vng test ruptured eardrum

Hi -- I was diagnosed 16 years ago and have gone through phases of active vertigo then remission over the years. I'm one-sided on the left. January and February were particularly difficult, and my ENT (neurotologist) wanted to see whether destructive surgery would be an option, since I had very poor word recognition and tested at the "severe" level. She ordered a VNG to determine how much balance was being supported by each ear. The test was 8 days ago.

During the VNG, my eardrum ruptured when warm water was put in. I felt the water go into my sinus. The ear got infected, and the first round of antibiotics (oflaxacin) hasn't worked. On Thursday my ENT took a sample to culture, and the course of treatment for the infection will be determined in a couple of days. Meanwhile, I'm struggling with headache, imbalance, nausea, and mild vertigo episodes daily.

Although the audiologist conducting the test apologized and took responsibility ("I did this to you, and I'm so very sorry")and expressed great concern for my wellbeing, the doctors who saw me afterward were not forthcoming. They say there must have been something wrong with my eardrum when I came in (the audiologist did check it prior to the test), and it's small and will just heal up. They sent me home without a followup appointment, without instructions on how to care for it (e.g. don't let it get wet), without an explanation of what happened (other than blaming me), and without a phone number that would actually be answered. Within 2 hours of arriving home there was intense pain, discharge, spin and vomiting, and no way to get through to anyone for hours (literally) on hold.

Apparently there was enough data gathered before the VNG had to be suspended to determine that I am using both sides nearly equally for balance. Because the loss of balance would be so significant if the vestibular function were completely removed, the ENT is now thinking gentamicin injections 2 weeks apart, up to 4 total would be best. I would start vestibular therapy at the same time, but probably need a walker to get around for a few months. She also expressed concern about my Menieire's going bilateral, as hearing in my right ear has dropped somewhat. As to the ruptured eardrum, she said it may never heal. She didn't offer a patch, and I didn't ask (a little overwhelmed at that point). Doesn't keeping a hole open sound like a good way to invite further infection?

Anyway, now I'm feeling unsure about what the doctors are telling -- or not telling -- me. Reading up on the potential side effects of gent and struggling with similar symptoms now, I'm not excited about any destructive treatments. Periodic (10/month in Jan/Feb) vertigo episodes may be better than constant imbalance, nausea, etc.

Apologies for the rambling message; I'm kind of flooded with questions and concerns. I live alone, can't drive safely with the imbalance, and don't know how I will manage. Oh, and the contractors are supposed to be coming to remodel my kitchen/dining and re-side the house. Ugh.

Has anyone out there had a medical "incident" (error) and felt like you weren't getting a straight story about what happened? Have you had balance testing to understand what vestibular function you might lose before having gentamicin? Have you heard of problems with the water caloric test perforating the eardrum? Have you had a ruptured/infected eardrum on top of your Meniere's? What if you're not sure you can trust your doctors?

 

Thank you, Pupper and mbg. Meniere's can be so isolating, and it's difficult to find people who actually understand it. There is a Meniere's and Tinnitus support group nearby that meets monthly, but only a couple of us have Meniere's, and by nature of the disease, we are not consistent in-person attendees.

Pupper, when I found this site, I read a couple of your recent posts. I've never joined an online forum and don't do Facebook, but your candid and thoughtful posts -- along with kind replies from other members -- made me feel like this is a good place for support. I wish you all that's good in your next go at that elusive nerve.

Legal action tends to bring a lot of negativity into one's life, but if there is lasting harm from this and no one is talking with me candidly about how to deal with it, then you're right -- a lawyer may be my best advocate. I'm not sure what the damage may be, and the doctors aren't talking about it. My hearing loss went from severe (80 decibels) to profound (120 decibels), so it wasn't of much use before the incident. The consistency of the imbalance is new and distressing; I am hoping it will clear up when the ear infection does. It has made it impossible to drive safely, and I need a stick just to walk around the house. Tinnitus has been louder, but was always there before. I really don't understand why my ENT said the hole may never heal, and I don't understand the consequences of that. I also don't understand how this happened in the first place.

I did reach out to the clinic's Patient Relations person, who was interested to know about how I was sent home without instructions or a phone number that would be answered and how the ball was dropped multiple times in getting the antibiotics called into the pharmacy. I think there will be a systemic review on that. I also asked to be reimbursed for my out-of-pocket expenses related to the incident -- antibiotic co-pays and transportation for followup. She said she would get back to me on how to make that happen and to save my receipts.

