posted
Has anyone here had this done, and has it been beneficial?
Does it clear up clogged ears as well as dizziness?
Is it really as simple as a 5 -10 minute visit?
I realize that it wont work for everyone, but I will try whatever I can to to stop my ears from clogging, pounding... Plus I am sooo dizzy much of the time....
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Keebler
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- First, for today, get some GINGER CAPSULES. Also what really helps is a diet free of: gluten, dairy, corn and soy. Most ear doctors suggest this.
MAGNESIUM & LIVER SUPPORT are also vital for the ears. VINPOCETINE is also good. FOLIC ACID, B-6, B-12 also essential. BETA CAROTENE, too.
More detail about all that in the Tinnitus thread link to follow.
As you know, the Epley maneuver only works on one kind of vertigo, what is called Benign Positional Vertigo. If that is the cause of the vertigo you have, yes, one session can be a miracle.
But, usually 2 - 3 sessions are best to ensure follow-up. And you should be allowed some time to rest afterword in the doctor's office so, no, I don't think a short appointment to shuffle you in and out is enough time. The resting part in important.
It would best to see a neurotologist (pronounced neuro-otologist) for a full examine.
Various kinds of dizziness and vertigo go with lyme and other tick-borne infections, and can also be side effects of many Rx and OTC products.
If possible, it would be best if the neurotologist were lyme literate but even if they are not, they can be instrumental in determining so much about what is going on and why -- and you'd have your LLMD to consult for any Rx advice from the ear doctor. Ear doctors often like to prescribe steroids and that can be a disaster for a lyme patient.
I will be back with a link. -
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Keebler
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The NBC News article below features the Epley maneuver, a technique for prompt clearing of benign paroxysmal positional vertigo � BPPV � a common cause of severe dizziness.
Note: not all dizziness is BPPV. A special exam can determine if it is BPPV or offer further assistance in diagnosis and treatment if it is not.
It's great to see this sort of thing in the news, especially since doctors are not taught this in medical school.
The article seems accurate, however, Dr. Epley who developed the maneuver, is a neurotologist. The article refers to him as an otologist. A neurotologist has neurological training and credentials beyond that of an otologist.
I have seen Dr. Epley, myself. He was the first doctor to tell me to get tested for lyme. However, no MD in my state would treat lyme that did, in fact, come back positive after I finally got the right tests.
He is retired now, but still does research.
I recall my disappointment when in his office one day and saw the miracle that the Epley maneuver brought to 2 others in the waiting room. They sang his praises.
So, when I got to his office, I said "I want that same treatment that worked for those guys out there !"
He said with empathy, "sorry, you don't have the same thing they have. It would not work for you."
- New guideline says simplest treatment for ONE SPECIFIC TYPE of vertigo is also the best -
By JoNel Aleccia - Health writer -updated 5:33 a.m. PT, Wed., May. 28, 2008
The next time the world starts spinning, Larry Janisch will know exactly how to make it stop.
But two months ago, when the 50-year-old Phoenix man woke up one Saturday reeling from vertigo, he had no idea what to do.
�I felt like I was drunk,� he said. �I couldn�t stand up. I kept falling over.�
Fortunately for Janisch, he works at a hospital where a vestibular therapist, a specialist in inner ear disorders, is almost always available.
Within 10 minutes of walking into the lab at Banner Good Samaritan Medical Center, Janisch was better, thanks to a simple technique that neurology experts have verified as the best way to treat benign paroxysmal positional vertigo � BPPV � a common cause of severe dizziness.
A series of gentle head and neck movements known as the canalith repositioning procedure is the fastest, easiest way to cure BPPV, according to a new guideline developed by the American Academy of Neurology.
About 3 million new patients a year in the United States are diagnosed with the problem characterized by dizziness, lightheadedness, imbalance and nausea that can last for days � or even months.
Traditional treatments have ranged widely, from drastic measures such as sedatives to nerve surgery to nothing at all.
�Instead of telling patients to �wait it out� or having them take drugs, we can perform a safe and quick treatment that is immediate and effective,� said Dr. Terry D. Fife, an assistant professor of clinical neurology at the University of Arizona, who led the study presented in the latest issue of the academy�s journal.
�No special chair is needed, no goggles are needed, no special device is needed, just the hands � and the knowledge,� added Fife, who also directs the Balance Center at the Barrow Neurological Institute.
