MANAGEMENT OF BALANCE DISORDERS MANAGEMENT OF BALANCE DISORDERS CLINICAL HISTORY AND PHYSICAL EXAMINATION A thorough interview Dr Sandeep tries to understand in detail the symptoms, their duration, triggers, and any accompanying issues like hearing loss or tinnitus. A detailed physical examination is then performed, this includes assessing the ears, neurological functions, and certain reflexes related to balance. DIX-HALLPIKE MANOEUVRE AND ROLL TEST This test is used specifically for suspected cases of BPPV, this involves moving the patient’s head in certain ways to provoke symptoms and observe for abnormal eye movements, aiding in diagnosis. AUDIOLOGICAL TESTS Pure-Tone Audiometry: Measures the softest sound a person can hear at different frequencies. Tympanometry: Assesses the condition of the middle ear and mobility of the eardrum. VESTIBULAR TESTS Videonystagmography (VNG): Records eye movements to assess balance function. Electronystagmography (ENG): Similar to VNG but uses electrodes. Vestibular Evoked Myogenic Potential (VEMP): Measures the responses of muscles in the neck and around the eyes to gauge vestibular function and diagnose the particular part of the inner ear involved in balance disorder. IMAGING STUDIES MRI Provides detailed images of the inner ear and brain, useful for ruling out tumours like vestibular schwannoma or neurological issues. CT Scan Can be used to identify abnormalities or infections in the ear structures. It is particularly useful for diagnosing superior semi-circular canal dehiscence leading to vertigo. LABORATORY TESTS Blood tests may be done to check for infections, autoimmune disorders, or other underlying systemic conditions. In rare cases, a lumbar puncture might be considered to rule out central nervous system disorders. POSTUROGRAPHY This test measures how well a person can maintain upright posture in different environmental conditions. It’s especially useful for diagnosing non-specific balance disorders. GAIT ANALYSIS An assessment of the patient’s walking pattern to identify any irregularities that may be contributing to balance issues. PSYCHOLOGICAL ASSESSMENT Sometimes, balance disorders can have a psychological component, especially in cases of phobic postural vertigo. A psychological evaluation may be advised. ADDITIONAL SPECIALISED TESTS Depending on the suspected underlying cause, additional tests like a glucose tolerance test for diagnosing metabolic disorders may be considered. Dr Sandeep Uppal and his expert team employ a combination of these diagnostic tools to ensure a thorough understanding of each patient’s condition. With state-of-the-art equipment and a patient-centric approach, they aim to provide the most accurate diagnosis, which is the cornerstone for effective treatment and management of balance disorders and vertigo. COORDINATED CARE WITH CARDIOLOGY Why a Cardiology Opinion? While ENT specialists primarily focus on issues related to the ear, nose, and throat, it’s essential to rule out cardiovascular problems that can sometimes mimic or contribute to balance issues. For patients who require it, Dr Sandeep Uppal and his team coordinate closely with cardiologists. This multidisciplinary approach ensures that any cardiac-related causes of dizziness or balance issues are comprehensively addressed, allowing for a more targeted and effective treatment plan. ORTHOSTATIC HYPOTENSION A sudden drop in blood pressure upon standing can cause dizziness and falls. It’s crucial to rule out cardiovascular causes for this. ARRHYTHMIAS Irregular heartbeats can sometimes cause episodes of dizziness or feeling faint. Tests like an ECG or Holter monitoring can be valuable. CAROTID ARTERY STENOSIS Narrowing of the carotid arteries can reduce blood flow to the brain, causing balance issues and dizziness. This may require imaging tests like carotid ultrasound. VALVULAR HEART DISEASE Some antihypertensive or heart medications can have side effects like dizziness or imbalance. A cardiology review can help in medication adjustment. MEDICATION SIDE EFFECTS Some antihypertensive or heart medications can have side effects like dizziness or imbalance. A cardiology review can help in medication adjustment. Diagnostic Tests in Cardiology Electrocardiogram (ECG): To detect arrhythmias or other cardiac anomalies. Holter Monitoring: A 24-hour ECG to catch intermittent arrhythmias. Echocardiogram: To visualize the heart valves and other structures. Blood Tests: To check for markers of heart disease. Stress Tests: To assess cardiovascular fitness and blood flow. TREATMENT OF SPECIFIC BALANCE DISORDERS BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) Canalith Repositioning Procedures: Epley or Semont manoeuvre to move the dislodged crystals back to their original location. Vestibular Rehabilitation: Exercises to improve balance and reduce dizziness. Medications: Usually not required, but meclizine or diazepam may be prescribed for short-term relief. MÉNIÈRE’S DISEASE Dietary Modifications: Low salt diet to reduce fluid retention. Diuretics: To control fluid levels in the inner