Post on 30-Jan-2015
description
transcript
11
Medical Management of Medical Management of Vestibular Disorders and Vestibular Disorders and Vestibular RehabilitationVestibular Rehabilitation
22
IntroductionIntroduction
Basic inputs - vision, proprioception, and Basic inputs - vision, proprioception, and vestibular systemvestibular system
Provide ocular stability, gait control, and Provide ocular stability, gait control, and balancebalance
Disorders of vestibular system are major Disorders of vestibular system are major disruptors causing spatial disorientationdisruptors causing spatial disorientation
Many causes of dizziness, vertigo when Many causes of dizziness, vertigo when caused by a loss of vestibular functioncaused by a loss of vestibular function
Management strategies for vestibular Management strategies for vestibular disorders has continued to evolvedisorders has continued to evolve
33
PathophysiologyPathophysiology
Vestibular labyrinth - detects linear and Vestibular labyrinth - detects linear and angular head movementsangular head movements
Semicircular canals - angularSemicircular canals - angularHair cells organized under cupulaHair cells organized under cupula
Otolithic organs (utricle, sacule) - linearOtolithic organs (utricle, sacule) - linearHair cells attached to a layer of otoconiaHair cells attached to a layer of otoconia
Vestibular nerve - superior, inferior branchVestibular nerve - superior, inferior branchAfferent nerve fibers are bipolar - cell Afferent nerve fibers are bipolar - cell
bodies lie within Scarpa’s ganglionbodies lie within Scarpa’s ganglion
44
PathophysiologyPathophysiology
Balance requires –Balance requires – Normal functioning vestibular systemNormal functioning vestibular system Input from visual system (vestibulo-ocular)Input from visual system (vestibulo-ocular) Input from proprioceptive system (vestibulo-spinal)Input from proprioceptive system (vestibulo-spinal)
Central causes compromise central circuits that Central causes compromise central circuits that mediate vestibular influences on posture, gaze mediate vestibular influences on posture, gaze control, autonomic fxcontrol, autonomic fx
Disruption of balance between inputs results in Disruption of balance between inputs results in vertigovertigo
Goal of treatment: restore balance between Goal of treatment: restore balance between different inputsdifferent inputs
55
PathophysiologyPathophysiology
Vestibular system influences autonomic Vestibular system influences autonomic systemsystem
Intimate linkage in brainstem pathways Intimate linkage in brainstem pathways between vestibular and visceral inputsbetween vestibular and visceral inputs
Alteration of vestibular inputs results in:Alteration of vestibular inputs results in:nausea, vomitingnausea, vomitingPallorPallorRespiratory/circulatory changesRespiratory/circulatory changes
66
Medical TreatmentMedical Treatment
SymptomaticSymptomaticSpecific therapySpecific therapyVestibular rehabilitationVestibular rehabilitation
77
Symptomatic PharmacotherapySymptomatic Pharmacotherapy
Predominant targeted vestibular Predominant targeted vestibular neurotransmitters:neurotransmitters: CholinergicCholinergic HistaminergicHistaminergic GABA neurotransmitters - negative inhibitionGABA neurotransmitters - negative inhibition