As to the aftereffects of the proposed gentamicin treatment, it was my ENT who said I would probably need a walker for a while after it. She said the VNG showed that my balance function in the bad ear is "robust", and that is the reason brain re-wiring may be more difficult in my case.

The suggestion to get a second opinion is a good one, especially since my trust has been eroded by the evasiveness of the doctors. Under the circumstances, I'm not too keen on seeing another doc from the same university clinic where I've been treated, but there is another major medical center about an hour away that may have someone with the right expertise.

Thanks for being out there; it really helps.

 

Just an update here since last post. The culture for infection came back negative, so the antibiotics weren't actually needed, though I have just finished the course. But better safe than sorry on that. The test for cerebral spinal fluid leak came back negative as well, thank goodness. The watery discharge stopped two days ago, and starting yesterday the ENT put me on steroid drops to address the inflammation she saw at the examination. Where I had been having 1-3 vertigo episodes a day since the incident, I haven't had one in 2 days now. But the imbalance continues, and I'm not safe to drive.

I received an email from Patient Relations saying they wouldn't tell me about getting medication and transportation expenses reimbursed until after their 30-day review, but to keep saving receipts.

I see the ENT next on April 12, and made two monthly follow-up appointments at the suggestion of my brother, who is a family practice MD. The ENT appointments so far have been double-booked, and there hasn't been time to get questions answered.

I'm getting mixed information about the treatment plan for the puncture. The ENT (not my regular) who saw me the day of the incident said they could patch it. My regular ENT said it may never heal, and I was too overwhelmed by her drop of the "bilateral bomb" to think to ask about a patch then. Yesterday I called the triage nurse, who checked with my ENT and said they would wait a year before considering a patch.

I asked about swimming, showering, etc. and how the ear would be protected while the hole is open. She said once the infection (that apparently never was) is cleared up, I can swim anywhere if I wish without covering the ear, so long as I don't dive. This surprised me, as it seems like putting out a welcome mat for new infections. I did a bit of research on tympanoplasty (eardrum patch) indications. On Medscape, "Chronic infections and cholesteatoma can also [in addition to hearing loss] result from perforations of the tympanic membrane. A perforation is a significant risk for the development of otitis when swimming in lakes, rivers, oceans, or pools." The Mayo Clinic website gives similar information. I will clarify this when I see the ENT next week and try to settle conditions and timeframe for when a patch would be done if the puncture is not closed. Hopefully I will be lucky and the hole will close within several weeks, and all this will soon be moot. Still, I find myself guarded in what to believe about this incident and feeling I must check that the clinic is working on my behalf to make the situation right.

I have not contacted a lawyer, as I don't yet know whether there will be significant harm or cost. I could have someone write a letter if the clinic balks at reimbursing medication expenses. My brother said that perforations in the lower part of the eardrum, where they typically place PE tubes, heal better than punctures higher up, where mine is. So I am keeping a watchful eye on the puncture situation.

Pupper commented about mixing up Meniere's and punctured eardrum symptoms, and that's the reality of it. A punctured eardrum can cause loss of hearing, vertigo, and tinnitus just like Meniere's. I'm not too concerned about the hearing loss -- even though it was 40 decibels, it went from "severe" to "profound", and that ear wasn't much use before the puncture. The tinnitus is a little louder, though not much. But the real problem has been going from vertigo at 10/month to 15/week. With 48 hours since the last spin-and-wretch, I'm knocking on wood that there's a sustainable improvement underway.

Friends and neighbors have offered both company and assistance with driving, errands, food and even laundry. It's so nice to have their support as well as this forum.

 

Yesterday after the time I posted with hope of sustained improvement, I had two attacks, perhaps 6 hours apart. Although the spinning quieted down within 30 minutes, it would start up again if I moved my head. In general it's been 1 - 3 hours of immobility, which is briefer than my "normal" Meniere's episodes that go 2 - 6 hours. Imbalance has been nearly constant for the last 3 weeks. Hard to tell how much is related to the actual puncture, related to stress, or related to possible degradation in my "good" ear.

I think there must have been some miscommunication between the ENT and the nurse regarding the swimming with punctured eardrum. I will definitely check with the ENT when I see her next week.

The ENT is sending me for vestibular assessment and therapy on the 17th. I've had it before -- it was about an 8-week process, and I think it was helpful in building resilience from the residual imbalance that comes after a phase of vertigo episodes. I'm not sure how much sense it makes to do it right now, though. First, the logistics of getting to appointments is difficult -- can't drive because of the sudden vertigo and imbalance with head movements. Second, here on the north coast (Minnesota) we are still getting snow (9" yesterday) and below freezing temps, so walking to the bus stop is perilous. Walking in any open space is difficult with active imbalance. Third, if the ENT is planning to do gent injections, I would have to start therapy all over again from the beginning anyway.

