Hi All,

This was emailed to our faculty today. We generally have many speakers coming through giving seminars on everything from genetics to viruses throughout the year. See below:


Re: Physicians workshop this Thursday (24th) at 1700-1800.

Professor Michael Halmagyi from RPA (Royal Prince Alfred Hospital) will be speaking and answering questions for the whole session on "A practical approach to dizziness."

He is a world authority on the subject and a great speaker. It will be quite a show...so don't miss it!

Guess who will be sitting in the front row? I'll post back later if there is anything earth shattering that comes to light.

Cheers...Scott

That rocks!
I wish I wasn't all the way out here in San Francisco. Can't wait to read about what you learn.
- Cori

Wow guys! I just got in the door after a most amazing seminar from Professor Michael Halmagyi. I must say I couldn't wait to pass this on to all of you. I feel really privileged to be able to access this stuff. So grab a decaf ;) and read on. This guy is the top neurotologist in Australia and has published a stack of papers in the scientific literature such as Neurology and the American Journal of Otology. His unit sees nearly 3000 patients a year.

The seminar was unique because he was presenting to doctors only (except for me of course who was sitting in the front row). In other words, it was a no BS approach and he spelled things out from their point of view. He began by saying - surprise, surprise - that nobody really likes treating dizzy people in the medical field. ENTs tend to not be interested because they prefer stuff where an operation is required, where they can cut something or remove something (typical). Furthermore, there is no answer that is 100% accurate to explain dizziness and all that comes with it. He said that text books on this stuff are by and large useless!! Therefore most doctors don't want to touch it with a barge pole - too hard basket. I couldn't believe it. In fact he said the only reason he got into neuro-otology (this was tongue-in-cheek) was because it was easy to be employed in the field as nobody else wanted to do it! But the upside to it was that, and this is good for us, there is such a high rate of success in treatment that it makes the doc look and feel good. It is good for their reputation - again he said this in a facetious way.

So what causes vertigo? In a nutshell it happens when there is an inequality in activity in the right and left vestibular nuclei (this is how he termed it). Unequal activity means the patient will feel the illusion of motion. He also called it "asymetrical action in the vestibular nuclei". He said the vertigo per se NEVER lasts and that the brain will always sort it out. Recovery from vertigo (note, this is not disequilibrium) occurs in the same way in all mammals - through the activation of receptors in the inner ear. I didn't get the name unfortunately. So there is no such thing as permanent vertigo - period. He said that disequilibrium and vertigo are 2 completely different kettles of fish however.

On the topic of nausea and vertigo. They have no idea why this happens. They are actively looking for a plausible link but don't have one despite tons of research into this area. He said many patients have sudden vertigo for 7 days which is then followed by 3 to 4 months of nausea to which he replied, "God only knows why".

In 90% of cases, patients that report to the ER (like I did on the day it struck) have either labyrinthitis or a cerebellar infarction (this one is rare). Strangely, he never mentioned VN. So how do they distinguish between the two? He uses a process of rapid head movements on the patient and watches how the eyes react. There are different types of eye movement, one of which is called "saccades" or rapid and sudden eye movement as opposed to smooth tracking of an object. Saccades eye movements are in no way linked with the vestibular system in the way that other eye movements are. They are strictly run by the eye only. So what he does is he holds the patients head and suddenly moves the head left or right and then up or down while the patient fixes his/her eyes on something. In a normal person the eye will stay on target regardless of the speed of the head turn. This is because the vestibular system and the eyes work together to keep the eyes on target. But, when there is vestibular damage, this cannot occur. Instead the eye relies on Saccades movement to reach the target following the rapid head movement. Saccades movements are slow to react initially compared to movements where the inner ear is involved. So what happens is the head is suddenly moved and then there is a lag of about 100 milliseconds and the eye jumps back to the correct place. He demonstrated this on a video of a patient with complete destruction of the lateral semicircular canals. When the problem is in the cerebellum (the brain) these delayed eye movements don't occur, which rules out vestibular damage. He mentioned that when both vestibular organs are completely trashed that the world becomes a very shakey place. For example, we are able to keep our eyes fixed on a page of writing while moving the head all over the place, but try keeping your eyes fixed on a page if you shake the page. It's impossible. He said that without the vestibular apparatus our world would be like looking at a shaking page of writing all the time - sounds hideous.

