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Programme 4. - Balance Problems
RADIO 4
THURSDAY 22/03/07 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
ROSALYN DAVIES
PRODUCER:
PAMELA RUTHERFORD
NOT CHECKED AS BROADCAST
MYERS
Dizzy spells are always worth getting checked out because if your head is spinning you can easily lose your balance and your footing and take a tumble. Now sometimes dizziness is a symptom of an underlying medical condition: it could be high or even very low blood pressure, it could be heart arrhythmias or even anxiety. But sometimes it stems from damage to the inner ear which is where the delicate organ of balance is located. And in today's programme it's these balance disorders of the inner ear that we're focusing on; conditions such as labyrinthitis, positional vertigo and Ménière's Disease. Some of these conditions, as you may well know, are easier to live with than others, some are more treatable but there's always something to be tried so if you'd like advice or information call us now - 08700 100 444 - to speak to our expert today who is Dr Rosalyn Davies, she's a consultant in audio-vestibular medicine at the National Hospital in Queen's Square.
I have to say Rosalyn before preparing for this programme I didn't really know that there was such a thing as audio-vestibular medicine, can you very briefly explain what that actually means?
DAVIES
Yes of course. It is the specialty of hearing and balance and we are physicians, rather than surgeons, so we don't operate, we like to investigate and diagnose our patients and manage them thereon.
MYERS
At a balance clinic.
DAVIES
At a balance clinic ideally yes.
MYERS
Okay, well there are plenty of people who would like to speak to you about their problems with dizziness and balance and Mr Vang is first up. Dizziness and vertigo since - oh - 1971, that's a very long time, so you've been struggling a little bit with this have you Mr Vang?
VANG
It's just Vang - I don't use prefixes. Well yeah - over the years I've come to terms with handling it, the varying different kinds of dizziness of I have. It initially started off with vertigo and regularly the most common cause of the bouts is vertigo. But I have experienced a wide range of complaints that cause dizziness and vertigo. One of the most frustrating things being that the majority of them you just don't know what the hell the cause is.
MYERS
So you struggle and other people just look on and don't quite understand what you're going through?
VANG
Well that is a major problem - unfortunately ever since Alfred Hitchcock brought out Vertigo the second you mention vertigo everyone thinks fear of heights, which it's not.
MYERS
Absolutely, well let's get Rosalyn to comment on that. We are using these terms vertigo and dizziness, are they entirely interchangeable and in a way how can you explain to people what you're going through, how unpleasant it may be?
DAVIES
It is a very difficult symptom to describe. In the medical world we use vertigo to mean an illusion of movement. However, the word dizziness encompasses a lot of other sensations, like light-headedness and muzziness, as well as vertigo itself. Yes it is a very disorienting symptom and it's very difficult to explain to other people.
MYERS
And vertigo as in fear of heights doesn't really come into the picture?
DAVIES
The fear of heights is what we call physiological vertigo - we all get it if the conditions are extreme enough. Most of the patients we see with dizziness and vertigo have what we call pathological causes for their vertigo - there's some disorder that's underlying their symptom.
MYERS
Well thanks for putting the question and helping us define our terms a little bit Mr Vang. If I may I'd like to go on to our next caller - Jane Bayliss - who - well she uses the term dizziness, which is due to your neck position while you're asleep. So how uncomfortable is this Jane and is this something that's come on recently?
BAYLISS
Well no I've been suffering from this for six or seven years. I occasionally, very occasionally, wake up in the morning with dizziness that can last all day. My blood pressure is fine but I started to suffer neck stiffness on waking a few years ago and changed to an orthopaedic pillow and that helped greatly. But I was wondering if there could be a connection between my neck position while sleeping and the dizziness because it's also occurred after painting a ceiling?
MYERS
Ah now that has my guest's eyebrows shoot up when you talk about painting a ceiling. What are you thinking Rosalyn in this case?
DAVIES
Yes indeed, yes indeed. Hello Jane.
BAYLISS
Hello.
DAVIES
The painting and the ceiling does make my mind immediately jump to one particular cause of vertigo. There is a particular head position that can trigger dizziness and is caused by a condition that we shorten to the term BPPV - benign paroxysmal positional vertigo. And it's very characteristic this particular condition in that people have a spin, which is really quite short lived, less than a minute, when they turn themselves on to one side in bed or indeed in slightly other unusual situations, if they're changing a light bulb from a ceiling lamp or if they're looking up at an airshow, for example, and they've held their head back for a long period of time. The reason also for my eyebrows shooting up is simply that it's a very treatable condition and we can give a manoeuvre which dislodges the crystals which have accumulated in the back canal of the balance organ in the inner ear and redistribute them, so that they no longer cause the problem.
