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Medical and Surgical Management

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

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Medical and Surgical Management

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  1. Medical and Surgical Management Of the Balance Disordered Patient

  2. Medical Management of Balance Complaints

  3. 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

  4. 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,

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

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

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

  8. Perilymph Fistula

  9. 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.

  10. 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

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

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

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

  14. 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

  15. 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

  16. 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

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

  18. 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.

  19. Rehabilitation for Balance Disorders Canalith Repositioning Maneuvers Vestibular Rehab

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

  21. Posterior Canal BPPV

  22. The Epley

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

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

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

  26. 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.

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

  28. Vestibular Rehabilitation • Habituation • Adaptation • Substitution

  29. Brandt-Daroff Exercises

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

  31. 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

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