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Exploring Vestibular Disorders: Differentiating Dizziness, Vertigo, and Ménière's Disease

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Unlock the mysteries behind dizziness, vertigo, and lightheadedness with renowned experts Dr. Douglas Beck and Dr. Joseph Sakumura. Join us as we explore how the different sensations of movement can reveal underlying vestibular disorders. Dr. Sakumura details the critical role of nystagmus in differential diagnosis, guiding us through the nuanced process of identifying whether a vestibular disorder is peripheral or central, and how the direction of nystagmus can indicate the affected ear.

Discover the nuanced differences between vestibular neuritis and Meniere's disease. We'll unpack how herpes simplex virus contributes to vestibular neuritis, leading to sudden and severe vertigo, in contrast to the recurring episodes of Meniere's disease. Our conversation also tackles the challenge of distinguishing these conditions from migraines, which often manifest with similar symptoms. Expect to gain a comprehensive understanding of the diagnostic hurdles faced by healthcare professionals in this complex area of vestibular health.

Our final focus is on Meniere's disease and endolymphatic hydrops, exploring their shared symptoms and the diagnostic criteria from the Barany Society. Dr. Sakumura shares insights into the use of electrococleography (ECOG) for evaluating endolymphatic hydrops and discusses the intricate surgical approaches for Meniere's disease treatment. We also dive into the cautious prescription of vestibular medications like Meclizine, stressing the necessity for accurate diagnosis before treatment to ensure effective patient care. Tune in for an enlightening discussion that promises to deepen your understanding of these critical topics in vestibular health.

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Blaise M. Delfino, M.S. - HIS:

Thank you, partners. Redux: faster, drier, smarter, verified Cycle built for the entire hearing care practice. Faderplugs the world's first custom adjustable earplug. Welcome back to another episode of the Hearing Matters podcast. I'm your founder and host, Blaise Delfino, and, as a friendly reminder, this podcast is separate from my work at Starkey.

Dr. Douglas L. Beck:

This is Dr Douglas Beck with the Hearing Matters podcast, and today I'm interviewing Dr Joseph Sakamura. I've been following Dr Sakamura's career for quite a few years now. He received his Doctor of Audiology degree from the University of Kansas Medical Center. He went on to complete his residency and clinical training at the American Institute of Balance, hanging out with my old friend Dr Richard Ganz, and Dr Suckermore specializes in the diagnosis and rehab of balance disorders in children and adults. His specific areas of clinical interest include complex and atypical BPPV, vestibular migraine and the psychosocial aspects related to vestibular disorders. Joe has a wide range of experience and expertise in the scientific, medical and business development aspects of vestibular practice. He is a published author and invited speaker globally. If you haven't seen Dr Sakamura on stage, you've missed something. I've seen him present quite a few times and I always enjoy it and I always take way too many notes. Joe, welcome, good to have you here.

Dr. Joseph Sakumura:

Thank you so much, doug. What an honor it is. I've followed the podcast for a long time and obviously your career being one of the titans of industry, so can't tell you how honored I was to have the invite to come on and talk vestibular with you.

Dr. Douglas L. Beck:

All right, let's talk vestibular. So I want to start with what is the most common sign and symptom that people will come to you with, because people talk about dizzy, they talk about vertigo, they talk about lightheaded. What's the most common complaint that you deal with?

Dr. Joseph Sakumura:

Yeah, that's a spot on question, because we know that dizziness and balance disorders are actually the third most common complaint of all Americans to their physicians and it's actually the number one complaint of individuals over the age of 60. So it's largely dependent on the conduit or where they entered the system as a dizzy patient, because dizziness is obviously a very, very generic term and, getting to the bottom of what dizzy means, the flavor of dizzy, right? It's kind of like strawberries. If you ask somebody what a strawberry tastes like, how will they describe it? So I always refer to the flavor of dizziness and the actual subjective experience that the patient's having, because if you just Google dizziness, right, a million different things could be going on. So ideally, the most common complaint that would indicate to us that they have a true peripheral vestibular disorder is going to be true vertigo, where the room is actually spinning around them or movement is happening.