Now here's what blew me away. First, I was the only one in a room full of 50+ doctors asking him questions throughout the seminar (when he prompted for questioning that is). At the end of the seminar I asked him why he would diagnose with these head movements and not use the caloric test instead and what were the advantages of each test. He said that the each test was useful depending on the "frequency" of the damage. I didn't understand this (Subs - any idea?) but I think calorics are not as sensitive in detection as the head movements are. I told him I had had the caloric and that nothing showed up. So next he gets me up in front of the room with all these doctors and demonstrated the technique!!! I was loving this - free testing for Scott! He showed that I have suffered slight damage to the right lateral canal only. It was hard for him to pick up at first but I could even feel how my eyes were slow to flick back to the target when he turned my head suddenly to the right only. I fely quite lousy after the head movements I must say. But I FINALLY know what is wrong after 18 months. I was happy and sad at the same time. Happy that I know but sad that something has been permanently wrecked by a lousy virus. I have to say that he loved my questions!! No one knew what I was talking about except him. All of you guys would have been just as into it. In fact, I was imaginging if the room had been filled with all of us...he might have gone mad - LOL. :D

On the topic of labyrinthitis, he said that it is rare for all 3 canals to be affected. It is usually one or two max. He showed us some really interesting videos of BPPV and labs diagnoses. My heart really went out to the poor people in the video who were suffering. In the videos, you could clearly see the eye nystagmus created by the different head movements. Some were "tortional" (circular jumping movements by the eye) and others were left and right. All movements ceased after about 10 seconds. He said lateral canal BPPV was difficult to treat and that BPPV occurred when the semi-circular canals became "gravity" sensitive from the ear rocks (but nothing new there). Lastly he said MAV was very common and that he had seen many patients with this.

The last thing I want to mention here from the seminar are the dangers of some antibiotics, namely gentamicin. There are a percentage of individuals who are extra sensitive to this antibiotic. It is thought that certain people have a mutation in a gene within the cell's mitochondria (the cells powerplant) that prevents the inner ear from detoxifying itself. These people will experience total vestibular destruction from gentamicin. Nowadays they give people a test dose first luckily. It's injected and will cause vestibular damage within 10 minutes if it's going to occur. They usually run tests after the first dose. If there is any loss in V function, they stop the therapy. In China there are entire families totally whacked out from "streptamicin" he said. Whole families without balance because of a genetic predispositon to this drug - nasty stuff.

I asked the question we all want to know - "how long does this take to go away?". He couldn't give me a concrete answer. In some it just takes forever while in others it goes quickly...of course we all know this. Some he said, will carry the symptoms for life but rare. And when I asked him about disequilibrium, he said they don't know why it occurs really and why it hangs around for so long. Some people will experience the symptoms of bilateral vestibular loss with only one side knocked out. This occurs in 1 in 5 cases. They don't know why. In other words, complete bilateral loss would not cause vertigo because there must be asymetric input from both sides for this happen. Symptoms of bilateral loss are ataxia (failure of muscular coordination, irregularity of muscular action) and oscillopsia (the subjective sensation of oscillation of objects viewed).

So there you have it. I hope there's so new info for some of you in this. At least I finally know what happened to me.

Cheers....Scott :cool:

Hi Scott,

Wow, thanks for all that. What a bonus. Wish I could've been sitting in the front row too. I've never fully grasped the Saccades thing. This cleared that up for me. Obviously I would have been dying to answer him questions about MAV and how he makes a differential diagnosis. I've heard Hamalgyi mentioned a lot.

Hope you're still doing well, Scott. I'm ok ish - still a bit foggy and my symptoms vary, but the worst of the dizziness is at bay for the moment.

best,

hbep

Hi hbep,

Glad to hear the dizziness is much better for you. You've certainly put up with this for quite some time and deserve a permanent break from it. I'm pretty good really although right now I'm feeling really flat and quite strange after having my head turned in all directions at high speed like that. It was really good to hear this stuff from the horses mouth...I took in every single thing he said and filled 3 pages of paper with notes. Another good thing about it is that he was in a chatty mood (he had to be) and we all know how many doctors aren't chatty. You usually have to extract the info with pliers.

