Question
Nine months ago I had an infection that spread to my inner ear that caused vertigo and vestibular weakness. A denist thought it was an upper wisdom tooth and removed it. Went to balance therapy and fully recovered. Three months later, the infection came back and the dentist discovered that it was a cyst next to my bottom wisdom tooth on the same side and removed both. My vertigo and vestibular weakness returned. Went back to balance therapy and nothing worked. Been to 2 neurologists and 2 ENT's and they basically prescribed Meclizine. I've had a CT scan, MRI's and MRA's of brain and neck and everything came back normal. Had about 20 different blood tests to rule out everything from anxiety to thyroid conditions. Everything neg. The problem I'm still experiencing is fullness of ears and feeling liquid moving around in both ears along with vision problems. Dizzy spells happen daily. Was also prescribed Diamox to get rid of fluid, but stopped working. My question is, could I have nerve or joint damage in my neck from the forceful pulling of the cyst and wisdom tooth. It feels like my ears and neck are inflammed and full of pressure. At times a cold compress behind my head and ears is the only thing that works during a dizzy spell, along with an epeley manouver. It's been very difficult to function some days and hard to take care of my 15 month old. Any help would be greatly appreciated.

Answer
Dear Jennifer,

From what you have described, irritation of the ganglion (group of nerve cells outside of the central nervous system) in the neck called the trigeminal ganglion or the vagus ganglion could have occurred, and both can lead to some symptoms of dizziness.  The more likely scenario is that the nerves are not damaged, but rather you may have some upper cervical joint dysfunction which will also affect both of these ganglions without specific nerve compression...just chronic irritation, along with an associated inner ear problem.  These issues are easily missed upon diagnostic testing such as MRI, MRA and CT and will not have any findings with blood tests.  A functional orthopedic and neurologic examination must be utilized to make the diagnosis along with the clinical presentation.

The specific reasons why I believe the above are first, you stated the problem(s) tends to get better with an Epley maneuver...only inner ear dysfunction will improve with the maneuver...if there was any nerve irritation/damage the Epley would not help.  Secondly, if the occiput (skull bone) does not move appropriately upon the top of the spine, headaches, dizziness, and nausea can occur. The occiput dysfunction is easily addressed with simple adjustments, and the relief is usually instantaneous with pain, but may take a a few days regarding dizziness/nausea...I do this in my office every week, and any chiropractic physician should be able to perform this adjustment.  I would highly encourage you to have this area evaluated by a chiropractic physician

Concerning the Epley maneuvers, I want you to understand how this works regarding the tiny stones in the ear (otoliths), their relationship to balance, the inner fluid (endolymph), and the other associated structures.  

Benign Paroxysmal Positional Vertigo (BPPV) dizziness is generally thought to be due to debris which has collected within a part of the inner ear.  This debris can be thought of as "ear rocks", although the formal name is "otoconia". Ear rocks are small crystals of calcium carbonate derived from a structure in the ear called the "utricle" (figure #1) below. While the saccule also contains otoconia, they are not able to migrate into the canal system. The utricle may have been damaged by head injury, infection, or other disorder of the inner ear, or may have degenerated because of advanced age. Normally otoconia appear to have a slow turnover.
BPPV is a common cause of dizziness. About 20% of all dizziness is due to BPPV. While BPPV can occur in children (Uneri and Turkdogan, 2003), the older you are, the more likely it is that your dizziness is due to BPPV. About 50% of all dizziness in older people is due to BPPV. In a recent study, 9% of a group of urban dwelling elders were found to have undiagnosed BPPV (Oghalai et al., 2000).

The symptoms of BPPV include dizziness or vertigo, lightheadedness, imbalance, and nausea. Activities which bring on symptoms will vary among persons, but symptoms are almost always precipitated by a change of position of the head with respect to gravity. Getting out of bed or rolling over in bed are common "problem" motions. Because people with BPPV often feel dizzy and unsteady when they tip their heads back to look up, sometimes BPPV is called "top shelf vertigo." Women with BPPV may find that the use of shampoo bowls in hair salons bring on symptoms. An intermittent pattern is common. BPPV may be present for a few weeks, then stop, then come back again.
 