Vomiting center transmitters:Vomiting center transmitters: Dopaminergic (D2)Dopaminergic (D2) Histaminergic (H1)Histaminergic (H1) SeratonergicSeratonergic
Multiple classes of drugs effectiveMultiple classes of drugs effective
88
Symptomatic PharmacotherapySymptomatic Pharmacotherapy
Antihistaminergic - dimenhydrinateAntihistaminergic - dimenhydrinateAnticholinergics - scopolamine, meclizineAnticholinergics - scopolamine, meclizineAnti-dopaminergic - droperidolAnti-dopaminergic - droperidol(gamma)-aminobutyric acid enhancing (gamma)-aminobutyric acid enhancing
(GABA-ergic) agents - lorazepam, valium(GABA-ergic) agents - lorazepam, valium
99
Symptomatic PharmacotherapySymptomatic Pharmacotherapy
Some drugs of the antihistamine class are Some drugs of the antihistamine class are useful for symptomatic control of vertigouseful for symptomatic control of vertigo
Have anti-motion sickness properties in large Have anti-motion sickness properties in large part due to inhibition of vestibular system H1 part due to inhibition of vestibular system H1 histaminergic neurotransmittershistaminergic neurotransmitters
Examples include dimenhydrinate (Dramamine) Examples include dimenhydrinate (Dramamine) and promethazine (Phenergan)and promethazine (Phenergan)
Also suppress the vomiting centerAlso suppress the vomiting center
1010
Symptomatic PharmacotherapySymptomatic Pharmacotherapy
1111
Symptomatic PharmacotherapySymptomatic Pharmacotherapy Two recent ER clinical trialsTwo recent ER clinical trials
Marill et al. 2000Marill et al. 2000 50mg IV dimenhydrinate vs. 2mg IV Ativan50mg IV dimenhydrinate vs. 2mg IV Ativan Benadryl more effective for symptomsBenadryl more effective for symptoms
Irving et al. 2002Irving et al. 2002 50mg IM dimenhydrinate vs. 2.5mg IM droperidol50mg IM dimenhydrinate vs. 2.5mg IM droperidol Equally effectiveEqually effective
Response is dose-dependentResponse is dose-dependent All medications are sedating All medications are sedating Newer non-sedating antihistamines do not cross Newer non-sedating antihistamines do not cross
blood-brain barrier - little therapeutic valueblood-brain barrier - little therapeutic value
1212
Specific PharmacotherapySpecific Pharmacotherapy
Vestibular Neuritis *Vestibular Neuritis *Meniere’s Disease *Meniere’s Disease *Benign Paroxysmal Positional Vertigo *Benign Paroxysmal Positional Vertigo *OtosyphilisOtosyphilisVertebrobasilar InsufficiencyVertebrobasilar InsufficiencyMigraine (with vertigo)Migraine (with vertigo)
* * more common more common
1313
Vestibular NeuritisVestibular Neuritis
Sudden onset of peripheral vertigoSudden onset of peripheral vertigoUsually without hearing lossUsually without hearing lossPeriod of several hours - severePeriod of several hours - severeLasts a few days, resolves over weeksLasts a few days, resolves over weeks Inflammation of vestibular nerve - Inflammation of vestibular nerve -
presumably of viral originpresumably of viral originSpontaneous, complete symptomatic Spontaneous, complete symptomatic
recovery with supportive treatmentrecovery with supportive treatmentTreatment aimed at stopping inflammationTreatment aimed at stopping inflammation
1414
Vestibular NeuritisVestibular Neuritis
Ariyasu et al.Ariyasu et al.20 patients: double-blinded, crossover20 patients: double-blinded, crossoverMethylprednisolone vs. placeboMethylprednisolone vs. placebo90% decrease in vertigo within 24 hours vs. 90% decrease in vertigo within 24 hours vs.
