Session 9: vestib management Flashcards

1
Q

What are the three main management options for vestibular disorders?

A

*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.

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2
Q

When is each management option typically used?

A
  • 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.
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3
Q

At what levels of care is medication used to manage vestibular disorders?

A
  • Primary care (GP): For initial symptom management.
  • Secondary care (ENT): For more specialized treatment.
  • Tertiary care (specialist balance clinics): For complex or refractory cases.
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4
Q

What symptoms are medications typically used to treat?

A
  • Acute symptoms: Example: An attack of labyrinthitis.
  • Chronic symptoms: Example: Ongoing symptoms in Ménière’s disease.
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5
Q

What are vestibular suppressants, and how do they work?

A

*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.
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6
Q

What are anti-emetics, and when are they used?

A
  • 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.
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7
Q

What are some other medications used for vestibular disorders?

A
  • 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).
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8
Q

What are the challenges in using medications for vestibular disorders?

A
  • 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.
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9
Q

When is surgery considered for vestibular conditions?

A
  • Surgery is performed rarely and only for extremely disabling symptoms.
  • Risks include hearing loss, as most procedures are destructive rather than corrective.
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10
Q

What is a labyrinthectomy, and when is it used?

A
  • The vestibular end organ is destroyed (chemical or surgical).
  • Used for fluctuating disorders with significant hearing loss, such as severe Ménière’s disease.
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11
Q

What is chemical labyrinthectomy (Gentamycin treatment), and how does it work?

A
  • 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.

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12
Q

What is vestibular neurectomy, and what are its limitations?

A
  • 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.
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13
Q

What is perilymph fistula repair, and when is it used?

A
  • 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.
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14
Q

What is an endolymphatic shunt, and why is it rarely performed?

A
  • 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.
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15
Q

What is superior semicircular canal dehiscence (SSCD) repair?

A
  • A plate is placed over the hole in the bony labyrinth.
  • Limitations:
  • Can cause significant hearing loss.
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16
Q

What is canal plugging, and when is it used?

A
  • 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.
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17
Q

What is Vestibular Rehabilitation?

A

Treatment of vestibular disorders designed to:

– Reduce symptoms
– Improve balance function
– Reduce disability
– Improve general activity levels

18
Q

Who is suitable for VR?

A

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

19
Q

what does vestibular rehab usually consist of?

A
  • 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

20
Q

what is vestibular rehabilitation less useful for?

A
  • Patients without a vestibular problem
  • Fluctuating vestibular problems
    e.g - Active Ménière’s Disease
  • Perilymph Fistula
21
Q

what are the aims of vestibular rehab?

A
  • Patient education
  • Improve balance
  • Reduce motion provoked symptoms
  • Improve general conditioning
  • Decrease disability
22
Q

what are the components of vestibular rehab?

A
  • Information provision
  • Exercise therapy
  • Practical advice
  • Counselling
23
Q

what is information provision?

A
  • Explanation of:
    – The condition causing the balance
    disorder/dizziness
    – Relationship between patients’ symptoms and the
    condition
    – The treatment
    – Likely outcome and factors affecting outcome
24
Q

What types of exercises are included in exercise therapy for vestibular disorders?

A
  • Habituation exercises
  • Adaptation exercises
  • Gaze stabilization exercises
  • Postural stability exercises
  • Gait exercises
25
Q

Why is a personalized exercise programme more effective than general vestibular rehabilitation?

A

Personalized programmes target the specific symptoms and needs of the patient, leading to better outcomes.

26
Q

What are habituation exercises, and how do they work?

A
  • 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.
27
Q

What are adaptation exercises, and how do they work?

A
  • 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.
28
Q

What are gaze stabilization exercises, and what do they improve?

A
  • Purpose: Improve the ability to maintain gaze during head movements.
  • Mechanism: Train the brain to resolve mismatches between vestibular and visual information.
29
Q

What are postural stability exercises, and what do they address?

A
  • Purpose: Reduce body sway and improve balance.
  • Mechanism: Strengthen balance systems through targeted movements to stabilize the patient’s posture.
30
Q

What are gait exercises, and what issues do they target?

A
  • Purpose: Address walking (gait) problems caused by vestibular dysfunction.
  • Mechanism: Improve coordination, balance, and walking mechanics through repetitive training.
31
Q

What are Cawthorne-Cooksey exercises, and what do they target?

A
  • Definition: A set of exercises designed to improve vestibular compensation and balance.
  • Targets: Gaze stabilization, postural stability, and reducing dizziness through repeated movements.
32
Q

What are examples of Cawthorne-Cooksey exercises?

A
  • 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.
33
Q

Why are these exercises effective? cawthorne cooksey

A
  • Repeated performance improves vestibular compensation.
  • Regular practice leads to faster recovery and reduced symptoms.
34
Q

Why is counselling important for patients with balance disorders?

A
  • 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
35
Q

What additional strategies can support patients with balance disorders?

A
  • 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.
36
Q

What are the two main treatment approaches for BPPV?

A
  • 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).
37
Q

What are the advantages of manoeuvres for BPPV?

A
  • Quick to perform.
  • Rapid effect.
  • 80–90% effective
38
Q

What are the disadvantages of manoeuvres for BPPV?

A
  • Not suitable for patients with neck/back problems.
  • Side effects include lightheadedness lasting a few days.
39
Q

What is the Epley manoeuvre? and benefits

A
  • 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
40
Q

What are the disadvantages of exercises for BPPV?

A
  • Take longer to treat the condition.
  • Require patient compliance.
  • May not be suitable for patients with neck/back problems.
41
Q

What are Brandt-Daroff exercises, and how are they performed?

A
  • Repeated exercises, usually 5–10 times per side.
  • Performed at least once daily.
  • Correct head positioning is crucial.