Question: “A friend of mine has been housebound for 2 months with Vertigo… Do you know anything about a virus that can cause Vertigo?”

Answer: Yes vertigo can be very debilitating and can be caused by a virus. However, there are other potential causes of vertigo, each with different implications.

I recommend going to an ENT specialist or neurologist to help determine the specific cause and therefore the appropriate treatment.  

Definition:

• Vertigo is a term that is sometimes inappropriately used as a synonym for dizziness. In reality vertigo is a relatively specific symptom that refers to the sensation of spinning and/or rotation (vertigo is from the Latin verto which means to turn).
• Dizziness on the other hand is an imprecise term that is often used by patients an attempt to describe a variety of symptoms including light-headedness, faintness, confusion, tingling, unsteadiness, trouble walking, giddiness as well as a spinning sensation. Each of these potential symptoms have dizzying list of far reaching implications. Because of the lack of specificity and potential associated diagnostic confusion, doctors generally don’t use the term dizziness. As you can imagine, interchanging the term vertigo and dizziness can lead to erroneous conclusions and treatments.

Overview:

• There is a complicated series of parts in your head that work together to give you balance and self orientation. This set of parts is known as the vestibular system. When a part of this system is damaged or disturbed it can give you the symptom of vertigo.

Vestibular system:

• There are many parts to this complicated system, but I think it is easiest to think of it as two major parts: Let’s call it the 'inside part' and the 'outside part.'
• The more 'outside part' is a labyrinth of tiny tubes in your middle ear that include the semicircular canals.
• The 'inside part' includes the nerves that carry the sensory information from the labyrinth to the brain, and the brain itself.
• Each part of this system can be damaged in different ways.

What it looks like:

• I did some medical art of the labyrinth recently for a friend’s text book. I guess since I created the image, it is safe for me to put it up here in order to help with the description (see picture below).
• The whole thing is really tiny and imbedded in the skull bone.
• Most people have two of them; one set in each middle ear.
• The semicircular canals are the three different long loop looking things in the picture.
• The curly thing is the cochlea which is the hearing part of the middle ear.
• The whole labyrinth is hollow and filled with fluid. The fluid is called endolymph.
• The inside walls are covered with millions of tiny sensory hairs.

Artwork by Thomas Osborne, MD.

In the next edition of "Head and Neck Imaging" by Peter M. Som and Hugh D. Curtin

How it works:

• When you move your head the fluid moves around inside the labyrinth.  This fluid motion triggers the tiny sensory hairs inside. Moving your head right to left will cause fluid to move in one area more than another area. Front to back movement will cause other areas to have more fluid movement. Etc.  
• Now looking back at the image (above) you can see that the semicircular canals are set up at right angles to each other. This orientation is the most efficient design to decipher 3D spatial angulations.
• Fluid motion triggers the sensory hairs in the different parts of the labyrinth. That information is sent to the brain via a specific nerve (the eighth cranial nerve aka the vestibulocochlear cranial nerve).
• The eighth cranial nerve then plugs into the brainstem where a lot of other vital information is processed. Additional nerves connect back and forth from the brainstem for additional processing and verification with other sensory input.

Problems:

• An injury to any part of this system can cause vertigo. There is a long list of potential causes each with subtle and profound differences.  I will address some of the more common causes.

Infection:

• Many different types of infections can target the labyrinth; a general term for infection or inflammation of the labyrinth is called labyrinthitis. However, most causes are thought to be viral.
• An infection can cause abnormal activation of the nerve hairs in the labyrinth. This haphazard activation will be interpreted by the brain as motion when there is no motion.
• This can further confuse the brain when sensory input from the eyes do not verify that spinning is actually occurring. To this end, vertigo can be worse when you close your eyes and there is less correct sensory input from the eyes to combat the incorrect input coming from the labyrinth.

Benign paroxysmal positional vertigo (BPPV):

• This is a common problem which is typically made worse by a particular head position.
• There are tiny calcium crystals known as otoconia (stones) in a part of the labyrinth known as the utricle. In patients with BPPV, the crystals migrate into one of the semicircular canals and cause problems when they abnormally trigger the sensory hairs in their new abnormal location.
• Specific movements of the head can diagnose the problem (Dix-Hallpike maneuver).
• Other specific head maneuvers can guide the stones away from locations in the labyrinth that cause problems (Epley maneuver, and the liberatory or Semont maneuver).
• These maneuvers can be taught to the patient or patient’s spouse/partner/friend so it can be done at home if/when symptoms come back.

Drugs:

• Some toxins such as drugs or alcohol can target the labyrinth. One common class of drug are aminoglycoside antibiotics.

Injury:

• A fracture that goes through the temporal bone and labyrinth can disturb the delicate balance and cause vertigo. However, if you did something to fracture that hard bone, the diagnosis should not be a dilemma.