30% of placebo group30% of placebo groupPlacebo switched to steroid after 24 hours Placebo switched to steroid after 24 hours
with decrease in vertigo over next 24 hourswith decrease in vertigo over next 24 hours16 patients receiving steroid with resolution 16 patients receiving steroid with resolution
had normal ENG within one monthhad normal ENG within one month
1515
Meniere’s DiseaseMeniere’s Disease
Hallpike and Cairns - 1938 found Hallpike and Cairns - 1938 found endolymphatic hydrops by histologyendolymphatic hydrops by histology
Implicated a disturbance of salt and water Implicated a disturbance of salt and water as pathologyas pathology
Classic triadClassic triadRecurrent vertigoRecurrent vertigoFluctuating SNHLFluctuating SNHLTinnitusTinnitus(aural fullness very common)(aural fullness very common)
1616
Meniere’s DiseaseMeniere’s Disease
Widely accepted medical treatmentWidely accepted medical treatmentDietary salt restrictionDietary salt restrictionDiureticsDiuretics
Thiazide diureticsThiazide diureticsDecrease Na absorption is distal tubuleDecrease Na absorption is distal tubuleSide effects - hypokalemia, hypotension, Side effects - hypokalemia, hypotension,
hyperuricemia, hyperlipoproteinemiahyperuricemia, hyperlipoproteinemiaCombination potassium sparing agentsCombination potassium sparing agents
Maxzide, DyazideMaxzide, DyazideAvoids hypokalemiaAvoids hypokalemia
1717
Meniere’s DiseaseMeniere’s Disease
At least 3 months of diuretic therapy At least 3 months of diuretic therapy recommended before discontinuingrecommended before discontinuing
Sulfa allergies - can try loop diuretics or Sulfa allergies - can try loop diuretics or alternate therapiesalternate therapies
1818
Meniere’s DiseaseMeniere’s Disease
Carbonic anhydrase inhibitors Carbonic anhydrase inhibitors (acetazolamide)(acetazolamide)““inner ear glaucoma”inner ear glaucoma”Decreased Na-H exchange in tubuleDecreased Na-H exchange in tubuleDecreased CSF productionDecreased CSF productionDiuretic effect not as long-lastingDiuretic effect not as long-lastingSide effects - nephrocalcinosis, mild Side effects - nephrocalcinosis, mild
metabolic acidosis, GI disturbancesmetabolic acidosis, GI disturbances
1919
Meniere’s DiseaseMeniere’s Disease
VasodilatorsVasodilatorsBased on hypothesis - pathogenesis results Based on hypothesis - pathogenesis results
from ischemia of stria vascularisfrom ischemia of stria vascularisRationale - improve metabolic functionRationale - improve metabolic functionIV histamine, ISDN, cinnarizine (CA agonist), IV histamine, ISDN, cinnarizine (CA agonist),
betahistine (oral histamine analogue)betahistine (oral histamine analogue)Anecdotal successAnecdotal successNo demonstrated beneficial effects in studiesNo demonstrated beneficial effects in studies
2020
Meniere’s DiseaseMeniere’s Disease
Newer theoriesNewer theoriesMultifactorial inheritanceMultifactorial inheritanceImmune-mediated phenomenaImmune-mediated phenomenaAssociation of allergiesAssociation of allergies
Study by Gottschlich et al.Study by Gottschlich et al.50% meeting criteria have antibodies to 70-kD 50% meeting criteria have antibodies to 70-kD
heat-shock proteinheat-shock protein70-kD HSP implicated in AI-SNHL70-kD HSP implicated in AI-SNHL
2121
Meniere’s DiseaseMeniere’s Disease
Immunosuppressive agents gaining favorImmunosuppressive agents gaining favorSystemic and intra-tympanic glucocorticoidsSystemic and intra-tympanic glucocorticoidsCyclophosphamideCyclophosphamideMethotrexateMethotrexate
Shea study - intractable Meniere’sShea study - intractable Meniere’s48 patients IT dexamethasone 48 patients IT dexamethasone 66.7% elimination of vertigo66.7% elimination of vertigo35.4% improvement in hearing (>10dB and/or 35.4% improvement in hearing (>10dB and/or
15% change in word recognition score) 15% change in word recognition score)
2222
Meniere’s DiseaseMeniere’s Disease
