1 / 32

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

lconnell
Download Presentation

Medical and Surgical Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Medical and Surgical Management Of the Balance Disordered Patient

  2. Medical Management of Balance Complaints

  3. 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

  4. 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,

  5. Other Medical Interventions • Diuretics -- Meniere’s: • Dyazide • Lasix • Diamox • Vasodilators (microcirculatory enhancement) • Pavabid • Niacin

  6. Dietary Management • Reduced Sodium (< 1500 mg) • Meniere’s • Labyrinthine Concussion • Dietary Exclusions • Migraine: caffeine, alcohol, chocolate, cheese, etc.

  7. Surgery • Reparative: Middle ear surgery Perilymph Fistula Sac decompression/Endolymphatic shunt • Ablative: Labyrinthectomy Vestibular Nerve Section Canal Plugging Chemical destruction

  8. Perilymph Fistula

  9. 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.

  10. 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

  11. Rationale for Ablative Procedures • Fluctuating or progressive peripheral dysfunction doesn’t allow compensation to occur • Surgery produces stable peripheral lesion • Permits central compensation

  12. Labyrinthectomy • Surgical Destruction of the inner ear • Trans- canal or trans-mastoid • Eliminates vertigo in 90 to 93% of cases • Hearing is sacrificed

  13. Vestibular Neurectomy • Control of unilateral Meniere’s in pts with some hearing. • Approaches: • Middle fossa • Retrolabyrinthine • Retrosigmoid • 95% relief from vertiginous attacks

  14. 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

  15. 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

  16. 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

  17. Canal Plugging • BPPV pts who do not respond to positioning/ libratory maneuvers • Plug produces single canal paresis • Success above 95% • Alternative to singular neurectomy

  18. 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.

  19. Rehabilitation for Balance Disorders Canalith Repositioning Maneuvers Vestibular Rehab

  20. Canalith Repositioning • Posterior Canal (85-95% success) • Epley • Semont • Horizontal Canal (100% success) • Barbecue Roll • Appiani • Casani

  21. Posterior Canal BPPV

  22. The Epley

  23. Epley Issues • Speed of maneuver: fast isn’t necessarily good. • Is vibration necessary? • Follow up movement restrictions? • Follow up exercises?

  24. The Semont • The “slam dunk” maneuver • Designed with cupulolithiasis in mind • No different in success rate than Epley

  25. Horiz. Canal--Barbecue Roll: • Start supine • Rolls toward unaffected ear • in 90 degree steps • 2 to 3 times around

  26. 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.

  27. Casani, et al. (2002) • Start sitting facing foward • Lay to affected side head held straight • Turn head toward affected side • Return to sitting.

  28. Vestibular Rehabilitation • Habituation • Adaptation • Substitution

  29. Brandt-Daroff Exercises

  30. Cawthorne-Cooksey • Exercises scaled • From simple to difficult • From isolated parts (eye movement only, e.g.) • To generalized movement (eye & head, whole body)

  31. 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

More Related