Transcript 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
• (e.g., Meniere’s, Migraine, etc.)
– Tx of Reactive Depression
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,
Other Medical Interventions
• Diuretics -- Meniere’s:
– Dyazide
– Lasix
– Diamox
• Vasodilators (microcirculatory enhancement)
– Pavabid
– Niacin
Dietary Management
• Reduced Sodium (< 1500 mg)
– Meniere’s
– Labyrinthine Concussion
• Dietary Exclusions
– Migraine: caffeine, alcohol, chocolate, cheese,
etc.
Surgery
• Reparative:
Middle ear surgery
Perilymph Fistula
Sac decompression/Endolymphatic shunt
• Ablative:
Labyrinthectomy
Vestibular Nerve Section
Canal Plugging
Chemical destruction
Perilymph Fistula
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.
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
Rationale for Ablative Procedures
• Fluctuating or progressive peripheral
dysfunction doesn’t allow compensation to
occur
• Surgery produces stable peripheral lesion
• Permits central compensation
Labyrinthectomy
•
•
•
•
Surgical Destruction of the inner ear
Trans- canal or trans-mastoid
Eliminates vertigo in 90 to 93% of cases
Hearing is sacrificed
Vestibular Neurectomy
• Control of unilateral Meniere’s in pts with
some hearing.
• Approaches:
– Middle fossa
– Retrolabyrinthine
– Retrosigmoid
• 95% relief from vertiginous attacks
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
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
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
Canal
Plugging
• BPPV pts who do not respond to positioning/
libratory maneuvers
• Plug produces single canal paresis
• Success above 95%
• Alternative to singular neurectomy
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.
Rehabilitation for Balance
Disorders
Canalith Repositioning Maneuvers
Vestibular Rehab
Canalith Repositioning
• Posterior Canal (85-95% success)
– Epley
– Semont
• Horizontal Canal (100% success)
– Barbecue Roll
– Appiani
– Casani
Posterior Canal BPPV
The Epley
Epley Issues
• Speed of maneuver:
fast isn’t necessarily good.
• Is vibration necessary?
• Follow up movement restrictions?
• Follow up exercises?
The Semont
• The “slam dunk” maneuver
• Designed with cupulolithiasis in mind
• No different in success rate than Epley
Horiz. Canal--Barbecue Roll:
•
•
•
•
Start supine
Rolls toward unaffected ear
in 90 degree steps
2 to 3 times around
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.
Casani, et al. (2002)
•
•
•
•
Start sitting facing foward
Lay to affected side head held straight
Turn head toward affected side
Return to sitting.
Vestibular Rehabilitation
• Habituation
• Adaptation
• Substitution
Brandt-Daroff Exercises
Cawthorne-Cooksey
• Exercises scaled
– From simple to difficult
– From isolated parts (eye movement only, e.g.)
– To generalized movement (eye & head, whole
body)
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