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In order to hear, we have an ear drum that vibrates with the sound and 3 little bones located in the middle ear that move back and forth in order to transmit the sound to the inner ear where the nerves are. In order for the ear drum and the bones to move properly, the middle ear space has have a pressure equal to that of the air outside the ear. But if you change altitude, the pressure outside changes and you have to adjust the middle ear pressure. This is done through the Eustachian tube (ET), which connects the middle ear to the nose and the outside. When people blow the nose too hard, this can close the ET. Any nasal congestion, swelling can do this. A growth in the back of the nose can press on this opening too. This is why we are concerned when the ET is blocked on one side without an obvious cause, we must look for the cause. Inhaled toxins can injure the ET system too.
With blockage, patients are aware that they can't hear as well; this is because the closure of the ET causes a vacuum to form in the middle ear that prevents the normal vibration of the ear drum. If this closure persists, the body tries to fill this vacuum and the normal air containing cells of the mastoid bone change to mucous making cells and give a condition called Serous Otitis Media or fluid filling the middle ear.
When the ET is blocked, a nasal decongestant such a Zephrex LA is useful. Proteolytic enzyme preparations with papin and bromelain (make sure you use a formula with calibrated enzyme activity) are especially helpful. Drink huge amounts of hot tea. The important thing is to be VERY gentle on trying to clear the ears because you can do more harm by forcing. You may hold the nose and try to gently force air out the ear. Or put your tongue to the top of the mouth and swallow. In my office we use the" cookie machine", a tank of helium with a nasal adapter. When the patient says "cookie" we deliver a jet of helium to inflate the ears.
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Tinnitus
Do you have Tinnitus (ringing in the ears)?
Ringing in the ears is a subjective symptom, a sound heard by the patient that cannot be recorded by today's instruments, much like pain. If it is very loud it can distract from sleep and thinking. It can be caused by Meniere's disease - an increase in fluid pressure in the inner ear. It is treated by reducing that presage. High blood pressure may cause tinnitus, and lowering the pressure is effective. Loud noise and associated hearing loss is a causal factor too. Large doses of aspirin and certain aspirin products may bring it on. Avoid these if they are the cause. Stress is not a cause, but once tinnitus becomes annoying the person feels stressed.
For tinnitus that fails other treatment, Vitamin B6 ( Pyridoxine) 100 milligrams twice a day is worth trying for 3 months. I personally have had little success with Niacin in doses large enough to cause a flush, but it may be worth trying. I was first to publish about the use of muscle biofeedback in the 70's for tinnitus. It is successful because when the muscles are relaxed, you stop making it worse by tension and anxiety. You cannot feel anxiety when the muscles are fully relaxed! This is done by the patient at home as follows: sit comfortably in a chair with a large mirror in front of you. Practice relaxation by breathing in at the count of 4 and out at the count of 6. As you exhale, let a signal go through your to relax. Look at your face - you should see your facial muscles relax. You use the mirror as a form of visual feedback to learn how to relax properly. Do this 20 minutes a day. Then, every hour on the hour do the breathing exercise without the mirror for 2 minutes. By doing this relaxation, you break the anxiety reinforcement cycle. You may still have the tinnitus, but you aren't making it worse by anxiety reinforcement. Some doctors prescribe Xanax pills to accomplish this, but my patients do fine with the mirror and breathing exercise. Certain tinnitus patients respond to masking and might benefit by a sound that "covers" the tone or discharges the neural source of the tinnitus. Whether tinnitus is the type that can be masked or not can be tested by an audiologist.
The first step is to measure the tinnitus. First the audiogram (hearing test) is performed, then the patient is asked to identify which of the tones of the audiometer match the ringing. Then the volume or loudness is matched by introducing the sound at various loudness levels. To avoid confusion, loudness is measured in our office with a slightly different sound tone.
The sound is then heard by the patient for a variety of time periods starting with 5 minutes and the patient may report a true masking phenomenon. This is analogous to having a light shine in your eyes (discharging the rods and cones), and then you can't see for a while. If the patient expresses relief, we make a 30 minute tape of the tinnitus sound which he then uses at home with a portable type of tape player and a single ear piece into the affected ear. The success of masking varies widely. Some patients may get relief with short periods of masking and others require longer exposure to the same sound. This differs from using music or white noise for masking in that the same sound is used as the tinnitus. (Coleus) The advantage of this masker is the price; we are using a single tape and the portable tape players every household with a child already owns. Another is that the volume is easily adjusted. And socially, so many people nowadays work and play with a Walkman c type instrument, that many patients prefer this to the standard masking device in the ear. If the masking is needed for periods longer than 30 minutes the tape can be rewound.