Ménière disease:

• Although there is some controversy as the exact cause of Ménière disease, most believe it is caused abnormal/impaired drainage of endolymph.
• Symptoms are somewhat variable but classic symptoms include vertigo, symptoms of ringing in the ear, hearing loss and a sensation of fullness in the ear.
• Attacks of vertigo can be severe, incapacitating, and unpredictable.  However, with Ménière disease symptoms of vertigo rarely last up to 24 hours.
• Ménière disease is usually a diagnosis of exclusion (only diagnosed when all other causes have been ruled out).

Tullio phenomenon:

• Tullio phenomenon is sound induced vertigo.
• This is caused by a bony defect that results in abnormal flow of endolymph.
• Loud noises causes pressure changes in the labyrinth and when there is a bony defect, fluid moves more than it should. Abnormal endolymph motion = vertigo.

Schwannoma:

• A schwannoma is a specific type of slow growing tumor that can press on the eighth cranial nerve and therefore cause nerve malfunction. This process usually causes a slower onset of more mild vertigo, often with additional symptoms of hearing problems.

Brian injury:

• Injury to the brainstem or cerebellum (where the sensory information is processed) can also cause vertigo. A stroke will result in acute systems which needs to be treated as an emergency. Other diseases such as multiple sclerosis, Lyme disease and tumors can cause acute or slower onset of symptoms.

Vertebrobasilar insufficiency:

• Decreased blood flow to the brainstem and/or cerebellum without a stroke can also cause vertigo. This can be a warning sign of a potential future stroke.

Psychogenic vertigo:

• Psychogenic vertigo is vertigo in public places. This is often associated with Agoraphobia (fear of open spaces, crowds, leaving home).

Treatment:

• Treatment depends on the specific type of problem causing the vertigo. Example: BPPV can be treated with specific head maneuvers, Lyme disease is treated with antibiotics, schwannoma can be treated surgically, etc.
• The right diagnosis will lead to the right treatment. A through neurologic exam from a qualified doctor is essential. I recommend going to an ENT specialist or neurologist. Additional testing may also be needed to confirm suspicions or rule out other possibilities.
• Obviously the ideal goal is to fix the root cause; however, sometimes this is not possible. 
• Medications that treat the symptoms of vertigo can help patients cope during and after the medical evaluation. The following medications may help.
• -Antihistamines: Meclizine, dimenhydrinate, promethazine
• -Anticholinergics: Scopolamine
• -Tranquilizer: Diazepam

Question: “I've come to understand that not all doctors are created equal. What are some things I can do to pick a good general physician for myself?”

Answer: This is a very important question, but not an easy one to answer for many reasons.

   

There is some good news and some bad news for you in your quest:

• The good news is that all medical doctors in the US must meet rigid qualifying criteria to be able to practice.
• The bad news is, as you said, not all doctors are created equal. As in any profession, there are some people who are better at their job than others.
• So how do you separate the wheat from the chaff? Unfortunately, I do not have a magic formula; however, I do have some thoughts that may help.
• There are some things that you can work out before you see a physician but other things will have to wait until you actually step foot in the doctors office.

Before you step foot in the office:

Medical insurance:

• Many health insurance plans will require that you choose a primary care physician from their approved list of providers. Start with this list and save yourself some time.

Minimal requirements:

• I would recommend that your physician has at least met the basic residency requirements of an ACGME certified medical specialty and is board certified.

Ask around:

• Ask other people you know about their PCP. If a trusted friend likes their doctor, then that is definitely something to explore. Be sure to ask them why they like their doctor because their reasoning may not apply to your needs. This admittedly is not a perfect solution; what some people perceive as good is not necessarily going to work for you, but this is a great start.
• If you like your current doctor, but can’t see them anymore for geographic or insurance reasons, then ask your doctor if they can recommend a referral.

Background search:

• Some people believe that the prestige of a physicians medical training will reflect the quality of the doctor. The rational being that the better the medical school/internship/residency/fellowship, the better the doctor that is produced.
• Another perspective is that high level medical training programs will select for the best candidates.
• It is hard to prove if this is a legitimate argument and I don’t think that this method has ever been tested to be a valid strategy for selecting the best physician. In addition, I have known some great physicians from little known medical programs. I have also heard stories of subpar physicians form the most prestigious medical institutions.

Seek a specifically trained physician for a specific situation:

• Some primary care physicians are more experienced in some medical situations than others and will therefore be in a position to provide better care for that specific circumstance.
• As we all know, the more someone (anyone) does something the better they will be at that task. Some of these are obvious; you don’t go to your kid's pediatrician to have your gallbladder removed, and you shouldn’t go the ER for a routine mole check. Etc.
• To this end, consider that some doctors may have additional training in a medical field specific to your needs. This additional training may not always be designated with a certificate of merit or fellowship but may just be an area of particular physician interest.
• If you are an athlete/weekend warrior, then a doctor with additional training in Sports Medicine might be a big plus.
• If you are older, then additional training in Geriatrics will help.
• If you are often sick or have an immune disease then you would be lucky to find a PCP with additional Infectious Disease training.
• Additional Women’s Health training can provide a physician with insight into problems that a general trained physician may not have experience with.

