Medical and Surgical Management

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Medical and Surgical Management

• Of the Balance Disordered Patient

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Medical Management of Balance Complaints
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Acute vs. Chronic Balance Problems

• Acute
• Reduce discomfort
• Suppress emesis
• Sedation
• Chronic
• Suppression of Vestibular Symptoms
• Tx of Specific Conditions
• (e.g., Menieres, Migraine, etc.)
• Tx of Reactive Depression

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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,

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Other Medical Interventions

• Diuretics -- Menieres
• Dyazide
• Lasix
• Diamox
• Vasodilators (microcirculatory enhancement)
• Pavabid
• Niacin

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Dietary Management

• Reduced Sodium (lt 1500 mg)
• Menieres
• Labyrinthine Concussion
• Dietary Exclusions
• Migraine caffeine, alcohol, chocolate, cheese,
  etc.

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Surgery

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

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Perilymph Fistula
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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.

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Endolymphatic Sac Decompression/Endolymphatic
Shunt

• For E. Hydrops
• Remember natural history of Menieres
• 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

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Rationale for Ablative Procedures

• Fluctuating or progressive peripheral dysfunction
  doesnt allow compensation to occur
• Surgery produces stable peripheral lesion
• Permits central compensation

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Labyrinthectomy

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

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Vestibular Neurectomy

• Control of unilateral Menieres in pts with some
  hearing.
• Approaches
• Middle fossa
• Retrolabyrinthine
• Retrosigmoid
• 95 relief from vertiginous attacks

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Neurectomy Complications

• Incomplete sectioning (up to 5)
• Neuroma growth (lt1)
• CSF leak (10)
• Facial weakness (lt1 with monitoring)
• Ongoing Headache (25 or more)
• Transtympanic Gentamicin is preferred

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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

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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

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Canal Plugging

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

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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.

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Rehabilitation for Balance Disorders

• Canalith Repositioning Maneuvers
• Vestibular Rehab

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Canalith Repositioning

• Posterior Canal (85-95 success)
• Epley
• Semont
• Horizontal Canal (100 success)
• Barbecue Roll
• Appiani
• Casani

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Posterior Canal BPPV
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The Epley
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Epley Issues

• Speed of maneuver
• fast isnt necessarily good.
• Is vibration necessary?
• Follow up movement restrictions?
• Follow up exercises?

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The Semont

• The slam dunk maneuver
• Designed with cupulolithiasis in mind
• No different in success rate than Epley

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Horiz. Canal--Barbecue Roll

• Start supine
• Rolls toward unaffected ear
• in 90 degree steps
• 2 to 3 times around

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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.

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Casani, et al. (2002)

• Start sitting facing foward
• Lay to affected side head held straight
• Turn head toward affected side
• Return to sitting.

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Vestibular Rehabilitation

• Habituation
• Adaptation
• Substitution

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Brandt-Daroff Exercises
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Cawthorne-Cooksey

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

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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