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Vestibular Disorders

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Title: Vestibular Disorders


1
Vestibular Disorders
  • Menieres Disease
  • Endolymphatic Hydrops
  • Michael J Disher, MD
  • Ear, Nose, and Throat Associates
  • For Wayne, Indiana

2
Dizziness
  • Imprecise Term
  • Lightheadedness
  • Imbalance / Unsteadiness
  • Faintness / Giddiness
  • Sensation of Swimming or Floating
  • Episodes of Mental Confusion
  • Minor Seizure

3
Vertigo
  • Hallucination of Motion
  • Subjective Vertigo
  • Im spinning
  • Objective Vertigo
  • The room is spinning
  • Does not Localize
  • Chãng mÆt

4
Epidemiology
  • 11.3 Million Visits per year involve
  • a complaint of dizziness
  • 5-10 of all initial visits to MDs
  • Dizziness ranks 10th by age 65
  • Ahead of low back pain and headaches
  • 40 of population over the age of 40
  • will experience dizziness
  • NIH Study

5
Initial Management
  • Rule Out Non-Vestibular Causes
  • Cardiac
  • Neurologic
  • Systemic
  • Not unlike a syncope evaluation

6
Warning Signs
  • Cardiac Findings
  • Neurologic Findings
  • True Loss of Consciousness
  • Facial Paralysis
  • Pain
  • Headache
  • Cervical Pain
  • Otologic Findings
  • Sudden Hearing Loss
  • Purulent Drainage
  • Otalgia

7
Initial Management
  • Rule - out Acute Event
  • Neurologic and Cardiac Evaluation
  • Control Initial Symptoms
  • Antivert (Meclizine)
  • Valium (Diazepam)
  • Phenergan (Promethazine HC)
  • Patient Education and Support
  • Majority of patients with an acute balance
    disorder recover spontaneously with only
    symptomatic treatment

8
Medical Treatment
  • Vestibular Suppressants
  • Antivert (Meclizine)
  • Antihistamine
  • Tablets 12.5mg, 25mg, 50mg
  • Dose 25mg TID prn
  • Adverse Reactions
  • Drowsiness
  • Rarely
  • Dry Mouth
  • Blurred Vision
  • Caution due to Anticholinergic Effect
  • Asthma, Glaucoma, Enlarged Prostate

9
Medical Treatment
  • Vestibular Suppressants
  • Valium (Diazepam)
  • Benzodiazepam
  • Tablets 2mg, 5mg, 10mg
  • Dose 2mg QID prn
  • Adverse Reactions
  • Drowsiness

10
Medical Treatment
  • Anti-emetics
  • Phenergan (Promethazine HC)
  • Phenothiazine
  • Tablets 12.5mg, 25mg, 50mg
  • Dose 25mg QID prn
  • Adverse Reactions
  • Drowsiness

11
The Balance System
12
Labyrinthine Anatomy
13
Membranous Labyrinth
14
FUNCTIONAL PHYSIOLOGY-HEAD STILL
15
FUNCTIONAL PHYSIOLOGY-HEAD RIGHT
16
Vestibulo-ocular Reflex (VOR)
17
Vestibular Lesion
18
Vestibular Lesion
19
Compensation
  • Acute
  • Cerebellar Clamp
  • Short term improvement
  • Significant symptoms remain
  • Chronic
  • Central nervous system plasticity
  • Long-term recovery
  • Full recovery often possible

20
Vestibular Compensation
  • Goals
  • Gaze Stability
  • Postural Control
  • Under both Static and Dynamic Conditions
  • Characteristics
  • Enhanced by Head Movement
  • Delayed by Inactivity
  • Inhibited by Vestibular Suppressants
  • Hindered by Preexisting or Concurrent Central
    Vestibular System Dysfunction
  • Somewhat Fragile and Energy-dependant Process

21
Vestibular NeuritisLabyrinthitis
  • Viral Cochleitis
  • Acute Vestibular Crises
  • Severe Vertigo 12 - 24 hours
  • Residual Motion provoked Symptoms for days -
    weeks
  • Gradual Improvement
  • Compensation
  • Hearing Loss Labyrinthitis
  • Stable Uncompensated Lesion

