BENIGN POSITIONAL
PAROXYSMAL VERTIGO,
TINNITUS, AND HYPACUSIA
IN A 48-YEARS WOMAN,
TREATED WITH ANTISTRESS
DRUGS.
Renato Cocchi, a neurologist and a medical
psychologist.
Abstract.
This report deals with of the case of a
48-yeras-old woman suffering from Benign Positional Paroxysmal Vertigo (BPPV), tinnitus
and biauricular hypacusia. In her history there was not hypertension, diabetes,
labyrinthine infections, vascular troubles of the vertebral arteries, etc. It
is supposed that the BPPV can rise up even from a district excess of the
glutamate.
Its neurotoxicity could also have notched
the hearing organ, so producing both hypacusia and tinnitus. An external stress
was not found, but we cannot exclude some stress as a consequence of the
illness itself, driving to depression.
The woman had one-month treatment with
antistress drugs, with reduction of the intensity of the BPPV episodes with
related following asthenia and reduced need to leave from her job. Till now,
she did not feel any improvement on the tinnitus and on the hypacusia
Key words: Benign positional paroxysmal
vertigo, tinnitus, hypacusia, stress, glutamate, GABA, antistress drug therapy.
Drug modulation of stress responses
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I t came to my observation the case of a
woman suffering from several years, recently from benign positional paroxysmal
vertigo (BPPV) which followed the tinnitus and a hypacusia. It deserved a
report either for the link between BPPV and hypacusia, already mentioned when I
described the preceding BPPV case (Cocchi, 2003 ), either because again treated
with antistress drugs, at least as first approach.
The case history.
08 September 2003. F, she was 48 years old
at the first consultation, and in menopause. Till now she did not find any
relief to his troubles, in spite of the many consulted specialist physicians.
She suffers from continuous tinnitus in the
right ear, like a whistle, of varying intensity. She started to have it in 1997
when she was 42, and she feels it even at night. Now she hears it desultorily
even to left ear.
Lately vertigoes occurred, which start with
a strange sensation from her stomach, followed by objective vertigoes, with
nausea, vomit, diarrhea, alternating feelings of heat and cool. After the dizzy
episode she is asthenic and has the need to rest.
Brain NMR and CAT resulted negative.
She told of a severe hearing loss to the
right ear, for which now she holds the telephone receiver in her left side. Her
right ear is oversensitive to the noise.
Three audiometer tests between November 2002
and March 2003 showed a 50-70 decibel fall to the right ear from 250 to 8000
Hz. This fall had greater severity between 250 and 1000 Hz. As for the left
ear, there is a linear fall of 20 decibels between 250 and 8000 Hz.
Interesting is the fact that for both ears,
but mainly in the left one, the hearing fall overlaps both the air and the bone
pathways. This shows neurisensorial deafness. At the right side, the threshold
of the auditory response inclines to overlap the pain threshold.
Possible signs of unstable half-brain
dominance: She normally has right dominance. To the test "Which is the
opposite of red colour," she answers instinctively White, which is the
opposite of the colour Black. Abruptly bad feelings against otherwise beloved
persons can occur but she refuses these feelings as extraneous to her
personality. She used to have ugly dreams.
She has depressive moments, suffers more the
cool. There is active searching of sweets a few more than the normal, in
particular the chocolate. She likes the meat broth and she would prefer it to
the pasta. Potentially she has dry hairs, but she used to dye them. She doesn't
have cramps, but muscular tension, and she doesn't slobber during the sleep. In
the mornings she wakes up tired. Disbandment and faint feelings occur. She has
mediastinal oppression and lump in the throat, which last she tries to resolve
by drinking something. No colics nor diarrheas outside the vertigo episodes
occur.
She has pallor days with accentuated eye
sockets, but no blood hypotension either now or in past. Diffused oversweating
is very frequent. The need to count objects or other is denied, as well as
nighttime bruxism, or jaw's tension by day. She does better in the mornings. Besides,
she reports tachycardia and air hunger. Normal bowel function. She is not
hungry in the morning. She suffers from alternating migraine, at times in the
right side or in the left side.
Specially asked on it, she cannot give
information on her birth and her behaviour during the first year of life.
Other: She was always emotionally
hypersensitive and very tidy-up. She fears to lose her job, if will have
continuously to leave for this illness.
Therapy (daily doses, by the oral via):
Carbamazepine 200mg; pyridoxine 75mg; amitriptyline 4mg; bromazepam 0.6mg; A
polyvitaminic compound with mineral salts, one tablet every week.
15 October 2003: The first checkup.
Vertigoes: A little improved for what concerns
them; They last now less time. Every attack in past was stronger, while since
she does this drug therapy, only one episode was severe. First the vertigoes
lasted 10-15 minutes [Is this time overestimated?], and profound fatigue left,
for which she had to lie down to recover her strength.
Now she has very short lasting fits, which
not leave her prostrate, and then she has less need to rest after each attack.
No any nausea, vomit and other previous symptoms had recurred. She thinks that
the vertigoes are "more manageable," and she did not have any episode
at night.
Tinnitus: Unchanged, if not worsened to the
left ear. She is going on to feel it even during the night.
Hypacusia: She did not observe any
improvement and she cannot phone with the receiver at the right ear. The right
ear is always hypersensitive to noises.
Possible problems of opposite half-brain
dominance: More frequents ugly dreams. There is still an emergency of bad
feelings against otherwise beloved persons.
Stress symptoms: Depression did not reduce,
but missing muscular tension. She has eaten less chocolate, has little more
energy, fewer sensations of disbandment and faint; less anxiety, less
mediastinal oppression, less lump in the throat, less eye sockets; less
oversweating.