Dr. Douglas L. Beck:

Well, let me ask you a question, because for many, many years I know we made specific reference to patients with vertigo as a spinning vertigo sensation and we would ask is it that the room is spinning around you or are you spinning around the room? Does that make any actual difference? I know we documented it on a lot of people, but I don't know that it mattered. It does.

Dr. Joseph Sakumura:

It makes a huge difference Because if the world, if I'm perceiving the external world moving, it actually indicates that I likely have nystagmus, and nystagmus is a direct result from peripheral vestibular mismatch or dysfunction. Now, if I perceive that I'm moving with respect to the world being stable around me, that's actually the first indicator that it's probably actually not a true peripheral vestibular problem. It could be central, it could be a space occupying lesion, it could be blood pressure, it could be a thousand different things. But the first indicator that somebody has a true active, acute or uncompensated vestibular problem is that sensation of external movement.

Dr. Douglas L. Beck:

And on the same topic now, if I see the world going clockwise versus counterclockwise, does that point to the probable vestibular culprit, whether it's my left or my right ear? Great question.

Dr. Joseph Sakumura:

The answer is yes, if the person can perceive that accurately. So when we look at localization of which ear is the involved ear right versus left? We're actually clinically we're looking at patterns of which ear is the involved ear right versus left? We're actually clinically we're looking at patterns of nystagmus, which direction the slow phase or the fast phase beating of the nystagmus is. And depending on which direction the nystagmus is beating, that indicates to us okay, the left ear has become weak, or the right ear has become weak, or the right ear has BPPV, or whatever the case is.

Dr. Douglas L. Beck:

And that would be consistent with the slow phase of the nystagmus, if I'm remembering.

Dr. Joseph Sakumura:

The fast phase of the nystagmus. So the beating phase of the nystagmus is always and this is one of, if you remember, ewald or Alexander's laws the fast phase is always going to beat towards the ear that is relatively hyper excited, going to beat towards the ear that is relatively hyper excited. So that terminology is important because you can have destructive lesions that actually damage one ear or you can have excitatory lesions like BPPV, that cause one ear to become excited versus the other. So the fast phase, the beating phase, beats towards the ear that's more excited. So the slow phase is going to be opposite of that.

Dr. Douglas L. Beck:

Thank you. And what's the accuracy of that? I mean, is that true? 80% of the time, 100% of the time, 100.

Dr. Joseph Sakumura:

Take it to the bank. It's a lot. So if somebody can perceive and tell you Dr Beck, dr Sakamura, I can tell that when the room is moving on me, it slowly shifts to the left and then beats back to the right If they can actually perceive that, which I've found rare in clinical practice if ever, it will always tell you which ear is involved. The problem is you can't always trust what the patient is seeing. That's why we objectively look at eye movements with video nystagmography, electro nystagmography, those different kinds of things.

Dr. Douglas L. Beck:

All right, so let's talk about probably the most common vestibular disorder that is related to the inner ear primarily is BPPV benign paroxysmal positional vertigo. Tell me about that. What are you looking for when you're diagnosing that? And then let's talk about things like the Epley maneuver, repositioning maneuvers and how they work.

Dr. Joseph Sakumura:

Yeah, yeah, yeah, great question. So I first just to touch on really, really quickly the history of BPPV is fascinating because it actually goes all the way back to Adler and Barony in the 1920s.

Dr. Douglas L. Beck:

Right, the Barony box and all that stuff.

Dr. Joseph Sakumura:

Yeah, we start hearing or reading in the literature that there's this benign vertigo and nystagmus that happens positionally.

Dr. Joseph Sakumura:

Remember that Epley and testing for and treating this doesn't come until the 90s. So it's really fascinating. But if you look at certain pillars of truth with BPPV, a lot of it has remained unchanged and that's this notion that you're looking for otoconia or otoliths that have been displaced off of the utricle and they're now floating around disrupting the function of the ear being moved and triggering vertigo when there's head position changes. So, knowing the history, I always tell clinicians that I'm training understanding that piece helps you understand the clinical profile of the patient, the test findings, the treatment and all those kinds of things. So when you're looking at BPPV and differentiating it from other causes of dizziness, the first thing that you're looking at is the patient is going to have transient or short episodes of positionally provoked vertigo. So what that looks like. When you're asking a patient this, you're not going to frame it like that, but you're going to be looking for somebody that I lay down and I get really dizzy. The room spins.

Dr. Douglas L. Beck:

And the dizziness lasts two to three, maybe four minutes.

Dr. Joseph Sakumura:

Actually, it can be as short as 10 seconds all the way up to four minutes and beyond. It depends on the canal that's involved, it depends on the variant that's been involved, but it can be anywhere between seconds. But one of the things we've learned over the last 10 years is that it can be persistent even longer than minutes. We used to think, oh short, short, short. Now we're learning that the variants and some of the different styles of BPPV, if you will, can result in longer episodes, and to a large degree that depends on which canal we're talking about.

Dr. Joseph Sakumura:

Yeah, absolutely so. We've got three semicircular canals. You've got three different variants. You can have BPPV in the posterior is about 93% of cases, because gravity always works, gravity always wins. It's going to be the lowest point that they're going to be pulled to. You can have horizontal canal BPPV, which is about six to 7%, and then you've got the one percenters that have debris actually lodged up in the anterior superior canal up there.

Dr. Douglas L. Beck:

And the theory is that, as the otoconia stimulates the epithelial lining, because then the inner ear is perceiving motion that is not really there, it's actually cupular deflection.

Dr. Joseph Sakumura:

So the cupula is the epithelial, rather than you know a lot of audiologists, especially students, we think that the canal is lined with hair cells and the whole thing is lined. But the epithelial, exactly the cupula, becomes displaced because of a vacuum force that these crystals cause when they're moving. I always tell patients it's like moving the marble through the maze. Depending on which way the marble's moving, it pulls endolymphatic flow. The cupula follows that pull and ultimately leads in the depolarization of hair cells and stimulation and that perception that the world is moving.

Dr. Douglas L. Beck:

And that's the what was that called Fugulopetal.

Dr. Joseph Sakumura:

Ampulofugal or ampulopetal. Yeah, that's exactly right. Yeah, it's excitation inhibition, very, very similar yeah.

Dr. Douglas L. Beck:

All right. Good, it's been about 100 years since I read that, so in the patient with BPPV. So the most typical thing is they get into a position that stimulates that sensation and once you've discovered that that's consistent with their nystagmus, and rotary nystagmus in particular, tell me about how rotary nystagmus helps to bag the diagnosis.

Dr. Joseph Sakumura:

So it actually all goes back to those same principles we were talking about with nystagmus and excitation and inhibition. So, based on the position that we have, the patient in right, and that's the position that's going to put the canal in the plane of where gravity's pulling on that canal or the otoconia- in that canal.

Dr. Joseph Sakumura:

They should be exciting that specific cupula and the nystagmus should follow that exact same pattern. So, for example, in the case of a right posterior canal, bppv, you're going to have rotary torsional, which is like little doorknobs spinning, rather than left or right Rotary torsional nystagmus that's up beating and rotational beating in the direction of that right ear in this case. So again, you can do that without any goggles. You don't need a goggle or vision denied or any of that.

Blaise M. Delfino, M.S. - HIS:

However, yeah, I mean agnes.

Dr. Joseph Sakumura:

However, it's helpful if you have that, because you're able to really pick out the properties of that nystagmus.

Dr. Douglas L. Beck:

So that's Sure, and you can document it, so it's repeatable.

Dr. Joseph Sakumura:

Absolutely, and that's what bags the diagnosis. Is that okay? The clinical profile, the patient's case history, has told me they're experiencing bouts of positional vertigo. I they're experiencing bouts of positional vertigo. I've put them into the gold standard head position, which is the Dick's Hall Pike position, where they're rotated and lying in an excitatory position for that canal. That position elicited this type of nystagmus Boom. Book them, they're ready for treatment.