MYERS
Now I've heard this manoeuvre described as quite miraculous - it completely gets rid of this horrible dizziness for people - is that right, is it that simple?
DAVIES
Well it is very satisfying for the doctor to suddenly have a patient who describes the characteristic symptoms. There are two manoeuvres that we frequently use for this condition and both of them have a 70% success rate and when I say success I mean cure. And one of them is the Epley manoeuvre - Jack Epley, from the States, devised this and it was first published in 1989. And the other is by Alan Semont from Paris in France and was described in the very early '90s. I think they are both as effective as each other, just depends what your particular practitioner is used to doing.
MYERS
Jane stay with us but let me bring in Jack Harper who's in Northern Ireland, I think also with a question about indeed what might be this positional vertigo that we're talking about, is that something that you've been diagnosed with or something that may be affecting you Jack?
HARPER
No it was something I was actually diagnosed with about 10 years ago. And I discovered on my own during the course of experiencing these bouts that if I slept on one side only at night, that is in fact my left side and not my right side, I could keep the vertigo at bay. If I turned over in the night or during the day or whatever and slept on my right hand side the bout would last for not only the whole day but perhaps even for weeks. So I learnt to lie only on my left hand side, my problem is that I don't get a good night's sleep. Now if you can return to me my full night's sleep I'd be very grateful.
MYERS
And if I can throw in yet another because I think this is obviously - we've touched a nerve here, an e-mail that's just come through from Christine Cotton who says that her 23-year-old son suffers from severe dizzy spells which wake him up during the night. He says that sleeping with two, three pillows helps him but wonders if dehydration is a factor and obviously would like to get a good night's sleep just as you would Jack. So some general advice there for people with these kind of symptoms.
DAVIES
I think you need to go to your local balance unit and ask to be diagnosed as to whether you might have BPPV - benign paroxysmal positional vertigo - as this is the condition that can be so easily treated.
MYERS
Jane is that something, if you're still with us, advice you'd like to follow up do you think?
BAYLISS
Yes I would certainly.
MYERS
Well a miracle cure would be good wouldn't it?
BAYLISS
It certainly would.
MYERS
I mean just because it's so intriguing can you say a little bit more about what's going on inside the inner ear, do we actually know when people have this condition? And you've talked about people striking certain poses - painters - I've heard people - cameramen for example in the media - get the problem too. So what is going on to cause it?
DAVIES
It's due to loose chalk crystals which when they're in the right place within the inner ear are very helpful and they're part of the sense detector mechanism for our balance. However, it's quite easy to dislodge them from the jelly membrane on which they sit and a mild bang to the head or alternatively as a sequel to a labyrinthitis they can fall off their perch, so to speak, they're then within the fluid system of the inner ear and over a period of time they deposit and they tend to deposit where gravity pulls them to. So this is most frequently the back canal of the inner ear and if enough of these crystals accumulate together they actually block this back canal and it means that certain head movements, which are in the plane of this back canal, will trigger the vertigo.
MYERS
Okay and the manoeuvre just sorts it out?
DAVIES
And the manoeuvre allows these crystals to fall slowly, slowly, again with gravity, back through the 180 degrees that they need to travel to get out of the open end of this canal and back into the chamber called the vestibule where they can actually be reabsorbed.
MYERS
Fascinating, thank you, I hope that's been helpful to Jane and Jack and Christine and indeed others who think this may be their problem.
Let's go to Gordon now in Eastbourne who has got giddiness. Tell us a bit more and have you had treatment?
GORDON
Well actually it first occurred with labyrinthitis three years ago, it was on Boxing Day, it's a day I remember well and it was quite distressing. But after analysis by my doctor I was given a course of antibiotics which cleared it up pretty quickly but it took me three or four months to learn to really walk again and retain my balance properly. And since then it's improved generally throughout but recently after some three years after that happened I went on holiday to Mallorca and I flew there and back and when I got back I noticed within 24 hours of returning that I was feeling quite woozy and my balance was slightly affected. And it got quite bad after two or three days but I put it down to the fact that I'd been at high altitude in a pressurised aircraft. But since then this wooziness has been with me all the time and there's no loss of balance but occasionally I well get up and go to walk forwards and lurch slightly to one side, if you know what I mean. And that's about all I can tell you so far.
MYERS
Well that's quite enough to be going on with and a helpful description perhaps for you Rosalyn?