Diagnosis:  The physician makes the diagnosis based on your history, findings on physical examination, and the results of vestibular and auditory tests. Often, the diagnosis can be made with history and physical examination alone. Figure #2 above, illustrates the Dix-Hallpike test. In this test, a person is brought from sitting to a supine position, with the head turned 45 degrees to one side and extended about 20 degrees backward. A positive Dix-Hallpike test consists of a burst of nystagmus (jumping of the eyes). The eyes jump upward as well as twist so that the top part of the eye jumps toward the down side.

With respect to history, the key observation is that dizziness is triggered by lying down, or on rolling over in bed. Most other conditions that have positional dizziness get worse on standing rather than lying down (e.g. orthostatic hypotension). There are some rare conditions that have symptoms that resemble BPPV. Patients with certain types of central vertigo such as the spinocerebellar ataxias may have "bed spins" and prefer to sleep propped up in bed (Jen et al, 1998). These conditions can generally be detected on a careful neurological examination and also are generally accompanied by a family history of other persons with similar symptoms.

Electronystagmography (ENG) testing may be needed to look for the characteristic nystagmus (jumping of the eyes) induced by the Dix-Hallpike test. It has been claimed that BPPV accompanied by unilateral lateral canal paralysis is suggestive of a vascular etiology (Kim et al, 1999). For diagnosis of BPPV with laboratory tests, it is important to have the ENG test done by a laboratory that can measure vertical eye movements. A magnetic resonance imaging (MRI) scan will be performed if a stroke or brain tumor is suspected. A rotatory chair test may be used for difficult diagnostic problems. It is possible but uncommon (5%) to have BPPV in both ears.

Treatment:  There are two treatments of BPPV that are usually performed in the doctor's office. Both treatments are very effective, with roughly an 80% cure rate, according to a study by Herdman and others (1993). If your doctor is unfamiliar with these treatments, you can find a list of knowledgeable clinicians from the Vestibular Disorders Association (VEDA) .

The maneuvers, named after their inventors, are both intended to move debris or "ear rocks" out of the sensitive part of the ear (posterior canal) to a less sensitive location. Each maneuver takes 10-15 minutes to complete. The Semont maneuver involves a procedure whereby the patient is rapidly moved from lying on one side to lying on the other (Levrat et al, 2003). It is a brisk maneuver that is not currently favored in the United States, but it is 90% effective after 4 treatment sessions.

The Epley maneuver (canalith repositioning procedure), is illustrated in figure #3 below. It involves sequential movement of the head into four positions, staying in each position for roughly 10-30 seconds. The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, recurrent treatments may be necessary. Some authors advocate use of vibration in the Epley maneuver. According to Hain et al. (2000,) this has not substantiated. Use of an anti-emetic prior to the maneuver may be helpful if nausea is anticipated. Some authors suggest that position 'D' in the figure is not necessary (e.g. (Cohen et al. 1999; Cohen et al. 2004 ). Again, according to Hain, this is a mistake, as mathematical modeling of BPPV suggests that position 'D' is the most important position (Squires et al, 2004).

When performing the Epley maneuver, caution is advised should neurological symptoms (for example, weakness, numbness, visual changes other than vertigo) occur. Occasionally such symptoms are caused by compression of the vertebral arteries (Sakaguchi et al, 2003), and if one persists, a stroke could occur. If the exercises are being performed without medical supervision, we advise stopping the exercises and consulting a physician. If the exercises are being supervised, given that the diagnosis of BPPV is well established, in most cases we modify the maneuver so that the positions are attained with body movements rather than head movements. After either of these maneuvers, you should be prepared to follow the instructions below, which are aimed at reducing the chance that debris might fall back into the sensitive back part of the ear.