Dr. Douglas L. Beck:

Joe tell me about how Dr Epley went about dealing with posterior canal rotary nystagmus and BPPV as a result. What happened with him?

Dr. Joseph Sakumura:

Yeah, so Dr Epley, like much of his predecessors, there was no known treatment for BPPV before him, so he developed with PVC tubing. He modeled the inner ear and developed basically the way he writes on it, like a marble, through the maze treatment to literally reposition, using gravity to move the ear into special positions, specific positions in order to work the debris around this circular tube and dump it back into the utricle, which is where it belongs. So Epley's maneuver has held true for now 30 to 40 years.

Dr. Douglas L. Beck:

It's still very effective and fixes 90 plus percent of cases after just two maneuvers, which is remarkable, and what happened to him at Harvard, because I think that was an interesting yeah.

Dr. Joseph Sakumura:

So originally when he positioned because, remember, up until this point, surgery doesn't fix this. Do we send the patient home with these exercises where they're kind of flopping around or moving around? Maybe they can habituate to it? We're not really sure. And he positions in a Harvard lecture hall I can cure this with no surgery and no medication. And he actually famously in the 80s was laughed out of Harvard before eventually publishing his paper in 1992. So I actually was fortunate enough to meet him a couple of times before he passed in July of a couple of years ago. Fascinating story and his maneuver, 30 years later, is still widely accepted, utilized and the science continues to support literal curing of a condition that impacts and affects so many people. We owe a lot to Dr Epley and his findings and his studies.

Dr. Douglas L. Beck:

That's fantastic. It really is. Tell me about vestibular neuritis. How does that get diagnosed? What are the signs and symptoms?

Dr. Joseph Sakumura:

So vestibular neuritis is actually? Now what we've learned is that it's typically going to be neuritis, referring obviously to inflammation of the vestibular nerve, and we now know that it's very, very commonly the herpes simplex virus, so chicken pox, shingles, some of these kinds of things. Basically, what happens is it reaches out and it loves to impact specifically the balanced portion of cranial nerve eight. So it creates a dysfunction and it actually creates Doug, a sensory neural vestibulopathy, because, remember, the nerve is running through a bony channel and when there's edema of that nerve, swelling on top of the nerve is the blood supply to the peripheral vestibular system. So you get nerve damage in that bony canal and you also get a reduction of blood supply, which equals a reduction in hair cell.

Dr. Douglas L. Beck:

And so you can imagine that that would also impact hearing a little bit while that neuritis is active.

Dr. Douglas L. Beck:

And, just as a reminder, the canal you're talking about is the internal auditory canal and within that canal you have the superior vestibular, the inferior vestibular, the cochlear nerve, the facial nerve, and the blood supply is the labyrinthine artery and it's a little bit smaller than this PEM right? So you've got this very, very important, all these very important neural tracks running through a very, very small, very, very hard canal and what you're saying is that the vestibular neuritis exacerbates in accordance with other herpes viral manifestations. This to me is really important because when you look at stuff like CMV, cytomegalovirus, and you look at some of the research on this and I think people will find this kind of shocking but herpes virus is. Probably 70 to 80% of all people in the world have some sort of herpes virus and most of the time it's dormant and it doesn't do a thing. But then you have cases like CMV, where children might pass a newborn infant hearing screening and then 12 months later they have a massive hearing loss which could be attributed to CMV in many cases.

Dr. Douglas L. Beck:

Vestibular neuritis, I think is very interesting, but I think it's often confused with Meniere's disease. How would you tell the difference?

Dr. Joseph Sakumura:

Typically with vestibular neuritis you're going to have a big one, singular, sometimes with a secondary kind of a more minor episode, but typically you're going to have a big as I tell patients a big bang where you have a sudden onset of vertigo. That doesn't seem to. It's unlike BPPV, it's not positionally provoked. Patient could be sitting there and all of a sudden boom like a train hits them. There's vomiting, there's nausea. It's very, very intense, lasts anywhere from 30 minutes to hours.

