Dr Prueter "Balance and Hearing."Apr 16, 2022 at 10:26 am

2:26PM Apr 16, 2022

Speakers:

Cindy Helmich

Teresa Gonzalez

Ray Furner

Dr Prueter

Keywords:

people

called

dizziness

inner ear

balance

system

patients

problem

important

vestibular

condition

symptoms

vertigo

question

medications

generally

tinnitus

physical therapy

crystals

migraine

In our balance system, our inner ear is constantly working together. There's constant push pull mechanism. So that's one one way, our eyes moving the opposite way and vice versa. And so that feedback from the visual system is critically important. And it can be affected by anything. So if you know, if you have corrective lenses that aren't appropriately fit, that's going to play an impact. If you have cataracts, even if you've had cataracts repaired there's still a significant potential detriment with this system because it's been no records. It's better that they've been fixed rather than have that that that cataract unrepaired, but nonetheless, having some sort of procedure can affect the balance system and in a way and so previously mentioned point patients so the feeling not only of our feet touching the ground, but the feeling of each individual joint as we move about our system or about our environment, and so having an awareness having that sensation of different types of services and different types of movements will certainly have a big impact on our balance system. And so, as we age, you know, we lose a lot of these mechanisms, you know, I always tell patients, you know, when you were a kid, you know, you loved to be tossed around and flipped around and upside down and merry go rounds and all that stuff. And as we age, we generally don't do that type of stuff on a regular basis. And so it's, you know, you you don't use it, you lose it kind of mechanism. And so, you know, that has an impact on our balance system as a whole. But we also have to think about, you know, that as we age, our brain or neurons, you know, aren't the same as they were a decade or two decades before and you know, this is just a very simple picture of an MRI of somebody who is young or has somebody who's old and you can just see the, the normal changes that that can take place, but of course, there can be more significant changes, you know, with people who have various neurologic problems. So when we talked about the specific inner ear causes of dizziness, as I mentioned previously, the ones that cause that illusion of motion so that true sensation of vertigo are generally just four different thing. So the first one is this benign positional vertigo, and I'm sure everyone has heard about the crystals in your ear. So these crystals are part of those organs that I mentioned previously, the Sakyo and the huge nickel and sometimes these little crystal as you can see here, are in the wrong place. So they should be in this area here. And they float around in this canal here and so when they float around, they cause typically a positional vertigo. So the most common thing is people lie down in bed, and they feel the room spinning it typically only lasts a few seconds. And the reason is because these crystals are just not in the right place. And so we do a very specific head maneuver, most commonly the Epley maneuver that puts those crystals back into place. The other inner ear problem that people experience is one called Menieres disease and this is one where people get episodes of vertigo. But this vertigo can last multiple hours at a time and they experience a fluctuation of their hearing as well as ear fullness and pressure and this is a condition that unfortunately is recurrent can last many years if it's not controlled well. The next one is something called Vestibular neuritis. And this is a condition that is not recurrent. It's a single episode that comes on suddenly. And unfortunately these patients are quite miserable. They're very severe vertigo that can last a day or two or until treatment is initiated. And oftentimes, people go to the emergency room because they think they're having a stroke. But really it's just something called the Vestibular neuritis, where you get inflammation of the balance nerve and it it's very titillating in

short lived.