Tiny crystals lodge in sensing tubes. BPPV is caused when tiny calcium carbonate crystals in the inner ear dislodge and land in the sensing tubes that detect motion and gravity.
When sufferers move their heads, those �ear rocks� cause severe sensations of spinning or whirling.
�It�s bad,� recalled Janisch, a physical therapist.
The condition is typically caused by head injury in people younger than 50. It�s far more common in older people, however, as aging causes degeneration in the structures of the inner ear.
The canalith repositioning procedure works by moving the calcium crystals out of the sensing tubes and into another chamber of the inner ear, where they�re safely reabsorbed.
Fife and his team reviewed 40 years of research on treatment of BPPV, including 925 articles published from 1966 to 2006, to provide the first evidence-based recommendation for treatment of BPPV.
Final analysis showed that the procedure, also known as the Epley maneuver , should be offered to BPPV patients of all ages, he said.
A second, more vigorous, technique, known as the Semont maneuver, is also possibly effective, but there�s not enough evidence to say for sure, Fife said.
While the new guideline is gratifying, the Portland, Ore., otologist who came up with the Epley maneuver nearly 30 years ago wondered what took the AAN so long.
�I think it�s about time,� said Dr. John Epley, 78.
Epley�s technique involves positioning a patient on his back, with his head hanging slightly over the edge of a bed or table and tilted 45 degrees toward the affected ear.
Then the patient�s head is moved into a series of four positions until it is rotated 90 degrees toward the other ear.
Technique cures vertigo in most patients_The maneuver, which resolves vertigo in about 80 percent to 90 percent of patients, is widely used, but only among doctors who know about it, Fife said.
The technique is not taught in medical schools and most general practice doctors may have heard only rumors of a quick, easy way to treat vertigo.
�I think for physicians, the new thing is the evidence-based status,� said Fife, who hopes the guideline will encourage more doctors to use the method.
Besides, Epley�s technique has been controversial. In the early years, he was ridiculed by colleagues for suggesting that such a simple treatment could have profound effects on vertigo. �Everyone thought it was crazy,� Epley said.
More recently, there�s been debate over which of several repositioning techniques works best. European doctors, for instance, seem to favor the Semont maneuver, Fife said.
Others prefer techniques such as the Brandt-Daroff maneuver, one of several alternatives aimed at shifting the calcium crystals.
Even Epley has tried to improve on the physical technique with a device called the Omniax chair, which holds patients in place while it rotates them 360 degrees.
Epley received research funding from the National Institutes of Health to study the chair and he expects federal Food and Drug Administration approval of the device soon.
The chair is useful for the small percentage of patients who can�t be cured with the regular maneuver, as well as those too large, too old or too frail to be perched on a bed or table, Epley said.
For Michelle Soper, 37, an elementary school secretary in Banks, Ore., one treatment in the Omniax chair in March appears to have cured bouts of recurrent BPPV.
�I would go to roll over in bed and my whole room would spin. I�d look up, it would spin. I�d look down, it would spin,� she said. �After the chair, it was unbelievable.�
Home treatment a possibility
But Fife and Epley agree that most BPPV patients don�t need the chair. They only need a few minutes with a doctor or therapist trained in the maneuver.
With practice, some patients can even learn to perform the Epley maneuver on themselves, Fife said.
Although BPPV will resolve on its own in up to half of patients, the new guideline could make the difference between enduring months of life-altering dizziness � or only a few days.
�We hope more people will see there is some value in treating symptoms sooner rather than later,� Fife said. -
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Keebler
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- ALL EARS. Specifically for LYME patients - lots of details about ears and what can help:
Topic: TINNITUS: Ringing Between The Ears; Vestibular, Balance, Hearing with compiled links - including HYPERACUSIS -
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lymeboy
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posted
Thank you....it was that post that prompted my question. I had heard of this. I dont have the money to go to any more doctors. I have some pretty serious ear symptoms though, from the incessant, overly clogged ears, to occasional hypersensitivity and pulsating, to ear pain. I went to 2 ENT's and they rushed me out the door, said my ears were fine. Otolaringolgist said the same. Regardless I am deaperate to get them under control....I gather from many posts that this is something that some people have to deal with forever
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Keebler
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Reprinted from The Oregonian, Sunday, December 31, 2006
Cursing the Cure: Doctor and Invention Outlast Jeers and Threats
- by Joe Rojas-Burke
Excerpts:
John Epley is a doctor and innovator. Years ago, he took aim at a medical curse that has disabled millions of people and defied treatment. He came up with a cure that was astonishingly simple. No surgery. No pills.