Dr. Joseph Sakumura:

But typically after that one big bang and maybe a little aftershock, they're done Versus Meniere's, of course, is going to be characterized by multiple different episodes and different known triggers and these kinds of things. But you're right, it's challenging for the practitioner to diagnose if they don't have access to certain technology and if they don't know what they're looking for. So vestibular neuritis, as you mentioned, depending on where in the anatomical piece of that nerve where it's impacted, there could be hearing changes, there could be other types of symptoms that may lean towards Meniere's and some of these kind of things. But typically it's the singularity of the attack that's going to indicate something like a neuritis versus a Meniere's or vestibular migraine or some of these other kind of things no-transcript.

Dr. Douglas L. Beck:

You have a low frequency fluctuating hearing loss, you have tinnitus and your imbalance or, but not necessarily, spinning vertigo, more of a general dizziness, and that can go on for 20 years. I mean, yeah, meniere's does tend to progress, and what percentage of patients who have Meniere's go on to have bilateral Meniere's?

Dr. Joseph Sakumura:

I mean, I'm thinking it's the majority, but I- yeah, I think the most recent data I've looked at is 70 to 80%, but I think there's a lot, there's a great deal of variance there. You've also, we've got to remember, with Meniere's it's virtually, it's a clinical diagnosis. So, again, depending on the speciality that they're coming out of, you know, if they're seeing an otolaryngologist and they're going through the right steps and seeing the proper personnel, the Meniere's disease diagnosis is quite accurate. But I can't tell you how many patients I've come away from interactions and they said oh yeah, my primary care doctor, an urgent care doctor, diagnosed me with Meniere's disease 30 years ago. So it's one of those things that can be a little bit challenging to track and all of the things that have now come to light on is it Meniere's versus, is it not? I think for a long time Meniere's was somewhat of a wastebasket diagnosis.

Dr. Douglas L. Beck:

Yeah, I think so too.

Dr. Joseph Sakumura:

And now we of course know about migraine and all these other otologic pathologies. That sort of opens the bandwidth of what could be happening in a given patient at a given time.

Dr. Douglas L. Beck:

And it's so important that you mentioned migraine, because I think the vast majority of people with dizziness and off balance it's more often migraine than it is otolaryngologic.

Dr. Joseph Sakumura:

Yeah, If you look at the AMA estimates, less than 1% of people have Meniere's disease. One in four women identify as migrainers. One in six men identify as migrainers and a subset of those patients are going to have a manifestation of the migraine, not of headache, not of lower, you know, occipital pain, not of some of these other classic migraine would have been thought of as classic migraine symptoms, but rather true spinning, vertigo or some of these other different kinds of things that are associated with migraine.

Dr. Douglas L. Beck:

It is very, very hard to differentiate and I think that you know, when you go in with these signs and symptoms, particularly into an emergency room boy, the clinicians who see you you know they have to take the route based on the presentation at the moment and deal with it then. But if it doesn't get better quickly it's almost always worth pursuing doing. Let's talk a little bit about Meniere's disease and endolymphatic high drops, because endolymphatic high drops sometimes manifests the same as Meniere's disease, or am I wrong on that?

Dr. Joseph Sakumura:

Yeah, my great mentor, also a good friend of yours, john Ferraro. I happened to be lucky enough to have him as a clinical professor. I did some rotations with him and the definition that we always used was that Meniere's disease can also be defined as idiopathic endolymphatic hydrops. So there's been all of these different types of Meniere's disease, flavors of Meniere's disease, classifications of Meniere's disease over the last 10, 20, 30 years, where there was atypical Meniere's that didn't have vertigo and nystagmus. There was atypical Meniere's that didn't have vertigo and nystagmus. There was atypical Meniere's that didn't have. I think the important thing to focus on now is that the, the Barony Society has given us really, really great diagnostic criteria of Meniere's disease and definite Meniere's disease checks all four boxes rotary, vertigo, oral fullness, roaring, tinnitus and fluctuating hearing loss.