And luckily, you know no real intervention is needed except for just supportive care why this happens is challenging. There are various theories, none of which have really been proven but the good thing is it's not a recurrent condition and most people recover just fine. If they have something called a labyrinth itis that's the same type of condition except that all affects their hearing so they get that severe room spinning vertigo that can last all day or two, but they also have associated hearing loss. And so when we talk about again dizziness it's important that we differentiate between vertigo and imbalance so, in all of these conditions, that the inner ear is being stimulated inappropriately, right so when the inner ear is being stimulated, that causes vertigo. Now, if the inner ear is not functioning appropriately, we call that hypo function, meaning it's not functioning to its full potential, and those people don't get vertigo, but they suffer from imbalance. So either the inner ear is being stimulated and you get the vertigo, or the inner ear is not working up to its full potential and you can have imbalance and so sometimes it's not just an inner ear problem. It can also occur coming from the brain as well. So the most common phenomenon that is a combination of inner ear from tingling called vestibular migraine, and so oftentimes people hear of traditional migraine which is a classic pounding, throbbing headache, white sensitivity, nausea and vomiting, while patients can also have this migraine affecting the vestibular or the balance system, and they have a similar presentation, like I described with many years, except often their symptoms are inconsistent. So the super migraine patients can have various types of dizziness so they can get true room spinning vertigo. They can have episodes of kind of this brain fog lightheadedness, imbalance sensation Can I see your symptoms? So it's confusing because it kind of includes everything. But that's kind of what makes the diagnosis easiest because it doesn't really fit any particular pattern that was previously described. And then the other one is something called Three PD or persistent perceptual postural dizziness. And this is a very challenging condition because it can develop after having any sort of inner ear problem you know history of benign positional vertigo or veneers or labyrinth itis or vestibular migraine. And the problem with this is that it can become a very chronic condition because people have a will develop a fear of developing that dizziness and that fear you know, chronically is fatiguing and can certainly prevent people from carrying out normal daily activities. And it is generally not a structural or, or there's there's an objective test that can determine this. People have this you know, insult to their inner Yorker and I just have a really hard and intricate process. And you know, this is sometimes people get better just with rehabilitation, but sometimes people need some medications. To help kind of get them over that hump. So excluding the typical vestibular conditions, when we'll have other symptoms such as lightheadedness, pre syncope, feeling like they're gonna pass out, or orthostatic hypotension which means their blood pressure is dropping too low. It often seems like it could be a you know, a vestibular or an inner ear problem. And they are related because of course, the inner ear requires blood flow, right? And so if somebody's blood pressure is not high enough or what we call our autonomic system, our autonomic system is our ability for our body to adapt, doesn't respond quick enough. You could certainly have that. So they always say there's a direct, direct relationship between our

auto mechanism and that because we require that flight or fight, sorry, fight or flight response to carry out our actions. And so, if people don't have that ability to respond to certain stimulation, then their vestibular or their balance system may not allow the blood pressure to react perfectly and vice versa. So it's a it's a relationship that is directly involved. And so, what I mean by that is, you know, we have what's called a barrel reflex is part of our autonomic nervous system. This means that when we're sitting our blood flow and what blood pressure to be quite different than when we stand right so when you stand, you have an immediate change in position, your your inner ear senses that change in position. It then tells our blood vessels to contract and or dilate to certain parts of your body. And obviously, this is an instantaneous response. And and so what I'm saying is if you don't have a good functioning inner ear system, then your blood pressure system may not react appropriately. And then of course, if you have a low blood pressure system, then of course it kind of becomes like this snowball effect where both systems come together. So the next thing to talk about are your non inner ear or non vestibular causes of dizziness and like I said, generally this is a blood flow or like a stroke type type symptoms. So it's important, you know, if somebody has, you know, strong cardiovascular history, in other words, they've had problems with blood pressure problems with stroke in the past or heart attacks or blood clots or things like that. It's very important to make sure they're not having a stroke. Now isolated dizziness, so in other words, no other symptoms you know, no facial weakness, no numbness, no tingling, no change in their voice while or anything like that.