ear. Intra-tympanic Steroid Injections: For severe vertigo attacks. Surgical Options: Endolymphatic sac decompression or vestibular nerve section in extreme cases. VESTIBULAR NEURITIS Corticosteroids: To reduce inflammation of the vestibular nerve. Antiviral Medications: If a viral infection is suspected. Vestibular Rehabilitation: To help with balance issues post-recovery. LABYRINTHITIS Antibiotics or Antivirals: If the cause is bacterial or viral. Corticosteroids: To reduce inflammation. Symptomatic Treatment: Antiemetics for nausea and antihistamines for dizziness. Vestibular Rehabilitation: For persistent balance issues. CENTRAL VERTIGO Identification and Treatment of Underlying Condition: Such as medication for multiple sclerosis or surgery for brain tumours. Symptomatic Treatment: Antihistamines or anticholinergics for dizziness. Physical Therapy: Adaptation exercises for improving balance and coordination. GENERAL TREATMENT OPTIONS Medications: Antihistamines like meclizine, anticholinergics like scopolamine, or benzodiazepines like diazepam are often used for symptomatic relief. Lifestyle Modifications: Stress management techniques like mindfulness and relaxation exercises can sometimes help in managing vertigo symptoms. Ongoing Care: Dr Sandeep and his team offer long-term follow-up care to monitor symptoms and modify treatment strategies as needed. COMPREHENSIVE CARE FOR BALANCE AND DIZZINESS AT THE ENT CLINIC Dr Sandeep Uppal and his team specialize in providing meticulous examinations to identify potential causes, ensuring expert diagnosis and a wide range of treatment options for various balance disorders. Their commitment to excellence includes the utilization of cutting-edge diagnostic technologies and evidence-based therapies, guaranteeing patients receive the highest standard of care. Their holistic approach seamlessly integrates state-of-the-art diagnostic techniques and evidence-based treatments, aiming to deliver individually tailored and thorough care for individuals dealing with balance and vertigo disorders. Take action now by scheduling an appointment with Dr Sandeep Uppal, highly experienced ENT Specialist based in Singapore, through our or connecting with us via

HOW DO WE MAINTAIN BALANCE? NORMAL BALANCE MECHANISM: AN OVERVIEW Balance is a complex bodily function that allows us to stay upright and navigate through our environment. Understanding the nuances of the balance mechanism is crucial for diagnosing and treating related disorders. This guide aims to explain how the normal balance mechanism operates within the human body. KEY COMPONENTS INVOLVED IN BALANCE INNER EAR Contains the peripheral vestibular system responsible for detecting changes in head position and motion. EYES Provide visual cues to help orient the body in space. PROPRIOCEPTORS Sensation from touch and vibration receptors located in muscles and joints that provide information about body position. CENTRAL NERVOUS SYSTEM (BRAIN) Processes information received from the inner ear, eyes, and proprioceptors to control balance. VESTIBULAR SYSTEM IN THE INNER EAR The vestibular system is a key component of the balance mechanism. It consists of three semi-circular canals and two otolith organs (utricle and saccule): SEMICIRCULAR CANALS Detect rotational movements. OTOLITH ORGANS Sense linear movements and gravitational force. THE BALANCE PROCESS DETECTION OF MOVEMENT Any head or body movement stimulates the vestibular system in the inner ear. SIGNAL TRANSMISSION These stimulations are converted into electrical signals and sent to the brain via the vestibular nerve. INTEGRATION OF INFORMATION The brain receives signals from the vestibular system, eyes, and proprioceptors and integrates this information to assess the body’s position and motion. MOTOR RESPONSE Based on the integrated information, the brain sends commands to muscles to make necessary adjustments to maintain balance and orientation. FEEDBACK LOOP This process is continuous, providing real-time updates to the brain to sustain balance during all forms of activity and rest. BALANCE DISORDERS Balance disorders encompass various conditions, including benign paroxysmal positional vertigo (BPPV), Meniere’s disease, and vestibular neuritis, affecting the inner ear’s function and causing dizziness and vertigo. Other disorders like labyrinthitis and acoustic neuroma involve the vestibular nerve, leading to balance problems. Additionally, conditions such as postural orthostatic tachycardia syndrome (POTS) can disrupt autonomic nervous system function, impacting balance. READ MORE ABOUT MANAGEMENT OF BALANCE DISORDERS HERE>> REGAIN STABILITY AND CONFIDENCE IN YOUR LIFE Do not let balance issues compromise your daily life and well-being. Take a proactive step towards finding solutions by scheduling a consultation with Dr Sandeep Uppal and his team at The ENT Clinic. We offer a holistic approach to address and manage balance issues, helping you regain stability and confidence in your everyday activities. Trust The ENT Clinic to help you find your balance and live life to the fullest.

