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Vestibular Disorders

Vestibular Disorders. Meniere’s Disease Endolymphatic Hydrops Michael J Disher, MD Ear, Nose, and Throat Associates For Wayne, Indiana. Dizziness. Imprecise Term Lightheadedness Imbalance / Unsteadiness Faintness / Giddiness Sensation of Swimming or Floating

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Vestibular Disorders

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  1. Vestibular Disorders Meniere’s Disease Endolymphatic Hydrops Michael J Disher, MD Ear, Nose, and Throat Associates For Wayne, Indiana

  2. Dizziness Imprecise Term • Lightheadedness • Imbalance / Unsteadiness • Faintness / Giddiness • Sensation of Swimming or Floating • Episodes of Mental Confusion • Minor Seizure

  3. Vertigo Hallucination of Motion • Subjective Vertigo “I’m spinning” • Objective Vertigo “The room is spinning” Does not Localize “Chãng mÆt”

  4. Epidemiology • 11.3 Million Visits per year involve a complaint of dizziness • 5%-10% of all initial visits to MDs • Dizziness ranks 10th by age 65 • Ahead of low back pain and headaches • 40% of population over the age of 40 will experience dizziness • NIH Study

  5. Initial Management • Rule Out Non-Vestibular Causes • Cardiac • Neurologic • Systemic • Not unlike a syncope evaluation

  6. Warning Signs • Cardiac Findings • Neurologic Findings • True Loss of Consciousness • Facial Paralysis • Pain • Headache • Cervical Pain • Otologic Findings • Sudden Hearing Loss • Purulent Drainage • Otalgia

  7. Initial Management • Rule - out Acute Event • Neurologic and Cardiac Evaluation • Control Initial Symptoms • Antivert (Meclizine) • Valium (Diazepam) • Phenergan (Promethazine HC) • Patient Education and Support • Majority of patients with an acute balance disorder recover spontaneously with only symptomatic treatment

  8. Medical Treatment Vestibular Suppressants • Antivert (Meclizine) • Antihistamine • Tablets 12.5mg, 25mg, 50mg • Dose 25mg TID prn • Adverse Reactions • Drowsiness • Rarely • Dry Mouth • Blurred Vision • Caution due to Anticholinergic Effect • Asthma, Glaucoma, Enlarged Prostate

  9. Medical Treatment Vestibular Suppressants • Valium (Diazepam) • Benzodiazepam • Tablets 2mg, 5mg, 10mg • Dose 2mg QID prn • Adverse Reactions • Drowsiness

  10. Medical Treatment Anti-emetics • Phenergan (Promethazine HC) • Phenothiazine • Tablets 12.5mg, 25mg, 50mg • Dose 25mg QID prn • Adverse Reactions • Drowsiness

  11. The Balance System

  12. Labyrinthine Anatomy

  13. Membranous Labyrinth

  14. FUNCTIONAL PHYSIOLOGY-HEAD STILL

  15. FUNCTIONAL PHYSIOLOGY-HEAD RIGHT

  16. Vestibulo-ocular Reflex (VOR)

  17. Vestibular Lesion

  18. Vestibular Lesion

  19. Compensation • Acute • Cerebellar Clamp • Short term improvement • Significant symptoms remain • Chronic • Central nervous system plasticity • Long-term recovery • Full recovery often possible

  20. Vestibular Compensation • Goals • Gaze Stability • Postural Control • Under both Static and Dynamic Conditions • Characteristics • Enhanced by Head Movement • Delayed by Inactivity • Inhibited by Vestibular Suppressants • Hindered by Preexisting or Concurrent Central Vestibular System Dysfunction • Somewhat Fragile and Energy-dependant Process

  21. Vestibular NeuritisLabyrinthitis Viral Cochleitis • Acute Vestibular Crises • Severe Vertigo 12 - 24 hours • Residual Motion provoked Symptoms for days - weeks • Gradual Improvement • Compensation • Hearing Loss = Labyrinthitis • Stable Uncompensated Lesion

  22. Vestibular Neuritis Labyrinthitis Acute Management • Rule-out Acute Event • Neurologic and Cardiac Evaluation • Vestibular Suppressants • Education and Reassurance

  23. Vestibular Neuritis Labyrinthitis Long-Term Management • Increase Activity • Wean Vestibular Suppressants • Education and Reassurance • Vestibular Exercises • Vestibular Rehabilitation Therapy

  24. Vestibular Rehabilitation Therapy Goals • Reduce symptoms provoked by motion or position • Improve equilibrium • Improve quality of life by increasing activity levels