 

Here's my update after seeing my ENT today. The good news is that my ear stopped draining a few days ago, and today it looks like the hole has closed. I learned that the reason that water calorics are more often done for VNG is that they tend to be more specific than using air. However, air should be used if there is a perforation or danger of perforation. In my case it was the force of the fluid that broke the eardrum -- not any kind of poke with the tube that provides the water.

The hole occurred in a location near to where I had had a single steroid injection years ago. Normally the tympanic membrane is three layers of cells thick. When the numbing agent is used before an injection, it can cause thinning of the membrane, to the point where it heals to just a single cell layer. The high potency steroid that is injected can also cause thinning of the membrane and impede healing back to the three-cell-layer thickness.

The VNG test typically involves two stimulations -- one warm and one cold. The first stimulation is often the least reliable because it is so surprising to the vestibular system. Because of the rupturing on the first stimulation, we never got to the second stimulation, leaving the doctor unsure of the results that showed that I was using my bad ear for balance even a little more than my good ear. That could have been because my bad ear was so overstimulated when the water went through the eardrum, or it could be that my better ear is degrading -- thus the worries about bilateral involvement. Also, the two audiograms done before and after the puncture both showed a 10 decibel decline in my good ear from the prior year.

I have continued to have nearly daily vertigo episodes without any warning; but at least it has been a while since there have been multiple attacks in one day. Because I am not getting any advance warning -- such as, increased tinnitus in the ear prior to an attack, we cannot tell which ear is causing the vertigo. If it is a bilateral situation, the treatment options available can have significantly different effects on quality of life in the near and long term.

So we are going to repeat the VNG test on both ears using air calorics in order to try to get a handle on which ear is providing how much balance. We will also do the rotary chair test to help see how well the central nervous system is accommodating for vertigo. Having this information ideally will help us determine whether destructive treatment (i.e., gentamicin or labyrinthectomy) would be advisable or helpful, and which ear should be treated -- since it's possible that this new plague of vertigo could be coming from my "good" ear in the early stage of degrading.

The repeat VNG test is on 4/20. I'm having a vestibular assessment on 4/17 primarily to determine how to keep me safe at home and to try to improve my quality of life. However, the doctor mentioned, vestibular therapy is often not as effective during an active vertigo phase because the brain can't find a baseline to set to. Still, she thinks there can be some improvement and it's definitely worth doing.

I will discuss test results and options with my ENT on 5/14, and my vestibular therapy goal will be to get to Chicago in June for a dear friend's graduation.

Meanwhile, I'm continuing my indoor seedling garden in hopes the Minnesota soil will warm up before next winter. More snow is expected Saturday. Sigh.

 

Hi Cricket -- yep, sounds like we're in the same boat. I too take 5 mg. valium at first sign of dizziness, and carry a bucket with meds, water, phone, and towel from room to room in the house. The spinning usually lasts at least 30 minutes, then it settles down, but it may be another hour or 5 before I can get up without setting the spins off again. During the spinning I cannot read or watch TV or do anything but be motionless with eyes closed. The other med I sometimes take is Zofran if the nausea won't settle down, but it has a side effect of constipation that may need additional OTC med to get the plumbing working.

Though we haven't discussed it explicitly until we know more about the status of each ear, my ENT seemed to imply that there may be no good options. The VNG will help tell which ear is most problematic, and the rotational chair will help understand how well my brain might accommodate to the imbalance that a destructive treatment or further natural degradation may cause. Talk with your ENT about both tests, and especially the water vs air calorics in the VNG. I think my case was rare, and if your doctor thinks he/she can get the needed data from air stimulation, you can be on the safe side. If he/she presses for the water treatment, then it's fair to question how you can be sure your poor eardrum can tolerate it. Beyond that, there isn't any reason to fear the VNG. Yes, it's uncomfortable for a few minutes but usually clears up right after the stimulus stops.

You don't mention how much hearing loss you have, but whatever it is, keeping the cochlea intact is required to become a candidate for implants later on. I'm profoundly deaf on the left and degrading on the right, so my cochlea are very precious. No surgery for me.

I'm trying to put a brave face on the bilateral thing, at least until the testing is completed and my doctor and I can discuss prognosis and options. My daughter has been accompanying me to appointments, which has been incredibly helpful to review things afterward. Do you notice that your cognitive function is affected by the brain's extra work to make up for the vestibular dysfunction?