DAVIES
Yes. It's quite a typical story I would have to say Gordon. You describe a very unpleasant illness about three years ago and you said was a most distressing Boxing Day. You took several months to recover and it's during that recovery period that the brain does its adjustment to the impairment that you acquired on Boxing Day or around about that time that damaged your inner ear balance organ. And I think it's worth remembering that although the brain is magnificent in its capacity to repair and adjust and recalibrate it's vulnerable and there are certain situations in which that process of compensation can break down. And it sounds to me that since your holiday you've de-compensated slightly, I mean as you say you haven't got the full balance story back but you do lurch occasionally to one side and you feel woozy in the head. I would have to say that I think you're a good person to go and have some balance exercises and clear this up completely.
MYERS
So this compensation for what's happened in the inner ear, the infection or whatever's caused the labyrinthitis then, this is the treatment - to get your brain to sort of cope with it, is it as simple as that?
DAVIES
It is, it is. I mean clearly the actual mechanisms are far more complex and we don't have all the answers. But yes the brain is amazingly plastic and can re-bold, restructure, however one likes to think of this conceptually and make sense of change signals from the one damaged ear and after a while it accepts those signals as the new normal.
MYERS
I hope that's been helpful Gordon. If I may I'll just move to another e-mail from Lisa who has also labyrinthitis, she's pregnant, she's wondering whether this is going to get worse or get better or whether it's going to change in any way and how long it's going to last - will it follow her through the pregnancy and beyond? One wouldn't like the idea of having a small baby and losing balance.
DAVIES
No absolutely. Hormones certainly do seem to trigger dizzy problems, they're obviously not the underlying cause and somebody who's had a problem, like Gordon, who's had a labyrinthitis and has recovered by a process of compensation may then become vulnerable in the pre-menstrual period or sometimes the first few days of the cycle. And in those situations again we find that the balance exercises do help. In Lisa's particular situation she just does need to watch out that when the new baby comes along that wherever possible she can get a good night's sleep - the tiredness is also a trigger to the brain not remaining well compensated.
MYERS
And if I may throw in another e-mail from Veronica who says that her husband has inner ear problems is it okay to fly, now Gordon said that he thought this had perhaps been brought on by flying, is flying a trigger for these symptoms if you have already have that problem or could it in fact cause a problem of the inner ear?
DAVIES
I think these days there is no question that the flying itself causes the problem. The cabins themselves really are not very different in their pressure to ground ambient pressures. I think the issue ...
MYERS
So you're saying it doesn't cause the problem?
DAVIES
It doesn't cause it. What can happen though is if somebody's Eustachian tube, which is this tube that joins the middle ear to the back of the throat, doesn't open and close easily with swallowing then you can have a build up of pressure in the middle ear and that can have a knock on effect on the balance and the dizziness can come back. So we do advise anybody who's about to fly who has a dizzy problem to consider taking a decongestant before they fly to make sure that they can open and close that Eustachian tube properly.
MYERS
Thank you. We'll go to Rosemary Kirkbride who's been having funny turns for a number of years and wondering if this could be connected with inner ear problems. What makes you think it might be Rosemary?
KIRKBRIDE
Hello. It's - well it's the dizziness and nausea that I get with it but unusually it always occurs in the early hours of the morning, it always wakes me up, I don't get this problem during the day.
MYERS
Okay, enough to be going on with Rosalyn?
DAVIES
That's interesting, it sounds like you've had it for some time, only occurs in the early hours in the morning but sufficient to wake you up?
KIRKBRIDE
Oh yes.
DAVIES
Do you actually spin?
KIRKBRIDE
I feel very poorly I have to say.
DAVIES
You feel very poorly - do you spin, does the world zip off to one side and rotate?
KIRKBRIDE
It does as soon as I get out of bed, I wake up feeling very poorly with a rapid heartbeat and sweating profusely and feeling very nauseous and as soon as my feet hit the floor then everything does spin and I have been known to sort of actually pass out on the floor, it's very momentarily but it has happened.
DAVIES
It does quite dramatic. It does sound also as if you have had some investigations already.
KIRKBRIDE
I have yes.
DAVIES
Yes. There are several different things that come to my mind and I would certainly with you sitting in front of me want to explore some of those ideas a little bit further. I think properly what I would say in this situation is that where there isn't a relatively straightforward explanation you do need to be in the hands of somebody who is medically trained to look at the other causes of balance disorders. And perhaps this might be the moment to also say the rapid heartbeat needs looking at, I mean whether this itself is a palpitation due to you being very anxious because of a very unpleasant symptom of dizziness and nausea or whether in itself your heart has just decided to beat a little faster. And I would want to explore that a little bit further as one example for all of this.