22
Vestibular Neuritis Labyrinthitis
  • Acute Management
  • Rule-out Acute Event
  • Neurologic and Cardiac Evaluation
  • Vestibular Suppressants
  • Education and Reassurance

23
Vestibular Neuritis Labyrinthitis
  • Long-Term Management
  • Increase Activity
  • Wean Vestibular Suppressants
  • Education and Reassurance
  • Vestibular Exercises
  • Vestibular Rehabilitation Therapy

24
Vestibular Rehabilitation Therapy
  • Goals
  • Reduce symptoms provoked by motion or position
  • Improve equilibrium
  • Improve quality of life by increasing activity
    levels

25
Vestibular Rehabilitation Therapy
  • What happens in VRT?
  • Assessment
  • Find movements and positions which provoke
    symptoms
  • Look for stance and gait problems
  • Assess Risk for falls
  • Look for other physical problems which might
    limit VRT
  • Education and Reassurance
  • Home Exercise Program (HEP)
  • Habituation Exercises
  • Small, controlled, repeated doses of provocative
    movements
  • Graduated Program
  • Balance and Gait Training
  • General Conditioning

26
Menieres Disease Endolymphatic Hydrops
  • Cochlear Cross-sectional Anatomy

27
Temporal Bone Cross-sectional Anatomy
  • Mild Hydrops

28
Temporal Bone Cross-sectional Anatomy
  • Severe Hydrops

29
Endolymphatic Hydrops(Menieres Disease)
Symptoms
  • Episodic Severe Vertigo Lasting for Hours
  • Fluctuating Low Frequency Hearing Loss
  • Roaring Tinnitus
  • Aural Fullness
  • Unstable Lesion

30
Endolymphatic Hydrops
Medical Management
  • Sodium Restriction
  • 1500 - 2000 mg per day
  • Not just no salt shaker
  • Must change eating habits
  • 64 oz fresh water per day
  • No Water Softener, which may add salt
  • Diuretic
  • Avoid Caffeine, Sugar, Nutrasweet, Tobacco

31
Endolymphatic Hydrops
Intratympanic Decadron
  • Advantages
  • Non-Destructive
  • Helpful with Hearing Loss
  • Disadvantages
  • Less Effective than Gentamicin

32
Endolymphatic Hydrops
Intratympanic Gentamicin
  • Advantages
  • 70-90 Control of Vertigo
  • Office Procedure
  • Disadvantages
  • Destructive Procedure
  • Risk of Hearing Loss

33
Endolymphatic Hydrops
Meniett
  • Advantages
  • 50-70 Control of Vertigo
  • Non-Destructive
  • Disadvantages
  • Requires PET

34
Endolymphatic Hydrops
Surgical Management
  • Endolymphatic Sac Shunt / Decompression

35
Endolymphatic Hydrops
  • Endolymphatic Sac Shunt / Decompression
  • Surgical View

36
Endolymphatic Hydrops
Surgical Management
  • Endolymphatic Sac Shunt / Decompression

37
Endolymphatic Hydrops
  • Surgical Management
  • Endolymphatic Sac Shunt / Decompression
  • Advantages
  • Non-Destructive
  • Hearing Preservation
  • Out - Patient Surgery
  • Disadvantages
  • Controversial
  • ? 50 - 90 Effective
  • Surgical Morbidity

38
Endolymphatic Hydrops
Surgical Management
  • Vestibular Nerve Section

39
Endolymphatic Hydrops
Vestibular Nerve Section
40
Endolymphatic Hydrops
Vestibular Nerve Section
41
Endolymphatic Hydrops
  • Vestibular Nerve Section

42
Endolymphatic Hydrops
  • Surgical Management
  • Vestibular Nerve Section
  • Suboccipital vs.. Middle Cranial Fossa
  • Advantages
  • 95 Control of Vertigo
  • Preserves Hearing
  • Disadvantages
  • Intracranial Procedure
  • Destructive Procedure

43
Endolymphatic Hydrops
Surgical Management
  • Labyrinthectomy

44
Endolymphatic Hydrops
  • Labyrinthectomy

45
Endolymphatic Hydrops
  • Surgical Management
  • Labyrinthectomy
  • Advantages
  • 95 Control of Vertigo
  • Extracranial Procedure
  • Disadvantages
  • Destructive Procedure
  • Sacrifice Hearing

46
Migraine Headaches
Prevalence Study
  • 20,000 Patients Diagnosed with Migraine
  • Who had HA at least once per year
  • 17.6 Adult females
  • 5.7 Adult males
  • 4 children
  • 18 had HA one or more per month
  • Highest prevalence 35-45 years
  • Lowest prevalence gt 50 years
  • Of those in the 20,000 deserving Dx of Migraine
    only
  • 29 males and 41 females aware

47
Migraine Events
  • Migraines are Neurological events
  • Most common symptoms is Headache
  • Events can range from no pain to severe pain with
    permanent ischemic damage
  • Most common non-pain form of a migraine is
    visual, but any aura symptom can occur in the
    absence of pain, including dizziness

48
Migraine Events HIS Classification
  • Migraine without aura
  • Migraine with aura
  • Migraine with prolonged aura
  • one Symptom lasts gt 60 min but lt 7 days
  • Basilar migraine
  • Migraine aura without headache
  • Childhood periodic syndromes
  • Migrainous infarction

49
Migraine Head Ache History Clues
  • Head pain localizes
  • May be associated with eyes
  • Throbbing
  • Light or sound sensitivity - motion sickness
    especially in childhood
  • Scintillating lights - with or without pain
  • Family members with migraine
  • Mild to severe - hormonal and food triggers
  • Headache with caffeine withdrawal

50
Migraine classification - IHS
  • Migraine without aura (Common migraine)
  • At least five attacks meeting the criteria below
  • Duration 4-72 hours
  • Headache has at least two of the following
  • Unilateral location
  • Pulsating quality
  • Moderate to severe intensity (inhibits or
    prohibits daily activities)
  • Aggravation with physical activity that increases
    intra-cranial pressure, eg. Walking stairs,
    straining,, etc
  • During headache at least one of the following
  • Nausea and / or vomiting
  • Photophobia and / or phonophobia

51
Migraine classification - IHS
  • Migraine with aura (Classic migraine)
  • Meets criteria for Migraine without aura with the
    following addition
  • Reversible neurological dysfunction
  • Gradual onset over minutes, lasting lt 1 hour
  • Headache before, during or up to 1 hour after
    aura
  • Migraine aura without headache (acephalgic
    migraine, migraine equivalent)
  • Aura as described above - head pain never
    develops. Rarely can last for hours

52
Migraine classification - IHS
  • List of symptoms that constitute an aura
  • Bilateral visual distortions
  • Paresthesia
  • Muscle weakness / coordination loss
  • Fluctuant hearing, unilateral or bilateral
  • Tinnitus, unilateral or bilateral
  • Lightheadedness / imbalance to true vertigo -
    movement provoked or spontaneous

53
Migraine classification - IHS
  • Basilar Migraine (Basilar Artery Migraine)
  • Meets criteria of Migraine with aura but has two
    or more of the following auras
  • Visual symptoms affecting all fields
  • Dysarthria
  • Vertigo
  • Tinnitus
  • Hearing loss
  • Diplopia
  • Ataxia
  • Bilateral sensory changes or weakness
  • Decreased consciousness

54
Vestibular Migraine Study (Cutrer Bahol) 91
patients
  • Symptoms
  • 70 true vertigo
  • 30 dizziness, imbalance, rocking, motion
    sensitivity
  • Relationship to headache
  • 5 consistently preceding or during headache
  • 65 variable
  • 30 completely independent

55
Duration of Vertigo Spells in Migraine (Cutrer
and Baloh, 1992)
  • Seconds 7
  • Minutes to 2 hours 31
  • 2 - 6 hours 5
  • 6 24 hours 8
  • gt 24 hours 49
  • (weeks of motion sickness punctuated by vertigo)

56
Migraine Prevention - Behavioral(Tusa, 1994)
  • Stress reduction
  • Aerobic exercise - for balance disorders Tai-Chi
  • Regular meals
  • Stable sleep schedule
  • Avoid nicotine
  • Hormone replacement
  • Migraine diet

