Medical management of vestibular disorders and vestibular rehabilitation

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


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


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


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


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


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


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


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


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


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


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


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


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


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


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

Date post:	30-Jan-2015
Category:	Health & Medicine
Upload:	webzforu
View:	666 times
Download:	2 times

Medical management of vestibular disorders and vestibular rehabilitation

Health & Medicine