After the eardrum puncture there was a week or so of constant imbalance and nausea along with episodes of vertigo, and I remember thinking quite clearly that I would prefer vertigo with hope of eventual "burn-out" over unrelenting and untreatable imbalance. I think vestibular therapy is effective for imbalance so long as the Meniere's progression and/or gent treatment has left enough function somewhere. But the Meniere's will continue to eat away at it, right? I don't know.

When I had VT before, it was because I couldn't get my balance back after an intense phase of vertigo episodes. The appointments were weekly, beginning with an assessment and a set of exercises to do each day. Ideally each exercise -- such as, moving your head side to side while keeping eyes fixed on a spot on the wall -- is done until just shy of provoking dizziness or nausea. As tolerated, the exercises are increased, until you are able to regain nearly full function. This time around they will assess how to keep me safe, whether I should be using a walker, etc. Last time they introduced me to using a hiking pole -- not to lean on (and certainly not to hike with), but to use the sense of touch to complement the visual balance cues. They also coached me in ways to accomplish simple (for most people) tasks like laundry, and suggested I arrange for a wheel chair to get through the airport, where the floor patterns and motion can be provoking. It was super helpful in giving me confidence and getting a sense of productivity and independence back. It's also helpful to have a goal to reach for, like going on a trip or being able to once again do something you've lost.

Maybe your local PTs are trained in VT while also doing other types of work. Worth asking. It may also be possible to have the assessment done at the far-away specialist and the follow-up locally. I understand what a challenge transportation can be for all these medical visits when unable to drive.

I will write another update after my May 14 ENT visit and the options we discuss. Almost certainly she will want to do a steroid injection in hopes of propping up the vestibula in the bad ear. We were going to do it yesterday if the eardrum hole were still open, but delayed when we saw it was healing so that we could get the repeat VNG first. Until we get more info, I'm taking an ostritch approach and trying to ignore any bad thoughts trying to get into my head. Occasionally it works.

Good luck, Cricket.

 

Thanks, jkc. I'll keep that in mind. I mentioned Dr. Hains to my ENT yesterday, and she nodded approvingly of his work.

 

Uffda -- we do have Scandinavians here in Minnesota, though my heritage comes from the French Canadians who came through Ontario and traded furs down the Mississippi. And the Dutch on my mother's side who could conquer the most massive forces of nature through engineering and will. Thanks for your words in admiration of fortitude, but I may be a whimpering fool in a month if forced to take head out of sand for the "no good options" discussion. I'll be back here trying to absorb strength from the experiences of you and others who have propped me up in the few weeks I've been with this welcoming community. You all provide the understanding and support that comes only with this unique experience we share and cannot be understood even by those who love us most. Be well.

 

Thanks for asking, Pupper. I chose to see the same audiologist who had accidentally punctured my eardrum, thinking that I might have extra leverage to get more info out of her than they usually give at test time. Lemonade out of lemons. It worked. I managed to stretch a 2-hour test into 3 1/2 hours with the audiologist. We did a lot, and I learned a lot. She repeated tests that seemed unclear, and even without ENT orders re-did the March 23 water calorics on the right ear because previously the results were a little out of bounds. They were better this time -- it was probably just beginner's anxiety previously.

Yep, nothing has changed in the way they do the tests -- count backwards by 7s, name all states beginning with each letter of the alphabet, etc. She said the purpose of those questions is to get your brain to stop thinking about compensating for the nystagmus to see how crazy it can get when you're distracted. Then they give you the dot to look at to see how well your brain can compensate when it tries. I learned the benchmark is to have the nystagmus beats drop by at least 50%, and mine did.

As to my big questions, I learned that there is significant vestibular function in my "bad" left ear, so any destructive treatment (like laby or gent) for the vertigo will put me off balance significantly. My ENT and I were hoping that ear was already fully dead as far as providing balance so my brain wouldn't need much re-training. Yesterday I met with the same wonderful vestibular therapist I've used before, and if anyone can put me to rights, she can. Might be a wobbly summer, though. My sister-in-law is planning to tie me to a tree for the Mother's Day barbeque.

I didn't learn about bilateral involvement today, or whether my "good" ear could be causing vertigo trouble. The audiologists are not trained to interpret the patterns of the results for specific diseases, and they don't see as many of us as they do of other diseases. So she could tell me what part of the vestibular system was being tested, but she didn't know what a certain nystagmus pattern meant for someone with Meniere's. Guess I'll have to wait for the ENT on that. 3 long weeks.

It wasn't too unpleasant today (admittedly the March experience set a low bar), but it's funny how exhausting those tests can be.