Chemical labyrinthectomyChemical labyrinthectomyDisabling vertigoDisabling vertigoAfter trial of adequate medical therapyAfter trial of adequate medical therapy
Intratympanic aminoglycoside (ITAG)Intratympanic aminoglycoside (ITAG)Allows treatment of unilateral diseaseAllows treatment of unilateral diseaseGentamicinGentamicin
Primarily vestibulotoxicPrimarily vestibulotoxic may impair vestibular dark cells (endolymph)may impair vestibular dark cells (endolymph)
Inherent hearing loss risk - 30%Inherent hearing loss risk - 30%
2323
ITAGITAG
Stock solution - 40mg/mL gentamicinStock solution - 40mg/mL gentamicin10 to 20 mg injected over round window10 to 20 mg injected over round windowPatient supine, ear up for 30 minutesPatient supine, ear up for 30 minutes Instructed not to swallowInstructed not to swallowBolus injections - weekly or bi-weeklyBolus injections - weekly or bi-weeklyEnd point variable - vestibular hypofunctionEnd point variable - vestibular hypofunctionAudiometry monitoring between injectionsAudiometry monitoring between injectionsTotal vestibular ablation not necessaryTotal vestibular ablation not necessary
2424
ITAGITAG
MinorMinor91% control of vertigo91% control of vertigo3% rate of profound SNHL (usually sudden)3% rate of profound SNHL (usually sudden)22% recurrence rate22% recurrence rate
Continuous deliveryContinuous deliveryMicrowickMicrowickRound Window MicrocatheterRound Window Microcatheter
Direct injection (labyrinthotomy)Direct injection (labyrinthotomy)Significant hearing lossSignificant hearing lossOut of favorOut of favor
2525
BPPVBPPV
Most common causeMost common cause Dysfunction of posterior SCCDysfunction of posterior SCC Cupulolithiasis vs. CanalithiasisCupulolithiasis vs. Canalithiasis CupulolithiasisCupulolithiasis
Calcium deposits embedded on cupulaCalcium deposits embedded on cupula PSCC becomes dependent on gravityPSCC becomes dependent on gravity
CanalithiasisCanalithiasis Calcium debris (otoconia) displaced into PSCCCalcium debris (otoconia) displaced into PSCC Does not adhere to cupulaDoes not adhere to cupula
2626
BPPVBPPV
Head movementsHead movements Looking upLooking up Lying downLying down Rolling onto affected earRolling onto affected ear
Result in displacement of “sludge” / otoconiaResult in displacement of “sludge” / otoconia Vertigo lasting a few secondsVertigo lasting a few seconds Treatment approachesTreatment approaches
Liberatory maneuversLiberatory maneuvers Particle repositioningParticle repositioning Habituation exercisesHabituation exercises
2727
BPPVBPPV
Semont et alSemont et al CupulolithiasisCupulolithiasis Liberatory maneuverLiberatory maneuver Single treatmentSingle treatment Cure ratesCure rates
84%-one treatment84%-one treatment93%-two treatments93%-two treatments
2828
BPPVBPPV
EpleyEpley CanalithiasisCanalithiasis Canalith repositioningCanalith repositioning Move into vestibuleMove into vestibule Cure ratesCure rates
80% - one treatment80% - one treatment 100% - multiple100% - multiple
2929
BPPV - EpleyBPPV - Epley
3030
BPPVBPPV
Brandt and DaroffBrandt and Daroff Habituation techniqueHabituation technique Move to provoking Move to provoking
position repeatedlyposition repeatedly 98% success rate 98% success rate
after 3 to 14 days of after 3 to 14 days of exercisesexercises
3131
BPPVBPPV
BlakelyBlakelyCompared repositioning techniques with no Compared repositioning techniques with no
treatmenttreatment89% of all patients improved after 1 month89% of all patients improved after 1 monthNo statistical significance between groupsNo statistical significance between groups50% spontaneous remission after 1 month50% spontaneous remission after 1 month
3232
OtosyphilisOtosyphilis
Penicillin established treatmentPenicillin established treatment IM and IV routes acceptableIM and IV routes acceptable IM - 2.4 million units benzathine PCN IM - 2.4 million units benzathine PCN
