Tom Cuise and Jason Statham may look calm and collected after being in close proximity to a bomb explosion or gun fire, but that’s all an act. Labyrinthine concussion is a true risk of sensorineural hearing loss after head/neck trauma or sound/pressure proximity. Although 58% of people who had head trauma, from a tackle, fall or accident, suffer from inner ear concussion, it is still poorly understood. Loss of balance after trauma is one symptom of labyrinthine concussion, while hearing loss may be more common. Vestibular rehabilitation is part of labyrinthine concussion treatment.

Your “ear” is divided into three parts:

1. 1. Outer ear – your earlobe and ear canal to your eardrum
   2. Middle ear – eardrum and bones that transmit sound waves (malleus, incus, stapes)
   3. Inner ear – vestibular apparatus and vestibulocochlear nerve, CN VIII.

Your vestibular apparatus is like your body’s gyroscope. You have one on each side that communicates with your brain to enable balanced, smooth, coordinated movement by interpreting head and body position in space and changes in velocity.  Your vestibular apparatus are snugly embedded in your temporal bones. Your temporal bones are part of your skull, in your hairline above and around your ear. You may have heard the phrase “temporal headache” to describe pain in this area. Deeper within the bone, tucked into its special compartment or vestibule, sits your vestibular apparatus.

The hard bony labyrinth protects the soft membranous labyrinth, in the same way as the skull protects the brain. The bony labyrinth is filled with perilymphatic fluid that has a similar composition to cerebrospinal fluid. In contrast, the membranous labyrinth is filled with endolymph, with a similar composition to intracellular fluid. These different recipes of fluid result in different viscosities, which is important for the functioning of your gyroscopes.

You have five organs that sense movement and body position on each side, three semicircular canals (SCC) and two otoliths. These organs communicate with your brain via your vestibulocochlear nerve.

Balance

Balance is dependent on your eyes, body and ears, like a tripod. How the brain interprets the sensory information it receives from sight, proprioception and the vestibular apparatus determines if you can pirouette, land steady from a back flip or navigate the supermarket aisles without bumping into other customers.

Your semicircular canals detect changes in velocity. These three canals are at right angles to one another and communicate with the opposing SCC of the opposite side. That means your right posterior SCC communicates with your left anterior SCC. They can be described as the x,y and z axes of a 3D graph.

The otoliths detect changes in linear acceleration and gravity. Your utricle relays the change of linear speed, like the movement in a car. While your saccule detects gravitational change in an elevator.

Nerve impulses are generated when hair cells, stereocilia, at the base of the semicircular canal or otolith, the ampulla, are deflected because of the movement of endolymph, almost like seaweed in a current. This movement of the endolymph bends or deflects the stereocilia. This movement causes mechano-sensitive ion channels to open in the hair cell membrane. Potassium, from the potassium-rich endolymph, flows through these channels and changes the electrical potential. When the membrane’s electric potential changes the firing rate of the nerve cells also changes. This means more or fewer messages are sent to your brain to interpret the change in orientation or velocity.

You have experienced this in the real world: once you have reached a steady speed, in a car, plane or elevator, the deflection of hair cells stops, therefor you are not aware of the movement anymore, only when the speed of travel changes again will you notice it.

Hearing

Even though we do not treat hearing pathology as physiotherapists, we understand how important hearing is for spatial awareness. How would you know to check for oncoming traffic during your jog if you can’t hear the engine? Let’s follow a sound wave through your ear:

Your outer ear collects sound waves and sends them through your ear canal to your eardrum. Sound waves cause a vibration of the eardrum and ossicles (malleus, incus and stapes) of the middle ear. When the sound wave moves through the oval window into the inner ear, the cochlea vibrates, causing hair cells in the basilar membrane to vibrate too. These hair cell vibrations stimulate electrical signals through the cochlear part of your vestibulocochlear nerve to be interpreted by your brain as the sound you hear.

The labyrinth can be injured with any head trauma, not necessarily a direct blow to the ear. Causes of labyrinthine concussion include:

• Direct impact

This can happen within a controlled competitive environment, like a boxing match, or a tackle gone wrong that results in a knee to your face. Violent attacks or playful situations can lead to direct trauma to your face or ear from a blow to the head or a ball/club gone astray. This can all cause a labyrinthine concussion.

• Whiplash injuries

Any sudden acceleration & deceleration, which can happen with whiplash injury, can also cause a labyrinthine concussion. The impact of these soft tissue structures happens within the protective casing of your skull.

• Penetrating injury

Any foreign object that is small enough to enter your ear, like a twig or an earbud, may cause damage to the delicate structures within your inner ear.

• Pressure injury

Sudden and great changes in pressure, from a blast or dive, can lead to labyrinthine concussion.

Answer the following questions and test your balance if you suspect that you may have an inner ear concussion.

In 2013, Dr Zemek and colleagues published Predicting and preventing postconcussive problems in paediatrics (5P) study: protocol for a prospective multicentre clinical prediction rule derivation study in children with concussion, to identify peaditric patients with a high risk of developing persistent post concussive symptoms that presented to the emergency room after injury. By identifying patients with a higher risk referral could be done sooner. In this way high risk patients can receive quicker intervention. The risk calculator is scored out of 12 by answering the questions below.