Isolated

kind of dizziness are very, very rare. So less than 1% of time. It's a stroke, because a stroke typically has other sorts of neuropathic problems. The other thing that is huge is polypharmacy, and so so many different medications can cause dizziness too. And so it's really, really important to have a discussion with your family practice doctor about trying to get off medications Of course, unless they're absolutely necessary. And so antidepressants can can cause some dizziness, Parkinson medications or different anti psychotics, beta blockers or blood pressure medications calcium channel blockers are also blood pressure medications. diuretics are also used for blood pressure control. So any of these use it could come as low blood pressure which people perceive as dizziness, other medications, the anti late and ASIO lytic some medications that reduce stress or anxiety, they reduce the whole system and so that's why they reduce stress work, but they could also cause some dizziness, muscle relaxers in a similar kind of fashion they they relaxed the system, so of course they can cause them drowsiness and confusion. And then interestingly enough cholesterol medications can cause dizziness to it's definitely not very common, but I have had multiple patients say that once they stopped their cluster on medication, they're dizziness resolved. So this is something that kind of just mentioned previously and in a patient who has concerning symptoms for a stroke. They're gonna typically have Ed they're symptoms of numbness in the face or lambs weakness of the face, difficulty swallowing, memory loss, unexplained weight loss, slurred speech, hearing loss that occurs suddenly double vision. As you can see all these other symptoms can represent different neurologic problems that would occur with a stroke, not just an inner ear problem. And so when it comes to the management of dizziness and other individuals, it's very important to have a complete medical evaluation. So it's so I don't like seeing patient disease evaluated by their family practice doctor, because we need to rule out blood pressure problems, diabetes, thyroid problems, different types of neuropathy and things like that. And of course, you know, seeing their eye doctor having an eye exam. And so again, all these things can play a role in our balance system. So it's important to make sure all those systems are functioning and intact and doing well prior to seeing their end doctor. And so once we've come to a diagnosis, the majority of the time it's rehabilitation and you know, we have physical therapy for everything nowadays and it's great because physical therapy really takes care of most conditions. Certainly, surgery is extremely rare for balance problems, particularly in the elderly. And most of this is carried out with physical therapy. So general physical therapy is typically for, you know, orthopedic or muscle and bone type problems. Like you would do typical physical therapy after a knee replacement or hip replacement or things like that. And then just general exercise therapy. So you know, going into SilverSneakers just doing general type of balance exercises and things like that can all be helpful, but the stimulator of physical therapy is very, very specific. So I always tell patient, it's not like typical physical therapy, you're not doing what you've been doing strength training, you're not doing range of motion, you're not doing stretching. It's a neural type of physical therapy. And so we're training the nerves that are coming from your ears into your eyes, and of course, incorporating it into your balance system. So it's a lot of head motion type exercises and eye tracking, and things like that to get the visual and the inner ear system working well together. So the other thing that's very important when it comes to business is environmental and lifestyle. So I always emphasize what we call optimization of brain function. So it's very, very important that people are getting routine and regular sleep. They know the clean foods avoiding salt is a is a really big problem with the balance system. Where I should say too much salt is a problem, not drinking enough water. The inner ear is a very, very small, fluid filled system and it's very sensitive to fluid and salt balance. And so people who either eat too much salt don't drink enough water or drink too much diuretic type drinks like caffeinated beverages, can have a large impact on the balance system. The other thing that's really out there actually stress receptors of the inner ear. Now they're supposed to speak because when engineering systems and and so as we respond online are bound to be added. However, chronic stress can also put too much strain on the balance system and unfortunately you get this feedback cycle where our balance system is basically being overworked and overstressed. And so when is expected to respond, it can't. And so stress reduction is very, very important for a functioning balanced system. And then there are some things that are environmental even so allergies, there are allergy receptors of the inner ear, and so that is why sometimes anti histamine or over the counter allergy medications can actually help with dizziness because it be a little stiff. And so if if allergy medications don't help you know, you can do things what's called an immunotherapy or doing allergy treatments to so your body can develop a tolerance to these allergens. And then