weekly x 3 consecutive weeks is minimal weekly x 3 consecutive weeks is minimal treatment (some advocate up to 1 year)treatment (some advocate up to 1 year)
IV - 10 million units PCN G qD in divided IV - 10 million units PCN G qD in divided doses x 10 days, followed by 2.4 million doses x 10 days, followed by 2.4 million units benzathine PCN x 2 weeksunits benzathine PCN x 2 weeks
3333
Vertebrobasilar insufficiencyVertebrobasilar insufficiency
Vertigo, diplopia, dysarthria, gait ataxia Vertigo, diplopia, dysarthria, gait ataxia and bilateral sensory & motor disturbanceand bilateral sensory & motor disturbance
Transient ischemia - low stroke riskTransient ischemia - low stroke riskAntiplatelet therapy - aspirin 325mg qDAntiplatelet therapy - aspirin 325mg qDTiclid Ticlid
Platelet aggregate inhibitorPlatelet aggregate inhibitorRisk of life-threatening neutropeniaRisk of life-threatening neutropeniaOnly in patients unable to tolerate aspirinOnly in patients unable to tolerate aspirin
3434
MigraineMigraine
Concomitant vertigo and disequilibriumConcomitant vertigo and disequilibriumHeadache control improves vertigoHeadache control improves vertigoDiagnostic criteriaDiagnostic criteria
Personal/family historyPersonal/family historyMotion intoleranceMotion intoleranceVestibular symptoms - do not fit other causesVestibular symptoms - do not fit other causes
Theories - vascular origin, abnormal Theories - vascular origin, abnormal neural activity (brainstem), abnormal neural activity (brainstem), abnormal voltage-gated calcium channel genesvoltage-gated calcium channel genes
3535
MigraineMigraine
TreatmentTreatmentModifying risk factorsModifying risk factors
Exercise and dietExercise and dietAvoid nicotine, caffeine, red wine and chocolateAvoid nicotine, caffeine, red wine and chocolate
Abortive medical therapyAbortive medical therapyErgotsErgotsSumatriptinSumatriptinMidrinMidrin
Prophylactic medical therapyProphylactic medical therapyB blockers, Ca channel blockers, NSAIDs, B blockers, Ca channel blockers, NSAIDs,
amitryptiline, and lithiumamitryptiline, and lithium
3636
Vestibular RehabilitationVestibular Rehabilitation
Promoting vestibular compensationPromoting vestibular compensationHabituationHabituationEnhancing adaptation of VOR & VSREnhancing adaptation of VOR & VSRMay have initial exacerbationMay have initial exacerbation
3737
Vestibular RehabilitationVestibular Rehabilitation
Cawthorne - CookseyCawthorne - CookseyDeveloped in 1940sDeveloped in 1940sHead movementsHead movementsBalance tasksBalance tasksCoordination of eyes with headCoordination of eyes with headTotal body movementsTotal body movementsEyes open & closedEyes open & closedNoisy environmentsNoisy environments
3838
Vestibular RehabilitationVestibular Rehabilitation
Habituation of pathologic responsesHabituation of pathologic responsesPostural control exercisesPostural control exercisesVisual-vestibular interactionVisual-vestibular interactionConditioning activitiesConditioning activitiesB.I.D., most improve after 4-6 weeksB.I.D., most improve after 4-6 weeks
3939
VRT - ElderlyVRT - Elderly
Multifactorial causes of balance difficultyMultifactorial causes of balance difficultyNeed 2 of 3 systems functionalNeed 2 of 3 systems functional
vestibular, visual, proprioceptivevestibular, visual, proprioceptive
Good outcome measures with longer timeGood outcome measures with longer time Impact on complications of fallsImpact on complications of falls
4040
ConclusionsConclusions
Vestibular complaints common to ENTVestibular complaints common to ENTThorough evaluation and understandingThorough evaluation and understandingDx and treat acute symptomsDx and treat acute symptomsWean vestibular suppressantsWean vestibular suppressantsSpecific pharmacotherapy institutedSpecific pharmacotherapy institutedChronic, uncompensated disease benefits Chronic, uncompensated disease benefits
from early VRTfrom early VRT