New developments in balance medicine

1. New developments in balance medicine Tim Price Consultant ENT Surgeon November 2011

2. Balance disorders • 30% population consult on giddiness by age 65 • Commonest reason for GP appointment in the over 75’s • Early retirement/ chronic illness in 18% • 5500 patients per year-Leicester Balance Centre.

3. COMMON ENT CAUSES OF BALANCE DYSFUNCTION • BPPV • Vestibular neuronitis/ Labyrinthitis • Meniere’s disease / syndrome

4. Migraineous Vertigo {Migraine-associated Dizziness / Labyrinthine Migraine} • The most common cause of balance disturbance. • Occurs in 5-8% of all cases of migraine • 33% of cases have no headache • 66% have no neurological deficit. • Mean age of onset 40 years. • Female :male ratio 2:1

5. Migrainous Vertigo symptoms • Vertigo / dysequilibrium / or both • Variable duration (sec to days) • Aural fullness (10%) • Hearing changes (6%) • Visual blurring (6%) • Bilateral tinnitus (5%) • Unilateral tinnitus (4%)

6. Symptoms continued • Bilateral ear pain (2%) • Unilateral ear pain (2%) • Diplopia (1%) • Hemianeasthesia (1%)

7. Differential diagnosis • Vestibular paroxysmia • Meniere’s disease • VBI • Vestibular epilepsy • Familial episodic ataxia

8. Pathophysiology • Uncertain • Genetic basis • Vascular spasm / Hypoperfusion • Neuronal hyperexcitability (calcium channelopathy) • Trigger factors are important.

9. Management • Dietary {6 C’s} • Medication for both acute attacks and prophylaxis • Include TCA’s / beta blockers etc. • Referral for specialist opinion.

10. Conclusions • Migraine related balance disturbance is common • Can be difficult to diagnose. • High index of suspicion • Specialist opinion may be valuable. • Low dose TCA, beta-blockers and migraine diets are well tolerated and efficacious.

11. BPPV • 2ND MOST COMMON CAUSE OF VERTIGO.

12. Symptoms • Occurs with specific head movements. • Rolling over in bed. • May follow on from a minor head injury. • Symptoms very brief -fades after 30-60 seconds. • No hearing loss. • Spontaneous resolution in 3 to 6 months

15. Detection / diagnosis: • Dix Hallpike Manoeuvre Tests the posterior and anterior semi circular canalsGravitational effect – produces circulation of endolymph - otoliths in one of the canals produces drag A few seconds latency and then symptom of intense vertigo with rotational, geotropic nystagmus. fades after 30-60 sec.Repeatable but fatigable.

17. Treatment: • Epley manoeuvre

20. Labyrinthitis • Third most common cause of vertigo after BPPV. • Characterized by sudden onset of severe vertigo without associated hearing loss. • Usually completely remits within 6 months

21. Historical Synonyms • Epidemic vertigo (Charters 1957) • Neurolabyrinthitis epidermica (Meulengracht 1950) • Acute labyrinthitis (Burrowes 1952) • Vestibular paralysis (Hart 1965) • Vestibular neuritis (Coats 1969)

22. Vestibular Neuritis • Bell’s Palsy • HSV 1 has been implicated in the etiology • Found virus in 60% of all vestibular ganglia examined • Latent Herpes Simplex virus Type 1 in Human Vestibular Ganglia. Futura Y et al Acta Otolaryngol Suppl. 503:85-89, 1993. • HSV-1 Geniculate and Vestibular Ganglia. Arbusow V et al Ann Neurol 46:3,416-419, 1999.

23. The beneficial effect of Methylprednisolone in acute vestibular vertigoAriyasu L et al Arch. Otolaryngology Head and Neck Surg 116:700-703, 1990 • 20 patients • Placebo-controlled, blinded, randomized, crossover study • 9/10 steroid treated patients with significant early reduction in vertigo. • 3/10 placebo treated patients with significant early reduction in vertigo.

24. Methylprednisolone, valacyclovir, or the combination for Vestibular NeuritisStrupp et al NEJM 351:4, 28-35, 2004 • Prospective randomized double blinded trial • 141 patients • 4 limbs– placebo(38), antiviral (35), steroid (35), steroid plus antiviral (35) • Analysis of caloric response recovery Day1 or 2 versus one year. • Significant steroid effect, no effect of antiviral with or without steroid • Major flaw is late enrolement up to 3 days!

25. Where do we go from here? • Consider Vestibular Neuritis as a treatable acute neuropathy • Steroid therapy has some literature support. • Randomized placebo-controlled double-blinded trial with early enrollment. • Multicenter trial

26. Proposed therapy for Acute vestibular Neuritis • Vestibular sedative (Stemetil) • IV/IM Dexamethasone 8mg (hydrocortisone) • Oral Prednisolone • Acyclivir/ Famcyclovir.

27. And now for something completely different! • “Doctor I feel a bit dizzy and I can hear my eyes moving in my head” • “Doctor I can hear my foot steps in my head when I walk” • “I can hear my voice in my head”

28. Superior Semicircular Canal Dehiscence • Described in 1998 in: • Rare condition caused by a third window into the inner ear. • Sound- and/or pressure-induced vertigo due to bone dehiscence of the superior semicircular canal. • Minor et al Archives Otolaryngology Head Neck Surg. 1998 Mar; 124(3):249-58

49. Etiology • Signs and symptoms usually present during adulthood, and half of patients report a precipitating head injury. • Suggests two stage process: • 1. Anomolous development of thin layer of bone over SCC. • 2. Second event (trauma or sudden change in pressure) that fractures the thin bone or destabilizes dura over the dehiscence. • (? 3. or slow erosion due to gravity/pulse pressure.)

50. SCDS Symptoms • Autophony- hear the sound of their own voice as a distubingly loud and distorted sound deep in their heads. • Also hear creaking and cracking of joints, sound of footsteps, chewing and digestive noises, • eyeballs moving in their sockets like sandpaper on wood.