In another group of patients this same tape device can be used as a type of biofeedback device to reduce tinnitus. I call this nerve enhancement. Here the user places the tape sound into the unaffected ear, again using a single ear piece, and rests in a comfortable chair. It is best to be fully relaxed. Now he adjusts the tape volume of the tinnitus sound so that it is LOWER than in the affected ear. He than suggests that the body match the volume of tinnitus of the affected ear with that of the tape player. Ideally, the body SEES what to do and proceeds to reduce the volume in the affected ear. Over time, the volume is reduced until the patient is asymptomatic. What the actual physiology of this method is, is unknown. But then, similar processes take place in Biofeedback: the hand is warmed or cooled by showing the subject a reading on a dial of minute temperature changes. People learn to change temperature, heart rate, brain waves when they see the readings on the dial and are instructed to tell the body to change the temperature or the brain wave. And remember, rats can do the biofeedback changes as well as humans, which demonstrates that the "body" does the work independent of intelligence.
Reinforcement is one of the most important factors that bring patients to my office for tinnitus symptoms. In a reinforcement cycle, the more it itches, the more you scratch -the more the anxiety - the more it itches. Whether this involves contact lenses that result in spasm of the eye muscles, or the itch, or the dentures that don't fit well - anxiety can reinforce and make the symptoms much worse. This is particularly true in tinnitus when the annoyance or worry, may cause tight muscles and reduced circulation and increased awareness of the tinnitus and then more tinnitus, more worry and so on. When I published the first article on using biofeedback for tinnitus in 1975 (Grossan 1975) I described the benefits of breaking the reinforcement cycle. Performing nerve enhancement does this because in the relaxed state -muscle relaxation that is - anxiety is reduced and the reinforcement cycle can be broken. But experience has shown that an additional factor is at work here. By showing the body what to do right -reducing the tinnitus volume - the body proceeds to do it. My patients are instructed to do this process 15 minutes a day. The relaxation instructions are the same as in my 1976 article. (Grossan 1976) Breathe in at the count of 4 and out at the count of 6. As you exhale let that be a signal to relax your entire body. Or progressively relax from the feet, the legs, etc. to finally the jaw. Or visualize a relaxed scene. Science has shown that you cannot have anxiety if your muscles are fully relaxed. And you reduce or eliminate the need for drugs (Relaxation Excercises) The tape of the individual tinnitus sound can be prepared by the audiologist or my office can prepare them for you by having the audiologist perform a tinnitus match test and then sending us the results. The same tape can be used for masking or for the enhancement. It is necessary to use a single ear piece, in the affected ear for masking, and in the normal or unaffected ear for nerve enhancement.!
Sometimes the major benefit of this tape is that the patient can take charge of his own treatment, using either the enhancement or the masking. Indeed Dr Murai describes having the patient measure his own tinnitus and masking effect!
A nice introduction to Biofeedback is given in the pages of LifeMatters.
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Vertigo is the sensation of moving - either you feel like you are moving or the room feels like it is moving. This often occurs when the fluid in the inner ear - called the labyrinth - is affected.
Dizziness, on the other hand, is any sensation of unsteadiness, or feeling faint, or difficulty in walking, and can have many causes. Physicians sometimes have to work hard to get the patient to properly convey what they are feeling.
Keeping one's balance is a highly complex activity.
Balance consists of four elements. Your eyes can tell you which way is up. In the inner ear are three water tubes called semicircular canals. (Picture of ear at http://www.teleport.com/~Veda/gallery. html) They go in 3 different directions. Think of them as a carpenter's ruler with a bubble. The bubble goes up when you tilt your head. One canal or bubble system is for forward and back, one for side to side and one for up and down. There is a left and right system and the brain reads the signals like a pilot reading the dials. When the system is damaged, it learns to recognize that when the left ear says 60 it really means 40 and makes adjustments or compensates.
Your neck and back helps tell you that you are leaning to the side. Your feet are important, tells you if you are on an incline. All these are tied together in the brain. If you can't see clearly, or are in a fun house or given an illusion, you may feel unsteady. New bifocal glasses can also produce a similar effect.
