That spinning sensation

Q: I am an aerialist (trapeze performer) and am currently dealing with what might be BPPV, Labyrinthitis, or something similar. I am 41 years old. My first experience with BPPV was about 2 1/2 years ago onset was a few days after I had hit my head. I ignored it for a while (it would improve and worsen randomly over the course of a few weeks) but when my work became dangerous I did se a ENT specialist who didn't suggest anything other than rest and Meclizine. Meclizine only worsened my condition. After a few weeks off the trapeze I returned to my usual activities and was fine.

About three months ago I experienced a slightly milder form of vertigo along with fullness in the ear, ear pain, popping and congestion. I saw my chiropractor who did an adjustment maneuver the day after which I was unable to walk my vision was so distorted. I could only focus if I was perfectly still. After 2 days in bed I felt better and slowly resumed activity. Mild vertigo symptoms came back in about a week, during which time my ear symptoms had worsened and I again saw my GP who prescribed Zythrimycin (sp?) - the medication and 2 days of rest and I was completely fine.

3 weeks ago I caught a cold, which caused severe headache and sinus pain after a week and a half I developed distortion in my vision causing dizziness when jumping. My doctor again prescribed Z-pack and I was improving and the dizziness receded. I curtailed trapeze activity but was able to do some aerial work. I was feeling much better dizziness wise, but still had severe headache and sinus pain. My doctor prescribed amoxiclav and flonase which I started on Tuesday morning. My sinuses began to clear, however I still had sinus pain and some facial swelling on the left. I was able to have one training session without dizziness. Later that day (Wednesday of this week) warming up for a performance I experienced positional vertigo, sweats, intestinal distress, and a metallic taste in my mouth. I got through my show and stopped taking the AmoxiClav. I have been doing the Brandt Daroff exercises and after a day of rest am only dizzy on the first set when I move to the right. I rested all day on Thursday and Friday. By end of Friday I was able to complete the BD exersize without vertigo, as well as fold forward and look up.

I saw my doctor Friday afternoon. He took an x-ray and determined that my right sinuses are still very infected and gave me Cefuroxime. He felt the dizziness was unrelated and that if it did nos subside he would refer me to an ENT. I took my first dose of Cefuroxime with dinner Friday evening. I began feeling itchy within a few hours. This morning Saturday my dizziness has worsened. I will be calling my doctor's office later today.

So, that is my history - now for the questions. Is there a reason why antibiotics would be making my vertigo worse? Is it possible to recover from a sinus infection without the use of antibiotics? Is it detrimental for me to be working out in a gym setting if I keep my head upright? I have 11 shows next week starting on Tuesday under contract, and I believe that I can compensate well if the vertigo doesn't worsen. However, I am not sure how to spend my next few days - resting completely, partial workouts? This set of shows were to be the last shows prior to my retirement (I am 41) - so they mean a lot to me. That said, I don't want to be an idiot.

Thank you so much for your time.

A: Before I address your questions, I think it's important we verify that we're talking about the same things.

BPPV: benign paroxysmal positional vertigo. (See also this link.) This has a number of unique features:

1. There is a true vertigo (sense of spinning) when the patient's head is in a particular position. Most commonly, this is provoked by rolling over in bed to one side or the other.

2. If you stay in that position, the vertigo always passes in under a minute.

3. While you are experiencing the vertigo, an observer would see your irises rotate several degrees, correct, the rotate again. Nystagmus is a repetitive eye movement; with BPPV, the nystagmus is called 'rotatory'. Other forms of vertigo show horizontal or vertical nystagmus depending on the motion of the irises. BPPV, to my knowledge, is the only condition which demonstrates rotatory nystagmus.

4. If you immediately go back into the offending position, the vertigo is either nonexistent or much less severe (so-called "fatiguability" -- the symptom "fatigues" with repetition).

5. When you first go into the offending position, there is often a delay of a second or two, sometimes a few seconds ("latency").

6. BPPV responds promptly to positional maneuvers. My favorite is the Epley maneuver, but there are others. With once daily repetition of the maneuvers, nearly all cases of BPPV will resolve in two to three days, assuming the correct maneuver is used. That's where your ENT comes in.

Fullness in the ear, popping, ear pain, and congestion are not associated with BPPV. These symptoms suggest a different problem -- perhaps Eustachian tube dysfunction, an acute ear infection, or possibly otitis media with effusion (fluid behind the ear drum). These problems sometimes improve with antibiotics or a variety of medications which treat the underlying problem, such as sinusitis, allergies, or other nasal/sinus inflammatory conditions. If medications don't help, the ENT can lance the ear drum or place a ventilation tube.

Labyrinthitis is a much more severe condition than anything we have discussed so far. Most cases are caused by viruses. (Bacterial labyrinthitis is a rare but devastating condition which usually leaves the patient with permanent balance and hearing disabilities.) The patient experiences severe vertigo worsened by any kind of motion, and, unlike BPPV, the vertigo can last for hours or days. Nausea and vomiting are common. Ringing in the ears and hearing loss are common. If there's no ringing or hearing loss, but the other symptoms are as I have described, then vestibular neuronitis should be considered.

Viral labyrinthitis and vestibular neuronitis are "self-limiting conditions", which means they improve spontaneously over the course of several days or weeks without any specific treatment.

BPPV, on the other hand, can persist for months unless the patient uses the correct positional maneuvers.

BPPV not uncommonly follows head trauma, labyrinthitis, vestibular neuronitis, or even an upper respiratory tract infection. Once you have it, you can make it go away with positional maneuvers, but it can return weeks, months, years later without warning. Positional maneuvers will again work, but there's no way to get rid of BPPV permanently.

On to your questions:

Is there a reason why antibiotics could make vertigo worse? Not usually. Only as a side effect of the medication (which is, of course, possible for any med, but I don't commonly see vertigo as a side effect of antibiotics).

Is it possible to recover from a sinus infection without the use of antibiotics? Yes. Untreated, most people will fight off a sinus infection. Antibiotics will shorten the duration of the illness (assuming we're talking about bacterial sinusitis) and will also help to prevent the progression of acute sinusitis into chronic sinusitis. One downside of NOT treating with antibiotics: the infection is more likely to turn chronic.

Is it detrimental for me to be working out in a gym setting if I keep my head upright? Assuming you are being safe in your workouts, I see no harm in this, and in fact, the workouts are probably a good thing. How else will you be able to judge if you are safe for performing?

How should you spend the next few days? Tough to say. If your heart is set on performing, you need to be working out, steadily increasing the intensity so that you can determine if you are safe to perform. Only you can make that judgment, by the way -- I doubt any doc could look you over and give you a 100% guarantee of safety. The thing to do, then, is whatever it takes for YOU to figure out if you're safe to perform.

I'm still not certain what it is that currently bothers you. That's where a visit to the ENT would come in handy, but at this time of year, I suspect getting in to the ENT would be difficult on such short notice. If your current problems are more Eustachian tube dysfunction-related, then medications (or possibly even minor surgical procedures, as I've noted above) could help. On the other hand, if your current trouble is more like BPPV, then positional maneuvers are the way to go. By the way, I can imagine situations where your stunts as an aerialist could undo the benefit of the maneuvers. You would know it right away . . . but I would hope you could find that out during your workouts, and not during a show!

Remember, safety is paramount . . . but I doubt I need to tell you that. You have many years ahead of you and I would hate to see you get injured.

Best of luck to you.