Dr. Joseph Sakumura:

So if loss and then probable Meniere's disease is three out of the four, and then possible and whatnot, we actually have those same criteria for things like migraine. The problem is, if you look at the end of the diagnostic criteria that are put out every year is the very last one is not better accounted for by another disease or disorder is not better accounted for by another disease or disorder. So it creates a true diagnostic enigma when it comes to those. But back to the original question is that we know in Meniere's disease and endolymphatic hydrops that we've got an overproduction of endolymph or under a problem basically with the ears management system of endolymph in versus endolymph out. So I think there's always kind of that blurry line of what's Meniere's disease, what's endolymphatic hydrops, and I think for most people it's sort of blended as one.

Dr. Douglas L. Beck:

But you will see infrequently that people will have endolymphatic hydrops after things like a head injury or some of these other known etiologies that can be and when we really suspect endolymphatic high drops, we might look at electrococleography and looking at APSP ratios and in a positive result that would be a larger action potential than summating potential significantly. I want to say like one to three, something like that. But I wonder how accurate that is. John Ferraro and I did a paper on this many years ago and I think even John said that. John, if I misquote you, I'm sorry. I think that John said that it was a little bit of a crapshoot. In other words, if the APSB ratio was consistent with the signs and symptoms of the patient, that proves it.

Dr. Joseph Sakumura:

If it's inconsistent, that doesn't necessarily not prove it If you follow any of the audiology chat boards or listservs. It's kind of a hot topic in audiology. Why should we even do ECOG if the US-based, at least father of ECOG is saying it's kind of a crapshoot? So what's interesting is last I spoke with John is when you look at sensitivity, specificity of ECOG, it's at its highest when somebody's having an acute attack of mucus, Of course, of course. My answer to that is good luck getting somebody on an exam table and getting them still for a test while they're doing it.

Dr. Douglas L. Beck:

Yeah, they're probably not leaving their house when they're in the middle of an attack. I can tell you that intraoperatively this goes back like 30, 40 years. Dr Bill House, dr Daryl Brackman, a few other neurotologists at House and I were looking at SP-AP ratios and one of the questions I think it was Dr Daryl Brackman framed the question if we were to take a Meniere's patient or an endolymphatic hydrops patient and we get their AP-SP ratios pre-op and then we decompress the endolymphatic sac intraoperatively, would we see a change there? Now it probably had more to do with my. Technique was awful, but intraoperatively we never really saw anything consistent that would predict how the patient would do years later. But we did decompress a lot of endolymphatic sacs and endolymphatic sac surgery is not a walk in the park.

Dr. Douglas L. Beck:

It's a very difficult surgery. It's very quick because you drill away the mastoid to get down to the end of the lymphatic sac and some people just once they identify it, that's it, you know you don't need to go in and puncture it and put a tube in there. But there's many ways of doing that right. You can do a subarachnoid shunt, you can do a mastoid shunt and you can just decompress it by taking the bony covering off of it and the success rate of that was about two-thirds. About two-thirds of the patients who had an lymphatic sac surgery were no longer dizzy. That depended on whose hands it was in, and a lot of people thought well, maybe it's placebo, maybe it isn't.

Dr. Douglas L. Beck:

Fred Linthicum, a brilliant researcher, also out of the House Air Institute, fred did a study where he looked at post-operative patients, patients who had had antilevatic sac surgery, and he found that the vast majority of surgeons I hate to say, but they didn't identify the sac or they put the shunt in and it wasn't in the sac. And you know that's I'm not judging, I'm just saying that's historical record, that's in peer review research that Dr Lindhikin published, and so we don't really know. But I do know this. I know that Alan Shepard, who's one of the astronauts right who went to the moon, he was disabled with many years and he saw Dr Bill House, one of my mentors, and Bill did an lymphatic sac and a few months later he was cleared to go to the moon.

Dr. Joseph Sakumura:

And really cool, cool story. I've read on that one a lot. It is fascinating.

