Dr. Kramer, JFK Medical Center Dizziness & Vertigo Seminar

very gratified to see all of you come out tonight and introduce myself I'm Stephen Weiss I'm the chief marketing officer for a JFK health and I usually do these introductions so it is really my pleasure to in I'm going to do is I'm going to introduce each speaker before they speak so instead of instead of doing it all at once but really is my pleasure to introduce our first speaker who's a dr. Philip Cramer who's the director of the JFK vestibular laboratory it's this gentleman right here dr. Kramer attended Syracuse University which I have to give him applause for because I did as well so I like him already dr. Kramer attended Syracuse on an Air Force ROTC scholarship and receive a Bachelor degree in aerospace engineering in 1977 he then flew the b-52 in the Air Force and while there earned about yers degree in computer science after leaving the Air Force he picked up pre-med credits at Yale prior to attending medical school at the University of Connecticut so he's not very well educated I'm sorry dr. Kramer's neurology residency was at the University of Massachusetts followed by a fellowship in odo neurology which is the study of dizziness at Johns Hopkins in 1995 he joined our faculty and he joined the Faculty of Johns Hopkins in the department of neurology and the department of otolaryngology where he saw patients who were dizzy there he conducted basic science research on ballast systems publishing 20 papers during his career and numerous book chapters on dizziness he has received three NIH grants for research in the field of dizziness dr. Kramer joined our faculty 19 years ago and is currently an associate professor at both Seton Hall and Robert Wood Johnson he has been married to Lori for 26 years and shares us home with two adorable beagles everyone welcome dr. Kramer [Applause] Thank You Steven clearly Syracuse improved after I left good job while I'm up here I'd like to thank you all for coming it's very gratifying to see as many members of the public interested and I hope you'll learn something today that will help you I'd also like to thank alam shah for helping to arrange this along with steven and then helping throughout our tracy Josephine and Giovanni we couldn't do it without them so let's get to the show we're going to talk about the dizzy patient when I think of dizziness I usually think of vertigo which is spinning but we're going to get into that a little bit more so an overview of what I'm going to say first I'm going to talk about history and what I mean by history not the history of dizziness I mean the patient's history what the problem is when it started how it started I'm going to talk about the anatomy and physiology that explains dizziness and through that I'm going to talk about this thing called nystagmus which is one of the primary signs that I see when I'm examining a patient to help determine their problem I'll discuss nystagmus by discussing this thing called the vestibular ocular reflex and I'll discuss a little bit about brain processing and finally we'll get onto a few of the diseases that cause dizziness so history very important thing when you come in we'll be asking you and jigna will be doing the first part of your visit if you were to come to see us but when you see any doctor you need to be able to explain as best you can what you mean by dizziness because if you got that wrong then you're probably not going to be able to help the patient so vertigo and the little asterisk is because that's that the busyness that a lot of my talk is going to be about is a false sense of motion usually rotation disequilibrium is really just a fancy word for being off balance lightheadedness which doctors will refer to as near syncope suggest a cardiac a metabolic or a drug problem as in your drug side effect is causing a problem and then the other type of dizziness is this funny headed difficult to describe floating feeling like my head is in a different part of the room feeling I've every time I think I've heard it described and all the ways that could possibly describe the patient comes up with another one and if that's your dizziness then that's what we want to know but that's kind of because it is somewhat vague it's a little bit harder to diagnose so if you can tell the doctor what you mean by dizzy what dizzy feels to you without using the word dizzy that's going to be help very hopeful the next thing that you should know is when you get dizziness how long does the dizziness last I'm going to talk about a little bit about that later and Jigme is certainly going to spend some time about that so we're going to talk a little bit about the science behind dizziness well here is my narrow anatomy of the balanced system and I have one of my residents in back and don't think you're going to get away with this simplified version you need to know it in a little more detail but this is basically what it's all about in the middle hopefully you can see that you have a computer that computers the brain it talks back and forth with another part of the brain called the cerebellum and together they take all these inputs vision the input from your inner ear and the feeling in your feet it takes that they do some computations on that and they use that to control your eye muscles I'm going to get into that and that's really important to me when I examine a patient and it's important to you because it helps stabilize your vision but also be downward pathways that it uses to help maintain your balance okay so when I examine you I'm going to be looking for something called nystagmus and rather than trying to describe nystagmus I'm going to show you a nystagmus I'm not getting casual I'm going to show you a different form of nystagmus than I was planning to show you if you can get that working that would be great so nystagmus is a back-and-forth motion of your eyes usually going quickly in one direction and moving slowly in the opposite direction I'm going to explain to you why that's important but let me walk around the room and show you missed agus so I'm going to show you a normal nystagmus fortunately I wore a tie with stripes on it and that that's the key to this so what I'm going to be doing is concentrating on the stripes as they go by and I want you to look at my eye going to I'm going after wear my glasses I'm going to you to look at my eyes as I'm doing that and hopefully what they're doing is they're wiggling back and forth as I do that so I'm going to take a minute here to show you that a guy named Mach the same guy who invented Mach numbers back in the 1800's discovered this while sitting by the train and watching people look at the train go by and they saw their eyes going back and forth as as he did that and he was the one who discovered this is called optokinetic nystagmus here I'm shaking someone's head that isn't really nystagmus you're seeing there you're going to see it afterwards and he's wearing the goggles that we use with the patients and you notice that the eyes are moving rapidly in one direction and slowly in the opposite direction so that's nystagmus and I look for that when I examine patients and I'm going to tell I'm about to show you why okay so there's this thing called the vestibular ocular reflex I spent much of my career at Hopkins studying the vestibular ocular reflex and it is a reflex that keeps our point eyes pointed in the correct direction to stabilize our vision so if I'm looking at those gentlemen with the cameras if I'm looking at one of those cameras and I move my head back and forth I have to move my eyes in the opposite direction in order to be able to keep my vision pointed at that camera that actually even happens in the dark if we turned out all the lights and I pretend to look at the camera and move my eyes back and forth it is in vision that's bringing back my eyes back and forth it's my inner ear that's bringing it back and forth we can demonstrate that you can all demonstrate that now unless you have a problem with your vestibular ocular reflex by taking a piece of paper that you may have gotten here and hold it in front of you and you can take that piece of paper and go back and forth and know you'll know that it's difficult to read if you hold it still you can read it easily but if you go back and forth it's more difficult to read now if your vestibular ocular reflex is working and I suspect maybe with some of you it's not if you hold that piece of paper out and shake your head back and forth you should be able to read the paper much better but with the paper still but your head going back and forth and that's because your inner ear muscles I mean your eye muscles are getting a message from your inner ear and stabilizing your vision so how does the vestibular ocular reflex work it works because the activity in the inner ear increases when the head is turned towards that ear so when I start moving my head towards this year the nerve activity in that ear not the hearing part but the balance part increases I move towards that ear and decreases as I move away from that ear so as I move in this direction I'm moving towards this area it increases and when I move towards this year it increases in that direction but it decreases as I move away that neural activity is sent to your eye muscles to help move your eyes and let's see how even when I'm not moving my ears are firing my ears are putting out a signal that becomes important in another second you'll see why so the brain interprets any imbalance in the activity between the two ears of head rotation so as I'm moving my head this way there's more activity on this side less activity on that side my head knows that I'm moving my head my my brain knows I'm moving my head in that direction so let's look at that does little got in the middle is the brain and these lodges on either side are the nerve cells and you'll notice that here the BRIT the head isn't moving at all and you have the nerves are just sitting there firing at this base rate we'll call it five times a second so the brain looks at that and says five minus five that zero we must not be turning in this next example farther down we notice that there's a bunch of spikes underneath this side and not and fewer under this side so the head is rotating in this direction what the brain does is it takes nine minus three and it gets six so that's six that's not zero so we must be and it's unfortunate you can't see this arrow well we must be turning in this direction the opposite happens when we go in the opposite direction we get only three spikes on this side so three minus 9 is minus six so we are also turning and moving in the opposite direction when we sense that head rotation we get the eyes