Saturday, December 16, 2006

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.


At 7:38 PM, Anonymous Anonymous said...

In March '05, I was hospitalized for 3 days w/ what was diagnosed as "severe viral labrynthitis". I awoke in the morning with absolutely no equalibrium and no fore-warning. This happened again last mth, 3 days hosp, with BPPV. No eye nystagmus was ever present. I have "mini" episodes approx 6 x's year. Thinking of ear candling treatments!

At 4:49 AM, Anonymous Anonymous said...

I have had about 1 year history of sore throat which I related to singing too much. Conciquently I had my gallbladder out in September and was on antibiotics and my throat got better. I work for an ENT office as a nurse. Well as soon as I was off the antibiotics the sore throat came right back...and the cycle began. Seven rounds of antibiotics including one month of clindamycin, and doxycycline, and three rounds of prednisone. I did get relief initially until I was off medication about one week and finally the sore throat just stuck with me. After many exams my ENT saw an area of yellowish exudate where your adenoids used to be and sent me for a CT to rule out Thornwaldts cyst..the CT was essentially normal. So the final "guess" was lingual tonsillitis..I had all the "tale, tale" signs of this...I had my lingual tonsillectomy on Dec 9th,,rough!!! Anyway my throat is better, but still not normal. I have in the last two weeks developed a sweet taste in my mouth, even water tastes sugary. I am wondering if this area where the adendoids used to be could be the cause and is there any way to clean out this area to hopefully clear this up. I still have a sore throat the lower sore throat is gone, but I have soreness up higher now. I am so frustrated! I have been on more medications in the last year than I have my whole life. Please give me your thoughts.

At 7:03 PM, Anonymous Doug Hoffman MD said...

anonymous #1: you've given me very little information to go on. Just two comments: (1) BPPV is a common sequela to viral labyrinthitis. (2) BPPV is very treatable, and the treatment is NOT ear candling.

anonymous #2: you don't mention whether you ever had your palatine tonsils removed. If not, this would have been my suspicion a long time before I went after your lingual tonsils. As for the adenoids, if there's any adenoid tissue there whatsoever, it's definitely removable. And it wouldn't be nearly as nasty the lingual tonsillectomy!

Bear in mind that postnasal drainage could account for the taste disturbance and sore throat, too. Hope this helps!

At 1:59 PM, Anonymous Gwen said...

About once a year I have a severe labyrinthitis episode that resolves itself in about three days. I'm dizzy and nauseous no matter what I do - sit, lay down, walk. It's a miserable, horrible feeling I wouldn't wish on my worst enemy. It hits like a hammer and eases off slowly.

The rest of the year, I have normal BPPV symptoms.

My body has followed this pattern for about 7-years now. I haven't been able to determine the trigger for the severe episodes. It starts at different times of the year, I've lived in two different places, etc.

I'm guessing this combination of maladies is normal, if you're going to have the problem.

I've found that the treatment movements (forgotten what they're called) seem to work well enough, though they don't resolve the BPPV symptoms completely and don't touch the labyrinthitis symptoms at all. Meclizine works okay not great, and the Scop patches behind my ear don't do much more than give me a dry mouth.

I can't do anything during a severe episode. Can't do air travel for a couple of weeks afterwards. Otherwise, my activities aren't restricted much - no ladders or high spots. It would suck to be an aerialist - I would think this would be a career-ending condition for them.

I'm guessing this is just one of those chronic conditions one has to become used to. There doesn't seem to be any cure.

At 6:02 AM, Blogger singingtothewheat said...

About 13 years ago I got really sick and stayed really sick for about three weeks. In hindsight, I should have been hospitalized. They finally ended up telling me it was labrynthitis, sinusitis, tonsilitis and bronchitis. Good Grief.
I have a constant high pitched ring which NEVER goes away. I have a hearing deficit in all the upper ranges and totally lack any functional hearing in some of the parts of the upper ranges. Like the one for I.V. pumps. Hence, I always change out the bags on my patients prior to them going off.
I can't even imagine being an aerialist! I'd be a dead aerialist.

At 3:01 PM, Anonymous Anonymous said...

Tip to prevent ear infection with adult:
Preventative methods typically range from flushing the ear to chewing gum. Yes, chewing gum is recommended as it is known to help relieve pressure in the ear as well as creating good saliva flow. Chewing gum usually works a treat during plane flights when ears are affected during the landing procedure in particular.

At 4:08 AM, Anonymous Anonymous said...

qlkgsI really don't mean to be a smart aleck- you say you are a physician/surgeon and you have left out many symptoms of BPPV and other more serious conditions of the vestibular system- which is very complicated and involved in an astounding array of sensory intake and processing of stimuli.Many of those afflicted can suffer from severe anxiety, blurred vision, depersonlization, overwhelming fatigue,severe headaches, back pain,(as the muscles "attempt" to correct sense of falling toward the affected ear). Ear pain most certainly can be a symptom as can depression. There are various types of nystamus and contrary to your comment they are rarely "seen" while the eyes are open- usually they can be seen by a neurologist by careful visual following of his finger or while the Dix-Hallpike Manuever is being performed by a qualified physician.However- while the eyes are closed- nystagmus can be easily seen and quite severe with the eyeballs jumping,rolling or jerking rhythmically in several different directions.These problems are not well suited for an ENT- they are better handled by an otoneurologist as they are much more complex than an "ear infection" and have nothing to do with the throat or sinuses. There is an excellent website- one on which you can find most of the diagnosed spend much of their time battling fatigue,anxiety,depression,as well as the vertigo and nausea. The common medication of choice surprisingly to treat many of these conditions is Ativan which somehow seems to cause the loosened calcificated fractments which are freefloating and are mostly the cause of the contiuation of the problem, to return to the normal resting place. The website is Good luck and Thank You!

At 3:41 PM, Blogger bob said...

after 20 years I've had an episode of mild vertigo. From out of the blue or was it the keflex antibiotic I've been on for 8 days?

Always have a full feeling, a little ringing and a slight sensation when I rollover in bed quickly. But other than that, I've been fine.

History is that 20 yrs ago (while on my 10th day of 1800mg of motrin (herniated disc)) I had a violent episode of vertigo so that I couldn't stand up and barfed (that was the last ime I vomited so I don't have a queasy stomach. One positive test was when they blew hot/cold air into my ears which showed some dysfunction in my vestibular system.

What do you think is going on?


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