Best to you...Scott :cool:

Thanks for taking such copious notes and posting all that info, Scott.
It must have felt great to be the patient up there, even with all the head turning... sounds like it was worth it!
-Cori

Talk about being in the right place at the right time! Thanks for taking the time to be so detailed on this board Scott. You are always a wealth of information.

I may take it upon myself to write to this Professor myself.

You should have told him about this forum! Ha ha.

Wishing you a great day, xoxo

Wow - so v interesting scott.

For me in particular:

Some people will experience the symptoms of bilateral vestibular loss with only one side knocked out. This occurs in 1 in 5 cases.

As this is exactly what london said to me.

Wish id' been there - would have loved it!! xxx

Oh hbep was wondering about u and glad to hear dizziness bit better.

Thank you so much Scott, You just want to print that all out and send it to all the so called specialists we have all seen....just so you can say, see????We are not crazy.

all the best,
Kathy

Hi Scott

Great work---and a great write up!!

Think we should preserve/capture that work/info in the "Info Archive" sticky post

---not often---you get that kind of dialog with one of the best---he was pretty honest about it(this junk)----not what some want to hear/hope for---but about where they(medical types) are---with this junk.

....."depending on the "frequency" of the damage. I didn't understand this (Subs - any idea?)".....

Not sure what he meant by "frequency" ----I have seen on the various research center web sites,i.e., Northwestern(Hain), Univ of Penn, etc..comments that----the head movements vis-a-vis the eye's,i.e., nystagmus, Saccades, is thought---by them/some to be more conclusive---then the ENG/Caloric tests.....but his use of the word "frequency" in the context he was talking about---I'm lost on....

In any case---you did good!!

Make sure you capture/preserve it---it is a "gem"!!

:cool:

Subs - thanks for that. Think I will "peg it" in the archive. Always good to hear about this junk from a pro like that. A rare occurence for sure. I think the frequency thing was similar to the frequency in hearing in that there is a range we work within. The vestibular system also has a range of movement it detects I imagine, from very subtle to extreme movements. If that's the case then it might make more sense that the caloric is more sensitive then the fast head movements he was doing on me. But then why didn't the caloric detect any trouble in my ears I wonder? Perhaps the damage I received is only detected within the higher frequency/stronger head movements. This is all conjecture really...I should email him and clear it up.

CL - I thought of you when he discussed these head movement tests and wondered what reaction you'd get from this.....if the "saccades" eye movements would have been there for you in one or both sides.

Wow - yes, very lucky. In fact, the email was forwarded to me from my supervisor. As it turns out she has no functional right vestibular system at all so she was very interested to hear about it this morning too. The cochlear implant she has killed it. Surprisingly she experiences no dizziness. However she is not so good with balance in the dark.

Scott

HI Scott,
I know loads of others have already said thanks, but just wanted to add my thanks too for posting that. It sounds so interesting, Im going to print it out and keep for reference!
Cheers
Tess

Scott - perhaps I wasnt v clear - sorry for waffling - london showed left damage only - what I mean is I have bouncing and probs in dark which CAN be bilateral symptoms but I dont have a biliateral prob in my case - so the saccades - as on the calorics/eng would be on one side only.

I find it quite amazing this man doesnt use the eng, rotary chair etc!

xxx

Hi CL,

He does use the calorics as well (sorry, didn't make that clear) as it apparently picks up damage in the labyrinth best if the injury has affected a particular "frequency". Just like different frequency sounds are thrown at us to detect hearing loss in different ranges the caloric vs these head movements detect problems at different frequencies - or so he said (and that's how I understand it). I imagine the two overlap as well in many. But this might explain why the caloric doesn't always show something (also I realise the caloric only tests certain canals). Now there's a question I wish I'd asked - how to detect damage in all semicircular canals! The seminar ended up being more about diagnosis than "a practical approach" if you ask me. He was explaining this head movement technique mainly for differentiating between a vestibular injury and a cerebellar infarct in the ER.

Hey Tess - you're welcome. I love learning about this junk and passing on any info as we all do...imagine if we relied strictly on the GP or ENT for accurate info - nightmare!

Scott

I just noticed in the Archive that there is a link there to a paper by Professor Halmagyi I hadn't read myself. As it turns out this paper is pretty much identical to the lecture he gave Thursday complete with diagrams of the "Head Impulse Test" he performed on me for anyone interested reading more on the topic.