Physician age:

• Some people think that an older doctor will be a better doctor because they have more experience.
• However, others believe that a younger doctor will be better equipped because they have more experience with the latest medical advances.
• I don’t think there is a good answer here. The quality of a doctor in my opinion can’t be determined by their age.

Look around: 

• There are several online physician rating sights out there. However, I wonder who is writing the opinion on the websites or if anyone is policing the entries. I am skeptical about the usefulness of these sights.

Logistics:

• Beyond a doctor’s medical talents, you will need one that works for you schedule.  Consider:
• Office location
• Office hours
• Emergency availability
• How long does it take to get an appointment
• Average wait during appointments
• Number of patients booked per hour
• Is the doctor affiliated with a local hospital? If you prefer a specific hospital, is your doctor associated with it?

After you step foot in the medical office:

Physician personality:

• Some people will think their doctor is the best because they are nice. While, I would expect all doctors to be personable, I would not say that this automatically equates to good medical care. None the less, you definitely want a physician that:
• Listens to you, doesn’t interrupt you, and seems to be paying attention.
• Does not make you feel rushed.
• Is willing to listen to your theories on what's going on and is open to you getting a second opinion without making you feel guilty or ashamed.
• Perhaps most importantly, I would caution against an arrogant physician. Ego can and has clouded judgment. I have seen many unfortunate cases where a self-righteous physician has not allowed themselves to see significant medical issues because someone else proposed an alternative diagnosis or treatment.
• In my opinion, a great physician is one who does everything they can to be at the top of their field and at the same time is open to alternative explanations/care.
• The paternalistic (doctor tells patient) model of medicine needs to change to a more productive partnership between patient and physician.

Medical office:

• Beware if the office/exam rooms are not clean. Cleanliness is a necessity in medicine and may be a reflection of the quality of care in general.
• The doctor’s office and nursing staff should be courteous and respectful of your privacy.

The bottom line, if something doesn’t feel right, don’t hesitate to move on or get a second opinion.

Question: "My husband was given a prescription for fungal nails… and has been prescribed Lamisil… could this be dangerous to take with other meds?"

Answer: Good question. The answer is yes it could be a problem to take Lamisil with other drugs, but it depends (see below).

Background:

• Fungal infection of the toenails or fingernails is known as onychomycosis. This is a common but hard to treat infection.
• The following text is not intended to be a complete review of the onychomycosis or medications. You should see your doctor and discuss your condition and how it relates to you specifically.

What it looks like?

• Onychomycosis can have different appearances.
• Early on, the infection can be subtle and hard to detect.
• The infection can cause the nail to look yellow, green, or cloudy.
• The nails can become thick, rough and crumbly.  The nail can also separate from the nail bed. 
• Other diseases can look similar to onychomycosis, so you will need a doctor to evaluate and diagnose.

Photo credit: http://wikipedia.org/

Why does the fungus grow in the toenail?

• Since onychomycosis is a fungal infection, it will thrive in conditions where fungus do well; dark/moist places. Under the nail is one of those spaces. Tight fitting old sweaty shoes are also optimal living conditions for toe fungus.

How do you get it?

• Onychomycosis is a common infection and can be spread from person to person via floors or other surfaces.
• Therefore, some things that can help reduce your chance of getting the infection are: Don’t go barefoot in public bathrooms. You should ware flip flops in public showers. Don’t share nail files or emery boards.

Onychomycosis and diabetes:

• Onychomycosis can be a big problem for people with diabetes. 
• People with diabetes can get the infection easier than other people, the infection can be harder to treat and it can lead to more serious infections.
• Treating onychomycosis will decrease the risk of getting other/secondary infections that can lead to toe or foot amputation.

Treatment:

• There are several medications available.
• Topical medications have few side effects but are not very effective.
• Lamisil is the oral medication that your husband has been prescribed. The generic name for Lamisil is terbinafine (ter BIN na feen).
• Studies have shown that oral medications are more effective than topical medications. Some physicians advocate both oral and topical medications to increase effectiveness.
• There are even some promising drug-free treatments that use laser light. http://abcnews.go.com/Health/OnCall/story?id=7113863&page=1

Preexisting conditions:

• Lamisil is a medication that has a predisposition to adversely affect the liver. Therefore, people with liver problems should take this medication with caution.
• Kidney disease and autoimmune disease such as lupus may also be a particular problem with Lamisil. 
• As with any medication, there are potential side effects that can have a negative effect on some people regardless of preexisting health conditions.  It can be difficult to tell who will experience those adverse reactions.

