Balance; It is the state of a person or object to stand upright without tipping over. Dizziness, which is an illusion of movement, is a general definition of vertigo in the medical language and is not a disease, it is a symptom that can indicate many diseases or conditions.
How do we keep our balance?
While the human body maintains the balance, basically three systems come into play; Visual system, Inner ear and Musculoskeletal-deep sensory system. The stimuli emanating from these systems are processed and perceived and evaluated in the brain and related structures, so that the person continues to maintain his balance. When there is a problem in the perception and evaluation of balance information in any of these structures, for example in the inner ear structures or structures related to the brain, the person loses his balance and the complaint of dizziness occurs.
In this case, the person may feel as if he or she is spinning around, even though he is not actually in motion. Patients presenting with dizziness may complain of staggering or imbalance as if ‘the ground is slipping under their feet’, or they may describe a picture so severe that they think that the walls have collapsed on them or that there is an earthquake.
For all these reasons, listening to the patient’s complaints in detail and allocating sufficient time in this regard is the most important step in reaching the differential diagnosis. Important information such as the duration of the patient’s dizziness, how it was described by the patient, whether there are accompanying findings, etc., guides the diagnosis. Therefore, patients presenting with dizziness may need to be evaluated jointly with many branches such as ENT, Neurology, Internal Medicine, and Ophthalmology.
The inner ear balance system (Vestibular System) senses the movements of the head, interacts with the eye muscles, and exchanges information with the musculoskeletal system. As a result, the operation of all these systems together in a ‘Equilibrium’ is the most important and necessary step for us to maintain our balance.
As a result of the connections between the inner ear balance system and the eyes, involuntary eye movements called ‘nystagmus’ may occur in some pathologies. The most objective finding of vertigo, which is a subjective complaint, that can be observed by the ENT physician is this involuntary eye movement.
The presence, degree, type, and position of involuntary eye movements in the ENT examination will guide in terms of pathology in which area of the balance system, whether the cause of dizziness is due to the ear and related structures or the brain and its related structures.
Ear, nose and throat diseases can include many diseases and conditions that can cause dizziness. The most common causes of dizziness in ENT practice include BPPV, Meniere’s disease, and vestibular neuritis. Now, let’s briefly talk about these diseases with the names you are used to.
BPPV (Benign Paroxysmal Positional Vertigo): (Sudden onset of benign positional vertigo )
Popularly known as ‘displacement of crystals or ear stones’, it is a very common picture. So what exactly are these crystals? Where does it come from? Or is it actually already in our ear and is changing its place?
Structures of the inner ear:
Otoconias (Calcium Carbonate and protein biocrystals) are attached to a gel-like structure in the balance organ of the inner ear. When these crystal particles detached from here escape to other parts of the inner ear, namely the canal structures that sense movement, and get stuck here, the crystals in the canal create a warning/movement sensation, even if the patient is not in motion. While the eyes, brain and musculoskeletal system are trying to adapt to this new stimulus, a feeling of movement occurs even if the person does not actually move. This results in dizziness.
In this case, the patient applies to us with the feeling of dizziness that occurs with certain positions of the head, triggered by sudden movements, and subsides within a few minutes.
As a result, when these crystal structures, which actually exist in the inner ear system and are tightly connected to their location, break for some reason and move to other parts of the inner ear, they create the picture known as ‘crystals playing’ among the people, which is called BPPV.
In the treatment of this condition, it is primarily aimed to determine which area/channel in the ear these crystals have escaped to, and then to return these crystals to where they belong with appropriate position maneuvers. In the meantime, although treatments that will relieve the patient and relieve complaints such as nausea and vomiting are also used, the main thing is to apply maneuver therapy.
Meniere’s Disease is a disease that was defined a long time ago (in 1861) by a scientist named Prosper Meniere. Symptoms such as hearing loss, ringing/buzzing in the ears, a feeling of fullness and pressure in the ears can be seen in this disease that progresses with attacks of dizziness. It can be seen slightly more in women than in men. The main underlying cause is the increase in pressure in the inner ear structures for a reason (overproduction of inner ear fluids or inability to recover from the environment). During periods of increased pressure, the patient’s dizziness and other symptoms begin, and when the pressure returns to normal, the attack recedes.
