Medical and Surgical Management Of the Balance Disordered Patient

Medical Management of Balance Complaints

Acute vs. Chronic Balance Problems Acute: –Reduce discomfort –Suppress emesis –Sedation Chronic –Suppression of Vestibular Symptoms –Tx of Specific Conditions (e.g., Meniere’s, Migraine, etc.) –Tx of Reactive Depression

Acute Vestibular Crisis Vestibular Suppressants: –Antihistaminic (Antivert, Bonine, Drammamine) –Anticholinergic (Phenergan, Scopalamine) –Benzodiazepines (Valium, Ativan, Klonopin, Xanax) Antiemetics: –Phenergan, Inapsine, Zofran, Rubinul, Compazine Oral Corticosteroids –Decadron, Deltasone,

Other Medical Interventions Diuretics -- Meniere’s: –Dyazide –Lasix –Diamox Vasodilators (microcirculatory enhancement) –Pavabid –Niacin

Dietary Management Reduced Sodium (< 1500 mg) –Meniere’s –Labyrinthine Concussion Dietary Exclusions –Migraine: caffeine, alcohol, chocolate, cheese, etc.

Surgery Reparative: Middle ear surgery Perilymph Fistula Sac decompression/Endolymphatic shunt Ablative: Labyrinthectomy Vestibular Nerve Section Canal Plugging Chemical destruction

Perilymph Fistula

Perilymph Fistula Repair Exploratory surgery – controversial Success: –64% improve when fistula found –44% improve when no fistula found –Vestibular improvement common –Auditory symptoms (HL/tinn) generally not improved.

Endolymphatic Sac Decompression/ Endolymphatic Shunt For E. Hydrops –Remember natural history of Meniere’s –“Plumbing” has no basis in known function Moderately beneficial over 2 years Shunts close up by 4 years Neither very effective at 5 years No different than sham surgery

Rationale for Ablative Procedures Fluctuating or progressive peripheral dysfunction doesn’t allow compensation to occur Surgery produces stable peripheral lesion Permits central compensation

Labyrinthectomy Surgical Destruction of the inner ear Trans- canal or trans-mastoid Eliminates vertigo in 90 to 93% of cases Hearing is sacrificed

Vestibular Neurectomy Control of unilateral Meniere’s in pts with some hearing. Approaches: –Middle fossa –Retrolabyrinthine –Retrosigmoid 95% relief from vertiginous attacks

Neurectomy Complications Incomplete sectioning (up to 5%) Neuroma growth (<1%) CSF leak (10%) Facial weakness (<1% with monitoring) Ongoing Headache (25% or more)  Transtympanic Gentamicin is preferred

Chemical Destruction Transtympanic delivery of aminoglycoside Gentamicin perfusion is common Under local anaesthesia 4 to 6 injections (1/week) until vertigo occurs Contralateral ear unaffected Vertigo dissipates over 7-30 days post treatment

Chemical Destruction Vertigo eliminated in 84 to 100 % Hearing often worse: –30 % on average –Range: 3% to 58% (susceptibility) –(Compared to near 100% with streptomycin) Relapse rates reported: –up to 30% (susceptibility, again) –Repeat treatment/consider vest. nerve section

Canal Plugging BPPV pts who do not respond to positioning/ libratory maneuvers Plug produces single canal paresis Success above 95% Alternative to singular neurectomy

Surgical Follow-Up Adjunctive Medical Tx Vestib. Rehab. (esp. with ablative surgery) –Fixed deficit for brain to accommodate –VR helps brain learn to do so.

Rehabilitation for Balance Disorders Canalith Repositioning Maneuvers Vestibular Rehab

Canalith Repositioning Posterior Canal (85-95% success) –Epley –Semont Horizontal Canal (100% success) –Barbecue Roll –Appiani –Casani

Posterior Canal BPPV

The Epley

Epley Issues Speed of maneuver: fast isn’t necessarily good. Is vibration necessary? Follow up movement restrictions? Follow up exercises?

The Semont The “slam dunk” maneuver Designed with cupulolithiasis in mind No different in success rate than Epley

Horiz. Canal--Barbecue Roll: Start supine Rolls toward unaffected ear in 90 degree steps 2 to 3 times around

Appiani: Start sitting Lay toward unaffected side w/ head elevated and facing straight ahead. Remain 1 minute after nystagmus disappears Turn head toward table – 3 min post-nyst Return to sitting Lay on affected side to double check.

Casani, et al. (2002) Start sitting facing foward Lay to affected side head held straight Turn head toward affected side Return to sitting.

Vestibular Rehabilitation Habituation Adaptation Substitution

Brandt-Daroff Exercises

Cawthorne-Cooksey Exercises scaled –From simple to difficult –From isolated parts (eye movement only, e.g.) –To generalized movement (eye & head, whole body)

Assessing Progress Symptom amelioration Scales –Dizziness Handicap Inventory (Jacobson) –Vestibular Disorders Activities of Daily Living Scale –Vestibular Symptom Index (Black) Tests –Berg Balance Scale –Timed Up and Go Test