Children generally get car sick, as do dogs. After a while, however, they learn to compensate and no longer have this problem. When I teach in China, the first question I am asked is why the native Chinese get train sick and the ÒforeignÓ Chinese from Taiwan, Hong Kong, and USA do not. It is simply that the ÒforeignÓ Chinese have been raised with automobiles and have accommodated and the natives have not had this experience to learn accommodation.
If you get elevator sick, turn your head up so that the elevator motion affects the ear canals having to so with driving, which you are accommodated for.
Seasick? Turn your head so the boat motion is like an automobile stop and go motion. It helps to visualize an actual car ride.
Wearing extra high heels for the first time is a problem because the feet - spine are an important balance system and the high heels are a new way of using these essential muscles so it takes a while to adjust.
The eyes are a part of this system. A flashlight and lights on are important aids to balance.
We have a wonderfully adaptive system. Anyone can learn to spin on ice skates. You can have major damage to any part of the system and after a short time, especially with training, the body will adapt. A soldier is shot in the ear and loses one of his inner ear balance organs. He is extremely dizzy because he is getting all his input from only one ear. After a few weeks training, you would hardly know he has a problem.
This can also make a diagnostic problem for the doctor. If a growth is pressing on the balance nerve slowly, the patient may actually never complain of dizziness because he has learned to accommodate. Likewise, someone is in a serious accident and is no longer complaining of dizziness, but examination shows there is a damaged organ, but he has learned to accommodate. Even though the accommodation is good, I still urge my patients to carry a flashlight so they won't have a problem in a dark place, wear low shoes and thin socks, and avoid thick rugs. On the other hand, with vestibular rehabilitation training, we train people to walk on thick rugs with thick socks in order to strengthen the whole system. We train patients to balance themselves on a moving platform. We exercise them to move rapidly.
For simple dizziness I recommend that the patient turn his head or body so that the dizzy feeling comes on, then do it so slowly that there is no problem, then gradually increase the speed till the symptoms reoccur, then drop the speed again and gradually work the speed up. This allows the body to accommodate.
One of the most important trend in treatment today is to train people's balance system before they have problems. Falls, especially fractured hips are a significant health problem, especially among the aged. I have been trying to get health providers to offer balance training to everyone. It has been shown that giving this training can significantly reduce the number of injuries. One excellent form of balance training is Tai Chi. Here you practice your balance with various turns and positions. Now when you trip over the rug you can easily keep from being hurt.
Another major advance today is Vestibular Rehabilitation. After the doctor completes his examination and has ruled out and treated pertinent problems, he will refer the patient to a therapist trained in this field. Here the patient is analyzed from a physical therapy viewpoint: is the left leg a little weak? Is the back tilted because of poor muscle tone? Is the neck too stiff? Is the body tilted because one eye is weak? Surprisingly, we are often finding a treatable condition where by strengthening certain muscles the person is no longer dizzy. So today, instead of giving dizzy pills - which sometimes can reduce the patient's alertness and make him worse - we use these exercise modalities with increasing success.
Benign Positional Vertigo is a condition where some of the stones
in the inner ear come loose and rattle around. These stones called otoliths
are located like a child's catch toy on a cup. The symptoms are that when
you move a certain direction you feel dizzy and this is reflected in the
eye movements called nystagmus. When the stones are off the cup the treatment
is to use the
Meniere's Disease occurs when there is an increase in fluid pressure in the inner ear. Usual symptoms are hearing loss, tinnitus, vertigo, and a feeling of pressure in the ear. It is often episodic, may last a short time and then occur later on. It can awaken you out of a sound sleep. Treatment programs vary because we cannot measure the fluid pressure directly; in my practice I have patients on low salt, high potassium diet drinking distilled water. I usually use a diuretic such as Diamox in the acute stage. There are other successful methods used.
People who are dizzy can fall and break their bones. How do you prevent this? Check your blood pressure. Take the medicine your doctor recommends. Take the baby aspirin he may recommend. Be athletic. The more the exercise the less the dizziness will affect you. Do the vestibular exercises. Check with the Vestibular Disorders Association at http://www.teleport.com/~veda/ for more information and join their association. They actively promote patient information re prevention and treatment. They can refer you to local specialists and treatment facilities.
Shoes are important. I cringe when I see a senior in high heels. They can fall and fracture a hip. If a senior wears high heels, even if they have perfect balance, they increase their chances of falling or fracture by 10X. Honestly, patients come to see me for dizziness wearing high heels ! That's like coming to see me for a cough while smoking cigarettes!.
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