(Preapproved by Mod1)

http://jnnp.bmjjournals.com/cgi/content/full/68/2/129

Scott

Hi Scott,

You have certainly WOWED us with this great information. I am going to save this for the various Dr's I have been seeing both in Pennsylvania and Florida.

Thanks you so very much for the time it took to get this out to us. I am sure I speak for everyone on this board in thanking you for your knowledge and dedication. We are a world apart, yet so close.....

Nice work,
Linda

Scott

Thank You soooooooo much for this posting. Front Row seat, oh yeah, tell the vestibular story straight up!! :bouncing:

It's so good to know that Dr's are out there doing research and recognize the difficulty of treating the problem.

When I had the eye test done, you know the one with the goggles it showed the nystagmus and this was ebough for Dr to give me BPPV diagnosis, I feel the nystagmus most days, even when I am not dizzy so it makes sense to me that it is inner ear even more now based on what they said in the lecture. What I am still confused about is what the difference in nystagmus is between Labs and BPPV. But I guess the end results of both are the same?

Have not been on board in a while. Been busier lately which I think is a good sign. So it was a nice surprise to find this write up.

Thank You
Thank You
Jade :angel:

Hi Jade,

Great to see you back on the HB...but not because you're feeling worse I hope! From what I gather, eye nystagmus only occurs in BPPV and not in labyrinthitis (someone correct me if I'm wrong) although it's possible to have some BPPV after a lab attack, which could cause nystagmus. This happened to me but only once in the night last May. I def experienced some serious nystagmus when I turned my head to the right on my pillow just like I did in the caloric test. Actually, this probably further shows evidence that the right lateral canal is shot in my ear. Labs on the other hand will either temporarily or permanently trash some of the semi-circular canals, usually on one side only and no more than 2 canals (3 inflamed canals is extremely rare). This, of course, can be diagnosed by the siccades eye movements with a sudden head turn I explained earlier. Ain't this stuff just wonderful?

Best...Scott :cool:

ps good to hear you're busy and keeping your mind off of this thing.

hello from england
my name is demilee i am a new to the forum i have been reading all your replys about ear problems i am so exited to be a member of this group if you will all have me,i have been very sick for a few months now not knowing whats wrong with me im at my wits end 3 weeks ago i guess it just come to a head i started to feel realy dizzy and sick to the extent of not being able to function normaly managed to get into the ent to see the doc she said i may have menears disease but i have to wait 6 weeks for tests to be done at the balance clinic, i feel so frightend with whats happening to me as i cant get rid of the foggy heads and lighteness feeling and the nausea im a prisoner in my own home as i have to lay down a lot and cant do anything,would be so gratefull for any sugestions from all, i feel such a fool please forgive me if im going on a bit about it as i feel so alone and tired all the time, thank you

demilee

Scott,

What an awesome experience for you! So, did all the lame silent docs in the audience think you were some sort of expert or doc yourself?! :D

I wasn't clear; is there a difference between Saccades and nystagmus?

Glad to hear you're still feeling better.

T

Hi Demilee,

You are most very welcome to this board. You'll find there's lots of people here who will assisit you with ideas etc at anytime. Maybe good if you start a new thread with your story to make sure everyone sees it. All of the symptoms you describe are very normal for inner ear problems. I had all the same feelings as you, especially the prisoner in my own home - horrible stuff. But I promise you, things will come good again. It takes great patience and perseverence to win this battle but you will do it. Be very aware of your anxiety levels or any depression that comes with this mess....it's essential that it doesn't become set in or hang around indefinitely as this will really slow your healing and compensation. It's early days for you at 3 weeks and you may in fact be able to say goodbye to it within 6 weeks. This is quite common.

Hang in there and post any questions you have.

Hi Terri - Yeah, it was cool sitting in the seminar. Wish it went longer than it did (first time I've said that about a lecture!). Nystagmus is what you would have experienced with BPPV, that is, a turn of the head caused your eyes to jump back and forth rapidly for about 10-15 seconds before stopping. Did you get this? While this happened things in your vision would have been jumping back and forth. Saccades eye movements are those quick "adjustment" eye movements we use everyday while looking around. They are very fast but a little slow to react (about 100 ms). A quick head turn with a stuffed up inner ear means the eyes will rely on saccades movement only to readjust the eyes onto a target....and you can see the 100 ms lag. When the labyrinth is communicating with the eye properly, however, they work in sync and there is no 100 ms lag. Smooth as icing on a cake!