Dr. Douglas L. Beck:

And it's a true story, and so in Dr House's archives after he passed he had Alan Shepard's tube that went to the moon the only endolymphatic sac shunt tube that had ever circled the moon and I think, doug, that's.

Dr. Joseph Sakumura:

An interesting part of what got me intrigued in the vestibular sciences is how big of a role NASA and the astronauts had in the development of actually a lot of what we're using now commercially or clinically.

Dr. Douglas L. Beck:

Absolutely Because.

Dr. Joseph Sakumura:

I feel like when you look, just looking at the literature, for a long time people you know, equilibrium dysfunction and balance disorders were just kind of something that older folks had, and it was and then when you get to the advent of NASA and the moon missions and things you find the development of, you know, posturography and all these wonderful resources are dedicated to studying that system because it's now something that's no longer just ah, you're getting a little bit older. It's something that astronauts are dealing with.

Dr. Douglas L. Beck:

Absolutely, and it's a fascinating topic. We could spend hours on it. My closing note on the surgery and for people who are disabled by vertigo who literally are disabled by vertigo. They cannot participate in day-to-day activity, they cannot ambulate, they cannot go to work, they cannot drive a car. There are other solutions that some surgeons might put forth. The ultimate solution is if you can truly identify which ear is causing the problem and, presuming it's only one ear causing the problem, you know there are vestibular neurectomies that can be done and we've been doing those for many decades. I remember at least 50 to 100 that I was involved with. The neurosurgeon can literally go in to the skull base and look at the root entry zone of the superior vestibular and the inferior vestibular and quite literally section one of those if that's the one that we know is exciting the vestibular system.

Dr. Joseph Sakumura:

Yeah, I've seen over the last five, 10 years, even with gentamicin ablation and chemical neurectomy, and I think where I've always been in a gray area with that in terms of recommending the clinician is should I recommend this to my patient, should I not? I think you hit the nail on the head. It's the quality of life and how debilitated is the person.

Dr. Douglas L. Beck:

And these are ideas and suggestions that we mention explicitly so that the patient who needs help can seek the help of a neurotologist or an otologist who might have more options for them once there's a firm diagnosis that you know, that has identified which ear, which inner ear, is problematic. Because there's more that we could do and so many things have been tried, you know, from equalizing the pressure and reducing the difference in the endolymphatic sac pressures between endolymph and paralymph. Anyway, those are surgical decisions that you and I don't make. Those are up to the neurotologist, otolaryngologist, otologist and the patient themselves. I wanted to ask you many patients get prescribed meclizine or antivert and things like that. What are your thoughts on that? For general dizziness, I mean, a lot of people do get that prescription. What can you tell us about that?

Dr. Joseph Sakumura:

Yeah, I think you have to be careful with those. That's another hot topic that we hear a lot about in both the rehab world. So vestibular rehab and vestibular diagnostics is what is the role of vestibular suppressants like antihistamines, dramamine, some of those kinds of things? And I think until you have an accurate diagnosis of what's going on, you really want to avoid those, because what happens is when you have a vestibular dysfunction we use the example of vestibular neuritis earlier.

Dr. Joseph Sakumura:

When vestibular neuritis hits the ear, it damages one ear and this research shows us that that function does not come back. So the patient is left with a new normal. The only way that the brain can get them their quality of life back is through a process called compensation, which requires the brain to recalibrate to this new set of functional gyroscopes that it has. If a patient is just prescribed Antivert right after they've had this attack, without really knowing what's going on, it actually impairs the brain's ability to deal with this new set of hardware that it now has to learn to work with. So it has its place meclizine, antivert they do work, and for seasickness and some of these other kinds of things. But what I see far too often clinically is that a patient goes into a walk-in facility, says I'm dizzy, and they're oh, try this meclizine, this will work. Well, you haven't gotten to the bottom of the diagnosis of what actually is going on.

Dr. Douglas L. Beck:

To be clear, meclizine, as best I'm aware, is an antihistamine right. That's exactly right. Yep, yeah, all right. I want to ask your thoughts.