Now, think: Would his colleagues cheer his stroke of ingenuity by spreading the news -- and practice -- of the treatment to relieve suffering?
No. Inexplicably, they rejected him, ridiculed him, heaved accusations that threatened his license to practice medicine. . . .
. . . Hard sell
In Portland, some of Epley's colleagues were so skeptical that they began to question his medical skills. Some doctors stopped referring patients. . . .
. . . Epley labored on. Rejection drove him to work harder to convince colleagues. He no longer had time for hobbies or socializing . . . .
. . . More than 10 years after Epley took on BPPV, he'd finally gained the recognition that was vital to acceptance among his peers. But the stamp of approval did not sway the skeptics. Many doctors rejected or ignored Epley's breakthrough, even in his hometown. . . .
. . . Epley reflected on the reasons other doctors refused to accept his findings for so many years. "If I look back at medical school, much of it was misinformation," he said. "Physicians learn to just do the routine, to do the accepted things -- don't go too far out.
"They've got so much to lose if they stick their neck out."
---------------
Full article at link above. This is a fabulous account of a brilliant and dedicated ear specialist. -
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Keebler
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Dr. Dizzy's chair will set you straight -- by Greg Hardesty (The Orange County Register)
August 11, 2010
Excerpts:
The Epley chair
The rotational chair Casey uses to improve his balance has impressed top brass at Camp Pendleton. Physicians at the base are in the process of installing the machine to treat mild traumatic brain injuries suffered by troops returning from combat.
The showcase machine in Mango's office, however, is a contraption called the Epley Omniax - one of only 14 in the world, according to Mango. . . .
. . . The Epley chair is capable of moving a patient through 360 degrees in any plane and in any position relative to gravity - such as upside down.
While moving the patient in different positions, Mango monitors eye movements. This allows him to pinpoint which area of the inner ear is causing dizziness, and then treat the problem by moving the patient in a different position.
Mango characterizes the Epley chair as a milestone in technology that allows for the diagnosis and treatment of vertigo without surgery or medication.
"As recently as five years ago, we still were missing pieces of the puzzle," Mango says. . . .
- full article at link above. -
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Keebler
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The Epley Omniax System assists medical professionals to Detect, Diagnose, Differentiate, Treat, and Manage all forms of positional vertigo, including those caused by non-particle medical disorders, classic BPPV (benign paroxysmal positional vertigo) and its many variants.
The Epley Omniax System consists of an automated multi-axial (360�) patient positioning device, infrared video goggles, and a proprietary software with 3-D real-time monitoring and measurement of nystagmus, spatial orientation of the patient and of the semi-circular canals.
Designed to include these features and benefits:
� Detect, diagnose and differentiate subtle, latent, transient or combined compound nystagmus patterns using a standard or custom menu of positions and maneuvers.
� Easily maneuver and hold the patient in any position to observe, record and instantly play back nystagmus relative to the 3-D spatial orientation of the semi-circular canals.
� Efficiently perform multiple assessment and treatment maneuvers within a session since the Omniax is safe, comfortable, and practical for both patient and operator.
� Standardize care with repeatable, comparable, and precise maneuvers.
� Comprehensively manage all patients with position-related nystagmus and optimize outcomes for even the most difficult cases.
And, while this chair is best, there are other ways to give this a go if you have BPPV. Still best with a trained neurotologist who has first assessed and diagnosed you.
A search at YouTube for "Epley Maneuver: has many videos but I could find none as specific as I wanted. This one is interesting, although not the full Epley Maneuver, really:
DizzyFIX: New home treatment for Vertigo (BPPV Treatment). Global News
Video: 3 minutes
DizzyFIX is about $150.
=============================
A Google search: "Epley Maneuver" doctors
brought up some links. I was looking for doctors who have been trained in the Epley Maneuver. You may need to adjust the search. But, from that, here's one link to consider: --------------------
Instructions for Patients having the Epley Maneuver
Patient Information. Instructions for Patients Having the Epley Maneuver. Important: If you have any of these problems, please discuss them with the doctor. ...
