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Diseases of the Ear, Nose, and Throat
THE INNER EAR

MÉNIÈRE'S DISEASE
DEFINITION
Ménière's is characterized by fluctuating hearing loss, vertigo, and tinnitus (ringing or buzzing in the ear). The vertigo consists of dramatic and debilitating attacks, during which the patient feels that either she or the room is moving. These attacks may be so severe that the patient cannot stand and often has nausea, retching, and vomiting. Symptoms are absent between flare-ups.

The condition may affect only one ear or, in 20 percent of cases, may grow to include both ears. The base-line hearing between attacks gradually gets lower and lower. The attacks vary considerably from one patient to another and from episode to episode. One person may have weekly attacks lasting 4 hours; another may have attacks lasting 1 hour twice a year; a third may have three attacks a day; and a fourth, one attack in 6 years.

CAUSE
The exact cause of Ménière's disease is not known. It is believed to involve an increase of fluid in the labyrinth that puts pressure on the membrane of the labyrinth wall and affects both balance and hearing. Historically, accountants, dentists, otolaryngologists, and watchmakers people who do fine, meticulous work that requires great concentration and control of the hands for long periods of timeare more prone than others to develop this condition. In fact, it was originally called watch-maker's disease.

DIAGNOSIS
Diagnosis is based on the patient's description of symptoms and audiometry testing, in which the patient's ability to hear sounds of various frequencies conducted both through the air and through the bones in the head is evaluated.

TREATMENT
The only proven, reliable treatment for Ménière's disease is surgery, which selectively destroys the balance mechanism or the nerve responsible for the sense of balance. Alternatively, a prosthesis may be implanted to help drain the excess fluid that accumulates in the ear as an attack starts. If there is no hearing left and the only problem is dizziness, the physician may choose to destroy the entire inner ear via a safe and easy surgical procedure. Since there is no hearing, there is nothing to lose by this method, because the balance function can still be handled by the other ear, as well as by sight and muscle impulses.

Drug therapy usually can provide only symptomatic relief. Vertigo can be eased by anticholinergic agents, such as atropine or scopolamine, by antihistamines such as diphenhydramine or meclizine, or by barbiturate drugs such as pentobarbital that provide general sedation. The use of diuretics to reduce salt and water retention in the body also helps some patients.

For patients with bilateral Ménière's disease, treatment is more difficult. Sometimes surgical intervention on the most problematic ear will stop the majority of attacks. In the past, the antibiotic streptomycin was sometimes used in exceptionally large doses, which had the effect of destroying the balance mechanism while not affecting the hearing. Some patients are willing to endure having to use their tendon reflexes and their eyes to achieve balance (meaning they have no sense of balance in a completely dark room) in order to stop the attacks of vertigo.

HOME REMEDIES AND ALTERNATIVE THERAPIES
Some patients have found that lifestyle modifications, especially quitting smoking, can help decrease the frequency and severity of Ménièrre's attacks. Restricting fluid intake, by limiting water and other fluids to 6 or fewer glasses a day, may reduce fluid in the labyrinth and decrease attacks. A low-sodium diet and reduction of caffeine intake has helped some people.

MALE/FEMALE DIFFERENCES
The condition seems to be more common in women than in men.

  ACOUSTIC NEURINOMA
DEFINITION
A neurinoma is a tumor that arises from the cells of the thin sheath that covers a nerve. In the case of an acoustic neurinoma, the tumor arises on the vestibular rather than the acoustic nerve, and grows very slowly, often taking many years to mature. It may present only mild, transient dizziness and unsteadiness, tinnitus (ringing in the ear), and eventually a gradual loss of hearing in the affected ear. The tumor is not malignant.

CAUSE
The cause of acoustic neurinoma remains unknown.

DIAGNOSIS
Diagnosis is accomplished based on audiometry, brain stem response testing, and magnetic resonance imaging.

TREATMENT
If found while it is still small, an acoustic neurinoma can often be removed surgically with no damage to the facial nerve and the remaining hearing can be preserved. If the growth is too large to remove completely, partial removal may still be possible.

