Saturday, October 29, 2016

To Diagnose and Cure Dizziness Sooner Than Later

After focusing my medical practice on vestibular system disorders over a decade ago and seeing over a thousand new dizzy patients per year for many years, I have noticed that patients ask me one particular question more than any other. The question is:
why couldn't I have found you sooner?
Fortunately, with technologic and diagnostic advances in vestibular medicine, we are now much better able to recognize the cause of dizziness or vertigo and to therefore provide the most appropriate and effective treatment.  As with any symptom in medicine, the correct diagnosis is necessary in order to apply the most effective and appropriate treatment.  Vestibular function testing, when combined with the patient's clinical symptoms and physical examination findings, enhances our ability to arrive at the most likely diagnosis.  We are now able to differentiate brain from inner ear disorders causing dizziness/vertigo and thus know whether a CT or MRI is needed (usually not).  We can quickly identify and instantly cure patients with benign paroxysmal positional vertigo (BPPV), aka the 'crystal' problem.  Based on the diagnosis, we know whether medication or a physical therapy intervention would be most useful.
Unfortunately, many patients go months or years without a correct diagnosis, undergoing unnecessary (and sometimes multiple) MRI or CT scans and/or carotid doppler studies. They are prescribed medications, such as meclizine, which are often ineffective.  They are sent to a physical therapist when the underlying cause of their dizziness or vertigo is something that physical therapy cannot help.  
For the specific case of BPPV, patients are amazed to learn that their vertigo can be cured with a simple head maneuver - they leave our office after their first visit cured of the vertigo they had been suffering with for months or years.  One particular patient who had been suffering with BPPV for many months actually fell and broke her hip as a result of vertigo and certainly wished she had received a diagnosis and treatment sooner.
In neurology, we have a saying:  "time is brain".  Indeed, in vestibular system disorders, timely diagnosis and appropriate treatment can save needless suffering, prevent painful and sometimes deadly falls, and save our healthcare system unnecessary expense.  
For further information or to schedule an appointment, click here to go to our website,, or call toll free 888-888-DIZZY (3499).

Dizzy? It's Not a Tumor!

Feeling dizzy or having spells of vertigo (an illusory sense of motion usually described as 'spinning') can be quite troubling to most people. Of utmost concern is whether these symptoms represent something serious, such as a brain tumor. Rest assured, isolated symptoms of dizziness or vertigo are an extremely rare presenting sign of a brain tumor. To quote Arnold Schwarzenegger in 'Kindergarten Cop' (using his Austrian accent) "It's not a tumor!"
Despite this, at least in the United States, it is the norm to proceed with a neuro-imaging study, such as CT or MRI, of the brain to "rule out" brain tumor, stroke, or multiple sclerosis (MS). There have been several studies concluding that doing CT and MRI scans for 'dizziness' or 'vertigo' in the absence of other neurologic signs or symptoms and in the absence of asymmetric hearing loss is not cost effective and rarely leads to a diagnosis.
Consider the following quote from Australian neuro-ophthalmologists who specialize in vestibular disorders:
"Balance disorders are common, while brain tumors are rare. An isolated balance disorder is thus rarely the presenting symptom of a brain tumor, and some physicians, particularly in countries infested with lawyers, worry about missing a brain tumor" - Hirose & Halmagyi, 1996 
What country do you think they are referring to ("infested with lawyers")?
On the other hand, vestibular function testing [which includes video-nystagmography (VNG)rotary chairvestibular evoked myogenic potential (VEMP) and audiogram(hearing test)] assesses for both central (brain) and peripheral (inner ear) causes for dizziness and vertigo and can be quite helpful in localizing 'where', and then 'what' is causing the problem. Vestibular function testing has been demonstrated to be much more accurate and much more cost effective than MRI or laboratory tests in determining the cause of dizziness and vertigo.
'Dizziness' and 'vertigo' are symptoms, not diagnoses. Proper treatment of vestibular disorders is based on first determining the cause of dizziness or vertigo. Determining the cause of symptoms begins with a thorough history and physical examination followed by vestibular function testing in select patients. At BalanceMD, we have developed a targeted, cost-effective approach to the diagnosis and treatment of vestibular disorders, noting that 91% of our patients report either a significant improvement or cure of their symptoms.
For further information or to schedule an appointment, click here to go to our website,, or call toll free 888-888-DIZZY (3499).

