Vestibular Foundations - Session 9: Vestib Management

*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.

• 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.

• Primary care (GP): For initial symptom management.

• Secondary care (ENT): For more specialized treatment.

• Tertiary care (specialist balance clinics): For complex or refractory cases.

• Acute symptoms: Example: An attack of labyrinthitis.

• Chronic symptoms: Example: Ongoing symptoms in Ménière’s disease.

*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.

• 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.

• 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).

• 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.

• Surgery is performed rarely and only for extremely disabling symptoms.

• Risks include hearing loss, as most procedures are destructive rather than corrective.

• The vestibular end organ is destroyed (chemical or surgical).

• Used for fluctuating disorders with significant hearing loss, such as severe Ménière’s disease.

• 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.

• 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.

• 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.

• 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.

• A plate is placed over the hole in the bony labyrinth.

• Limitations:

• Can cause significant hearing loss.

• 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.

Treatment of vestibular disorders designed to:

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

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

• 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

• Patients without a vestibular problem

• Fluctuating vestibular problems
  e.g - Active Ménière’s Disease

• Perilymph Fistula

• Patient education

• Improve balance

• Reduce motion provoked symptoms

• Improve general conditioning

• Decrease disability

• Information provision

• Exercise therapy

• Practical advice

• Counselling

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

• Habituation exercises

• Adaptation exercises

• Gaze stabilization exercises

• Postural stability exercises

• Gait exercises

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

• 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.

• 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.

• Purpose: Improve the ability to maintain gaze during head movements.

• Mechanism: Train the brain to resolve mismatches between vestibular and visual information.

• Purpose: Reduce body sway and improve balance.

• Mechanism: Strengthen balance systems through targeted movements to stabilize the patient’s posture.

• Purpose: Address walking (gait) problems caused by vestibular dysfunction.

• Mechanism: Improve coordination, balance, and walking mechanics through repetitive training.

• Definition: A set of exercises designed to improve vestibular compensation and balance.

• Targets: Gaze stabilization, postural stability, and reducing dizziness through repeated movements.

• 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

• Repeated performance improves vestibular compensation.

• Regular practice leads to faster recovery and reduced symptoms.

• 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

• 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.

• 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).

• Quick to perform.

• Rapid effect.

• 80–90% effective

• Not suitable for patients with neck/back problems.

• Side effects include lightheadedness lasting a few days.

• 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

• Take longer to treat the condition.

• Require patient compliance.

• May not be suitable for patients with neck/back problems.

• Repeated exercises, usually 5–10 times per side.

• Performed at least once daily.

• Correct head positioning is crucial.