like I said, we thought they were reliable. Because they were complaining of dizziness, and they were not able to work, and the CT reflected the breakdown of the bone, they went ahead and they had surgery that patched the bone. As you can see, the audiogram has improved, and what is most important, is they're no longer dizzy. Now, I told you that that wasn't a real traditional or real typical example of an audiogram, and why that is the case, and I'm going to show you four, is most of the time what you're going to see in these cases is really good bone conduction thresholds in the low frequencies. And by that I mean in the negative range. And so you can see here are two audiograms, yes there's some drop off in the highs in both of these cases, but you can see that they have these really fabulous low frequency bone conduction thresholds. You can see that there's a third one on the left hand side, so good low frequency bone, not quite as good. But what's really going to be common in all of these is that any of the middle ear sorts of things are going to be normal, so they're going to have normal tympanograms and normal acoustic reflexes, which we shouldn't expect. And if you look at the one on the right hand side, you'll see that there's a bilateral, and it's rare to have it be bilateral, but of course anything that happens on one side can also happen on the other. So this is a case where the disorder is confirmed via scanning, and then the person can choose to have a surgery, which will typically repair and correct the problem. But this is a less commonly known and certainly more newer finding. As we do a lot more scans, we're able to find a lot more information. So we've kind of looked at tumors already, but I do want to mention that that tumor that we saw was not a tumor specifically on the auditory or vestibular nerve, but we can have tumors on the auditory and vestibular nerve, acoustic neuroma, or vestibular schwannoma, and you can see there's a nice big one. They typically are not malignant and they do tend to be slow-growing, but they will affect balance in the inner ear and they can cause unilateral hearing loss, tinnitus, dizziness, and loss of balance. It can eventually affect the facial nerve, causing facial numbness and a facial droop. So those are the most common kinds of conditions for that. Then we have some others that I'm calling sort of inner ear, but they do tend to affect even beyond the inner ear. They can affect the whole auditory system, and that one's aging is the first one. Now the thing that's sad for me is it says that aging of the vestibular nerve endings begins at about age 55, which is next year for me, in case you wanted to know how old I was, which you probably didn't, but I'm telling you. But also we know that we don't have as good of information coming from our somatosensory system. Typically our vision starts to go, so all of these things together do tend to make us less steady as we get older, and we know that our vestibular system becomes less functional as we get older, and we will really tend to see this the most when we're doing things where we're trying to stand on an uneven surface, or if we're trying to walk in the dark where we're not getting as good of information perhaps from part of our trio of three inputs. And so aging can wreak havoc, and it can wreak havoc in the vestibular system and all the way up through the rest of the auditory system. We know that there are metabolic, hormonal, and vascular disorders that can take place throughout the entire system, and some of the most common of these are diabetes, chronic renal failure. So there are a variety of different kinds of things that can occur, and these are usually very difficult to pinpoint and very difficult to treat. We know that if you have a traumatic brain injury, you know, you fall and you hit your head or you're in a car accident, that that injury can affect really everything. It can affect things from the pinna that can be damaged if you, say, hit the steering wheel, all the way through to the occipital lobe. So the damage can take place anywhere, and because of that, it certainly can cause issues with your hearing and cause issues with your balance. Now traumatic brain injury doesn't just happen in car accidents and falling. I'm going to give you a little case here. Here's one where a person was hit by a baseball bat and they had a depressed basilar skull fracture, and you can see that they have no hearing on the left-hand side, and you can see their hearing has also dropped on the right. They had post-concussion syndrome. They had the profound sensorineural hearing loss. They had tinnitus. They had vertigo. They had vision loss, and they certainly had PTSD by the fact that they were jumped and hit with a baseball bat. So what I want to talk about on this one a little bit is if you had this person come to you and you can see that their discrimination score is 12% on their good ear and obviously they have nothing on their bad ear, what would you try? What would you do? And you would probably try the kind of traditional things, hearing aids maybe, maybe an FM kind of a system. In these particular