Vestibular Evoked Myogenic Potential (VEMP) testing Vestibular Evoked Myogenic Potential (VEMP) testing is a specialized diagnostic tool that Dr Sandeep Uppal and his team at The ENT Clinic frequently use for assessing the integrity of specific parts of the vestibular (balance) system. VEMP testing can offer invaluable insights into the functioning of the saccule and the inferior vestibular nerve, as well as the utricle, depending on the type of VEMP test conducted. TYPES OF VEMP TESTS CERVICAL VEMP (CVEMP) Details: Evaluates saccular function and the inferior vestibular nerve. Procedure: A loud sound stimulus, usually a click or a tone burst, is delivered to one ear via headphones, while the patient’s neck muscle responses are monitored through electrodes placed on the skin over the sternocleidomastoid muscle. OCULAR VEMP (OVEMP) Details: Primarily used to assess the utricle and the superior vestibular nerve. Procedure: Similar to cVEMP but the electrodes are placed below the eyes, and the eye muscles’ responses are recorded. UTILITY IN DIAGNOSIS INTERPRETATION Normal Response: Indicates that the vestibular organs and pathways are functioning well. Abnormal Response: Could suggest a dysfunction at some point along the vestibular pathway, such as a damaged saccule, utricle, or vestibular nerve. DIFFERENTIATING PERIPHERAL VS. CENTRAL ISSUES Details: A normal VEMP result often indicates that the peripheral vestibular system, which includes parts of the inner ear and vestibular nerve, is functioning correctly. An abnormal result, when correlated with other diagnostic findings, could suggest a central nervous system issue, such as a brainstem disorder or cerebellar pathology. Significance: Helps in tailoring the treatment approach by identifying the origin of the problem. MÉNIÈRE’S DISEASE Details: VEMP testing can show hyper-responsive or diminished reflexes in the affected ear, which may indicate endolymphatic hydrops—a condition where there is an excess of fluid in the inner ear. Significance: Helps in confirming the diagnosis and may influence the choice of surgical procedures like endolymphatic sac decompression. VESTIBULAR NEURITIS Details: An abnormal VEMP test might indicate an issue with the inferior vestibular nerve, which is often involved in vestibular neuritis. Significance: The test aids in determining whether vestibular neuritis is the cause of vertigo and whether the neuritis is affecting the saccule and its connecting nerve. SUPERIOR CANAL DEHISCENCE Details: Patients with this condition often exhibit abnormally low VEMP thresholds or heightened amplitudes, suggesting increased sensitivity of the vestibular reflexes. Significance: It provides valuable diagnostic information, which could be corroborated with imaging studies for a definitive diagnosis. ADVANTAGES Non-invasive: One of the key benefits of VEMP testing is that it does not require any surgical procedures or injections, making it a low-risk option. Speed: The test can be completed relatively quickly, often within 30 to 60 minutes, which is beneficial for patient comfort. Specificity: VEMP can specifically target different components of the vestibular system, such as the saccule and utricle, providing targeted diagnostic information. LIMITATIONS Hearing Loss: The test may not be useful in individuals with significant hearing loss, as an adequate auditory stimulus is required. Patient Cooperation: The test requires the patient to maintain certain postures and muscle contractions, which may be difficult for some individuals. By incorporating VEMP testing into their diagnostic arsenal, Dr Sandeep Uppal and his team at The ENT Clinic are able to offer comprehensive evaluations for patients suffering from balance disorders and vertigo. This allows them to create highly tailored treatment plans aimed at addressing the root causes of these conditions.