In these patients, hearing tests (audiometric examination) must be performed in the differential diagnosis. Again, for the differential diagnosis, a test called caloric test applied to the ears of the patient in the lying position – hot and cold air / water can be a guide.
We use some drugs in the treatment of a patient with Meniere’s Disease. In addition to drugs that suppress the feeling of dizziness and nausea, ‘diuretic’ drugs with diuretic properties may be recommended. With diuretic drugs, it is aimed to maintain fluid balance in the inner ear and keep the pressure in balance. In addition, some group drugs that increase the blood supply and nutrition of the inner ear can also be used. In addition to these, it is aimed to reduce inflammation/edema/inflammation in the ear by administering steroid group drugs directly into the ear, either by mouth or by intratympanic application.
In addition to all these medical support and treatment, salt restriction, regular exercise and stress management are also beneficial in reducing the frequency of attacks.
Surgical treatment may also be on the agenda for patients who have difficulty in doing their daily activities that do not respond to medical treatment.
Inflammation/edema/inflammatory state of the balance nerve
Sudden onset of severe dizziness. Nausea is a picture that manifests itself with vomiting. It occurs with inflammation/inflammation in the balance nerve for an unknown reason. The distinguishing point here is that the patient does not have hearing loss. Dizziness can persist for days. The severity of rotation may increase with head movements, but is often not related to position. In the treatment, drugs that suppress nausea, vomiting and dizziness can be given.
Vestibular Rehabilitation: In this therapy, which is called Balance Physical Therapy, it is aimed to regress especially the chronic balance complaint of the patient by giving some exercises. This balance rehabilitation program can be applied in the presence of a therapist in patients with age-related chronic balance problems, in cases related to the above-mentioned diseases related to the inner ear balance system, some brain-related diseases or balance disorders that do not improve after surgical interventions.
The aim of this rehabilitation program is to activate some adaptive mechanisms in the human brain.
In general, it is aimed to increase gaze stability, to increase postural stability, and to prevent recurrent dizziness with some movements, thus improving daily living activities.
There are many factors that affect recovery in vestibular rehabilitation. In particular, centrally acting drugs such as drugs that suppress the feeling of dizziness (vestibulosuppressants, antidepressants) prolong the average time required for recovery. Again, in the presence of an underlying tumor or in the presence of conditions such as ongoing inflammation of the inner ear structures (labyrinthitis), the benefit to be gained from vestibular rehabilitation may also decrease.
Tinnitus (Tinnitus): Tinnitus, which is a very common condition, can be defined in different ways from person to person (such as humming, sizzling, noise from the ear, creek sound, water sound). Tinnitus is actually a symptom, like vertigo (dizziness).
This complaint can be heard (objective tinnitus) or not (subjective tinnitus) by others other than the patient. Patients are often included in the second group.
Objective tinnitus can often occur as a result of some vascular, nerve, and muscle pathologies (palatal myoclonus, different functioning of the palate muscles), hypertension, or dysfunction in the jaw joint.
Subjective tinnitus is the perception of a sound without any acoustic stimulus.
Tinnitus can be unilateral or develop in both ears. It may occur after exposure to noise. There may be an underlying hearing loss. For this reason, hearing evaluation of a patient with a complaint of tinnitus is absolutely necessary. Even if the person does not have problems with hearing in his daily life, this evaluation should be done so that it can be understood whether there is an underlying hidden hearing loss.
While tinnitus is not very disturbing in some people, some patients may be affected enough to have difficulty in maintaining their daily lives and even falling asleep. This situation can be explained by neurophysiological mechanisms and connections. From this point of view, habituation therapy comes into play, enabling the person to adapt to this sound by activating or deactivating different systems.
Tinnitus is tried to be suppressed with some medical treatment options. (such as vitamins, agents to increase blood supply to the inner ear, antidepressants) Hearing aids and tinnitus masking studies are among the treatment alternatives.
In summary, patients with tinnitus complaints should be evaluated with a detailed history and examination, blood tests should be performed, inner ear structures should be imaged with tomography or MRI, blood pressure measurements and follow-up, hearing assessments should be made, and a personalized way of treatment should be determined according to all these results.