moving in the opposite direction and that's the beginning of nystagmus so the brain interprets any imbalance in activity is head rotation what I showed you before was normal just someone moving their head back and forth but now we're going to look at when there's a disease or a simulation of a disease when there's a problem so here in all of these notice there's only five marks on each ear so that tells you since it's five on one side five on the other the head isn't rotating in any of these examples and that's what happens here in the first one 5 minus 5 is 0 but notice here this X what I've done in this this little cartoon here is I've taken a knife figuratively and I've cut the nerve between the ear and the brain so now that information isn't getting from the ear to the brain so the brain sees this side is 0 but remember when you're not rotating even when you're not turning at all there is some base firing rate here so it seems nothing over here but 5 over here so it says 0 minus 5 is minus 5 so even though we're not turning the brain thinks the head is turning and if it thinks the head is turning it moves the eyes in the opposite direction and you get that nystagmus you'll also get the feeling like you are turning and then we go down to the other side the last example when we cut the nerve on the other side and you get the sense of rotation in the opposite direction and nystagmus in the opposite direction so now by looking at the direction of the nystagmus remember firstly when we looked at that at the video when we finally got it working we saw that the eyes were going quickly in one direction and slowly in the opposite direction so the that could tell me which side the problem is on so that's that's the basic simplified you know first thing you learn when you when you when you do your fellowship in busyness that's the beginning of what you learn about nystagmus it does become more complicated it's not left just left and right it can be up and down and it can also be if you turn your head like this believe it or not your eyes turn in your head like this it's called torsion so when you get a mixture of those different things that can mean all kinds of different things and it cannot only be your ear that causes the problem but sometimes it's the brain that's causes your problem so that's what I spent the time at Hopkins study is part of what I spit did was learning how to recognize various nystagmus and and know what that means and every once in a while I come up with it one that I haven't seen before it isn't published in the books and that you just have to kind of think out what it means okay so remember I said in the history not only do I want to know what you mean by dizziness I want to know especially if you have vertigo vertigo is spinning by the way if you've been to a doctor and they told you you told them you had dizziness and they said oh you have vertigo they're there they're misleading you vertigo is a symptom vertigo is the sense of spinning it's the same thing as going to a doctor and saying doctor my foot hurts and they say oh you have pain so if they tell you a vertigo you need to ask them what's causing the vertigo why do I have vertigo if you told them you up spinning you know yourself you have vertigo so if you have vertigo and it lasts a certain amount of time that's very very helpful in telling me or any other doctor what the problem is so here we have a list of diseases and you can ignore this column and you can ignore this column the bottom message is this last column how long does it last and you notice there's not much overlap here hours hours between men years and migraine I'm going to talk about that later but each of these has a different amount of time that they last lasting less than a minute lasting a few minutes lasting hours so with that it that's one of the biggest clues is to telling what the problem is and tonguing apart so when you go to the doctor you should already have in your mind what do you mean or how long does the dizziness last in Jigme is going to tell you more about that okay so let's start talking about various diseases until recently the most commonly diagnosed disease is something called benign paroxysmal positional vertigo I'm going to beam by disease did diseases that cause dizziness is that cause spinning benign paroxysmal benign paroxysmal positional vertigo you may know that as the crystals the loose crystals in your inner ear this is our fancy name for it and the what's caused by is introduction of crystals which are really called ona Konya into the semicircular canals into these tubes these hollow tubes when the crystals get into these hollow tubes they interfere with how the the tubes work and head movements with respect to gravity cause the crystals to move around in there and cause the the inner ear to send a full signal to the brain so let me show that this is this is an inner ear this is one of one of the semicircular canals and this is with a patient laying on their back and this little blue dot represents the crystals sitting there all clumped together so when the patient sits up it's going over to this diagram on your right that that blue dot moves down from here to here well there's fluid inside this inner ear tube and that pushes when the crystals move it pushes the fluid it pushes against this thing called the cupula and that changes that firing rate of the inner ear so it changes the signal that sends to the brain so falling debris which are the crystals pushes fluid in front of it thus deforming the cupula and changing the signal it sends to the inner ear so how do we diagnose BPPV the crystals so it's a rapid onset of vertigo with head movement relative to gravity so what do I mean by that things like rolling over and bed bending over rolling over in bed putting your head back rolling over in bed getting into and out of bed and did I mention rolling over in bed and the reason I say that is if you're not getting dizzy rolling over in bed then you're probably don't have this now doctors have to be very careful about this was very often you'll you'll ask a patient and I'm telling you this and it's a little bit funny but it should make you think about how you answer a doctor's question a doctor may ask you do you get dizzy rolling over in bed and I've done this with patients and they'll say no and I'll ask them well do you roll over in bed no well why don't you roll over in bed because if I do I'll get dizzy and it's funny but if a doctor doesn't know to follow that question then then you might not get to the right answer so think about what the doctor is looking for maybe think a little bit beyond what what they're asking rolling over and some patients will say no I don't roll over in bed do you turn over in bed oh sure and then I get dizzy so you have to be a little bit careful with these questions it lasts seconds so it used it will in reality it usually lasts 10 or 15 seconds it can last up to 30 seconds it can even last up to a minute so I had this once and my patients are always telling me last 2 or 3 minutes and then I do the maneuver and I notice what they have and I can make a definitive diagnosis and saying why are they telling me 2 or 3 minutes so when I got this once I knew instantly what it was I'd been in a car accident I knew that was a reason I could have it I had little signs of it I knew it's had so when I got it I said this is great I'm dizzy I'm going to time how long this makes time in mind how long this takes I'm going to time it in my mind so here you have someone who is educated in the science prejudice to how long it's going to last paying specific attention to it I swear to god it lasted two minutes in reality I bet it lasted 15 seconds but it was so horrible it seemed to last two minutes so it can be very hard to judge but if you can notice how long it lasts if you have a partner you could say it's starting now it's stopping now and maybe they'll look at a clock they'll figure it out but that's very important to us and the non exam we do this thing called a Dix hor Pike maneuver where we lay you down we try to bring out the dizziness and we see whichever side we do that on that you get worse on that's the likely side that you have the problem the treatment for it is it's often it's often self-limiting it often will go away in a couple of weeks but it can last years my record is a woman who had it for 30 years she slept cept she slept sitting up every night for 30 years she came to me I saw it I treated her she was great for two weeks it came back which is a problem with this I treated her again and I haven't seen her since so either I fixed her or I don't want to say 20 20 percent of the time it does it is recurrence and when it starts recurring we teach you the maneuver how to fix it Kath will teach you the maneuver how to how to fix it so you can do it yourself and not deal with these obnoxious doctors and in the waiting room so you can treat it yourself okay moving on to something called many years disease fancies doctors call it endolymphatic hydrops but it is due to D absorb decrease absorption of that inner ear fluid I was talking about it leads to a buildup of fluid buildup a pressure in the inner ear and that causes that cubular thing to displace to lay over it also causes leaking of the fluid and from that patients get dizzy so here's the things we look for and the yellow things are the really important things they should have vertigo a sense of spinning that starts usually over minutes it lasts minutes two hours and with that they get tinnitus allow ringing in their ears they can get fullness in their ears and after they've had several attacks Kramer's rule is they must have hearing loss on testing they should have hearing loss on in one ear hearing loss in one ear as opposed to the other ear if you don't have that then I don't diagnose it as menu disease the treatment is a low-salt diet and a diuretic okay labyrinthitis or vestibular neuritis they're almost exactly the same and often the terms are used interchangeably labyrinthitis is an inflammation of the inner ear vestibular neuritis is an inflammation of the nerve to the inner ear and it's very tricky to tell the difference between the two there essentially that's the same and it treated the same way so the diagnosis is made by vertigo nausea and vomiting with verdict it can either come on all of a sudden it can come on stuttering and it lasts days days constant spinning for days I often say after two or three days you no longer want to die it's really a horrendous problem it's often related to a viral infection herpes one that's the canker sore herpes has been cultured out in a number of patients they'll have nystagmus for the first couple of weeks