  PRESBYCUSIS
DEFINITION
Presbycusis is a type of sensorineural hearing loss that occurs gradually as people age. In some cases, there may be a loss of ability to discriminate sounds. That is, a person may be able to hear sounds, but may not be able to make words out of them. Presbycusis generally begins to affect people between ages 55 and 65, but may not occur until much later.

CAUSE
Tiny inner-ear hair cells (sensory neuroreceptor cells) degenerate, leading to a gradual loss of hearing. These cells send electrical sound impulses to the brain where sounds are received and processed.

DIAGNOSIS
Presbycusis is diagnosed based on the patient's report of the type of hearing loss experienced and several tests, including audiometry.

TREATMENT
Presbycusis cannot be cured. However, hearing aids usually can restore useful hearing.

HOME REMEDIES AND ALTERNATIVE THERAPIES
Learning to lip read can enhance understanding in those with moderate hearing loss.

PREVENTION
The onset and severity of presbycusis may be related to the degree of excessive noise exposure the patient has experienced in life. To protect yourself, wear earplugs in all noisy environments, avoid overamplified concerts, and use proper protective equipment when exposed to occupational noise such as heavy machinery.

MALE/FEMALE DIFFERENCES
Men are affected more often and more severely than women.

  LABYRINTHITIS
DEFINITION
Labyrinthitis is an infection of the inner ear. It produces extreme vertigoa feeling that the person or his surroundings are spinningand often nausea and vomiting.

CAUSE
Bacterial infection secondary to acute otitis media or to purulent meningitis can cause the condition. So can a viral infection, either arising independently or secondary to an upper respiratory illness such as a cold or flu. When the disease is caused by bacteria, there is a total loss of hearing on the affected side. However, if tuberculosis or syphilis is to blame, the hearing loss may be only partial.

DIAGNOSIS
Clinical examination of the ear and the patient's description of symptoms form the basis for a diagnosis of labyrinthitis.

TREATMENT
Treatment of bacteria-caused labyrinthitis consists of heavy doses of antibiotics. The viral form is usually self-limiting, and there is some difference of opinion among physicians about the existence of a viral form; often, the symptoms are ascribed to another cause. The only treatment for the viral form is bed rest, tranquilizers, and a medication such as Antivert to combat the dizziness.

HOME REMEDIES AND ALTERNATIVE THERAPIES
Keeping lights dim and remaining as still as possible can help ease the dizziness and nausea.

PREVENTION
Get prompt treatment for any middle-ear or respiratory infection. If your nose is congested, don't blow too hard since this can push infectious material into the inner ear.

  VESTIBULAR NEURONITIS
DEFINITION
Vestibular neuronitis is characterized by a sudden loss of the balance mechanism in one ear. The person is so violently dizzy that he or she usually cannot walk for several days or weeks, and may be unable to get up and move around at all. If the loss is total, the individual should be seen by a doctor at once.

CAUSE
Vestibular loss may be precipitated by a virus (viral neuronitis) or a tiny blood clot in the arterial system that brings blood to the balance mechanism. These blood vessels are so small that they can be blocked by a microscopic clot of no more than four or five red cells clumped together.

DIAGNOSIS
Diagnosis is based on symptoms, a physical examination, and several tests, including audiometry, electronystagmography, and magnetic resonance imaging of the head.

TREATMENT
Treatment, about which there is considerable difference of opinion, may depend on whether the loss of balance is total or partial and on whether it is treated within the first 24 hours or later. Anticoagulants (to thin the blood and perhaps dissolve the clot) are sometimes used at times in conjunction with vasodilators to expand the blood vessels and allow the clot to pass. These seem to work best when used in the first 24 hours. Corticosteroids may be used when the condition is thought to be caused by a virus. Other drugs may be prescribed to alleviate the discomfort of the vertigo, as in Ménière's disease (see earlier in chapter).

If the loss is only partial, the chance for spontaneous recovery is quite good. If the loss is total, the chance of spontaneous recovery is poor. With time, however, the balance mechanism of the other ear will compensate and the symptoms will disappear. Continuing symptoms indicate that the damage to the vestibular system is still in flux, preventing compensation by the other side.

HOME REMEDIES AND ALTERNATIVE THERAPIES
As with the vertigo of labyrinthitis, remaining very still in a darkened room can help ease dizziness.

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