let's see, stress sleep, and then just general exercise. So again, keeping those muscles strong, keeping that that awareness and say sensation, and all those things. So it's really, really important that we also talk about fall risk. So, you know, having a poor balance system can certainly contribute to significant complications. We certainly don't want to have these conditions develop and if we can prevent that from happening by incorporating good strong balanced systems, people will live longer, healthier lives. And so you know, it becomes a again, kind of like a rolling snowball effect when you're injured. You know, you're at more risk for mobility restrictions. You lose your independence, you know, you become confined nursing home and facilities. And so preventing falls and enhancing balance systems can have a big impact on these things. And so, I emphasize it's very, very important to make your home a safe place. And so if you have staircases you should make sure you have been rail Always make sure the floor is clean. No, no rugs on the floor, certainly no clothes on the floor. Make sure there are no loose cords or things that you could potentially trip on. Make sure your bathroom is safe. So handrails in the bathroom, non slip surfaces, things like that. You can't have enough light particularly nightlights at nighttime, because we have a decline in our vision as we age. You know we come visually dependent and you know your balance system shouldn't be dependent on your visual system. And so having more light will help us to improve our balance and prevent. And like I mentioned as being healthy, making sure we're not on to medications, getting regular vision checks, exercising regularly, and making sure that you have good shoes with good traction and as well as improving your diet. So when I mentioned that vestibular therapy, the rehabilitation repeating patient with dizziness is is fundamental to the individual components of our balance system. And so this might might get a little word here. I mentioned important relationship between your eyes and your inner ear so that's called the below Oglio reflex. So this Dibbler is their nervous system to adapt to change a lot of sizes with head motion so you can see like vor is patient in their head keeping their eyes fixed on or in the hands are holding the target. So in other words, he seemed like really simple exercises, but they really do a large long time patients balance system and then habituation means that you just your size that you don't necessarily feel comfortable with you do it to the point that it's unsafe. So you basically keep doing it more and more and more

totally comfortable

with it. So you you keep repeating exposure to this business stimulus until you can tolerate that motion. And then a substitution exercise means that you block certain sensory inputs and emphasize the one so you improve one channel of sensory input so you particularly focus on vision are particularly focused on somatosensory or your proprioception, your touch so you challenge the proprioception system. The the perfect example of this is closing your eyes while balancing so you can stand on one leg you can stand on two legs, you can even stand on others that are chanting they do all these different components to progress, their decision process. And then the last thing is optogenetic stimulation and this means that why should say that some people have a lot of sensitivity to a lot of visual activity. So some people get really uncomfortable when they go in in busy supermarkets or out in public or sometimes even driving the road and all that visual stimulation. And so this helps to desensitize people who are sensitive to that motion, particularly in their periphery they can't focus. And so an example of this is having the patient sitting in SPIN going to look at the center of it. So they see that peripheral motion, and they're able to strengthen their their focus of that particular sensation. There are some, you know, novel things that are happening with with treatment of vestibular conditions, they're starting to use virtual reality. They're also improving shoes and soles. And so there's something called Balance enhancing souls, which increased that proprioception that feeling of your feet touching the ground, and more and more people are getting active and even Boga and Tai Chi. And again, we're using novel here's air quotes, but Tai Chi has been around for centuries. But it's a great exercise opportunity for patients to improve their balance system. You can see many places many families are purchasing video game systems like Nintendo Wii, you know, there are all sorts of games that can be done where you're standing, and you're interacting with the game system. And then of course, the most important thing to emphasize is that it's very much a team effort. So like I said, we have multiple disciplines, we have multiple specialties. You're all involved with a balanced system. We're working with the eye doctor and maybe your neurologist and family doctor and EMT, and physical therapist and I addition, and you know, social workers and things like that. So again, any any way you can get the help, certainly the more the merrier, and the team effort can make everybody healthier and more of a system so that is the end of the PowerPoint. Let's open things up for questions.

information. Thank you so much. Incredible let me check here

look in the manual processes of balance, hearing or tinnitus

it all depends on how to get the actual if it's if it's just a little bit of fluid, you know, sometimes people will get a CT scan of some sort. And the radiologists will say, well, there's you know, fluid, the mastoid. Just generally speaking, it's an incidental finding. A lot of some of the mastoid is not going to cause any problems. Now if there's a lot or it's infected, it will it will certainly have an impact or here is really to have an impact on your balances to people that get ear infections. The balance is known because it's literally an inner hearing from middle ear is filled with fluid and it can indirectly impact the function of the inner ear

unfortunately, I can't see everyone's so Kathy or Cindy Can you help me? Do you see anyone having promotional Hey, great, great, great. See, we want on right

yes, I have a question. They indicated pressure may play a role in dizziness and I'm wondering Are you aware of any Pacific and local blood pressure measurements? It can be made the difference between say the inner ear and the forearm could be I don't think I've ever had a test other than a Yeah. limbic

or can you speak to that?