==============================
And there are other kinds of rotational chairs out there. Be aware that with or without the chair, each doctor may do things differently. The Epley chair, though, seems to really ensure consistency and the likelihood for an excellent diagnosis.
Still, with the chair diagnostics, we are talking about structural matters that cause vertigo. With lyme, swelling in the ears, brain and neck certainly can cause vertigo but so can the toxicity from lyme and from Rx. There are many lyme-related causes of vertigo that may not show on a structural test.
And, then again, there may be other things going on.
I hope you can find relief soon. Good luck. -
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Keebler
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- Sorry for posting all that. I'd been working at it and did not see your post that funds don't allow for more doctors - and that some ear doctors already proclaimed "no problem" - which, actually without this chair, and even with it, no one can say.
Doctors can miss a lot. However, had it been BPPV, they should have seen a clue (should have, being the key).
I'm worn out now but there are still some ways you might be able to tell if this is primarily BPPV. And there are some home moves you can do yourself.
I just don't suggest those as I've not found the best video - and hanging your head off the end of table might not be the best thing.
You can scour the web from here, though. You might look up some Yoga moves for vertigo, etc. the supplements listed and liver support can help.
Once lyme and other infections are well under control and your liver is working better (everyone's liver takes a hit with lyme and that often hits the ears) . . . well, many have seen all kinds and degrees of vertigo just leave when they get better from lyme.
In the meantime, there are many good suggestions for managing/coping along the way. Do let your LLMD know of all the ear stuff you mentioned. Hyperacusis is very hard on your adrenals so adrenal support is also vital. That's all in the Tinnitus thread.
Mold and other environmental concerns also need to be considered.
Good luck. This can get better. It has for many. -
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lymeboy
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posted
PLease don't apologize, you are so helpful and knowledgeable....
LLMD seems to think it could be a detox issue, hence his giving me NAC 3 months back, and more recently pectasol, which I have only just begun. My ears have only gotten worse. in June '09 I lost ALL hearing in one ear, which eventually returned over the course of a few days. That was actually the start of all of my really bad Lyme symptoms. That is when the dizziness started, the severe depression, joint pain, fatigue, everything. What makes the story actually cool is that I was in the middle of the country on a motorcycle at the time....yikes! I made it across without dying, thankfully! My ears have been bad much longer than that, (actually started clogging about 2 years after I was first treated for Lyme - 5 yrs ago) but since that moment, everything has been really severe. There are times when I would rather be deaf and have my balance, but ideally, I would like my ears back to normal!
I think my LLMD is a good one, but Im not sure if he is really addressing the ear thing properly. He SHOULD BE THOUGH! He's taking all my !@#%! money! I wonder what he is thinking when I make a VERY BIG POINT to tell him that my ears are among my biggest complaints. I think if my ear stuff went away, there would be many days that I wouldn't even think I was ill. I REALLY feel that my ears will be the key to turning a corner.
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I certainly can understand the expense and frustration of chasing doctor visits.
However, when it comes to ears/vestibular systems, you really can't just guess what might be going on because there might be more to your story. We all have " A Story".
NeuroTOLOgists are about as hard to find as a good Lyme doctor, there aren't that many around.
You can't blame your LLMD after all, there is a limit to the depth of what one doctor can hold.
It might have been better if he listened to your concern and then offered a referral to the appropriate doctor. But I also understand, he might not be able to do that because of what/how he practices.
It's unfortunate that the medical profession can ostracize a fellow practitioner because they treat patients in a different manner but it's the world we live in. Don't know if there is any answer now, maybe later with more research.
If you have insurance, a NeuroT would be covered unlike most LLMD visits, just something to think about.
If you have taken long term antibiotics, some are oto-toxic and that damage is often, sorry, permanent.
We just had a round of Zith in my family and that member had tinnitus within 2 days of starting it, thankfully, it went away when he stopped taking the medication. My Tinnitus increased while on Biaxin and seems to be a permanent change
Still, Tinnitus produces high anxiety in many people as it disrupts all aspects of life. I use a sound machine at night, I always sleep with a fan. When your ears are stuffy, the noise will seem louder.
Is your nose runny or your sinuses draining? Do you have pressure in your ear? Do you feel like you are hearing underwater? Sometimes the pressure comes from within, usually from sodium levels. But this is where the testing from a NeuroT would help clarify what you are dealing with.