cases, because the discrim was so poor, the person still really didn't do well. And so what was tried in this particular case was they were given kind of maybe old school but still good school auditory training where they were really taught to manipulate their environment and do the things that they could do to be able to place themselves in a situation where their FM might work or place themselves in a situation where their hearing aid would work. And so the three main, there were others, but the three main areas that were kind of important were conversing in quiet, when being spoken to by a woman with a higher frequency type voice, and talking to someone that they knew well. And what you can see is the pre-scores were really quite poor. And three months later, the post-scores were really quite good. So the person was able to sort of take back control even though their understanding scores were really quite low. And so I think, and I worked for a hearing aid manufacturer, I believe in technology and technology has become fabulous and we have so much that we can offer people. And so this is not a person who rejected any of these things, they used them. But I think the thing that's really important is that we realize that we really do have a lot of other options that we can still use, some of those old school things work really quite well too. So we kind of talked about infections and I talked about it more at the area of the vestibular nerve. But what I do want to also mention is those types of infections and inflammation can occur further up the auditory pathway and the vestibular pathway as well. So meningitis is inflammation involving the membrane of the brain and the spinal cord. And labyrinthitis can be something that occurs further up the auditory system and vestibular system as well. So things can occur a little bit more centrally than even the inner ear. Stroke is another one of those things where we know we can have damage that's further up the pathway. Oftentimes it happens because of high blood pressure, but it can happen for other reasons as well. And so we know stroke is something that can cause us to have vestibular and auditory problems. Okay, so I think I've completed where I'm supposed to be. I believe that I have approximately 12 minutes and that means that I can answer some questions. And so I'm hoping that you'll have some questions. I know that we have gone through that information fairly rapidly and that it was just kind of a shopping list of this, this, this, this, and this, but hopefully that will kind of summarize all the different things we think that can go wrong in the middle inner ear and further up the auditory pathway. So I'm going to quit talking and open it up for questions. Thanks, Julie. Julie, we're so excited that over 200 of your fellow colleagues have joined us today on this webinar. As Julie said, we do have some time for questions. So if you have a question for Julie, please enter it in the question box on your webinar dashboard. Julie, our first question comes from, let's see, comes from Kelly. Kelly asks, how do you test for dizziness to figure out what the problem is? Well, Kelly, that's a really good question and that might have been something I should have put in my presentation, but they only gave me an hour. I think they should have given me two, but you asked the question, so it's great. So there are a variety of different tests that are done for dizziness. There are things that can be done at the bedside. So there are different sorts of tests that perhaps a doctor might do right in the hospital if you were in the hospital. Or you might go to a neurologist and the neurologist might have you try to do some things. For example, standing with your arms out and you close your eyes and they look to see if you can walk. That would be an example of one that they could do. There are also some more defined testing that can be done. So one of them is called posturography. Posturography, you stand on a platform. You have what looks to be almost like a telephone booth, a three-sided telephone booth around you. And that telephone booth and what you're standing on varies. So at one point they'll give you faulty visual input or maybe they're going to give you faulty somatosensory input. And they look to see how you do in different conditions to see are you using your vestibular system? Are you able to use your somatosensory information? Do you use your vision? Are you really focusing on your vision and not relying on anything else? And if those systems are intact. So that's one thing that we do. Another test is called a rotary chair test. And in that test you're placed in, once again, kind of a big phone booth. Everything is dark. You have goggles on your head and they turn you, not super fast, but they turn you in the dark and they look to see does your vestibular system do what it's supposed to? So that's called rotary chair. And another really big test that's done is called ENG, electronistagmography. And that's done nowadays a lot of times using video goggles. And so you're put to a different positioning. At times water can be put in your ear. And we're specifically