So, we definitely acknowledge the inner inner ear that can be done during the charge of the inner ear fluid, or something called an eat contest, but doesn't doesn't provide a whole lot of information. So I don't typically there that test. Now there are studies that can be done such as an MRI that can schlubs us, but the disadvantages is no knowledge logic in Reason. Loading there, there's old proving technology. But specifically as far as pressure goes, Just wait one on what you can do at home I'm wearing on. But second, it's all important for pressure check different positions. So laying down sitting, standing, and things like that. And so there's something that Hardy ologists can do. It's called a tilt table test, and that's where they check blood blood pressure medic in different positions and to see how it responds to that and so some people will have what is basically something collaborative, which means sitting still, their blood pressure might be fine, but as soon as you go from sitting to standing doesn't react appropriately. They Whoa. You general medical blush or testing I think is important. And we just don't have that technology to to check. Blood flow the inner ear, but it's getting there. So you know we have you have some metrics that are created to increase the blood flow to the inner ear and they seem to be working. So we'll probably know.

I do have another question. And as I mentioned about high salt levels are low salt. This would be in the light blue light imbalance. What's the timeframe or changing an electrolyte balance? And how does that balance in actually measured?

So I get beat for one

patient same mostly the next day, they usually notice symptoms so this also you know people will go Friday and then on Saturday they've moved on so

that for our as far as the film goes,

you're getting into in years invasive so we don't have any tests to measure the year. Electrolyte numbers of course course we do have the ability to measure your electrolyte values in your blood, but it doesn't have a necessarily direct correlation with electrolytes or interfere with the inner electrolyte levels is it's often just a trial and error. You know, patients really have to kind of figure out what works best for them. So again, that's something probably in the future that we'll be able to test. But right now it's trying different lifestyle changes and trying different medications if the lifestyle changes don't work with that previously Yeah, that's that's exactly what most patients you know, they they'll go weeks and weeks and weeks I'd have symptoms. You know, they'll have have a a cheat day or whatever you want to call it or for FHI other six weeks maybe that is a thing. Let's just try it again. And sure enough, they have to have their country didn't even have their lives on Wednesday. And again, this doesn't necessarily apply to everybody. It just applies those people who have are sensitive to those assault. It's very real. A lot of migrations breath. I knew lots of people who have eliminated the smell from their diet and have completely cured themselves. And similar to an inner

ear condition called near these also think one of the challenges with this is it is

it's also you from personal belief you know, I don't want to say Instagram by the way I always say you know if all right reduces your symptoms, and we don't really have any way with everything. What does matter if you flat then keep doing what you're doing.

I believe Sandy Sandy

just raised a similar question. I was wondering if your information that you fit into more and more and more and more people complaining about

So tonight is tinnitus, ringing your name? The most common cause, of course is a hearing loss. So what happens is, when in your loss, it doesn't send as much information to the interviewers and it's going right into your ear does change and so it's just rain on your ear. So close to hearing loss. And I always spend, unfortunately there's no cure for this house. There's a lot that we can do a Batson to record your hearing loss and not do that hearing aids, hearing aids increase the Senate they also have to do some things a puts into your even in quiet situations and people love them feature here here. And the last thing is something that is more of a chronic process is something called neuroplasticity. And what that means is as your your pain is receiving this sound, it then adapts to the way that in a way that you used to call home down and doesn't send as much of that signal out when compared to a year. That's this this process is occurs in the brain which allows you to calm down. Now there are other things that can be most commonly addict tinnitus is something in your head and that is abnormal. That could be because he's doing something or temporomandibular joint dysfunction but people haven't practiced joint grinding or popping. That's a really common cause. It's from chronic headaches or migraines can cause it can even potentially actually cause it as it's happening in the neck back is really painful. can come calling sensation of your tinnitus as well.