1. Wait for 10 minutes after the maneuver is performed before going home. This is to avoid "quick spins," or brief bursts of vertigo as debris repositions itself immediately after the maneuver.
2. Sleep semi-recumbent for the next two nights. (Figure #4 above) This means sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch. During the day, try to keep your head vertical. You must not go to the hairdresser or dentist. No exercise which requires head movement. When men shave under their chins, they should bend their bodies forward in order to keep their head vertical. If eye drops are required, try to put them in without tilting the head back. Shampoo only under the shower. Some authors suggest that no special sleeping positions are necessary (Cohen, 2004; Massoud and Ireland, 1996). Others, think that there is some value (Cakir et al, 2006)
3. For at least one week, avoid provoking head positions that might bring BPPV on again.  Use two pillows when you sleep, avoid sleeping on the "bad" side, and don't turn your head far up or far down. Be careful to avoid head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means be cautious at the hair salon, spa, dentist's office, etc... Try  to stay as upright as possible. Exercises for low-back pain should be stopped for a week. No "sit-ups" should be done for at least one week and no "crawl" swimming. (Breast stroke is OK.) Also avoid far head-forward positions such as might occur in certain exercises (i.e. touching the toes). Do not start doing the Brandt-Daroff exercises immediately.
4. A week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can't fall or hurt yourself. Let your doctor know how you did.

**More than 394 patients have been reported in blinded studies comparing the Epley or Semont maneuver to either placebo or medical treatment. The results are clearly in favor of these maneuvers. The median response in treated patients was 81%, compared to 37.% in placebo or untreated subjects. The few instances where the Epley or Semont results were not compelling (e.g. Blakely et al, 1994), may have been instances where technique was not perfected.   

?  Blakley, B. W. (1994). "A randomized, controlled assessment of the canalith repositioning maneuver." Otolaryngol Head Neck Surg110(4): 391-6.
?  (Fujino, Tokumasu et al. 1994; Li 1995; Lynn, Pool et al. 1995; Wolf, Boyev et al. 1999; Froehling, Bowen et al. 2000; Sherman and Massoud 2001; Salvinelli, Casale et al. 2003; Simhadri, Panda et al. 2003) .
?  Froehling, D. A., J. M. Bowen, et al. (2000). "The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial." Mayo Clin Proc75(7): 695-700.
?  Fujino, A., K. Tokumasu, et al. (1994). "Vestibular training for benign paroxysmal positional vertigo. Its efficacy in comparison with antivertigo drugs." Arch Otolaryngol Head Neck Surg120(5): 497-504.
?  Li, J. C. (1995). "Mastoid oscillation: a critical factor for success in canalith repositioning procedure." Otolaryngol Head Neck Surg112(6): 670-5.
?  Lynn, S., A. Pool, et al. (1995). "Randomized trial of the canalith repositioning procedure." Otolaryngol Head Neck Surg113(6): 712-20.
?  Salvinelli, F., M. Casale, et al. (2003). "Benign paroxysmal positional vertigo: a comparative prospective study on the efficacy of Semont's maneuver and no treatment strategy." Clin Ter154(1): 7-11.
?  Sherman, D. and E. A. Massoud (2001). "Treatment outcomes of benign paroxysmal positional vertigo." J Otolaryngol30(5): 295-9.
?  Simhadri, S., N. Panda, et al. (2003). "Efficacy of particle repositioning maneuver in BPPV: a prospective study." Am J Otolaryngol24(6): 355-60.
?  Wolf, J. S., K. P. Boyev, et al. (1999). "Success of the modified Epley maneuver in treating benign paroxysmal positional vertigo." Laryngoscope109(6): 900-3.

Hope this helps Jennifer.

Respectfully,
Dr. Shawn Leatherman
www.suncoastehalthcare.net