• 0-3 = low risk
• 4-8 = medium risk
• 9-12 = high risk

Risk factor calculator:

Age

• 5-7 years scores 0
• 8-12 years scores 1
• 13-18 years scores 2

Gender

• male scores 0
• female scores 1

Longest symptom duration

• less than a week scores 0
• more than a week scores 1

Personal history of migraine

• no scores 1
• yes scores 1

Slow to answer questions

• no scores 0
• yes scores 1

Tandem stance

• 0-3 mistakes scores 0
• 4 or more mistakes scores 1

Headache

• no scores 0
• yes scores 1

Noise sensitivity

• no scores 0
• yes scores 1

Fatigue

• no scores 0
• yes scores 1

Using the risk factor calculater for a 14 year old boy, with no previous history of concussion of migraine, slow to answer questions, making less than 3 mistakes on balance testing, with a current headache, noise sensitivity and fatigue would score 6/12, placing him at a medium risk to develop persistent post concussive symptoms.

Our physiotherapists can identify if any central pathology is causing your symptoms through visual and balance screenings. Or is your vertigo caused by a different structure within the vestibular apparatus?

We make use of a bedside evaluation, which means all tests are done in the consultation room by your therapist or yourself.

Your history, symptoms and physical evaluation will guide us to suspect an inner ear concussion. This is when the experience of your physiotherapist is important to distinguish your vertigo type, duration of attacks, hearing loss, tinnitus and aural fullness.

We understand the physiological stages you’ll go through during your healing, and custom-fit your treatment program. Our physiotherapists can guide you to understand what you are experiencing and are able to make responsible decisions about your care and sport participation.

Objective audiometric testing will show the extent of your hearing loss. Labyrinthine concussion typically results in hearing loss of higher frequencies.

Your physiotherapist can refer you to an audiologist for a hearing test if necessary.

When you experience hearing loss after head or barotrauma a high resolution computed tomography (HRCT) will be used to exclude any fractures of your temporal bone. If no structural damage is found, a labyrinthine concussion is more likely to be the cause of your symptoms.

An MRI scan may be needed if your ENT suspects any bleeding within your labyrinth. This image shows all of the vestibular apparatus within the temporal bone as well as all of your cranial nerves. It can only be ordered by your specialist. If your physiotherapist suspects anything more than a labyrinthine concussion, you will be referred to the right specialist.

Your brain is sensitive to sensory mismatch. When the messages from your body’s proprioception, eyes and ears are different, the result is dizziness. This is a fantastic strategy to keep you safe, because when dizzy and nauseous, you won’t engage in travel and sport where the risk for injury is greater.

Although your brain has the amazing capacity for healing and creating new pathways with neural plasticity, it won’t “waste time”. It will force the quickest compensation that keeps you safe. With rehabilitation, we can ensure compensation and habituation that is functional and lasts. Waiting to long may mean we need to unlearn bad strategies before we relearn compensation. Don’t waste time, get the help you need.

• Complications

Chronic vertigo symptoms increase your risk of developing persistent postural perceptual dizziness (PPPD). PPPD/3PD is a chronic condition causing constant dizziness of varying intensity, usually triggered by an intense attack, like an inner ear concussion. It is worsened by movement, such as being in a car, and perceiving your surroundings as moving when they are not.

• Misdiagnosis

Many people are diagnosed with BPPV as the cause of their dizziness, when it is not.

• Misconceptions about treatment

When patients are wrongly diagnosed with BPPV, they expect a quick fix with a repositioning manoeuvre. Rehabilitation takes time and effort. No recovery is linear; there will be bad days, and you may feel frustrated and afraid. Nothing worthwhile is easy; be patient and put in the work.

Our priority is to determine the extent of the damage from your inner ear concussion. Labyrinthine Concussion treatment aims to facilitate the correct compensation of your vestibular apparatus to ensure balance and safety when you move and change position. We do this by slowly adapting your rehabilitation program to increase your capacity to correctly interpret sensory information from moving visual targets to you balancing and moving along.

The expected recovery for a concussion is between 2 and 4 weeks. If you experience your symptoms for longer it is considered persistent post concussion syndrome.

If your symptoms persits a month after your injury make sure you get the right treatment. Waiting too long can prolong your recovery even more.

• Your audiologist will test your hearing and prescribe hearing aids if necessary. This is not only important for having conversations, but also for your spatial awareness.
• Specialist audiologist treatment can help manage tinnitus intensity.
• Your doctor (ENT/GP) will prescribe cortisone and motion sickness oral medication to decrease inflammation and manage nausea from dizziness if necessary.

No, there are no specific surgical techniques to correct a labyrinthine concussion.

• BPPV

When otoconia move within your semicircular canals, you will feel extreme dizziness of short duration directly linked to head movements.

• Perilymphatic fistula

When perilymph can leak from the inner ear to the middle ear, you can experience hearing loss, vertigo, aural fullness, tinnitus.

• Meniere’s Disease

Hearing loss, vertigo, aural fullness and tinnitus without a history of trauma may be caused by Meniere’s Disease.

• Vestibular Schwannoma

This benign growth on the vestibulocochlear nerve can cause the same symptoms and facial weakness.

• Vestibular concussion
• Mild Traumatic Brain Injury (mTBI)
• Cochlear concussion
• Otitis interna vasomotoria
• Inner ear concussion
• Commotio labyrinthi