Cheers....Scott :cool:

Hi Demilee,

You are most very welcome to this board. You'll find there's lots of people here who will assisit you with ideas etc at anytime. Maybe good if you start a new thread with your story to make sure everyone sees it. All of the symptoms you describe are very normal for inner ear problems. I had all the same feelings as you, especially the prisoner in my own home - horrible stuff. But I promise you, things will come good again. It takes great patience and perseverence to win this battle but you will do it. Be very aware of your anxiety levels or any depression that comes with this mess....it's essential that it doesn't become set in or hang around indefinitely as this will really slow your healing and compensation. It's early days for you at 3 weeks and you may in fact be able to say goodbye to it within 6 weeks. This is quite common.

Hang in there and post any questions you have.

Hi Terri - Yeah, it was cool sitting in the seminar. Wish it went longer than it did (first time I've said that about a lecture!). Nystagmus is what you would have experienced with BPPV, that is, a turn of the head caused your eyes to jump back and forth rapidly for about 10-15 seconds before stopping. Did you get this? While this happened things in your vision would have been jumping back and forth. Saccades eye movements are those quick "adjustment" eye movements we use everyday while looking around. They are very fast but a little slow to react (about 100 ms). A quick head turn with a stuffed up inner ear means the eyes will rely on saccades movement only to readjust the eyes onto a target....and you can see the 100 ms lag. When the labyrinth is communicating with the eye properly, however, they work in sync and there is no 100 ms lag. Smooth as icing on a cake!

Cheers....Scott :cool:
thank you sooo mutch scott for your kind reply it means a lot to me as you will know it makes you feel so alone when your like this some days you feel life isnt worth living but i feel mutch better now i have found people in the same situation as myself and i know im not going crazy...............thanks a million.......

Scott, you lucky duck!

I know we all would have loved to have been there. I've always admired and appreciated your feedback you give to all on this board. You've outdone yourself now.

Thank you so much. I will print that out and take it with me to every doctor I see. I have to agree with jade, I am so glad that there are docs who are working on this. Actually I'm quite shocked. Like my family doctor told me, "they like to put people like you in a throw away bin, don't let anyone do that to you".

What a wealth of information we all have now, thanks to you. And thank you for pinning down on the Saccades. Talk about making it crystal clear!!!

I'm sure you know how much it means to someone to get such a straight forward barrel of information from someone so knowledgable. That's more than what most of us have received after yearssssssssssssss of searching.

You are a credit to this board. I nominate you for Chief Investigator. :)

Thanks again for taking the time, it justs proves to us here, and any new arrivals that we really do care for each other.

Much love, xxxxxxxxxxx

SL

Hey Scott:
I read your post about the seminar with much interest. Also checked out the corresponding article in the archive. Very cool stuff...thank you again for sharing what you have learned/experienced to help others in the process...
I had one question for you. This is something that has confused me and now I am convinced that there is some disagreement on the definition of "vertigo"
Evidently this doctor makes a def. distinction between spinning(vertigo) and disquelibrium.
I was just curious if he had anything to say about those of us with "disquelibrium".
I appreciate your taking the time to share such great info. with the board. :)
Elisabeth

Hi Terri - Yeah, it was cool sitting in the seminar. Wish it went longer than it did (first time I've said that about a lecture!). Nystagmus is what you would have experienced with BPPV, that is, a turn of the head caused your eyes to jump back and forth rapidly for about 10-15 seconds before stopping. Did you get this? While this happened things in your vision would have been jumping back and forth. Saccades eye movements are those quick "adjustment" eye movements we use everyday while looking around. They are very fast but a little slow to react (about 100 ms). A quick head turn with a stuffed up inner ear means the eyes will rely on saccades movement only to readjust the eyes onto a target....and you can see the 100 ms lag. When the labyrinth is communicating with the eye properly, however, they work in sync and there is no 100 ms lag. Smooth as icing on a cake!