after maybe even a little bit longer that helps to diagnose and then some inner ear tests in which you have Elizabeth isn't here yet Elizabeth will be coming later she'll be talking to you about the inner ear testing that can show results that help us lead to the diagnosis the treatment part of it is just time it just takes time to get better during that time actually kind of in the wrong order here klonopin or meclizine are two drugs that help get in the balance system and can can make it a little bit more survivable take the edge off as you start to get better once you can tolerate it then we send you to cat for physical therapy and she can get you better much faster than just sitting around but it can be those first few days can really be a dreadful problem first few days you're spinning then you finally can get out of bed you're walking around touching objects for the next week after three weeks maybe you're able to go back to work and this is in this is the typical case sometimes it's much less severe sometimes it's much worse all right kiai a transient ischemic attack these are like what people often refer to as mini strokes little temporary strokes but they can cause dizziness the problem with the TIAA is it can be a warning that you're going to have a real stroke most of givingness is relatively benign this can be a bad warning so this is supposed to be a brain stem I drew this I'm a doctor not an artist I'm sure you'd agree this is the brain stem and this is that cerebellum cerebellum thing hanging off the back and these are all the blood vessels that go that feed the brain stem in the cerebellum and this middle one the it's greevey ated Aiko is right here and it feeds the inner ear this is this is the inner ear over here on the right and the blood supply to the to the inner ear here so if you lose blood supply to any of that even temporarily you can get spinning from that so how do we make the diagnosis T IAS come on suddenly just like that they last minutes very suspicious two to five minutes now I just told you about BPPV they last less than a minute but it feels like it's two minutes so that's why a very precise history can be useful it's so 2 to 5 minutes is very suspicious but it can be up to half an hour you look for other signs like facial numbness loss of pain in the body your palate being off this is why we do a neurologic exam on you to make sure that that to look for those other things and then we can do some imaging testing MRIs m-ras but this is this is the basic way that we try to find out if you have a TI a it's a temporary a transient ischemic attack then you go to the doctor three days later well they're going to see a normal exam so then it becomes low to you of high cholesterol are you in your 70s do you smoke do you have diabetes you have high blood pressure you're at risk of having a stroke maybe we better work that up but it can be very difficult to diagnose in the afterthought okay vestibular migraine so before I said the crystals used to be the most commonly diagnosed cause of dizziness it has just been passed out by vestibular migraine what our vestibular migraines vestibular migraines are migraines just like any other migraine except they don't necessarily cause headache doctor how can I have a migraine without a headache migraines are these very complicated things we actually don't know the pathophysiology of it that well we're beginning to make some crossing some milestones in that making some headway on it but it's a very complicated thing maybe some of you have had or know someone who have had an ocular migraine and this is right there raise your hand no you don't have no that's a HIPAA violation don't raise your hand an ocular migraine will cause stars or a hole in your vision or wavy lines and you never get a headache or some people never get a headache with it that's because the migraine phenomenon is hitting back here and that disturbs your field of vision here if the migraine phenomena hits here this arm goes limp and and temporarily because this is the part of my brain that controls my vision I mean my arm if it hits in the back of the brain down here where I control my balance then I have trouble with my balance and I can have spinning so the diagnosis may include loss of a stimuli function but if a patient complaint complaints sound like migraine except instead of them saying headache they say dizziness than it is likely a vestibular migraine photophobia light bothers derive sauna phobia loud noises by their eyes you know when you're dizzy you like to lie down in a dark room and sleep it off that really smells of a stimuli migraine if they have a past medical history or a family history of migraine that makes it even easier to diagnose and maybe eating chocolate MSG or red wine will trigger it okay the thing is the differential diagnosis of this thing it can be easily confused with is that other thing called then years disease my most common difficult decision to make is in when I see patients is whether they have migraine or many years disease because both of them can cause hearing loss both of them can cause tinnitus and both of us cause fullness in your ear the treatment are various medications these are the ones I like to use Zoloft and antidepressant that's off-label that's not fda-approved for that but I found it very effective for treating migraine elavil and topamax are FDA approved for treating regular migraine nothing is FDA approved for treating vestibular migraine because it's just such a hard animal to get in touch with supplements such as magnesium coq10 and vitamin b2 have been helpful and for patients who don't want any of that want to try something a little bit less invasive we can teach you a diet which might help prevent migraine okay ototoxicity this is when you lose function in both ears so those those little ear cells that were that we're having spikes underneath you know get none of that the brain stem has nothing to look for to figure out whether you're spinning one way or the other so it's a bilateral broth loss of a scribbler function caused by drugs antibiotics such as gentle myosin Vanko myosin gentle myosin lasix gentle myosin you're getting my point I've probably seen 50 of these and 48 of them were due to gentamicin to a Judith Anne Co myosin and you can also get it from an autoimmune problem example of autoimmune disease is something like lupus that's when your antibodies attack yourself but mo the time I see it it's due to gentamicin he diagnosed it by history of exposure to something like Genco myosin at the right timing that you have the loss they lose dynamic visual acuity that's when they're shaking that the thing I just showed you when they shake their head they can't see very well and then we can do some testing that will help show us that the treatment has done is prevention not using the drug and knowing if anyone in your family has had a reaction to that drug because it can be hereditary and then again we send them to Kat because she's the one who can best fix them we can't fix the year but she can teach you how to cope with it okay my last the last disease I'm going to talk about is something called a vestibular schwannoma used to be called an acoustic neuroma and I often find myself saying acoustic neuroma I always wondered when my parents called their friends there the women by their maiden name it's bad they've been married for 40 years why you could using the maiden name because that's what you learned and that's what you do now I do that and I do it with acoustic neuroma vestibular schwannoma I call them acoustic neuroma so anyway it's a growth on the nerve that inner ear nerve it's not cancer it uses it the problem is because it can grow slowly it can and touch the nerve and not touch the nerve it can mimic almost any one of these diseases I've talked about so it's really that thing out there that that doctors are afraid of that they don't want to miss because it's easy to confuse with other diseases it comes with a hearing loss on one side almost always and you work it up with an MRI if you're not treated it can lead to bad stuff like a loss of hearing on one side it can lead to loss of balance on that side the nerve that controls the muscles of your face are on that side so if it got bad enough you could actually get paralyzed on one side of your face and and I guess if it got if you'd really let it go it could kill you the thing is they grow very very slowly so usually you know you're going to catch it even if you make a mistake you'll catch it by then JFK is a center of excellence for the treatment of it we can we can treat it in various ways depending how big it is so I don't find them often but when I do I know I know I've got a good place to send them and then these are the these are the two beagles that own me that that is stand and that is Stanley and that's oliver stan and Ollie this just worked out that way and and when my wife and I travel we admit to by ourselves we admit that we don't miss each other that much we've missed them so that's all I had Stephen if you want to do the intros or so he's going to introduce jigna Jigme is my nurse practitioner that we that we've taken on because i was backed up six months we're not backed up anywhere near as far and I just want to tell you she's really nervous about talking so when she comes up they began so next up is jigna patel nurse practitioner at JFK vestibular laboratory tell you a little about Jigme jigna grew up in Clarksville Tennessee outside of Nashville completed her Bachelors of Science in Nursing in Austin Peay State University she pursued her further education at Texas Woman's University received her Masters of Science in Nursing she's certified with the ik at the American Academy of nurse practitioners worked in primary care nutrition and wellness has recently moved to the lovely state of New Jersey from North Carolina lives with her husband her in-laws and two wonderful children Jigme I am the nurse practitioner that works with dr. Kramer it has been my honor and privilege to work with him for over a year now so upon your first initial visit you will first be evaluated by me whether you like it or not this is where I will obtain your history and perform just a basic neurological exam dr. Kramer will do more of an extensive exam so what I'm going to try to teach you in the first or in the next few minutes really is just to help you tell us how you can give us some good information about your dizziness so the two biggest things are what does your dizziness feel like and the timing of it so giving a description of your dizziness is probably one of the most difficult things to do because when you're feeling dizzy you're not thinking about the details of it you just want it to go away you want it to be over so as dr. Kramer had mentioned we'll probably repeat some of the same descriptions here some points to really keep in mind are if you feel it is vertigo so again vertigo is the sense of spinning you feel like you're spinning or the world around you is spinning it's not a diagnosis it is just spinning the other descriptions we get a lot or if the dizziness is not vertigo people often feel off balance they feel like they're floating as a bouncing swaying brain foggy some people will say they feel like they're drunk all kinds of descriptions we've heard many and when we think we've heard at all we really haven't so again it's it's very important to try to determine if your dizziness is spinning or if it's a different type of sensation so then we can help diagnose what type of busyness you might have another very crucial part of the diagnosing dizziness is the timing so timing meaning is your dizziness episodic or is it constant if it is episodic then how long does just the dizziness occur again we understand it's really difficult to pay attention as dr. Kramer said he thought you know he would be able to see if it's a few seconds but it felt like it was a minute so knowing this if this were to occur to you or if this is happening a good suggestion would be just to try to start tracking your dizzy episodes and when it's happening how long is it lasting whether if you're getting spinning or if you're getting these other types of busy sensations how long is just the dizziness happening is it seconds minutes hours that kind of thing just to generalize in that form of time that will really help us to help you and if it is constant when did it become constant so constant meaning that it never goes away it might wax and wane it varies with intensity but you are really dizzy all the time it never goes away whether you're sitting or laying down so one of the the biggest things I think we come across is when patients do come to us they tell us oh I'm just dizzy all the time and it's just I don't I don't know you know better than we know how your dizziness feel so if you can really try to differentiate the timing of it and really just how long it's lasting they'll just be really helpful for us so other symptoms that we do ask that may come with your dizziness or nausea vomiting headaches and migraines any hearing changes or tinnitus which is ringing in your ears if there's any vision problems or if you've been falling these may come with or without your dizziness and then when we do ask the timing again we're just asking about the dizziness and not the other symptoms that you might be feeling they may you know they may come together they may not come together just varies so most patients that come to us have seen multiple doctors they've sought treatment elsewhere as a part of your evaluation it's really important that you personally bring any testing results that you may have had this can include anything from a hearing test or an audiogram and the inner ear testing which is the vestibular testing where they put hot air and cold air into your ears that's the vestibular testing any MRIs or cat scans of your brain you may have had or any bloodwork as well so often when you ask your other providers to fax those results to us good old you know EMR medical system often it doesn't get to us so if you have those records it's very important that you do try to bring it to us it really helps dr. Kramer to look at some of those test results as we're trying to diagnose it we'll just speed up the process of us trying to treat you and help you so after my part of the exam is finished you then do see dr. Kramer and then he further evaluates your symptoms if you have your testing he will review all that and then he'll determine your treatment and then your follow-up visit so the most important form that I see some of you have in your hands that we need completed prior your visit if you decide to come see you is this dizziness questionnaire dr. Kramer has specifically created this form to help determine the type of dizziness that you may have so it's pretty detailed as you can see there's a whole checkoff list in the back there's you know multiple questions on the front there but having that completed prior your visit it really really helps us narrow down the type of dizziness you have and then we can really you know try to help you so I think between when we have a break if you'd like to pick one up we have a bunch up here we ask that you do take it and then if you do decide to schedule an appointment or come see us please bring that to your first visit or when they asked you to send back the new patient paperwork or anything like that you know you can put it in that packet and we can definitely review it the other thing is is it's also very important that you do find out with your insurance company if you require referral to be seen because dr. Kramer's practice is a specialized field some insurances do require that you have a referral so finding that information out getting the referral and then making your appointment will just help speed up your process and then we can see you sooner yes so just make sure that before you know you decide to schedule your first visit you have specific forms filled out you get the information about your insurance and just a referral process again I think you know we're very pleased with the amount of people that showed up to the seminar and we look forward to very much trying to take care of many of you if you decide to come see us thank you so our next speaker is Kat Ferraro physical therapist PT ot outpatient Kat's a physical therapist who has worked at JFK for nine years in the outpatient physical therapy department she graduated from Ithaca College with her master's degree in clinical science her specialty over the past six years has been vestibular rehabilitation where she trains the new staff in all aspects of the vestibular system she wants to make sure they are all equipped in thoroughly evaluating me treating patients with dizziness and balance disorders she works closely with dr. Kramer and jigna Patel to assure the best care for shared patients once a week they evaluate patients for more comprehensive approach hi everyone can you hear me yes hi I'm you Katarina Ferraro but everyone calls me Kat so it's so I'm a physical therapist I work at our outpatient department across the street in the hospital and I've had the pleasure of working with dr. Kramer for about five years now evaluating patients with dizziness or balance issues and I am going to give a brief overview of what it is that we do in vestibular physical therapy basically what vestibular rehab is all about is it's um when you come in we do design a comprehensive program to treat individuals with functional limitations due to symptoms of dizziness which can include vertigo motion and tolerance lightheadedness all the descriptions that dr. Kramer and Gina talked about and balance problems so along with symptoms of dizziness and imbalance people can also suffer fatigue and weakness that we could also address with physical therapy so the first day of therapy is an evaluation so along with the diagnosis that we gather from the doctor from the referring doctor we also perform our own evaluation and examination we look at things such as posture range of motion strength we look at different balanced tests we look at coordination we do a visual screen which we look at the eyes and we also look for a nystagmus and things like that we do testing for BPPV which is benign paroxysmal positional vertigo we also look at memory and some cognitive testing so after looking at all those things we do come up with an individualized program to work with whatever you know is wrong so there are three treatment theories that vestibular rehab relies on and I'm going to discuss them in length so basically a situation adaptation and substitution as well as the catalyst maneuver to treat BPPV so the first treatment theory is habituation and basically what that is is we teach exercises and different movements that produce dizziness that are performed in a controlled setting and in various intensities so basically there is a test that we do called the motion sensitivity quotient that kind of goes through all these different positions and we see which ones make you the dizziest and then we pick a few of those out and we usually do through two five-hour petitions over a few weeks until they no longer produce dizziness so yes you are going to get dizzy with physical therapy but it is going to help you so you really have to give it a chance because you know usually people come in and they're like oh my god has helped so much worse after therapy but that is the point we have to stimulate your vestibular system in order for it to adapt so if you do feel that way you know coming from the first or second appointment please give it a chance because you know or we know that it is going to get better and hopefully the therapist will educate you on that it is going to get better you know it is going to be a little bit worse before it gets better the symptoms the next treatment approach is called adaptation and that is the vestibular ocular reflex that is the main exercise that we focus on that's what dr. Kramer spent most of the time talking about and basically how he said you look at a target or you take a piece of paper and you move your head back and forth and that's pretty much how you do the exercise so this exercise can be done in sitting it could be done in standing we change the surface we change how long you do it for we can change the lighting we could tailor it to whatever things that you have to do in your life that will make you will help with this the next treatment approach is called substitution and this is using alternate strategies to help replace the loss of function or compromised function within your system so this treatment approach we do a lot of balance exercises we try to do other strategies teach you other strategies to replace loss of function and other systems that you may have this is the best treatment option for bilateral vestibular loss that dr. Kramer mentioned that is caused by the gentamicin there's also exercises to increase visual and somatosensory systems so that is you know your vision system and also joint receptors in your legs your ankles we can teach you all those exercises there's also an exercise called the cervical ocular reflex which is very similar to the vor in case you do not have function in the vor this is used using your joint receptors in your neck to basically do the same movement and we also go over risk factors to prevent Falls and go over different strategies for that so now the biggest one that we really work on and the MOOC that we see the most is we treat for BPPV which is the crystals so this is a catalyst repositioning technique most commonly called the Epley maneuver that we use to treat the posterior and anterior canal of your vestibular system which is the most common and then also there's different maneuvers to treat the horizontal canal but basically if you could see in the picture here we go so this is it's very important for us to get this maneuver right and before we even perform this maneuver we do a dict all pike test and we check the right or the left side and we look for symptoms of the vertigo the spinning and also we look for a nystagmus which dr. Kramer talked about so then after we find out which side is affected we do a series of these repositioning movements to help move the crystals back into where they belong and basically the way we move the head and the body follows the shape of the canal and it repositioned the crystals back to where they're supposed to be and basically we do spend a lot of time doing this maneuver because it can be performed incorrectly it has to be very specific we have to get a lot of movement in the neck in order for it to be done correctly and we also can teach you how to do this on your own so if BPPV happens again and it may in most patients you are well equipped with a handout and we've practiced it several times so that you can treat it on your own hopefully with a family member and you know not have to go back to the doctor as often so this is pretty much most of what we do along with different balance exercises and then like I said before there's additional maneuvers that we can also do depending on which canal is affected and how long the vertigo and the nystagmus lasts for basically we can determine this from testing done by the doctor or testing that is done for through the vng a rotary chair or event which actually Elizabeth will talk about it's a good Segway so there's I just wanted to let you know there's other maneuvers out there that I'm not going to get into detail with but it could be other canals could be affected by BPPV and that's it we have one more speaker and then you'll be able to ask your questions last speaker is Elizabeth a spell audiology audiologists and speech pathology and audiology department Elizabeth has a doctorate of audiology from Vanderbilt University and has been at JFK Medical Center for five years she's part of a team of audiologists that met with neurology twice per week to discuss all balanced testing completed in our facility she believes that multidisciplinary care for patients experiencing dizziness is the key to a successful diagnosis and intervention and she is very excited to be here this evening Elizabeth hello all thank you for coming out this evening okay so I'm an audiologist which the first question most people say when I say I'm an audiologist is what and I don't know if they're joking so I always answer the question but that means that I diagnose and treat hearing and balance disorders um for all ages this talk specifically is about balance so the vestibular system um there are a lot of different tests that can be done I'm going to talk briefly about the major ones the ones that are most often recommended by neurology and then there's a lot of other specialty tests like they suspect manures disease maybe you have one of these other tests or something but by and large there's a couple tests that often get recommended because they're the best at looking at the system at large looking at a lot of different parts of the system in the shortest amount of time which is the goal um vestibular test of your balance testing kind of gets a bad rap I don't know how many of you have either gone through it or known someone who's gone through it but a lot of times people come in and they say oh I'm so anxious like I heard from a friend this was going to be terrible or I read on the internet that this was going to be terrible ninety five percent of the time really people finish the test and they go oh that wasn't so bad like I really I thought that was going to be worse it was okay so we really really try hard to walk you through what we're going to do make you feel better about what we're going to do and you're always in charge if we're doing something that's too much for you you can let us know and then you let dr. Kramer know see what he says um so this is a big deal because more than 40% of people according to the National Institute of Health will report feeling dizzy at some point in their life that's why on a Wednesday evening even in our community we got so many faces out here to learn more about dizziness it's just a big reoccurring thing that if it doesn't happen to you you probably know someone it has happened to um and then there's you know a lot of increased medical risk cost of health care risk of Falls when you're off balance so you know I don't have to stress it to you because you're here you're my audience but it is important to assess and to diagnose um the balanced system and some of this is going to be summary from what was probably already stated but there's a lot of different systems in your body that helped control your balance your visual system your somatosensory sentances system so your sense of touch so if you have numbness and you're fit in your feet and toes obviously balance is going to be more of an issue for you and then predominantly my role as the vet in the vestibular system um so some of the the main tests that are recommended that this I don't have a slide on but one of the first tests that's often recommended is a hearing test and many many times the first response with my patient is I don't understand why the doctor ordered this I'm not here for my hearing maybe I have a hearing problem maybe I don't have a hearing problem it's really not the point it's not why I'm here so I try to help you understand why the doctor our doctor or some many other referring doctors will recommend a hearing test first the hearing the inner ear that controls the part of your hearing is is millimeters away from the part that controls your balance so oftentimes we can see a difference between your ears in your hearing test maybe you don't know maybe you don't suspect a problem or maybe you don't see any difference between your ears but every once in a while we say oh you know what in some of these high-pitched tones your right ear doesn't hear as well as your last year and it's the first piece of the puzzle well you've just heard for an hour how complicated this can be in a differential diagnosis and to figure out what's going on so if we find your right ear is worse than your left that's the first answer to a question we might have not even known we had so hearing test is often the first part of your battery of tests on another test that we is probably the most often recommended test is the V ng or video nystagmus II um so just to review a little bit of what's been told to you already nystagmus is that motion of the eyes when it's trying to pikal II it means the brain feels like it's moving and it's trying to maintain focus on something so that you don't feel dizzy anymore it's a reflex it's not anything you can control and sometimes like you have a little kid spinning in a chair it's normal to see nystagmus their eyes move all over an adult who acts like a little kid but nystagmus is sometimes normal it's a normal variant when you when you evoke it um it shouldn't happen when you're sitting still so part of what we test that's the positional testing part is you're just sitting still or you're laying in different positions and we're watching your eyes so your eyes are the gateway to the soul and the vestibular system we really want to know does your brain think you're moving when you're not along those lines does your brain think you're moving more than you're moving when we move you so we're going to let you back we're going to watch your eyes as you lay down we're going to watch your eyes as you sit up we look for that BPPV thing those crystals floating around in your ear that's going to show up in your eye movements it's another thing that sometimes confuses patients like while you're watching my eyes I don't have a problem with my eyes so I'm dizzy so you know first I have to explain parts on the eye part um caloric testing is the last part of the vng that is really the most likely part of the test to make you feel anything so what we do is we put some cool air in your ear we change the temperature in your ear changing the temperature in your ear tricks your brain into feeling like you're moving you usually feel like you're moving for about 3060 seconds and then it typically goes away pretty quickly um so we do that with cool air we do that with warm air and comparing the two ears can give us an ideas one year a lot weaker than the other is one year a lot stronger than the um and this so this looks at all different parts of a similar system not just the inner ear but the pathway is going from the inner ear to the eyes to be it's back to the brain to try to give neurology or whoever you're referring physician is some idea of is there a problem in your vestibular system and if the answer is yes can we help narrow down where that problem is another of the most common tests is called the rotary chair and that's the one we're just the name of it gives people I don't know about that um really the rotary chair it does look very intimidating it really because the whole point of it is that nothing's moving except your eyes so you get in and there's a seat belt and there's a leg thing and there's a head thing and people say what are you going to do to me like it really looks like I'm going to send you to the moon but really it's again that's the test where everybody gets out of it and they say okay it really it looks bad I shouldn't have read that article online like it really like it was okay so for most people most people drive themselves home most people are okay but if you know yourself and you know I don't think that would be okay for me bring somebody else to drive you you don't have a back-up plan um but for most people it's okay and what's nice about this is this doesn't matter if you've got wax blocking your ears it doesn't matter this looks at more of those central pathways between your ear in your brain so we turn the chair in a circle and we watch your eyes and then we stop the chair and we watch your eyes again then we turn the chair the other way watch your I stop the chair or watch your eyes and again comparing does your eyes do the same thing when you move left versus right gives us some really really good clues about where the problem is in your vestibular system