  25. Vestibular Rehabilitation Therapy What happens in VRT? • Assessment • Find movements and positions which provoke symptoms • Look for stance and gait problems • Assess Risk for falls • Look for other physical problems which might limit VRT • Education and Reassurance • Home Exercise Program (HEP) • Habituation Exercises • Small, controlled, repeated doses of provocative movements • Graduated Program • Balance and Gait Training • General Conditioning

  26. Meniere’s DiseaseEndolymphatic Hydrops CochlearCross-sectional Anatomy

  27. Temporal Bone Cross-sectional Anatomy Mild Hydrops

  28. Temporal Bone Cross-sectional Anatomy Severe Hydrops

  29. Endolymphatic Hydrops(Meniere’s Disease) • Episodic Severe Vertigo Lasting for Hours • Fluctuating Low Frequency Hearing Loss • Roaring Tinnitus • Aural Fullness • Unstable Lesion Symptoms

  30. Endolymphatic Hydrops Medical Management • Sodium Restriction • 1500 - 2000 mg per day • Not just ‘no salt shaker’ • Must change eating habits • 64 oz fresh water per day • No Water Softener, which may add salt • Diuretic • Avoid Caffeine, Sugar, Nutrasweet, Tobacco

  31. Endolymphatic Hydrops Intratympanic Decadron • Advantages • Non-Destructive • Helpful with Hearing Loss • Disadvantages • Less Effective than Gentamicin

  32. Endolymphatic Hydrops Intratympanic Gentamicin • Advantages • 70-90% Control of Vertigo • Office Procedure • Disadvantages • Destructive Procedure • Risk of Hearing Loss

  33. Endolymphatic Hydrops Meniett • Advantages • 50%-70% Control of Vertigo • Non-Destructive • Disadvantages • Requires PET

  34. Endolymphatic Hydrops Surgical Management Endolymphatic Sac Shunt / Decompression

  35. Endolymphatic Hydrops Endolymphatic Sac Shunt / Decompression Surgical View

  36. Endolymphatic Hydrops Surgical Management Endolymphatic Sac Shunt / Decompression

  37. Endolymphatic Hydrops Surgical Management • Endolymphatic Sac Shunt / Decompression • Advantages • Non-Destructive • Hearing Preservation • Out - Patient Surgery • Disadvantages • Controversial • ? 50% - 90% Effective • Surgical Morbidity

  38. Endolymphatic Hydrops Surgical Management Vestibular Nerve Section

  39. Endolymphatic Hydrops Vestibular Nerve Section

  40. Endolymphatic Hydrops Vestibular Nerve Section

  41. Endolymphatic Hydrops Vestibular Nerve Section

  42. Endolymphatic Hydrops Surgical Management • Vestibular Nerve Section • Suboccipital vs.. Middle Cranial Fossa • Advantages • 95% Control of Vertigo • Preserves Hearing • Disadvantages • Intracranial Procedure • Destructive Procedure

  43. Endolymphatic Hydrops Surgical Management Labyrinthectomy

  44. Endolymphatic Hydrops Labyrinthectomy

  45. Endolymphatic Hydrops Surgical Management • Labyrinthectomy • Advantages • 95% Control of Vertigo • Extracranial Procedure • Disadvantages • Destructive Procedure • Sacrifice Hearing

  46. Migraine Headaches • 20,000 Patients Diagnosed with Migraine Who had HA at least once per year • 17.6% Adult females • 5.7 % Adult males • 4% children • 18% had HA one or more per month • Highest prevalence 35-45 years • Lowest prevalence > 50 years • Of those in the 20,000 deserving Dx of Migraine only • 29% males and 41% females aware Prevalence Study

  47. Migraine Events • Migraines are Neurological events • Most common symptoms is Headache • Events can range from no pain to severe pain with permanent ischemic damage • Most common non-pain form of a migraine is visual, but any aura symptom can occur in the absence of pain, including dizziness

  48. Migraine Events HIS Classification • Migraine without aura • Migraine with aura • Migraine with prolonged aura • one Symptom lasts > 60 min but < 7 days • Basilar migraine • Migraine aura without headache • Childhood periodic syndromes • Migrainous infarction

  49. Migraine Head Ache History Clues • Head pain localizes • May be associated with eyes • Throbbing • Light or sound sensitivity - motion sickness especially in childhood • Scintillating lights - with or without pain • Family members with migraine • Mild to severe - hormonal and food triggers • Headache with caffeine withdrawal

  50. Migraine classification - IHS • Migraine without aura (“Common migraine”) • At least five attacks meeting the criteria below • Duration 4-72 hours • Headache has at least two of the following: • Unilateral location • Pulsating quality • Moderate to severe intensity (inhibits or prohibits daily activities) • Aggravation with physical activity that increases intra-cranial pressure, eg. Walking stairs, straining,, etc • During headache at least one of the following: • Nausea and / or vomiting • Photophobia and / or phonophobia

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