Okay, Paula, kind of related. Question is about discuss directly within Genesis or, sometimes to get together for other reasons or causes and I think the main

system in the bank is the same that year. So there are some conditions that have relation likely condition. Vertigo and tinnitus as well as vestibular migraine is also a condition that has really as well as balanced systems and then a source of hearing loss then that tinnitus will will increase well.

Doctor, I have a question for you. You know, years ago when I first learned about that they would say you know, turn 33 suddenly to adjust that person. Place

so there are two plugins of your year was called the rhetorical goal, the secular and the best thing about it is like different layers on this on this highway or that within our local schools. And it is because pistols are made up and they sit on a layer underneath it. And so when you move your body those crystals act like a weight, okay? And in that Joe are nervous, okay? He's not supposed to do

any of that motion. Okay.

functional purpose however, some crystals can fall off when they fall off into the right place, and they see the organ that shouldn't be stimulated. And so pointless. Going to occur from drama. We see this a lot as your customers, right? We also see this as after somebody in your home because those nerves hold those Christians in places and you have a crystal and have a list of benefits that you're proud of. They can file it. So oftentimes we see this if it's benign, or we gotta go ask them. These have like a license and it's just and then we because there may assume we obviously see a relationship because there was a sudden shift not just with vitamin D deficient actually getting your arms around worldwide to have nine position versus you know, calcium supplementation in elderly patients. Vitamin D VoiceBase. Well,

yes, you see here. Okay, so I'm looking in the chat box. I don't see any more questions unless I'm just not seeing as I am using my phone, but what are the side policies and are there any treatments to reduce crystals?

The most common is called the Eberly maneuver. There are many, many many other tools which can all help the repositioning techniques, procedures. The Epley maneuver, fix things about 80% of people's and so we perform the Epley maneuver in our office. There are a couple other maneuvers that we've won. One is the Simonton was the barbecue Raul Fred for if they different canals effec generally speaking, yes. And my YouTube you know, if you want to learn how to do that, you're not gonna hurt anything but the only thing you might not correct because if they didn't do it for you or doesn't work, which again, is pretty rare. The physical therapist has a whole whole bunch of different sticky ones.

Do we have other questions for doctors Okay. Go ahead Did you have a question you think she can can you hear me? I know I am on my phone it will as you can see that made. It okay

I'll refer legit thank you I went to him and he could tell me take a diagnose my crab I don't know you personally. But there are a couple things that you can do. So I'll put this in the back. So

this word is a web site where you can search their headers that I would say probably a reason many people look for a logo

with regard to but these problems are nice I guess. But probably a lot of time do you ever, ever get things together and it keeps coming up is it a prayer rather there are

specific wiggly. Unfortunately the hearing doesn't come back. Once the vertigo stop hoarse fingers usually on the rubric. It doesn't really show the average of the Munir you're taking about seven years that's fair because visits many are years. But for other balance condition. There are certainly optimistic outcomes. Half Life changes, maybe we can put them in assistance such as climbing on the roof things. Generally, a very positive outcome. You know, people may or may not be able to do air but they still have wildlife justments Yeah. Julie had a question Oh core exercise yes it is has a role and balances system. So, we can have a balanced system which can be strong. So, you know, for your core strength is what they realize your body though it webs to the neck always update regularly do things

that are a little bit troubling to them. Every day bank balances there's a really, really great book by Carol Clement. It's called balance right? I'm not sure if I'm coming here, photo record. But this is a book that he denied daily life so you know look like when you when you run your morning stand. Stand on your you

know we're doing this just throughout the day that you can't get Chris, Chris take care keep us safe Yeah, yeah yeah yeah obviously thinking right then lands I think a good question. versus last year here is my Morgan Creek is just a I. Struggle