The Portland Otologic Clinic (POC) is organized and dedicated to the diagnosis and treatment of the more complex cases involving the ear and related structures, with particular emphasis on chronic disorders involving vertigo and imbalance. The POC has remained at the forefront in developing new methods for managing vestibular conditions.

By and large, these involve a change from the traditional methods of treatment, emphasizing definitive methods over symptomatic treatment, and minimally invasive methods over surgical treatment.

John M. Epley, M.D., founder and medical director of the Portland Otologic Clinic, developed the canalith repositioning procedure, known internationally as the "Epley Maneuvers". This is an effective, non-invasive treatment for a common type of vertigo known as benign paroxysmal positional vertigo(BPPV).

New Diagnostic Methods

The first imperative of treating "dizziness disorders" is proper diagnosis. The POC has pioneered the development of specific tests that have have been invaluable in the diagnosis of the more complex vestibular disorders. This has allowed us to successfully treat conditions that could not be identified, or even detected, by routine vestibular testing.

	Positional Vertigo(BPPV)
	New Treatment via the Round Window
	Meniere’s Disease Treatment
	Post-traumatic Vertigo

Positional Vertigo

We have proven that the cause of positional vertigo is abnormal, displaced particles, called canaliths, within the SCC, and that these can usually be effectively repositioned by non-invasive means, with immediate symptom resolution.

The most common form of positional vertigo is Benign Paroxysmal Positional Vertigo (BPPV). For this we developed the CANALITH REPOSITIONING PROCEDURE. It utilizes the induced nystagmus to track the densities during the repositioning process. Often called the "The Epley Maneuvers", this has become the universal treatment of choice for this condition.

For the more complicated problems, we developed the OMNIAX positioning system, a multi-axial automated chair combined with infra-red videonystagmography. This major advance in technology has become a regional and national resource for treating positional vertigo, especially the more complicated problems such as canalith jam, heavy cupula and horizontal canalithiasis. This has added greatly to our ability to locate the densities and to reposition them accordingly.

New Treatment via the Round Window

We are now using a new "transtympanic" (through the ear drum) method of medication delivery to the inner ear. This involves instilling medications into the round window area of the middle ear, whence they diffuse into the inner ear. This is much more effective than giving the medications systemically. Also, this avoids the side effects that can occur with systemic (oral, intramuscular ) delivery of these medications. This method has been effective in treating Meniere’s disease, chronic labyrinthitis, post-traumatic vertigo, sudden hearing loss and severe intractable tinnitus.

Meniere’s Disease Treatment

If conservative treatment with diet and medications fails, we have effectively used transtympanic medications, both to control vertigo attacks and to minimize hearing loss. This is effective in over 90% of cases.

If surgery is indicated, we usually recommend an endolymphatic sac procedure, also called an "endolymphatic shunt". This is a conservative, non-destructive procedure designed to drain off the excess fluid. Its short-term effectiveness rate is about 80-90%, but unfortunately many of these develop recurrence within the next few years.

Destructive surgery can provide a greater long-term prognosis, but unfortunately has a high risk factor and long recovery period. In our opinion, destructive procedures of any kind should be considered only as a last resort.

Post-traumatic Vertigo

New concepts regarding this condition and new diagnostic methods have resulted in a different management approach at the Portland Otologic Clinic, resulting in resolution or excellent improvement in most cases.

Our theory is that the traumatic incident causes the gravity sensors in the otolith organ to become sensitive to pressure changes and sound. This altered sensitivity can be the direct result of trauma, but is more often a secondary delayed process probably involving an autoimmune reaction. Less commonly, it is due to a perilymph fistula (a tear which allows the fluid from the inner ear to leak into the middle ear). However, the role of the  perilymphatic fistula in this condition is not as important as it was once thought to be.

Because of constant aggravation by internal pressure changes and external sound stimuli, this abnormal "irritable focus" can introduce frequent false cues to the brain regarding the direction of gravity. Over time, the brain learns to ignore these false cues and to depend largely upon visual cues for balance control. Then, any interference with visual cues, such as darkness, a moving object in the visual field or a patterned background, can cause disorientation and loss of stability. Also, the extra mental strain (sensory overload) that is required to function with this problem causes difficulty in concentration and in doing mental tasks.

This "irritable focus" can be treated with transtympanic medications that either desensitize the malfunctioning otolith organ or counteract the autoimmune reaction. This approach requires special tests to localize the irritable focus, and special methods of delivering the medication to the inner ear.

If a perilymphatic fistula is suspected, it should be ruled out with surgical exploration, and repaired if found.

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