Dizzy Patients Typically See 4-5 Doctors Before Receiving the Correct Diagnosis

In a 2011 survey by the Vestibular Disorders Association (VEDA), it was determined that those suffering from dizziness (the "dizzy" patient) were on average seen by 4-5 doctors before receiving the correct diagnosis.  As is the case with any medical condition, without the correct diagnosis, the most appropriate treatment cannot be administered.  
Symptoms of dizziness are typically subjective and an accurate diagnosis at first may not be straight forward.  Many patients suffering from dizziness typically see several doctors and undergo multiple tests while accumulating large medical bills and no answers.  The time "dizzy" patients spend in this process can be months to years and may result in painful fall-related injuries while seeking help from various healthcare practitioners.
"Dizzy" patients may initially be seen by their primary care physician or go to an urgent care facility or emergency room, then, as the potential underlying cause for dizziness can be diverse, referred to ENT (Ear, Nose and Throat - aka Otolaryngologist), a neurologist and/or cardiologist.  Studies reveal that many undergo brain or sinus CT and/or MRI scans, carotid doppler studies, EEG, EKG, echocardiogram, tilt table testing, and blood tests, all of which have low yield in arriving at the correct diagnosis for most "dizzy" patients.  Vestibular suppressant medications, such as meclizine, diazepam or promethazine, typically offer little relief and the majority of "dizzy" patients do not significantly benefit from PT (physical therapy).
The knowledge and technology we have available today in the diagnosis and treatment of the "dizzy" patient has advanced significantly and is different than what would have been considered standard of care just 20 years ago.  At the initial visit to a physician experienced in vestibular disorders, the "dizzy"patient will be given the most likely diagnosis and a short list of differential diagnoses.  Vestibular function testing and an audiogram (hearing test) are generally the most valuable tests to obtain for the "dizzy" patient, and will help confirm or refute the diagnosis suspected by clinical information obtained in the history and physical exam.
Arriving at the correct diagnosis is vitally important because effective treatment of "dizziness" depends on the diagnosis.  One cause of dizziness requires a specific sequence of head movements which can result in an instant cureanother cause is treated by reducing dietary sodium and/or a diuretic medication, while the most common cause of dizziness improves or resolves with a migraine-preventative medication, and other causes benefit from a specialized form of PT (physical therapy) known as vestibular rehabilitation therapy.
Especially in this age of high deductible health insurance plans, patients are seeking the most expedient and accurate diagnoses and the most effective treatment in a cost-effective manner.  With the advanced diagnostic and treatment capabilities available today, "dizzy" patients should no longer have to see 4-5 doctorsbefore receiving the correct diagnosis.
BalanceMD is a specialty medical clinic designed to help all patients suffering from dizziness, vertigo and imbalance.  For further information or to schedule an appointment, click here to go to our website,, or call toll free 888-888-DIZZY (3499).

by Scott K Sanders, MD, PhD and Michelle Koley MA, CCC-A

Wednesday, September 7, 2016

3PD – Persistent Postural-Perceptual Dizziness

3PD is a new name for conditions formerly known as phobic postural vertigo and chronic subjective dizziness.  As the features, diagnostic criteria and treatment options of 3PD have been refined over the past several years, 3PD will appear for the first time in the next International Classification of Diseases, being released in 2017.

What is 3PD?  3PD is a non-vertiginous, waxing-waning dizziness and/or unsteadiness, persisting for at least 3 months, with symptoms present at least 15 days per month, but typically daily.  3PD often follows a separate triggering event (vestibular neuritis, vestibular migraine, head injury) that caused dizziness, vertigo or unsteadiness.  With the anxiety or worry over an underlying sinister cause (such as a brain tumor) of these symptoms or with the anticipation of having another vestibular event, symptoms of 3PD develop.

What are the symptoms of 3PD?  The symptoms of 3PD include dizziness and /or unsteadiness, worse when upright, head or body in motion, and in visually busy environments, becoming worse later in the day.  Exacerbation of symptoms in grocery or large stores, when reading, scrolling on the computer or cell phone, and with exposure to complex patterns on carpeting, wallpaper or clothing, is common.  The dizziness and/or unsteadiness become intrusive and those affected often report trouble focusing/concentrating or “brain fog”.

How is 3PD treated?  Once other causes are ruled out with appropriate vestibular function and/or other diagnostic testing, a combination of medications, such as benzodiazepines and SSRIs (selective serotonin reuptake inhibitors) and vestibular rehabilitation therapy is often effective.  With significant underlying anxiety, cognitive behavioral therapy may also be helpful.

For further information or to schedule an appointment, click here to go to our website,, or call toll free 888-888-DIZZY (3499).