um all of these have been touched on already by dr. Kramer some of the more common balance abnormalities um even if you go into the office and it's like oh you have clear-cut BPPV you have those crystals in your ear we're going to send you to physical therapy sometimes they send you anyway for more testing and and why that is is because what we don't want to happen is we don't want oh I went to JFK and I they have the best balanced Department and I got tested and they said I had BPPV it turns out I have beat and I had a virus that affected my right inner ear so I went to therapy and they fix my BPPV but I still feel dizzy like so we don't want to get part of the answer we want to really figure out is that the only thing going on with you even bedside when we're able to get an answer for you there might be more to the story so that's where we come in to do all these other tests as recommended most commonly hearing tests vng rotary chair um and again summary of what we've already talked about what are your treatment options okay so what you found a problem what do we do now um vestibular rehab with we'll send you to cat um medication will send you back to dr. Kramer's or modifications which are often good for either one of those remedies so modifications you know adequate lighting in your house getting rid of uneven surfaces things like that which physical therapy is also a great great resource for things like how can I better modify my environment to be safe in my home and maintain my independence as long as possible because that's often something that's in the back of people's minds so hopefully that answers your questions about some of the major audiology portion of testing and there's more specific questions about hey my doctor wanted event what does that mean I'm happy to field them okay have a great night so let me get this right first thing we do is come to see you get diagnosed and then you send us to these other people so you'll come in and the very first person you'll see is jigna and she'll get a history convey it to me then I will examine you she'll do some of the exam I'll do the exam specifically to the vestibular system I may ask a few questions and then I may or may not diagnose you sometimes I'll diagnose you and you won't get to see Elizabeth because I just know what it is but sometimes I know what it is but as she was just saying elegantly I know what it is but gee maybe there's something else so you'll see Elizabeth and very often as I'm sending you to Elizabeth I might send you two cat that's the appropriate thing or it may be medication so what after you see me you may see medication and not see either of them or you may see physical you may see both of them it's all very variable tailored to the person my question is could you give me a definite definition I found maybe what ringing in the ear is so what you said I okay okay yes so what she's asking about what we would call tinnitus or ringing in the ears I do see patients for that as well we didn't talk about it as much and what it sounds like there's actually if you go on the web and I can't tell you exactly where you can hear by talking to people and listening to them they've actually simulated the sounds that many people have and some of them are bizarre some the most common one and I get it occasionally myself is it sounds like crickets that that is the most common form of tinnitus but it can also sound like bells ringing it can sound like boards creaking it can sound like weird space music it can sound like they can they can and if we let it go long enough that's what it sounds like yep so it's very variable the one to look out for though is when it's pulsing and when it does that take your pulse and if it's timing for your heart with your heart that's really important because what you're hearing is most likely a blood vessel or a blood flow of some kind and 99.999% of the time no big deal some of those times it's it's not a big deal but we can do something we can fix an artery or a vessel and fix it but very I shouldn't say very rarely occasionally it's something it could be an aneurysm you're hearing so that's really an important thing the other important type of tinnitus is is when you hear it in one ear and not the other because that can be that that our old friend there that acoustic neuroma can cause it in one ear or not the other so the two really and if it's both ears and it's equal and it's not bothering you then to be honest it's no big deal if you want to come in and we can reassure you that's fine but if it's really bothering you then that's something we may be able to help you with we won't make it go away but we may be able to help you with it but if it's one ear or if it's work either of those those are important to come in for just briefly add to that ringing in your ears is oftentimes a sign of damage to the nerve in your ear so we would recommend a hearing test and if that ringing in your ears is really something that's very bothersome to you we also do something here in our audiology department called a tinnitus evaluation where we make recommendations for what are some different like sound generators what are some different ways that we can help you either therapeutically or with them with a device to help it so that that is left bothersome to your day-to-day life because even though it's a very very common thing there's a small percentage of the population that it's very debilitating for um so if you're somebody who finds yourself like I can't sleep at night this is really interfering with my daily life there's you know there's often nothing that can be done from a medical perspective but there's quite a bit that can be done from a therapeutic and intervention perspective so do reach out if you're one of them I have a question about the crystals I hear a lot about crystals what is the etiology and composition of crystals are the is there any place that they would normally be found versus moving into a part of the year and what would cause that migration so they are calcium carbonate crystals if that helps you there they're essentially like little crystallized bone and we use them in our balanced system so the most of what we were talking about the semicircular canals they sense motions such as this turning motions in the three different planes but the linear motion back and forth forward and back up and down the sense of which where gravity is in relation to me that's what the the crystals are involved with you can think of them as the the the Tootsie Pops you know the stick with a candy on top they are the candy on top they are little weights and if you imagine this if I were to move the base of this quickly the weight of this if this were very heavy is going to want to stay still and when that happens there's stress here at the bottom in my hand and little nerve ending sense that and they use that information to sense when I'm moving in a straight line so that's why they are there so we need that weight because they're little pieces of bone they can act as pieces of weight and that's that's why they they originated there they sit in a little gel like surface and you know we're talking this big you know but they sit in a gel like surface and they can from time to time fall off now I'm going to say a bad thing here one of the main reasons they fall off is as we get older so so you're more likely to get this as we get older but I had it 15 years ago and so you know I was in my 40s and that's because I got hit in a car accident I got knocked out so a hard head blow can knock can knock it out if you get men years disease and it disrupts your inner ear that can make them fall off people with migraines any kind of migraines not particularly vestibular are three times more likely to get them get it than the general public and people with labyrinthitis are also that that inflammation to the ear can also cause them to knock off so you know here you go you get men years or you get migraine or you get labyrinthitis and you think you're over it and lo and behold now you the loose crystals so those are the main reasons we know that they come off but 50% of the time it's what we call idiopathic in EO Pathak means the doctors an idiot and and when we don't we don't know why it happens we can't find the bottom line to it did that answer your question yes it didn't I just have one other question sure the pulsatile tinnitus what would you do would you do an MRI I would do an MRA which is like an MRI it to the patient it seems exactly like an MRI but it it looks at the blood vessels and what I do is I will listen to see if I can hear the the pulsing if I can I'll do an MRA if I can't I'll do an MRA if I can't and the MRA if I can't hear it and the MRA is negative I stop there if I can't if I can hear it and the MRA is negative then there's enough risk that something's going on I'll do an actual arteriogram you know where they put a catheter in your groin and and and shoot in contrast there's a little bit of risk of that but if I can hear it that means I know something's going on and it's worth the risk I have a question I had Lebanon that I said about 30 years ago 30 to 30 years ago now lightheadedness seems to come and it seems to coincide with allergy and cold is it connected or you by call do you mean cold temperature or : I mean heaviness in sight so how can i connect those it may have nothing to do with the labyrinthitis it may be that so once you get a labyrinthitis that ear never recovers cat makes it better by adjusting your brain to to adjust to that but now you've got this this difference so when you get some type of illness that can throw off your balance system it's going to throw off the goods I differently than the bad side and you've got new adjustments to it sinusitis colds allergies the book says they don't affect they don't cause dizziness they don't cause vertigo anyway but that's at the first level maybe because it affects this and it affects that and maybe it you get dehydrated because you've got this or something like that you're not sleeping well that could trigger a migraine so on the first order it doesn't directly affect but on the second order it can my question is for Katerina the Epley maneuver that was shown on the screen the Epley maneuver it looked like the shaking of a head or could you explain it what the app limine or get our sample yes I mean I mean we could demonstrate it but no I'm just kidding basically what it is it's not really shaking of the head but it is so you start off in sitting and I hold the patient's head I think we're going to demonstrate it all right do you want me to think in the wisp okay you want to you want to hold the mic for me move back a little bit more okay so basically