Lamisil with other drugs:

• Lamisil can alter the livers ability to process/metabolize other medications.  Therefore, Lamisil can alter the concentrations of other drugs in the body. This can result in too much or too little of a particular medication. Not all medications are affected in this way and some are more vulnerable to body concentration alteration than others.
• This does not mean you should not take Lamisil.  However, you should have your liver evaluated before taking the medication.  You should also be sure that your doctor knows about all the other medications you are taking (prescription/nonprescription/herbal or otherwise).

Take as prescribed:

• Treatment for onychomycosis is long; It may take several months for your nails to return to normal.
• If you stop taking this (or any) antimicrobial medication before the prescription is complete then the infection may become resistant to that medication.

When you are taking Lamisil:

• Call your doctor at once if you have symptoms of liver damage. Signs of liver damage may include:
• Nausea, abdominal pain, loss of appetite, fatigue.
• Itching, dark urine, clay-colored stools.
• Jaundice (yellowing of the skin or eyes).

There is more in-depth information about Terbinafine (Lamisil) at: http://www.drugs.com/pro/terbinafine.html

Question: "How do you become a radiologist in the US?"

Answer: Many years of blood sweat & tears, (and a little luck).

Overview of a 7 step program

1). College or University:

• Graduate from a 4 year college or university with excellent grades.

2). Pre Med:

• Try to get into Medical School during or after college by jumping through multiple hoops. Regardless of who you are you have to excel in the many prerequisite science classes (biology, chemistry, organic chemistry, biochemistry, physics, calculus, etc). These classes are usually taken during college but can be taken after. Get superior scores on the MCAT exam. Get excellent letters of recommendations. Demonstrate success in extracurricular activities. Doing all of these things won’t guarantee acceptance into medical school, it is just the minimum. It would help to win the Nobel Prize. 

3). Medical School:

• Graduate as a Medical Doctor from a 4 year medical school. The amount of information to learn in medical school has been likened to "Drinking from a fire hose." Obtain superior scores on local and national medical examinations. Get more excellent letters of recommendations.

4). Internship:

• Complete a rigorous 1 year ACGME internship in internal medicine or surgery. These generally entail long hard stressful hours with little sleep.

5). Residency:

• Get accepted into a 4 year ACGME radiology residency program. It’s competitive; more doctors want to get in than there are available positions. Once you are in, you soon realize that you have much more to learn than you ever imagined. Willpower, commitment and fear will help to fight exhaustion.

6). More exams:

• Pass a series of challenging written and oral national examinations throughout the training.

7). Graduate from radiology residency:

• Take a moment to contemplate what happened to your youth and wonder how to pay back your student loans.

Additional training:

• Some radiologists will go on to do more in-depth advanced training/fellowship in a subspecialty field of radiology such as Neuroradiology, Neurointerventional Radiology, general Interventional Radiology, Musculoskeletal Radiology, Body Imaging, Nuclear Medicine, MRI, Ultrasound, Women’s Imaging, Pediatric Radiology, etc.
• These optional training programs last an additional 1 to 3 years.

Total time investment:

• For someone such as myself, the total higher education time commitment was 15 years.
• Each medical specialty has different training requirements which reflects the unique challenges of the specific individual field. As a comparison, a general pediatrician or family doctor only needs to complete a 3 year residency program after medical school.

Question: "What is a radiologist?"

Answer:  A radiologists is a highly trained physician who utilizes the latest medical technologies to diagnose illness and direct medical care.

Diagnostic Radiology:

• Radiologists are the only doctors who are specially trained to interpret medical images which include x-rays, ultrasound, computed tomography (CT), nuclear medicine, positron emission tomography (PET) and magnetic resonance imaging (MRI). In doing so, radiologists are able to provide other physicians with lifesaving information about their patients. Because of this essential relationship, radiologists have often been referred to as, “A doctor’s doctor.”
• Radiologists are central to patient care and their expertise is indispensible in every medical subspecialty. 

Interventional Radiology:

• Radiologists are also trained to perform minimally invasive image guided surgical procedures such as biopsies, paracentesis, thoracentesis, myelogram, lumbar puncture, kyphoplasty, vertebroplasty,  vascular surgery including aneurysm repair, uterine fibroid embolism, as well as many different infection and cancer treatments.
• Most patients will not see their radiologist unless there is a question or if the radiologist is performing a procedure.

Who is the person who takes my x-ray?

• The people who take your x-ray, MRI, CT, etc are technologists.
• Radiology technologists have completed separate training but did not go to medical school.
• Radiology technologists are not doctors or radiologists.
• However, sometimes a radiologist will help a technologist to obtain medical images.