Cheers....Scott :cool:

Hi Scott,

Thanks for the clarification. Boy did I ever get nystagmus! It was kinda cool in a weird, party trick sorta way. I showed my husband one time and he couldn't believe my eyes were doing that. Freaked him out! Luckily I never had nausea or anything with any of this stuff, so I could trigger the nystagmus just so people could see my eyes ping-ponging and understand what I was going through. It was also the hallmark that indicated to my ENT while doing the Epley that I def had BPPV.

Feeling a bit spacey the past couple days, but I think it's those damn hormones again. God I wish I were a man sometimes!

See ya :wave:
T

Hey Sharalee - such nice things you have said - you made my day! LOL...like the Chief Investigator title!

Elisabeth - I actually asked him specifically if he could expand on what exactly he thought caused disequilibrium and why it hung around for so long. He didn't give me a concrete answer because I don't think he really knows! He was clear on vertigo per se but not the stuff that hangs around for a long time in some of us. My guess is that disequilibrium is really not unlike being slightly drunk, in that the same mechanisms are at work. That's how it feels to me anyway.

From W-pedia: Inside the inner ears is a flexible blob called a cupula which moves when the body moves. This brushes against hairs in the ear, creating nerve impulses that travel through the vestibulocochlear nerve (Cranial nerve VIII) into the brain. However, when alcohol gets into the bloodstream it distorts the shape of the cupula, causing it to keep pressing onto the hairs. These 'fake' nerve impulse tells the brain that the body is rotating, causing disorientation and making the eyes spin round to compensate.

I reckon the damage that goes down in the labyrinth produces similar mixed up signals thus causing disequilibrium when slightly upset and more dizzy-like sensations when the irritation is much worse. Just a guess though and probably far more complex than that.

Terri - bummer about the spacey feeling. I'm still getting the odd day of that and I am a male! I gotta say, I am glad that I don't have to deal with the monthly hormonal thing some of you do on top of all of this. My fiance has a rough time with it....better it was me with labs than her that's for sure.

Scott :cool:

Scott: Thanks for the write up.

To add what I know, which may help clear some things up. When people talk about Frequency in respect to the vestibular system, they are talking about response to movement at various speeds, - as you rightly said in your analagy of hearing at different frequencies. When you move your head so you get 2 shakes per second then your vestibular system is receiving signals at 2hz, 4 shakes then 4hz etc etc. And just like your hearing it can become dysfunctional at different frequencies (for example some people having low frequency hearing loss, where they can't here low sounds properly), so it may only be at low speeds, or high speeds which causes you vestibular signals to be faulty. This is the main reason why the caloric tests aren't too accurate, as the test only tests your vestibular apparatus at certain frequencies (ie the frequency which happens to correspond with the stimulation brought about by the water/air). Also, calorics can't fully test the lateral canals, as the response from both sides work almost in unison (as opposed to the signals being opposites like the other canals).

The in office saccade tests he's describing are exactly what parts of the ENG and the rotation chair does, however I should image that the electrodes would be far more accurate than his eyes, and particular subtle saccade patterns are very informative about certain conditions (ie BPPV). But he has the advantage of being able to try several frequencies (ie moving/spinning your head at several speeds, until he sees the reaction he's looking for).

Nystagmus, is present at some stage in most vestibular disorders. Sponteanous nystagmus always occurs in labs/vn (it comes with the room spinning visuals), however it is usually quickly suppressed, but it can occur again on stimulation (ie when you get dizzy - but then it's not spontaneous), but it would not usually be present by the time any testing is carried out.

Thanks BennyGibb - this sounds correct to me and sounds like what he would have been referring to with regard to "frequency" of inner ear movements. In fact he did say that saccades eye movements will handle signals of up to 60 Hz, after which there is a lag in eye adjustment, that is, if the vestibular system is not working correctly with the eye, there will be that 100 ms lag in the eye's adjustment and the viewer will see the eye suddenly "flick" back onto the target. I don't recall having this done during the ENG, but I may have had it done and they missed it. I was so disorientated and messed up that day so early into labyrinthitis, that I really can't recall. I'll never forget the caloric however! That is permanently etched in my brain.

Best.....Scott

Scott and BennyGibb:
Geez...I'm sure glad there are people like you who have the heads and the patience to investigate all the technical aspects of this stuff for those of us who don't...if you guys don't already have Phd's in this area, I think you should get some honorary degrees for all the time you've put in.
Bet you were good in math too :rolleyes: