Transcript Vestibular Disorders - ORL-HNS

Vestibular Disorders
Meniere’s Disease
Endolymphatic Hydrops
Michael J Disher, MD
Ear, Nose, and Throat Associates
For Wayne, Indiana
Dizziness
Imprecise Term
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Lightheadedness
Imbalance / Unsteadiness
Faintness / Giddiness
Sensation of Swimming or Floating
Episodes of Mental Confusion
Minor Seizure
Vertigo
Hallucination of Motion
• Subjective Vertigo
“I’m spinning”
• Objective Vertigo
“The room is spinning”
Does not Localize
“Chãng mÆt”
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
Initial Management
• Rule Out Non-Vestibular Causes
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Cardiac
Neurologic
Systemic
Not unlike a syncope evaluation
Warning Signs
• Cardiac Findings
• Neurologic Findings
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True Loss of Consciousness
Facial Paralysis
• Pain
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Headache
Cervical Pain
• Otologic Findings
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Sudden Hearing Loss
Purulent Drainage
Otalgia
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
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
Medical Treatment
Vestibular Suppressants
• Valium (Diazepam)
• Benzodiazepam
• Tablets 2mg, 5mg, 10mg
• Dose 2mg QID prn
• Adverse Reactions
• Drowsiness
Medical Treatment
Anti-emetics
• Phenergan (Promethazine HC)
• Phenothiazine
• Tablets 12.5mg, 25mg, 50mg
• Dose 25mg QID prn
• Adverse Reactions
• Drowsiness
The Balance System
Labyrinthine Anatomy
Membranous Labyrinth
FUNCTIONAL PHYSIOLOGYHEAD STILL
FUNCTIONAL PHYSIOLOGYHEAD RIGHT
Vestibulo-ocular Reflex (VOR)
Vestibular Lesion
Vestibular Lesion
Compensation
• Acute
• Cerebellar Clamp
• Short term improvement
• Significant symptoms remain
• Chronic
• Central nervous system plasticity
• Long-term recovery
• Full recovery often possible
Vestibular Compensation
• Goals
• Gaze Stability
• Postural Control
• Under both Static and Dynamic Conditions
• Characteristics
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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
Vestibular Neuritis
Labyrinthitis
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
Vestibular Neuritis
Labyrinthitis
Acute Management
• Rule-out Acute Event
• Neurologic and Cardiac Evaluation
• Vestibular Suppressants
• Education and Reassurance
Vestibular Neuritis
Labyrinthitis
Long-Term Management
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Increase Activity
Wean Vestibular Suppressants
Education and Reassurance
Vestibular Exercises
Vestibular Rehabilitation Therapy
Vestibular Rehabilitation Therapy
Goals
• Reduce symptoms provoked by motion or position
• Improve equilibrium
• Improve quality of life by increasing activity levels
Vestibular Rehabilitation Therapy
What happens in VRT?
• Assessment
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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
Meniere’s Disease
Endolymphatic Hydrops
Cochlear Cross-sectional Anatomy
Temporal Bone
Cross-sectional Anatomy
Mild Hydrops
Temporal Bone
Cross-sectional Anatomy
Severe Hydrops
Endolymphatic Hydrops
(Meniere’s Disease)
Symptoms
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Episodic Severe Vertigo Lasting for Hours
Fluctuating Low Frequency Hearing Loss
Roaring Tinnitus
Aural Fullness
• Unstable Lesion
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
Endolymphatic Hydrops
Intratympanic Decadron
• Advantages
• Non-Destructive
• Helpful with Hearing Loss
• Disadvantages
• Less Effective than Gentamicin
Endolymphatic Hydrops
Intratympanic Gentamicin
• Advantages
• 70-90% Control of Vertigo
• Office Procedure
• Disadvantages
• Destructive Procedure
• Risk of Hearing Loss
Endolymphatic Hydrops
Meniett
• Advantages
• 50%-70% Control of Vertigo
• Non-Destructive
• Disadvantages
• Requires PET
Endolymphatic Hydrops
Surgical Management
Endolymphatic Sac Shunt / Decompression
Endolymphatic Hydrops
Endolymphatic Sac Shunt / Decompression
Surgical View
Endolymphatic Hydrops
Surgical Management
Endolymphatic Sac Shunt / Decompression
Endolymphatic Hydrops
Surgical Management
• Endolymphatic Sac Shunt / Decompression
 Advantages
 Non-Destructive
 Hearing Preservation
 Out - Patient Surgery
 Disadvantages
 Controversial
 ? 50% - 90% Effective
 Surgical Morbidity
Endolymphatic Hydrops
Surgical Management
Vestibular Nerve Section
Endolymphatic Hydrops
Vestibular Nerve Section
Endolymphatic Hydrops
Vestibular Nerve Section
Endolymphatic Hydrops
Vestibular Nerve Section
Endolymphatic Hydrops
Surgical Management
• Vestibular Nerve Section
• Suboccipital vs.. Middle Cranial Fossa
• Advantages
• 95% Control of Vertigo
• Preserves Hearing
• Disadvantages
• Intracranial Procedure
• Destructive Procedure
Endolymphatic Hydrops
Surgical Management
Labyrinthectomy
Endolymphatic Hydrops
Labyrinthectomy
Endolymphatic Hydrops
Surgical Management
• Labyrinthectomy
• Advantages
• 95% Control of Vertigo
• Extracranial Procedure
• Disadvantages
• Destructive Procedure
• Sacrifice Hearing
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
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18% had HA one or more per month
Highest prevalence 35-45 years
Lowest prevalence > 50 years
Of those in the 20,000 deserving Dx of Migraine only
• 29% males and 41% females aware
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
Migraine Events
HIS Classification
• Migraine without aura
• Migraine with aura
• Migraine with prolonged aura
• one Symptom lasts > 60 min but < 7 days
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Basilar migraine
Migraine aura without headache
Childhood periodic syndromes
Migrainous infarction
Migraine Head Ache
History Clues
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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
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:
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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
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 < 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
Migraine classification - IHS
• List of symptoms that constitute an aura
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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
Migraine classification - IHS
Basilar Migraine (Basilar Artery Migraine)
• Meets criteria of Migraine with aura but has two or more
of the following auras
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Visual symptoms affecting all fields
Dysarthria
Vertigo
Tinnitus
Hearing loss
Diplopia
Ataxia
Bilateral sensory changes or weakness
Decreased consciousness
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
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%
• > 24 hours
49%
(weeks of motion sickness punctuated by vertigo)
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
Dietary Triggers
Partial List
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Cheese
Red wine
Chocolate
Caffeine
MSG
Processed meats
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
Migraine - Pharmacological Rx
Johnson, 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)
Migraine vs Meniere’s
• 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
• Meniere’s
• Spontaneous Vertigo
• Unilateral tinnitus and
fluctuant hearing
• Permanent progressive
hearing loss likely
• Mild to significant
ENG findings - mild to
significant asymmetry
• Duration >20 min <24
hours
Migraine headache
Migraines are
• Diagnosis of Exclusion
• No tests for Migraines
• Suspect the Dx from the History
BPPV
Benign Paroxysmal Positional Vertigo
BPPV
Benign Paroxysmal Positional Vertigo
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
BPPV
Benign Paroxysmal Positional Vertigo
Symptoms
• Brief (<1min) 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
BPPV
Benign Paroxysmal Positional Vertigo
Diagnosis
• Hallpike Maneuver
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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
Hallpike
Maneuver
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BPPV
Benign Paroxysmal Positional Vertigo
Management
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Increase Activity
Generic Vestibular Exercises
Particle Repositioning Maneuver
Vestibular Rehabilitation Therapy (VRT)
Surgical
• Posterior Semicircular Canal Occlusion
BPPV
Benign Paroxysmal Positional Vertigo
Particle Repositioning Maneuver
BPPV
Benign Paroxysmal Positional Vertigo
Particle Repositioning Maneuver (PRM)
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BPPV
Benign Paroxysmal Positional Vertigo
Management
• Keep in Mind…
• Vertigo medications don’t help and may hinder recovery
• Patient’s don’t 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
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