Rhinitis, commonly known as the common cold, is a very common condition in society and can affect everyone several times in their lifetime. However, some people may experience frequent cold attacks. The nose, which is our breathing organ, becomes edematous with the picture of rhinitis, the discharge begins and the breathing function of the nose becomes impaired. The person may experience difficulties in daily activities, school and work life. More importantly, a nose that cannot provide its normal aeration function may pave the way for recurrent or chronic middle ear diseases.
Seasonal Allergic Rhinitis (Hay Fever): Findings occur at certain times of the year, especially during seasonal transitions. The rest of the time, the person does not usually experience discomfort.
Allergic rhinitis is actually a condition that occurs as a result of sensitivity to some allergens rather than a disease. These allergens, pollen, house dust mites, foodstuffs, medicines, etc. can take place in such a wide range.
Although it is recommended to detect the allergen and stay away from this allergen in the management of Allergic Rhinitis, this is often a difficult situation to implement. Some drugs are used in the treatment for Allergic Rhinitis. In fact, the definition of treatment may be insufficient for this picture. Namely; Allergy is actually a sensitivity response of the body to one or more allergens rather than a disease state. Therefore, the basic principle in treatment is to prevent the formation of a sensitivity response.
When an allergen is encountered, a substance called histamine is secreted in the body. In the treatment of allergic rhinitis, it is aimed to release this substance or to prevent this substance from functioning even if it is released. As a result, even if the person continues to meet with allergens and his sensitivity continues, since these substances are not released and cannot function, complaints such as nasal congestion, itching and sneezing will be seen less frequently.
Allergic Rhinitis should be differentiated from other common cold causes. If there is an underlying viral or bacterial cause, these should be treated.
Common findings in Allergic Rhinitis;
Itching of the nose, palate, throat and eyes
Nasal congestion, clear colored nasal discharge
sneezing several times in a row
bruises under the eyes
In these patients, intranasal anatomical structures should also be evaluated by endoscopic examination. The condition called Nasal Polyp (polypoid formations in the nose) may appear as a common condition with allergic rhinitis. For this reason, a detailed ENT examination should be applied to patients describing Allergic Rhinitis.
Adenoid (Adenoid Hypertrophy)
Adenoid enlargement (adenoid hypertrophy), especially seen in childhood; is the lymphoid tissue (Body defense cells) located at the junction of the nasal cavity and the oral cavity, becoming larger than normal. As this structure grows, the airway narrows and airflow becomes difficult. For this reason, the child feels the need to open his mouth while sleeping at night, snoring occurs because the airway is narrowed, sleep disorders such as apnea and restless sleep may result. When adequate and productive sleep is not achieved, situations such as distraction during the day, tendency to sleep, difficulty concentrating, and a decrease in school success in school-age children can be seen.
Children with adenoid enlargement may have frequent upper respiratory tract infections, as well as frequent postnasal drip complaints. In case of post-nasal drip that does not go away with treatment, adenoid examination should be performed and it should be investigated whether it is accompanied by an allergic condition.
On the other hand, when there is not enough airflow from the nose, the middle ear can also be affected by this situation, and frequently recurrent middle ear infections can be seen.
Inserting a Tube into the Ear:
Middle ear infections are common, especially in childhood. Middle ear infections can cause complaints such as ear pain, fever, restlessness, and even ear discharge. We encounter middle ear infections frequently in crowded environments such as nurseries and kindergartens, especially in the seasons when upper respiratory tract infections are common.
In cases where we call serous otitis or otitis media with effusion, with fluid accumulation behind the eardrum, a slight earache, a feeling of congestion in the ears and in some cases hearing loss can be seen. Hearing loss can be manifested by situations such as not being able to hear when called, and the need to watch television loudly, since children are often unable to express themselves.
First of all, acute infection should be treated, underlying allergic conditions should be investigated, and adenoid enlargement should be evaluated with a detailed ENT examination. Audiologically, the structure and flexibility of the eardrum and the patient’s hearing levels should be evaluated with tests and it should be determined whether there is a need for tube insertion.