Session 9: vestib management Flashcards
What are the three main management options for vestibular disorders?
*Medication:
- Treats acute symptoms (e.g., labyrinthitis attack).
- Can also manage chronic symptoms (e.g., Ménière’s disease).
*Vestibular Rehabilitation:
- Treats chronic or recurrent symptoms (e.g., uncompensated labyrinthitis).
*Surgery:
- Used for severe, disabling dizziness when other treatments fail.
- Example: Disabling symptoms of Ménière’s disease.
When is each management option typically used?
- Medication: For acute and chronic symptom relief.
- Vestibular Rehabilitation: For persistent, recurrent, or uncompensated vestibular dysfunction.
- Surgery: As a last resort for disabling dizziness not resolved by other treatments.
At what levels of care is medication used to manage vestibular disorders?
- Primary care (GP): For initial symptom management.
- Secondary care (ENT): For more specialized treatment.
- Tertiary care (specialist balance clinics): For complex or refractory cases.
What symptoms are medications typically used to treat?
- Acute symptoms: Example: An attack of labyrinthitis.
- Chronic symptoms: Example: Ongoing symptoms in Ménière’s disease.
What are vestibular suppressants, and how do they work?
*Definition: Medications that reduce nystagmus and symptoms of vestibular dysfunction.
-Types and Examples:
- Anticholinergics (e.g., amitryptiline):
- Prevent motion intolerance.
- Must be taken before symptoms occur.
- May delay vestibular compensation.
- Antihistamines (e.g., betahistine):
- Reduce motion sickness.
- Can be taken after symptoms occur.
- Benzodiazepines (e.g., lorazepam):
- Prevent motion intolerance.
- Act as central suppressants.
- Can cause sedation and delay compensation.
What are anti-emetics, and when are they used?
- Purpose: Control nausea and vomiting during acute vestibular episodes.
- Side Effects:
- Sedation or movement disorders (e.g., acute dystonia, pseudoparkinsonism).
- Use should be short-term to avoid withdrawal effects.
What are some other medications used for vestibular disorders?
- Diuretics (e.g., bendroflumethiazide):
Manage fluid balance in Ménière’s disease. - Calcium Channel Blockers:
Potential future treatment for Ménière’s disease. - Antidepressants:
- Treat depression associated with vestibular conditions.
- May prevent future symptoms.
- Steroids:
- Treat acute phases of Ménière’s disease and vestibular neuritis.
- Long-term use may prevent compensation in some cases (e.g., labyrinthitis) but is necessary for others (e.g., Ménière’s).
What are the challenges in using medications for vestibular disorders?
- The mechanism of action for many drugs is unknown.
- Varying levels of research exist on their effectiveness.
- Future research is exploring potential new drug options.
When is surgery considered for vestibular conditions?
- Surgery is performed rarely and only for extremely disabling symptoms.
- Risks include hearing loss, as most procedures are destructive rather than corrective.
What is a labyrinthectomy, and when is it used?
- The vestibular end organ is destroyed (chemical or surgical).
- Used for fluctuating disorders with significant hearing loss, such as severe Ménière’s disease.
What is chemical labyrinthectomy (Gentamycin treatment), and how does it work?
- A grommet is inserted into the tympanic membrane.
- Gentamycin is injected into the middle ear cavity.
- The drug passes through the round window and destroys hair cells in the labyrinth and cochlea.
- It often causes hearing loss but reduces vestibular function.
*Advantages:
- Less invasive than surgical labyrinthectomy.
Can be repeated if necessary.
What is vestibular neurectomy, and what are its limitations?
- The vestibular nerve (and sometimes the auditory nerve) is severed.
- Performed for fluctuating disorders with significant hearing loss, such as severe Ménière’s disease.
- Limitations:
- Not always successful; the nerve may regrow.
What is perilymph fistula repair, and when is it used?
- A leak in the inner ear is repaired using tissue from elsewhere in the body.
- Outcomes:
- Success rates are variable.
In some cases, inserting a grommet into the tympanic membrane is helpful.
What is an endolymphatic shunt, and why is it rarely performed?
- A drain is inserted to remove excess endolymph.
- Used in severe Ménière’s disease.
- Limitations:
- Research has questioned its value, so it is rarely performed today.
What is superior semicircular canal dehiscence (SSCD) repair?
- A plate is placed over the hole in the bony labyrinth.
- Limitations:
- Can cause significant hearing loss.
What is canal plugging, and when is it used?
- The affected semicircular canal is sealed off to reduce/remove symptoms.
- Uses:
- Treats BPPV or SSCD when other methods fail.
- Limitations:
- Rarely needed, as repositioning maneuvers suffice for most BPPV cases.
What is Vestibular Rehabilitation?
Treatment of vestibular disorders designed to:
– Reduce symptoms
– Improve balance function
– Reduce disability
– Improve general activity levels
Who is suitable for VR?