57
Dietary Triggers Partial List
  • Cheese
  • Red wine
  • Chocolate
  • Caffeine
  • MSG
  • Processed meats

58
Migraine Pharmacological Rx
  • SNRIs (serotonin-norepinephrine reuptake
    inhibitor)
  • Effexor XR (Venlafaxine HCl)
  • Zoloft (Sertraline)
  • Tricyclic Antidepressants
  • Pamelor (Nortriptylene)
  • Elavil (Amatriptylene)
  • Topamax (Topiramate)
  • Beta Blockers
  • Acetazolamide

59
Migraine - Pharmacological RxJohnson, GD - 1998
Substantial or Complete Control
  • Episodic vertigo
  • 92 (68/74)
  • Positional vertigo
  • 89 (56/63)
  • Non-vertiginous dizziness
  • 86 (56/65)
  • Aural fullness
  • 85 (34/40)
  • Otalgia
  • 63 (10/16)
  • Phonophobia
  • 89 (17/19)

60
Migraine vs Menieres
  • Migraine
  • Spontaneous Vertigo
  • Unilateral tinnitus and fluctuant hearing
  • Permanent progressive hearing loss unlikely
  • Mild ENG findings including mild asymmetry
  • Duration of vertigo seconds to days
  • Menieres
  • Spontaneous Vertigo
  • Unilateral tinnitus and fluctuant hearing
  • Permanent progressive hearing loss likely
  • Mild to significant ENG findings - mild to
    significant asymmetry
  • Duration gt20 min lt24 hours

61
Migraine headache
Migraines are
  • Diagnosis of Exclusion
  • No tests for Migraines
  • Suspect the Dx from the History

62
BPPV Benign Paroxysmal Positional Vertigo
63
BPPV Benign Paroxysmal Positional Vertigo
64
BPPV Benign Paroxysmal Positional Vertigo
  • Most Common Cause of Vertigo
  • 64/100,000/year
  • 50 of those over 65yo will have at least 1
    episode
  • Usually self-limiting, but can persist for years
  • Etiology
  • Head Trauma, Inflammation, Aging, Spontaneous

65
BPPV Benign Paroxysmal Positional Vertigo
  • Symptoms
  • Brief (lt1min) intense spinning following a
    movement
  • Rolling over in bed
  • Rising from Supine
  • Head tilt up (top shelf vertigo)
  • No Crisis Event
  • Hallpike Test Reproduces Symptoms

66
BPPV Benign Paroxysmal Positional Vertigo
  • Diagnosis
  • Hallpike Maneuver
  • Traditional
  • No Neck Extension if Elderly-risk of basilar
    stroke
  • No Neck Torsion if Cervical Problems
  • Sit-to-side-lying if Back Problems
  • Torsional Nystagmus

67
HallpikeManeuver
68
BPPV Benign Paroxysmal Positional Vertigo
  • Management
  • Increase Activity
  • Generic Vestibular Exercises
  • Particle Repositioning Maneuver
  • Vestibular Rehabilitation Therapy (VRT)
  • Surgical
  • Posterior Semicircular Canal Occlusion

69
BPPV Benign Paroxysmal Positional Vertigo
  • Particle Repositioning Maneuver

70
BPPV Benign Paroxysmal Positional Vertigo
  • Particle Repositioning Maneuver (PRM)

71
BPPV Benign Paroxysmal Positional Vertigo
  • Management
  • Keep in Mind
  • Vertigo medications dont help and may hinder
    recovery
  • Patients dont have to learn to live with it
  • Particle Repositioning Maneuver (PRM) and/or VRT
  • Combined have a 95 success rate
  • PRM works best for most, VRT for others
  • VRT may also be used to resolve residual symptoms
    after PRM

72
Bilateral Vestibular Weakness
  • IV Aminoglycoside Antibiotics
  • 10 with IV treatment for 1 week or more
  • Reduced Renal Function Increases Risk
  • Rotary Chair to monitor for toxicity
  • Change meds if toxicity is detected
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