And, even if you were deaf, you would still hear the annoying sounds of tinnitus because it's not originating in your ear but in the nerve and brain.
Some people have gained relief with having chiropractic adjustments to help the 8th Cranial nerve which might be impinged or inflamed. Some have had results with antiviral treatment. Neither worked for me...
Keebler already discussed liver detoxing, very important. With all the meds you possibly could have taken, toxins, viruses and parasites, your liver is working overtime and probably not keeping up very well. Our livers need some serious TLC. I use a product with Milk Thistle and other herbs in the morning and evening.
Vinpocetine is another supplement that helps with blood circulation in the inner ear plus good for memory but in small amounts. Some people notice heart palpitations.
There is a recent study on the use of Pycogenol as a Tinnitus treatment. I am giving this a trial run just to see if there is a reduction of tinnitus and it's not expensive.
There are some NeuroT's in NJ, btw.
I agree with you, Ears are some of the biggest complaints. I hope better days are ahead for you.
posted
no runny noses out of the ordinary. No sinus drainage that I have felt. Tons of pressure. consistently clogged ears. I do take milk thistle. I will look into a neuroT in my area. I am wary of other doctors, though, as they can just confuse the issue of Lyme through their own ignorance, or wind up sending you on an unnecessary goose chase.
Noises for me don't always seem louder. Certain pitches though, will make my ears pulse, and just make me feel woozy and anxious. This is a new symptom. I am afraid it has been wrought by the Zith, unfortunately
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"Noises for me don't always seem louder. Certain pitches though, will make my ears pulse, and just make me feel woozy and anxious. This is a new symptom. "
This is why you need to see another specialist and they need to know that some sounds cause a physical response.
An antihistamine is the first thing to try, next would be a diuretic but you need blood work to first confirm where your potassium levels are and know there are meds that are potassium sparing.
The diuretic very well may relieve the fullness feeling. Did you have tubes in your ears when you were a kid? I wonder if anything is going on in your Eustachian tubes?
Does your ear ever spontaneously clear? What about dizziness, do you have that?
Ever have a true vertigo attack? Dizziness and vertigo are not the same thing, btw.
If it were me, I would make the appointment with a NeuroT, have an exam, schedule the testing ( which is pretty tough) and get his take on the health of your ear and vestibular system.
I would not mention Lyme until later ( if then) after he has assessed your condition.
Why? Well, I did that once and everyone got all tense and irritable telling me to go to an ID. Of course I didn't because I did that a few years before and it was totally useless.
To further muddy the waters, I have had 3 attacks in the past few years where I lost almost all my hearing in one ear. The only thing that helped was a DEX injection and that is a steroid. My ear odyssey started long before my 48 tick bites.
My most recent attack left me with only 20% of hearing in one ear. I already had the discussion with my doctor from previous attacks, so I knew exactly what to do.
I called and got right in for a hearing test which confirmed the severity and the next day, I had a DEX injection. By evening, I could feel my hearing returning and a post op exam 10 days later confirmed my hearing was coming back.
Then I started LDN.
Next visit, 2 months later showed amazing results, enough that he was very excited and I an thrilled.
My hearing is now the best it's been in over 5 years. I rarely get a bit of fullness in that ear but I know how to do some manipulation and get relief.
I also pay strict attention to sodium intake, I keep mine around 1300mg per day. That means cooking from scratch and being careful about eating out.
I also eliminated all grains, dairy, coffee, artificial sweeteners from my diet this year.
My story isn't conventional but I do what I can to keep what I have, if that makes a bit of sense.
Can you switch Zith to something else?
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lymeboy
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my run with Zith just ended. No more Zith. I am awaiting my next Dr APPT, in 3 weeks. Currently Im only taking Plaquenil, with a bunch of herbs and SUPPS.
I have had moderate to severe dizziness on an average of every other day for 1.5 years now. Nothing has really cleared it up. My ears have not cleared spontaneously in almost 5 years. I first noticed this when I was working in NYC in tall buildings,after going up 70-80 floors, my ears would not un pop. I am not sure what vertigo is. I have had a few experiences where I've had to hold on to things and find a seat, because I felt like the room was tipping. Staircases would make me feel like I was being pushed downward. And I have also experienced the feeling of "floating" which has gone away for a good 6 months. The dizziness has definitely decreased since starting treatment. Right now I am looking for a neurotologist in the area. I dont think I will keep Lyme from them, because I dont want to deal with Steroid treatment, which is what another Dr had tried to prescribe.... I just dont want to deal with the goose chase, which is why I have only gone to Dr. M in the past 6 months
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Floating: sometimes this is described in Migraine Associated Vertigo.