VR can be used to treat patients with:
– Benign Paroxysmal Positioning Vertigo (BPPV)
– Unilateral vestibular lesion
– e.g - Labyrinthitis/vestibular neuritis
- Acoustic neuroma
– Bilateral vestibular lesions
– e.g - Caused by ototoxic drugs
– “Quiescent” Ménière’s Disease
what does vestibular rehab usually consist of?
- a balance excercise programme
*Advice regarding:
* The cause of balance problems
* How the cause relates to the patient’s symptoms
* Strategies for managing day-to-day problems
* Other methods of reducing effects of dizziness
– Counselling for the psychosocial effects of the
balance disorder may also be offered
what is vestibular rehabilitation less useful for?
- Patients without a vestibular problem
- Fluctuating vestibular problems
e.g - Active Ménière’s Disease - Perilymph Fistula
what are the aims of vestibular rehab?
- Patient education
- Improve balance
- Reduce motion provoked symptoms
- Improve general conditioning
- Decrease disability
what are the components of vestibular rehab?
- Information provision
- Exercise therapy
- Practical advice
- Counselling
what is information provision?
- Explanation of:
– The condition causing the balance
disorder/dizziness
– Relationship between patients’ symptoms and the
condition
– The treatment
– Likely outcome and factors affecting outcome
What types of exercises are included in exercise therapy for vestibular disorders?
- Habituation exercises
- Adaptation exercises
- Gaze stabilization exercises
- Postural stability exercises
- Gait exercises
Why is a personalized exercise programme more effective than general vestibular rehabilitation?
Personalized programmes target the specific symptoms and needs of the patient, leading to better outcomes.
What are habituation exercises, and how do they work?
- Purpose: Reduce dizziness triggered by specific movements.
- Mechanism: Repeatedly performing movements that provoke dizziness trains the brain to become accustomed to the stimulus, reducing the dizziness over time.
What are adaptation exercises, and how do they work?
- Purpose: Help the brain adapt to changes in vestibular input.
- Mechanism: Repeated movements create error signals, teaching the brain to interpret new vestibular signals correctly.
What are gaze stabilization exercises, and what do they improve?
- Purpose: Improve the ability to maintain gaze during head movements.
- Mechanism: Train the brain to resolve mismatches between vestibular and visual information.
What are postural stability exercises, and what do they address?
- Purpose: Reduce body sway and improve balance.
- Mechanism: Strengthen balance systems through targeted movements to stabilize the patient’s posture.
What are gait exercises, and what issues do they target?
- Purpose: Address walking (gait) problems caused by vestibular dysfunction.
- Mechanism: Improve coordination, balance, and walking mechanics through repetitive training.
What are Cawthorne-Cooksey exercises, and what do they target?
- Definition: A set of exercises designed to improve vestibular compensation and balance.
- Targets: Gaze stabilization, postural stability, and reducing dizziness through repeated movements.
What are examples of Cawthorne-Cooksey exercises?
- In bed/sitting: Eye movements (up/down, side-to-side), head movements (slow to fast).
- Standing: Throwing and catching a ball, bending to pick up objects.
- Walking: Walking with eyes open/closed, turning in circles.
Why are these exercises effective? cawthorne cooksey
- Repeated performance improves vestibular compensation.
- Regular practice leads to faster recovery and reduced symptoms.
Why is counselling important for patients with balance disorders?
- Many patients experience anxiety and depression as a result of their condition.
- Some balance disorders arise due to anxiety and panic attacks.
- Addressing psychological elements is essential for effective treatment
What additional strategies can support patients with balance disorders?
- Stress management and relaxation advice: Reduces the impact of balance issues.
- Home assessments: Identify fall risks and improve safety.
- Walking aids and home modifications: Provide stability (e.g., grab rails, panic buttons).
- Referral to specialists: Includes physiotherapy, psychology, or other relevant specialties.
What are the two main treatment approaches for BPPV?
- Manoeuvres: Return otoconia to the utricle (e.g., Epley manoeuvre, Liberatory manoeuvre).
- Exercises: Either return otoconia to the utricle or habituate the brain to the error signal (e.g., Brandt-Daroff exercises).
What are the advantages of manoeuvres for BPPV?
- Quick to perform.
- Rapid effect.
- 80–90% effective
What are the disadvantages of manoeuvres for BPPV?
- Not suitable for patients with neck/back problems.
- Side effects include lightheadedness lasting a few days.
What is the Epley manoeuvre? and benefits
- The most well-known BPPV manoeuvre.
- Quick to perform but may cause dizziness during the procedure.
- Some patients feel lightheaded for a day or two after the manoeuvre.
- Can be used for self-treatment at home.
- About 95% effective
What are the disadvantages of exercises for BPPV?
- Take longer to treat the condition.
- Require patient compliance.
- May not be suitable for patients with neck/back problems.
What are Brandt-Daroff exercises, and how are they performed?
- Repeated exercises, usually 5–10 times per side.
- Performed at least once daily.
- Correct head positioning is crucial.
