Project

by

Careen Young, M.S., CCC-A

SPA7317

Fall 1999-A

Scott K. Griffiths, Ph.D.

Positional Alcohol Nystagmus

Ingestion of alcohol has a great effect on the balance function test battery that we provide to patients today.  The effect is thought to originate in the peripheral labyrinth.  The Buoyancy hypothesis best explains what happens.  Alcohol is lighter than endolymph and when blood level approach 40mg/dL, alcohol diffuses into the cupula, rendering it lighter than endolymph, thereby transforming the semicircular canals into gravity – sensitive receptors.

Initially, the nystagmus is direction changing with changes in head position (beating toward the undermost ear).  This nystagmus appears approximately ½ hour after initial ingestion of the alcohol.  Although this nystagmust can be present in eyes open, it is more prominent in eyes closed.  There is a silent (intermediate) period beginning between 3.5 and 5 hours after cessation of alcohol ingestion, when positional vertigo is absent.  As time progresses, the direction of PAN reverses (beating toward the uppermost ear).  This second phase is known as PAN II.  Phase II of PAN begins between 5 and 10 hours after cessation of drinking when there is a falling blood level at about 20 mg/dL.  PAN II is usually associated with motion sickness and is concomitant to the hangover.

In addition to nystagmus induced by the buoyancy of all six cupulae, alcohol intoxication also causes a vertical velocity offset that is independent of the orientation of the subject in space.  This offset may represent a toxic effect on central vestibular pathways, producing a tone imbalance of the vertical vestibulo-ocular reflex.

Additionally,  patients with alcohol dependency have larger length of and area covered by the body sway.  The Romberg quotients of both the length and the environmental area tended to be larger.  The oscillation power spectrum obtained with eyes open and that obtained with eyes closed tended to be low at levels below 0.2Hz.  Dynamic posturography can detect the effect of alcohol on static and dynamic equilibrium.  Test conditions with absent vision appear to be the most sensitive.

It is important to remember that direction changing nystagmus can be provoked by alcohol and therefore, we must not attribute this to organic lesions until alcohol has been ruled out as a cause.

Interesting to note is the fact that age-related differences in alcohol impairment are not statistically significant.

Vitamin B-12 Deficiency

It is important to remember, before discussing any particular vitamin, that difficiency of most all vitamins can lead to neuropathy and thus, could potentially effect the balance system as such.

Vitamin B-12 deficiency, also known as Cobalamin or Pernicious Anemia.  Pernicious anaemia is an atrophic gastorpathy in which gastric parietal cells no longer produce hydrochloric acid thus leading to impaired absorption of iron.  This vitamin is also required for proper digestion, absorption of foods, the synthesis of protein, and the metabolism of carbohydrates and fats.  It aids in cell formation and cellular longevity.  In addition, it prevents nerve damage, maintains fertility, and promotes normal growth and development . 

10-30% of people aged 51 years and older may have protein-bound vitamin B-12 malabsorption.  It is more common in the elderly and is attributed to reduced pepsin activity and gastric acid secretion which interferes with cleavage of vitamin B-12 from dietary protein before absorption. The Recommended Dietary Allowance (RDA) currently stands at 2.4 micrograms/day.  The body can store up to five years worth of vitamin B-12.

Deficiency can cause abnormal gait, chronic fatigue, constipation, depression, digestive disorders, dizziness, drowsiness, enlargement of the liver, eye disorders, hallucinations, headaches, inflammation of the tongue, irritability, labored breathing, memory loss, moodiness, nervousness, neurological damage, palpitations, pernicious anemia, ringing in the ears and spinal cord degeneration.

A diagnostic procedure is uncertain in elderly patients with neurological symptoms and in cases with borderline cobalamin values.  Of use today is full blood count to determine cobalamin concentration in serum sample.  However, elderly patients and cases with neurological symptoms present borderline cobalamin values and no abnormalities in the blood count.  Therefore it is important to provide further investigation with methylmalonic acid, homocystein and the Schilling test.  There really does not exist a “gold standard” diagnostic procedure.

Patients with pernicious anaemia must be considered subjects with cumulation of risk factor for atherosclerosis; these risk factor must be actively sought and treated.  Iron deficiency is also a  common finding in patients with pernicious anaemia.

Surgical Trauma

Surgical trauma can happen at any time within the operating room.  Although many are uncommon occurrences, they do happen and sometimes they impact a persons balance system. 

Lateral Semicircular Canal

Surgical trauma to the lateral semicircular canal is a rare complication which does not always result in cochlear damage.  Transient cochlear depression with normalization of function within 6 weeks of trauma occurs in most instances. 

Vestibular symptoms are pronounced and although compensation is not delayed, positional dizziness and instability usually persist for several months and occasionally for a year or more.