looking to see does your vestibular system do what it's supposed to? And if not, does it not do it on one side? Does it not do it on the other? And so that's called ENG or VNG if you're using the vestibular goggle system. And then there are a few other kinds of tests that are similar to tests that are done maybe testing newborn babies where you put electrodes on a person's head and you do different things to them and you look to see what's going on with their vestibular system. So there's a group of electrophysiological testing that we can do as well. So that entire battery could be done on a person and it takes a few hours to do. And it really gives us a very good understanding of what part of the vestibular system is not doing what it's supposed to. So there are some very formal testing for vestibular conditions and many of these disorders that I showed you today, people if they were having this kind of dizziness, they would have been referred for those sorts of tests and they would have received those sorts of tests and then based on that information, we would have been able to sort out which of the disorders they were having. Great. Thanks, Julie. Julie, our next question is from Sheila. Sheila has a 53-year-old patient and asks, what could be a possible cause for one-sided tinnitus in normal hearing? One-sided tinnitus in normal hearing. Well, you know, tinnitus is a tricky thing. We know that tinnitus can be associated with hearing loss, obviously, the most common. It can be associated with damage to the structure. So when we say normal hearing, one of the things that might be interesting to do on this particular patient would be to do, say for example, otoacoustic emissions and try that on both sides and see if the emissions are as large and as robust and particularly in the higher frequency regions on both sides. Or to do extended high frequency audiometry to see if perhaps there's some hearing loss in the higher frequency regions and it might be that there really is a difference between the two ears, potentially, I'm just, you know, I don't know, but potentially a difference in the two ears, but it just hasn't gotten to the place where we're seeing it on a conventional audiogram. So I think that can be one of the things that can occur. We also know that if we look at the website of, say, the American Tinnitus Association, there are going to be people for whom there never really is a clear-cut diagnosis and there really isn't a clear-cut reason that they have their tinnitus and we can try different types of medications or we can try different kinds of things, but we're never really going to know. So I think that there's a potential that we're just not going to know why it is that the ear on that side has decided to fire and create the sound when, or not fire the way it's supposed to, could be either thing, on one side and not the other. So I don't have a good answer for you, but I would say when I get these weird ones where it's on one side different than the other, I try to look to see is it potentially a difference in the hearing, but in a region that we don't normally assess, that we would not normally assess here either. Great. Thank you, Julie. Julie, our next question is from Susan, and Susan asks, if a person has BPPV, does it ever go away? Yeah, so BPPV is one of the good ones because we can do the Epley procedure, and I keep saying the Epley procedure because I came from Oregon and that's where I spent my time working with vestibular patients, and John Epley was based in Portland and I had a good opportunity to know him and he was the first person to really look at this, but other people have developed similar sorts of procedures, and Epley is still a very popular one. So people can take use or make use of the Epley procedure, and almost everybody, and not everybody, but really almost everybody finds relief from the BPPV following that particular catalyst repositioning procedure, and maybe they don't have total relief, but it gets down to a place where they feel pretty comfortable with it, so that's the nice thing. The bad thing about it is that those otoconia, once they become dislodged for whatever reason and no one really knows why that happens, they don't like to stay there. They will eventually get back to the place that was causing the BPPV in the first place, and I guess I shouldn't be so definitive. There's nothing really in life that's always 100% certain every single time, but most patients that have BPPV will end up having to do the catalyst procedure again and again, so it's one that they have to do, but it isn't one of those things that's really, really tricky. It's fast, and it isn't invasive, and so most people, if you tell them you're going to probably have to do this again sometime in the next eight months to a year and a half, they'll be like, yeah, fine, that's no problem, I can do that again, and they'll just come back and they'll do it again, and then it'll last for a while, and then eventually they'll have to do it again. Thanks, Julie. Julie, our next question is from Erica, and Erica asks, when suffering from vestibular issues, we know that eye disturbances can occur with dizziness. Can it also cause sharp, stabbing-like pain in the ear as well? Eye issues that would cause sharp, stabbing-like pain in the ear. Okay, so my vote on that, although I am not the specialist on eye things, I would, if I had a patient who felt that it really was related to their vision, that whatever symptoms they were having with their vision when they were having them were also causing them ear pain, I would refer them on to an ophthalmologist and be sure that they saw the proper specialist for that. But I do think that it's always possible, because we know that many of the places where we have innervation, between the ear, the eye, our TMJ, all of those things are all really located very closely together, and I think that when you have a pain, sometimes it's difficult to know, so you'll have people with a bad tooth who think they have an ear infection, or people with an ear infection that think they have a bad tooth, and yet you would think you'd be able to tell the difference between a tooth and an ear and an eye. So I guess I would have to say, although I can't think of a specific cause or a specific reason why that would be the case, I certainly wouldn't discount it. But I would then bring in a colleague, an ophthalmologist, like I said, to help me with that assessment, because I would feel that I was out of my depth a little bit. So I think my answer isn't a complete answer, but I certainly wouldn't rule it out, particularly if the person felt there were symptoms that were going on visually that also were occurring at the same time that they were having the ear pain. Thanks, Julie. Julie, our last question comes from Alan, and Alan asks, if a person has a vestibular schwannoma and it is removed, will they always have issues with their balance? So, yeah, that's the $59, $69, $79 million question, really, Alan. We know that if a person has a vestibular schwannoma removed, and let's say they had hearing loss also associated with it, the hearing will most likely not come back. And what we also know is that, depending on the surgical procedure, the hearing might be completely obliterated. So it might be that they lose all of their hearing on that side if the hearing is part of it. We know that any pressure that's been caused on the vestibular nerve is not going to be correctable. It's just not going to get any worse. So in that sense, we would have to say that their functioning is not going to come back. But the good news is, much like when we looked at what Darwin told us about MDD, that when you get off the boat and you're off for a while, your vestibular system gets back to normal, that is truly the case for us. Our bodies are remarkable and they can adapt and they can learn what's the new norm, what's the new status quo. So a person will often, if they've had surgery, will be dizzy, maybe even worse than before, and they will go through a fair amount, oftentimes, of vestibular rehab, and the good news is what that's doing is teaching a person and teaching a person's vestibular system to accept the new norm. So there are many people who have had tumors removed, vestibular spinae removed, who then get back to what they consider to be truly normal gait, truly normal vestibular functioning. It probably is not the case that that's truly normal, but that's become their new norm. And maybe they need to be careful in some situations, maybe for example, they're going to be more unsteady if they're walking on an uneven surface, maybe they're not going to be as good at yoga as they used to be, or maybe they're not even going to be able to do the balancing poses of yoga, or something along those lines, but they will be able to create their new norm and be able to get back to everyday functioning. So I think that's a difficult one to answer, it always will depend on how big and how much and what surgical procedure, but I think that a person who's going to have to have a surgery like that should realize that there's going to be people that can help them get their functioning back so they can go about their, hopefully go about their daily activities. Great. Thank you, Julie. Julie, I'd like to thank you for an excellent presentation today, and I'd like to thank everyone for joining us today on the IHS webinar, Dizziness and Diseases of the Ear. If you'd like to get in contact with Julie, you may email her at jpurdy at rchsd.org. For more information about receiving a continuing education credit for this webinar through IHS, visit the IHS website at ihsinfo.org, click on the webinar banner, or find more information on the webinar tab on the navigation menu. IHS members receive a substantial discount on CE credits, so if you're not already an IHS member, you'll find more information at ihsinfo.org. Please keep an eye out for a feedback survey that you will receive tomorrow via email. We ask that you take just a moment to answer a few brief questions about the quality of today's presentation. Thank you again for being with us today, and we will see you at the next IHS webinar.

dizziness

ear diseases

vertigo

anxiety

Meniere's disease

BPPV

neurological conditions

balance

testing methods

symptoms