No more tachycardia reported, and less air
hunger.
One migraine episode of the right side but
her EEG is without signs of previous brain suffering. The present author
controlled the polygraphs. She suffers from the cold as first and is doing a
little best even in the afternoon.
Other: Always emotionally hypersensitive and
always very tidy-up. She did not have the menses, in spite of an episode of
premenstrual syndrome. She had less necessity of leaving from the job.
Therapeutic variation (daily dosing, by the
oral via ): Glutamine 125mg; carbamazepine 300mg; amitriptyline 10mg.
Discussion.
The association among tinnitus, hypacusia
and BPPV is surely of great interest and it results from Medline that it did
not receive much specific attention. Kessinger and Boneva, 2000, describe this
association in geriatric patients.
As I think, the three symptoms could have,
as the only causal agent, a glutamate excess, from his reduced transformation
into GABA.
When the amount of brain glutamate
increases, also the hypothalamus stimulation of the dorsal nucleus of the
vague, and of the nucleus of the solitary tract, grows. Both are the starting
points of the pararasympathetic stimulation, mainly neuroendocrine, in stress
conditions (Brann, 1995).
If we can succeed to reactivate the
transformation of the glutamate into GABA, reducing in this way the glutamate
excess, many symptoms improved could have done so, by following the reduced
glutamergic stimulation.
In this woman, after an antistress drug
therapy lasting one month, I think we may attribute to that the reduction of
the feelings of disbandment and of faint; of the mediastinal oppression, of the
lump in the throat.
Compensating symptoms also reduced, being
their functional needs decreased. In particular: The chocolate intake reduced (
The chocolate contains theobromine, a sympathetic mimetic amine); The
tachycardia missed (A compensating sympathetic symptom against the vagal
overstimulation); The air hunger reduced (A detension mechanism of the muscles
of the chest? The patient previously reported generalized muscular hypertony);
Oversweating reduced (Due to sympathetic compensating overfunction in a person
with low blood tension?).
Why in this patient could have happened an
increase of the brain glutamate? Quite certainly she already had a reduced
response to the stress, which always runs primarily on the GABA-glutamate
reverse pathway (Horger and Roth, 1995; Cocchi, 2003a).
Indications in this concern could be the
long lasting hypersensitiveness and the habit of being always tidy-up.
With the ageing and the starting of the
menopause, it may have been a reduction of the threshold of the response to
stress, as it normally happens following these two events. But, here, the
threshold has become too low, the normal response of the type A GABAergic
inhibition reduced because the reduction of the related receptors. (Cocchi,
Patrucco, Zerbi 1987). At the end the rate increased of the glutamate, could
have notched the cochlea and the balance organ, both being in this person, more
sensitive to the toxicity of the glutamate (Cocchi, 2003b ).
The oversensitiveness to the noise finds its
correspondent in the audiogram that shows an overlapping of the auditory
threshold and the pain threshold, in the right ear.
Compared to the first reported case (Cocchi,
2003a), there are elements in common: Gender, hyperactive personality,
peripheral feeling at once preceding the attack, hearing loss.
They disagree instead for the age of the
onset, the symptoms' progression, the tinnitus presence, a clear link with
stress.
After one month from the beginning of an
antistress drug therapy, the patient here described has noticed a reduction of
the vertigoes' severity, with the correspondent of a smaller asthenia after the
attack, and a smaller need to leave from the job.
Conclusions.
In 48-yeras-old woman suffering from Benign
Positional Paroxysmal Vertigo, tinnitus and biauricular hypacusia, it was
supposed that the BPPV can rise even from a district excess of the glutamate.
Its neurotoxicity could also have notched
the hearing organ, so producing both hypacusia and tinnitus. An external stress
was not found, but we cannot exclude some stress as a consequence of the
illness itself, driving to depression.
The woman had one-month treatment with antistress
drugs, with reduction of the severity of the BPPV episodes with related
following asthenia and reduced need to leave from her job. Till now, she did
not feel any improvement on the tinnitus and on the hypacusia
References.
Brann DW. Glutamate: a
major excitatory transmitter in neurendocrine regulation. Neurendocrinology
1995, 61: 213-225.
Cocchi R. Vertigine Parossistica Posizionale
Benigna e stress: Storia di un caso trattato con farmaci antistress. Immesso su Internet nel giugno 2003a ( www.stress-cocchi.net/Other5-it.htm ).
Cocchi R. Occorrerà
recuperare la nozione clinica di "terreno individuale"? Lo
Spallanzani, 2003b, 17: 19-22. (www.stress-cocchi.net/Speculation4-it.htm).
Cocchi R., Patrucco M.,
Zerbi F.: Presupposti razionali per l'aggiuntá di una benzodiazepina alle
forme epilettiche non controllate in monoterapia. Riv. Neurobiologia
1987, 33: 33-48.
Horger BA, Roth RH.
Stress and central amino acid system. In: Friedman MJ, Charney DS, Deutch AJ.
(eds). Neurobiological and clinical consequences of stress: From normal
adaptation to PTSD. Philadelphia, Lippincott-Raven 1995: 61-81.
Kessinger R.C., Boneva
D.V. Vertigo, tinnitus, and hearing loss in the geriatric patient.: J
Manipulative Physiol Ther. 2000,23: 352-362.
Posted on Internet on October 2003:
Copyright by Renato Cocchi 2003.
Author's address: dr Renato COCCHI, via Rabbeno, 3
42100 Reggio Emilia
renatococchi@libero.it
Drug modulation of stress responses
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