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

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The Balance System
12
Labyrinthine Anatomy
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Membranous Labyrinth
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FUNCTIONAL PHYSIOLOGY-HEAD STILL
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FUNCTIONAL PHYSIOLOGY-HEAD RIGHT
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Vestibulo-ocular Reflex (VOR)
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Vestibular Lesion
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Vestibular Lesion
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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

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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

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Vestibular Neuritis Labyrinthitis

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

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Vestibular Neuritis Labyrinthitis

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

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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

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Menieres Disease Endolymphatic Hydrops

• Cochlear Cross-sectional Anatomy

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Temporal Bone Cross-sectional Anatomy

• Mild Hydrops

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Temporal Bone Cross-sectional Anatomy

• Severe Hydrops

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Endolymphatic Hydrops(Menieres Disease)
Symptoms

• Episodic Severe Vertigo Lasting for Hours
• Fluctuating Low Frequency Hearing Loss
• Roaring Tinnitus
• Aural Fullness
• Unstable Lesion

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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

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Endolymphatic Hydrops
Intratympanic Decadron

• Advantages
• Non-Destructive
• Helpful with Hearing Loss
• Disadvantages
• Less Effective than Gentamicin

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Endolymphatic Hydrops
Intratympanic Gentamicin

• Advantages
• 70-90 Control of Vertigo
• Office Procedure
• Disadvantages
• Destructive Procedure
• Risk of Hearing Loss

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Endolymphatic Hydrops
Meniett

• Advantages
• 50-70 Control of Vertigo
• Non-Destructive
• Disadvantages
• Requires PET

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Endolymphatic Hydrops
Surgical Management

• Endolymphatic Sac Shunt / Decompression

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Endolymphatic Hydrops

• Endolymphatic Sac Shunt / Decompression
• Surgical View

36
Endolymphatic Hydrops
Surgical Management

• Endolymphatic Sac Shunt / Decompression

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Endolymphatic Hydrops

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

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Endolymphatic Hydrops
Surgical Management

• Vestibular Nerve Section

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Endolymphatic Hydrops
Vestibular Nerve Section
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Endolymphatic Hydrops
Vestibular Nerve Section
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Endolymphatic Hydrops

• Vestibular Nerve Section

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Endolymphatic Hydrops

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

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Endolymphatic Hydrops
Surgical Management

• Labyrinthectomy

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Endolymphatic Hydrops

• Labyrinthectomy

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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

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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

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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

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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

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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

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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)

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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

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Dietary Triggers Partial List

• Cheese
• Red wine
• Chocolate
• Caffeine
• MSG
• Processed meats

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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

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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)

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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

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Migraine headache
Migraines are

• Diagnosis of Exclusion
• No tests for Migraines
• Suspect the Dx from the History

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BPPV Benign Paroxysmal Positional Vertigo
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BPPV Benign Paroxysmal Positional Vertigo
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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

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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

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HallpikeManeuver
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BPPV Benign Paroxysmal Positional Vertigo

• Management
• Increase Activity
• Generic Vestibular Exercises
• Particle Repositioning Maneuver
• Vestibular Rehabilitation Therapy (VRT)
• Surgical
• Posterior Semicircular Canal Occlusion

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BPPV Benign Paroxysmal Positional Vertigo

• Particle Repositioning Maneuver

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BPPV Benign Paroxysmal Positional Vertigo

• Particle Repositioning Maneuver (PRM)

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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

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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