Once I had it and thought I was literally dying and went to the ER. I had bacterial pneumonia but ironically had just had a colonoscopy and had to drink that solution that is very high in sodium.
I think the trigger for me was sodium.
MAV is a migraine without the headache but can have tinnitus, dizziness, rotation, dizzy in bed also called BPPV, nausea, visual disturbances, too.
Staircases: Hain talks about this with MAV also. Walking in aisle of the grocery store, stores with high ceilings and florescent lighting are triggers. Wearing sunglasses and hats with brims helps a lot.
"visual dependence"
Part of the testing is to walk in a hallway to see if you walk straight or veer off. Also, walking on a foam rubber mat with your eyes closed. When I did it, I thought I was straight until I opened my eyes and found I had rotated 90 degrees.
Are you motion or light sensitive?
Lyrica ended up being the drug that helped me get past a 5 month migraine, dizziness, nausea period.
Here is Hain's page on MAV.
BTW, he does phone consultations, out of pocket, but people report back that he gets results. Just another idea/avenue if nothing else works out for you. At this point I imagine you just want to feel better and have an answer.
One never knows where these journeys will take us.
Best to you.
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lymeboy
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posted
Hmmm... this is pretty interesting. Laying down, I feel fine. it typically occurs while I am in motion. riding in the car used to be really bad, but that went away. I still cannot manage my motorcycle for more than 10-20 minutes. I don't ride it at all anymore }(. Motion sensitive yes, when I am walking or moving my own body, not when riding in a car or train, or anything like that. Light, sometimes, not much.
Visual disturbances - YES. Daily. I am constantly seeing "mice". I do not often get the spins. That has gone away for a good 6 months. Dizziness, yes. Lightheadedness quite often. I just walked on a mat with my eyes closed. I didnt turn, but I veered. In fact, I cannot walk any where with my eyes closed without veering. I have to fight veering with my eyes open. If I close my eyes and stand up straight, I have to stop myself from falling over.
As for the grocery store, I fell over twice in a Walmart. This was after the initial scare I had while riding my MC. I was walking down the Aisle, and could not stop myself from crashing into a bunch of toys. It would have been so much fun if it wasn't a serious symptom! I fell right over to the right. The whole store turned over on me. It happened again a week later in a different Walmart. I get migraines sometimes, but the dizziness is far worse. I am checking out Hain's page now. I would call him If I had the money, but all I have left is enough to cover my next LLMD visit. Literally I am out of all funds.So, hopefully someone can see me with my insurance. Thanks so much Amberini and Keebler for your help!
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Please keep us posted on your progress. If there is anything else I can help you with, just holler!
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Keebler
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- amberini,
so glad to see your help. You seem to know a lot about the ears and If the inner ear stuff interests you, please feel free to copy to your file any of the links I've posted and then post for others anytime you see relevant questions.
Everyone can feel free to copy and post as they like.
Each day, I hope to ease away from lymenet as I'm so tired and need to direct my own care better. But, each day there are at least 2 - 3 new requests for inner ear explanations.
If there are more who can answer the inner ear requests, then I can take some time off. Since you've answered here and over in the other thread about all this, and stuck with it, I just thought you might be interested in being a good reply person to keep your eyes alert for those needing ear help. Eh? -
[ 11-11-2010, 05:53 PM: Message edited by: Keebler ]
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Sure, I will try to help those who have ear questions.
We all have to take care of ourselves first and foremost but very hard to do when fighting these beasts.
I don't post too much but I have read this board for a long time.
You have wonderful links and knowledge that I know comes unfortunately from years of suffering. I am self-taught too.
I see you don't accept messages though I might like to send one sometime. Maybe there area more ear stories we can share.
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Keebler
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posted
- Amberini,
My PM is usually closed as it takes so much energy to reply to questions just out of the blue and I just don't have that energy. I sent you a PM. -
[ 11-14-2010, 10:43 AM: Message edited by: Keebler ]
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