this is where the patient starts off with and then we test both sides to make sure that we are treating the correct side so basically we'll do the right side first so we turn the head to the right and then I support the patient's head and then we quickly lay back on the count of three one two three so as you can see there's a lot of neck extension that needs to happen and the patient has to keep their eyes open so from here if they you know feel very dizzy they feel spinning and it goes away quickly and it usually does we also look at the eyes to make sure that there is nystagmus then the next position after they feel better is to turn their head the opposite way and then we wait here for the same amount of time make sure dizziness goes away then after that the patient turns their body the opposite way so then they turn their body looking down at the floor and then we wait until dizziness goes away and then the last position is they're going to sit up and then we have to be careful we have to make sure that we're supporting them here because sometimes the crystals they're getting repositioned and they're going to fall at this position and we have to make sure the patient doesn't fall back so basically that's what it looks like and we could do it to either side depending it's depending on which side the ear is affected what will that stop the spinning for the moment yes so you're going to feel vertigo while your head is in those positions the most common position is the first one is you're going to feel intense vertigo it will go away and then you should feel better with each position and when we do it again in the same treatment session you might feel 50% better and we do it again you might feel 85% better so it is very treatable and very successful if that is exactly what you have thank you welcome in reference to what you just did the manoeuvre I was in a car accident two years ago and I have three herniated discs in my neck plus a bulging disc and I didn't lose conscious don't recall hitting my head but afterwards I have vertigo like you would not let me do and I wanted to know whether or not when you when you do two maneuvers whether I can support the head and all that because I always have problems with it yes so we definitely make sure we support the head and it is a little bit uncomfortable because we do have to keep you there you know until everything kind of goes away and most common patient responses they just want to jump back up because you know they're spinning they feel uncomfortable but you know we do support the head we make sure that you do feel as comfortable as we can make it we could modify the position - based upon any restrictions that you may have in your neck that's also an option there's kind of different ways of doing it that might not be as stressful on the neck so we there any relation between a heartburn and the vertigo because most summer times when I heat I mean I have a kind of a spicy food I cannot feel that both the years were heavy I can fill the whole thing is spinning at least for a day or so so I've not seen any literature on that but I did have one patient who had vertigo he also had heartburn and I wasn't helping him with his vertigo but I sent him to dr. Rosen heck who here's my GI doctor and he treated him for the heartburn and the vertigo went away and what we postulated was that he was refluxing the stomach at is so much that it actually went through the eustachian tube and was irritating in his inner ear I've been looking for a second patient like that so I could have a series and I will publish I find this like oh maybe maybe you're the guy yeah I can I can play the part well thank you very much yes ma'am I wanted to know if there was any connection between the dizziness and the computer screen monitor yeah with the new flat-screens it's a little bit less so the older screens refreshed either at 30 Hertz 50 Hertz or 60 Hertz so essentially it's flashing before your eyes I don't think the newer screens I think they're flashing at 120 Hertz so it's so fast that it doesn't do it but you might be particularly sensitive but also but you know the other thing is the cellphones and scrolling on the computer that can very much may bring out dizziness and some people but looking at a straight screen lately has been less of a problem looking but if you're scrolling around and doing a lot of things on the computer and moving your head around a lot then we do have patients who are computer sensitive yes is that a connection between walks and ves and dizziness not really it's important to date the wax comes out of the years so that when we send you to to Elizabeth that it doesn't interfere with the testing and the wax can trap bacteria in the ear and and cause a problem but it is not a form of dizziness by the way the reason we tell you not to clean the wax out of your ears is not so much that we're afraid you're going to take that q-tip and drive it through your eardrum most people will feel the pain first and they'll back off there's a couple of reasons if you notice you notice the skin on the back of my hand or back of your hand when you move it it moves do you notice the skin at the tip of your finger and you move it it doesn't move same as the tip of your nose same as in your inner ear so when you take that q-tip and go back and forth the inner ear isn't moving so you're really abrading that inner ear and I've looked in some people's ears and it is just raw when they do that the other thing is waxes an antibiotic so it's helping to protect your ears now when it builds up too much that's a problem and either your primary care doctor and the ear doctor can clean it out or you can go to the pharmacy and ask it's called deep rocks but just ask the pharmacist those drops you put in your ears to get rid of the wax you put that in your ears you let it sit there for a while like five minutes you do that for three days it softens it up and then there's this little squeegee and they put water in and you squeegee the wax out that's the way to clean out your ears but wax itself right and it and tell me if I'm wrong Elizabeth it doesn't enter unless it's really packed in it doesn't interfere with hearing that much where do you get a difference no every once in a while like if we test you with headphone cuz a lot of times if you have a lot of wax we won't put inserts in your ears because we don't want to push it deeper so we'll put headphones on you and sometimes the headphones plus the wax will like collapse your ear closed and make it look like your hearings a lot worse but typically the only time wax affects your hearing is when it forms a complete plug and usually that's from q-tip use because you push some in a little bit at a time you pushed it deeper and deeper and deeper until it forms an ear plug there's sometimes I can tell one second sometimes I can tell when people use q-tips because they can essentially see the head of the q-tip David you know the impression from it and even even a couple pieces of cotton from it so q-tips bad I use the head of a Bic pen Oh second words me all right I've had the Epley maneuver and I've been fine since um but now where do I go from here do I just wait to see if it should happen again or do I come into follow us so you're fine now I have been yeah I had it years ago and then I had an episode and I struck my head while on vacation I hit a pipe and during the night and mine always occurred during the night in my sleep I'd opened my eyes the room would be spinning and that happened about 5:00 in the morning in Vienna I had hit my head on a pipe and I opened my eyes the room was spinning and I got up for some reason and then I fell right down on the floor and I had the effects for about two or three days I was nauseous I couldn't look up I came back and then I couldn't even lay down if I started to lay down a little bit on my left side I would have to sit back up finally I went to the Epley and I've been fine since but now where do I go from here do I do anymore if I find you mean fine you're fine I've been fine so I don't need fine you don't need anything else unless it comes back and then you need treatment by the way on this form sometimes we make our diagnosis by the back of the form if the first four boxes are checked and nothing else is checked yeah I mean we're not that cavalier to just say it's BPPV but we're really steered towards that so that's why this form is one of the reasons this form is very helpful but yes you're you're fine you're fine unless it comes back which it can because it comes back 20% of the time most of that time is after head trauma if the cause of it is head trauma so you are a little bit at risk of that happening I've been suffering from positional vertigo I thought years now however I have migraines also that you described and I also have my ear one of them I just wanted to know are they interconnected or are they three separate things what but you said your ear what about Yuri I have loss of hearing there and sometimes I have a it kind of rings okay oh so one way to put that all together would be that you had vestibular migraines which caused the hearing loss in one ear and also put you at increased risk of the crystals the another way to put that together is that two different things happen you have the vestibular migraine which also caused the crystals to fall off and you just also happen to have something happen to one ear so I can't say I can make it one thing and doctors try to make it one thing because they usually that makes the most sense rather than you have two things you have one thing but but I wouldn't be definitive about that if you have a hearing problem in one year and you've never had an MRI unless unless you had surgery and that's why you lost the hearing in that ear you need an MRI of your inner ear to make sure you don't have that growth and you don't have to run and get it tomorrow they grow very very slowly but that's something they that you need to be need to have done so they are connected so I can certainly connect all these things but I don't know they're connected you know for just from this little talk I can't tell you that it is but I can create it I can name a scenario that they're all connected but without getting a full history and examination and maybe even testing I can't know for sure I understand thank you the question for cat really I was told I do the eye exercises the adaptation I have the paper I was told suggested to do it three times a day it's never going to happen in my lifetime so is it worth doing it three times a week so yes so you do have to do them at least twice a day because your brain needs that constant repetition in order to adapt so unfortunately you know it