Dr. Douglas L. Beck:

On 25, 35, 45 years ago, when we were doing plain electro nystagmography, eng testing, before video nystagmography, we would often tell patients and this will be familiar to most audiologists over age 50, we would tell them okay, well, you know, we're going to take you off all your meds and you can't have coffee and you can't have breakfast, and blah, blah, blah, we're going to do this test.

Dr. Douglas L. Beck:

And then I remember I'm going to guess it was 15 or 20 years ago Devin and Gary Jacobson said you know, we don't tell our patients that we want to see them as they are and test them as they're going through their day in their normal you know pharmaceutical profile. And if we have a patient who's been dizzy for eight years, 15 years, 12 years, six days, and we've got them on drugs and then we take those drugs away and we test them, they're now in a brand new situation that may not reflect what they're going through on their day-to-day life. What are your thoughts on that? Should we be doing video nystagmography and, for 24 hours, 36 hours before that, discontinue their meds, or should we allow them to be tested based on the meds and the foods and the caffeine and the tobacco that they're using every day?

Dr. Joseph Sakumura:

Yeah, it's a really really good, interesting, interesting one that I answer I talked to a lot of audiologists about as well. So the differing schools of thought is that forever it was. We know that certain medications and even over.

Dr. Joseph Sakumura:

You know even coffee and caffeine and nicotine can have an impact on how the brain processes information from from the vestibular system. Sure, for example, if you come in and you're on a bunch of Zofran or Meclizine or suppressant meds and my job as the audiologist is to stimulate your ear and look at the eye movements that happen as a result of that stimulation if the brain is dampened by alcohol or whatever the dampener is, you're not going to see the result that you're actually trying to induce. So that school of thought I think gold standard. My preference, and the same goes for physical therapy is that we want to see the patient in whatever setting they're going to be that they want to be in. So if their goal is to be off of the medication at some point, or their goal is to get their life back to be off that medication, I'd like to see them off of that medication because of what it can do to the results. Now, I always recommend that with a grain of salt, because if somebody is drinking coffee and they see on my pre-appointment paperwork if you've had any coffee, I'm not going to see you. Well, guess what? That's now a barrier to them coming in for testing.

Dr. Joseph Sakumura:

The other thing is that if we tell people you can't take any of your meds and they've been on them for eight months prior and they can't even get out of bed because they're so anxious without taking their Xanax or whatever it is, it's a barrier to the entry of care.

Dr. Joseph Sakumura:

So what I always tell people is, in an ideal scenario, we'd like you to refrain from, if possible, speak with your physician. We'd like you to refrain from any medications that you're taking for pain, anxiety, depression, dizziness or sleep ideally. Now, if you can't come off of those or your physician doesn't approve you coming off of those, I'd still like you to come in for the evaluation, because we now know that certain medications have documented impact on our test results. I'd still like you to come in for the evaluation because we now know that certain medications have documented impact on our test results. So if I know that Doug is on suppression medication A, I know what to look for in your test results. That would indicate to me okay, that's an impact of the medication, versus okay, that's an organic abnormality that's a result of the dizziness problem that he's currently having.

Dr. Douglas L. Beck:

Well, joe, our time is up. You are a wealth of information and a joy to listen to. As I said when we started, every time I watch you lecture, every time I listened to you, I wound up taking a thousand notes. This time it's all recorded so I can just play it back. But I am so appreciative of your time and your expertise and I hope that we get to do this again, perhaps six months, 12 months, and we'll look at some specific disorders. We'll go into things like multifactorial, maybe vestibular migraine, maybe psychogenic.

Dr. Joseph Sakumura:

Yeah, huge topic, lots to unpack there. So thank you so much, doug. I really, really appreciate the invitation. Always a joy to speak with you.

Dr. Douglas L. Beck:

My pleasure. I wish you a joyful day and I thank you so much for your time. Joe, Take good care.

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Blaise M. Delfino, M.S. - HIS

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