MYERS
Thank you very much. I think we might have to leave that there. Let's go to Marilyn who is in North Oxfordshire and has had Ménière's disease for two, three years and looking for some advice today, thank you for ringing us for some advice, anything in particular that's puzzling you and that we might be able to help you with Marilyn?
MARILYN
Yes I wonder if there's any way that I can stop it once it starts. If I have a vertigo attack, for example, all you can do is go to bed and leave it. And they have given me a hearing aid but I do have a lot of noise in the ear and most of the time it just amplifies the noise that's in the ear and doesn't help very much. Is there anything else I can do?
DAVIES
Yes of course, you describe quite an unpleasant aspect of Ménière's is that the hearing impairment, when amplified with a hearing aid, can actually become rather a tinny sound and some patients with Ménière's don't find their hearing aid particularly helpful. But again we've got better hearing aids all the time with the digital hearing aids and we're able to be more specific in amplifying people.
MYERS
Rosalyn, obviously you will know and clearly Marilyn, our caller, knows that the hearing loss seems to be part and parcel of Ménière's disease, can you say a little bit more for those of us who don't know, however, what Ménière's is, what would be the other symptoms that would give you that diagnosis?
DAVIES
Of course. Ménière's is due to raised pressure in the inner ear and as we've mentioned the inner ear houses not only the balance organ but also the hearing organ and there is some sort of block to the flow of the fluids that normally exist in the inner ear and there is a build up of the pressure as a Ménière's attack comes on. The first symptom in most people is a low pitched buzzing noise in the ear, what we call tinnitus, that then develops into this very unpleasant vertigo with very dramatic spins, often with vomiting and very marked imbalance, so that the person has to go away and lie down. The hearing impairment is something that goes on around the same time and often as the vertigo improves the hearing comes back to normal and that noise goes away.
MYERS
But now you talked about - thank you for that - but what can our caller do for the vertigo attacks that are part and parcel of her condition?
DAVIES
Absolutely. Two things I would suggest. One of them is at the level of treating the horrible vertigo as it comes on and the other is to prevent the build up that actually triggers the attacks. If I just start with treating the horrible vertigo. There are a variety of different medications that are available to treat symptoms of dizziness, one of these is something that you can put inside your cheek and will dissolve quite quickly that way and if you're feeling a bit sick is better absorbed through the cheek tissue rather than through the stomach lining. So that's a good way to help, you may well have tried this if you've had Ménière's for a couple of years. We also can recommend a rectal suppository, although the British aren't so keen on rectal suppositories in general, but that's something else that we could do. But I would want to also look at your salt intake because we have a very clear clinical impression that patients with Ménière's do much better on low salt diets. So I would say to you it would be a good plan to stop adding any salt whatsoever to your diet and also to consider whether or not your GP might put you on what we call a thiazide diuretic, one of the ones that helps to eliminate salt from the body. Salt is associated with a build up of fluid and we've got strong clinical experience to believe that this makes a lot of difference for patients with Ménière's .
MYERS
Okay, if I may bring another caller in on this condition as well - Binny wants to speak to us, she's in Brighton. And you think you know what triggers your vertigo, you know you have Ménière's, but you want to check that with our expert today. So what do you think is causing the actual attacks?
BINNY
Oh yes, well I'm asking about two particular attacks. Normally I don't know what triggers my attacks but on one occasion I had a really very bad attack after I'd had my eyes tested and I wondered if it was anything to do with a strong light being directed straight into the eye, as happens when you're having your eyes tested? The other occasion was after I'd used one of these Echo MiniTech hearing aids at the theatre and after that I had a very bad attack and I wondered this was a constant use for two and a half hours and I wondered if that had been the cause of the attack.
DAVIES
I think there's always the question was this a coincidence in both of these instances or exactly as you've asked was it a definite trigger. I wouldn't be so sure that either of those was a definite trigger. The strong light in your eyes I can't see how that would have affected the build up of pressure in your ear. I mean the only other thing that we know that regularly triggers Ménière's would be a great deal of anxiety and it may have been that you were very worried about your eyes, understandably because eyes are very important to us once our balance isn't working so well.
MYERS
I'm afraid I'm going to have to stop you there. Thank you very much for that call Binny. And thank you very much to everyone who has phoned and to our expert today Dr Rosalyn Davies for her expertise on what I think is quite a tricky but important subject. Thanks very much to all who rang with their questions.
If you would like to listen to the programme again you can go to our website, that's at bbc.co.uk/radio4. You can also leave us a message there, we're always keen to hear from you about this or any of our programmes. You can get more information by calling our free and confidential help line, that's 0800 044 044.
And join me again if you will next Thursday at three for your questions on giving and getting best care at the end of life.
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