does sound like it's a hassle but if you don't do it with enough frequency your brain will never adapt to the motions and to improve that vor reflux that needs to get stronger so you know the best situation is all this in combination that habituation the adaptation and the substitution for someone who literally topples over I fell into my fireplace yesterday I just topple over so to do one without the other is not so helpful right yes are you in physical therapy right now I did you have you now now I'm looking at knee replacements up and we're you know triaging this whole body but so I mean if you have like a lot of exercises that you were given from the therapist just pick out yeah you know for to do a day you don't have to do every single one of them because that's not realistic or you know oh yeah I'm going to get back to it like yes so just pick a few of them to do every day don't go through the whole packet and then just vary them but try to do something every daily twice a day otherwise forget it yeah okay thank you you're welcome have there been any correlation or Studies on the relationship between cancer therapies and vertigo or any and the other things we discussed when I was saying gentle - and gentle myosin gentle myosin been christened and been platinum can cause vestibular loss I've never seen it it should be temporary it should come back but those are the only cancer treatments I know of that cause vestibular loss is there any connection between wine and vertigo let me explain occasionally that is that women age but occasionally I'll have a good wine occasionally and I noticed that there are some evenings after one glass of wine I'll roll over that night and have vertigo it doesn't always happen so there's a couple of ways one lapse is if there's a couple of things so red wine is a trigger from putting some people for migraine so it could be red wine is closing migraine another trigger is something called alcohol induced vertigo and it's actually PA n the word for it but it's basically due to if you remember that semicircular canal that little get little curved thing that tells your brain whether you're turning or not and the cupula in there the cupula flows it is neutrally buoyant it is the same density as the fluid that inner ear fluid around it but when you get alcohol in your body alcohol is lighter than water so when the alcohol comes into your body since there's blood vessels inside the cupula the q.q law will have alcohol in it and it will begin to float so it deflects and you begin to feel like you're spinning after a while though because the endo limp is treated it is created by structures that obviously have blood vessels coming to it alcohol begins to enter into the endolymph so now the endolymph that the cupula is floating in become as alcohol in it and that the cupula becomes neutrally buoyant again but life is cruel because now the liver starts digesting the alcohol and the cupola starts losing the the hole in the bloodstream and it begins to sink so you begin to spin in the opposite direction eventually the Enzo limp which is created by a vessel starts losing the alcohol and now the qpo floats back up to the neutral position and you stop floating so you can have you that's why you get bed spins when you drink and they prove this insanely by taking deuterium which is heavy water water where the hydrogen has an extra Neutron in it this is you know the stuff they make atomic bombs with but it didn't have any atomic weight in it they made they mixed they mix the alcohol with deuterium water heavy water so that the density of the alcohol would be the same the density of this mixture would be the same as water and they had people drink regular water and alcohol and deuterium and alcohol and the people would deuterium and alcohol didn't get losing and the people with with with the alcohol and water did get dizzy so if you really want to drink a lot and you don't want to get bit bed spins you should have deuterium ice cubes there about $230 a cube but yeah that's how alcohol can do it and neither either from the density of the alcohol or from the fact that it might be triggering a vestibular migraine thank you do you find that in history of your patients that a lot of them that have symptoms of vertigo that they also have had a history of motion sickness absolutely absolutely and those people most likely have vestibular migraine but it can be something else like you know think about it if your vestibular system is handicapped a little bit you're not going to handle motion as well but people with vestibular migraines are very motion sensor very often so when I hear that the first thing I think of is vestibular migraine hi um I've been diagnosed with labyrinthitis and I also get migraines quite frequently but I also have lupus so how would you go about doing some kind of differential diagnosis for my vertigo so it's possible that your labyrinthitis was caused by your lupus because labyrinthitis has just been I guess an inflammation of the inner ear I would expect that to be a recurrent labyrinthitis so you had the labyrinthitis once you're having it recurrently so if you're having it recurrently then it's I would have to think this out as to whether the recurrence the thing is recurrent migraines or lupus acting up with it there is there is a test you can do I haven't ordered it in years a I call it the $69 in test if you take if you took your inner ear and put it in a blender and then did this thing called plasmapheresis on it this a band would come out at 69 killa Dawn's all that means is a certain thing would show up so if you're disrupting inner ear then you we can do this test to your blood it's just a blood test and it would show that there's a lot of inner ear product in it and that might make me suspicious that your lupus was acting out on your inner ear the thing is though treats or lupus is the thing you do for it and if you're dizzy and and I can't also treat your migraine then I might just give you something to help with the dizziness those that that klonopin meclizine kind of thing by the way I hate meclizine the only the only the only good thing are what do I say the the only the most amazing thing about meclizine is when it works the klonopin works much much better but I have to say except for my wife on meclizine looks better for her so it's it's not it's not an all-around thing but usually I use klonopin so I might give you klonopin to try to relax it if I can't treat her in any other way I would certainly treat the migraine and treat the lupus and to figure out if lupus was causing your inner ear I might do that 69 killer doll test I had a vertigo attack last month ended up in the emergency room all right they sent me home and told me to go see a dorama gist but my previous vertigo was five years ago I went through all this space chair and everything else and they said take meclizine is needed I took her for a while I stopped it I had no problems for five years until last month is there a question yeah what I thought I had it five years ago that was it I didn't realize that I would get again so the questions I would ask you is how long did it last five years ago how long did it last this time that's long enough to get me to the emergency room because they couldn't stop the spinning this is where we stress long enough is not an appropriate answer has to be a time format of a second minutes hours days that's kind of what we're looking for it you know we probably need to further evaluate you with your symptoms because all the people have had vertigo in the past and it it comes back but it can again be anything that came back you know we don't know exactly what you had five years ago but basically you said it was long and it was still going on when they got hit to the hospital okay so that's many minutes to almost an hour ish so okay so that could have been that might have been a migraine back then it might have been a migraine now what we would have to do is break out each individual one and see they might have been both the same thing they could have been two different things a lot of dizziness goes away we always figure when when especially when I'm booked out month we always figure that we have a no-show it's someone with BPPV that went away and they just got better and didn't bother showing up so it may have gotten better and come back and main gun excuse me gotten better and then something else happened hard to tell we need to spend an hour with you to try to figure it out my doctor told me that I had extremely low vitamin D she prescribed me vitamin D 50,000 units weekly after the second week I had vertical so I called my doctor and as her if the vitamin D that was the only new thing that I was taking at the time and she said that vitamin D wouldn't cause vertigo but then after more days I end up having calcium deposits on my shoulders right and left and and then I kind of went in to check online and I saw that vitamin D increases increases absorption of calcium in your body so do you see any correlation because I don't know at this point what caused my vertical when first happened it was really badly it was only two days after that I have it it's very mild and I kind of live with it you know so my first thought would not be vitamin D you know you always afraid as a doctor of what you don't know I've never read an article about it I've never made that diagnosis though if I'm not suspecting it then I could be missing that diagnosis but I've never heard of that I've never read an article on it so I I don't you know I've not had not found a bunch of my patients are on vitamin D so I mean could this be a rare thing I suppose but I would think it's more common thing I mean this almost sounds like a labyrinthitis and the vitamin D was just happened to be there I mean we humans try to make correlations and sometimes those correlations aren't accurate why would exercise at a cardio rate bring on lightheadedness well it could be so this might not be a vestibular problem it might be that you're not getting the blood there it might be a cardiovascular problem it could be by cardiovascular you could have a blockage of an artery and when you have a big high demand of putting out you know when when you're exercising you're not you're moving blood to your muscles rather than to your brain or something like that I would I would think think of a non vestibular cause before I would think of a vestibular cause I have a stupider I mean inner ear brain thing alright if that's it thank you very much for coming out tonight have a safe ride home thank you

Channel: JFK Medical Center

Views: 91,415

Keywords: Health

Id: lKkJD0UBwX4

Length: 103min 10sec (6190 seconds)

Published: Thu Jun 15 2017