Clean injuries away from the ampullary end of the canal occurring in patients without preexisting inner ear disease appear to have a better prognosis.

Intraoperative closure of the defect, postoperative bed rest, and antibiotics are the basic elements of management.

Perforated Membranes

Perforated membranes have dizziness or vertigo combined with disturbances of balance. 

Treatment consists of sealing the round window membrane with a plug of fascia or periostium.

Cochlear Implantation

ENGs performed approximately one month after surgery for cochlear implant.  Many patients showed functional deterioration.  Almost half of the patients reported some kind of subjective dizziness.

There were three types, early, prolonged and delayed.  58% had early dizziness, 34% had prolonged dizziness and 8% had delayed dizziness.

Stapedectomy

Patients undergoing stapedectomy were put through static posturography in order to measure their sway.  Measurements were taken pre-operatively and 1 week, and 6 months after surgery.

Sway was greater at 1 week than pre-operatively.  However, by 6 months, sway measurements were no longer significantly different from pre-op or control values.  It is felt that sway became well compensated by visual and proprioceptive information and resolved fully with time.

Bibliography

Arndt HJ.  Spontaneous perforation of  the membrane of the round window – a major cause of sudden deafness.  Laryngol Rhinol Otol (Stuttg) 1984 Sep;63(9):439-44.

Bachli E, Fehr J.  Diagnosis of vitamin B12 deficiency:  only apparently child’s play.  Schweiz med Wochenschr 199 Jun 12;129(23):861-72.

Barber, Huhg O., Stockewell, Charles W..  Manual of Electronystagmography.  The C.V. Mosby Company.  St. Louis.  1980.

Canalis RF, Gussen R, Abemayor E, Andrews J.  Surgical trauma to the lateral semicircular canal with preservation of hearing.  Laryngoscope 1987 May:97(5):575-81.

Demiroglu H, Dundar S.  Pernicious anaemia patients should be screened for iron deficiency during follow up.  N A Med J 1997 Apr 25;110(1042):147-8.

Fetter, M, et al.  New Insights into positional alcohol nystagmus using three-dimensional eye-movement analysis.  Ann Neurol 1999 Feb;45(2):216-23

Ho C, Kauwell GP, Bailey LB.  Practitioners’ guide to meeting the vitamin B-12 recommended dietary allowance for people aged 51 years and older. J Am Diet Assoc 1999 Jun;99(6):725-7.

Itoh A, Sakata E.  Neurotological examination of patients with alcohol dependency.  Nippoin Jibiinkoka Gakkai Kaiho 1996 Aug;99(8):1110-8

Jacobson, Gary P. et al.  Handbook of Balance Function Testing.  Singular Publishing Group, Inc.  San Diego, California.  1997.

Jones A W, Neri A. Age-related differences in the effects of ethanol on performance and behavior in healthy men.  Alcohol Alcohol 1994 Mar;29(2):171-9

Kessler P, Veberova J, Bradackova I.  Occurrence of diabetes, hyperinsulinism and other risk factor for atherosclerosis in patients with pernicious anemia.  Vnitr Lek 1998 Apr;44(4):222-6.

Kubo T, Sakata Y, Koshimune A, Sakai S, Ameno K, Ijiri I.  Positional nystagmus and body sway after alcohol ingestion.  Am J Otolaryngol 1990 Nove-Dec;11(6):416-9.

Kubo T, Sakata Y, Matsunaga T, Koshimune A, Sakai S, Ameno K, Ijiri I.  Analysis of body sway pattern after alcohol ingestion in human subjects.  Acta Otalaryngol Suppl (Stockh) 1989;468:247-52

Ledin T, Odkvist LM. Effect of alcohol measured by dynamic posturography.  Acta Otolaryngol Suppl (Stockh) 1991;481:576-81.

Lesinski A, Kempf HG, Lenarz T. Tullio phenomenon after cochlear implantation.  HNO 46(7):692-4, 1998 Jul.

Lippy WH, Schuring AG.  Stapedectomy revision following sensorineural hearing loss.  Otolaryngol Head Neck Surg 1984 Oct;92(5):580-2.

Molony NC, Marais J.  Balance after stapedectomy: the measurement of spontaneous sway by posturography.  Clinical Otolaryngology and allied Science.  21(4):353-6, 1996 Aug.

Ribari O, Kustel M, Szirmai A, Repassy G.  Cochlear implantation influences contralateral hearing and vestibular responsiveness.  Acta Oto-Laryngologica 119(2):225-8, 1999 Mar.

Scherer H, Holtmann S.  Modification of vestibular tests by alcohol.  Laryngol Rhinol Otol (Stuttg) 1983 Dec;62(12):558-60.

Umeda Y, Sakata E.  Alcohol and the oculomotor system.  Ann Otol Rhinol Laryngol 1978 May-Jun;87(3Pt 1):392-8.