1 medical management of vestibular disorders dr. w. watad

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Medical Management of Medical Management of Vestibular DisordersVestibular Disorders

Dr. W. WATADDr. W. WATAD

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IntroductionIntroductionBasic inputs – Basic inputs –

Vision - ocular stabilityVision - ocular stability Proprioception - gait controlProprioception - gait control Vestibular system - balanceVestibular system - balance

Disorders of vestibular system are major Disorders of vestibular system are major disruptors causing spatial disorientationdisruptors causing spatial disorientation

Vestibular DD has remained stable over Vestibular DD has remained stable over the past several decades, but the the past several decades, but the management strategies continue to management strategies continue to improve improve

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The Goal The Goal

To review and discuss the medical To review and discuss the medical management of vestibular disordersmanagement of vestibular disorders

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PathophysiologyPathophysiology

Vestibular labyrinth - detects linear and Vestibular labyrinth - detects linear and angular head movementsangular head movements

Semicircular canals - angularSemicircular canals - angularHair cells - cupulaHair cells - cupula

Otolithic organs (utricle, sacule) - linearOtolithic organs (utricle, sacule) - linearHair cells - maculaHair cells - macula

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Vestibular nerve - superior, inferiorVestibular nerve - superior, inferiorAfferent nerve fibers are bipolar Afferent nerve fibers are bipolar

cell bodies lie within Scarpa’s ganglioncell bodies lie within Scarpa’s ganglion

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pathophysiologypathophysiology

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Balance requires –Balance requires –Normal functioning vestibular systemNormal functioning vestibular systemInput from visual system (vestibulo-ocular)Input from visual system (vestibulo-ocular)Input from proprioceptive system (vestibulo-Input from proprioceptive system (vestibulo-

spinal)spinal)Disruption of balance between inputs Disruption of balance between inputs

results in :results in :vertigo (acute) vertigo (acute) disequilibrium (chronic)disequilibrium (chronic)

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Central causes of vestibular dysfunction Central causes of vestibular dysfunction compromise central circuits that mediate compromise central circuits that mediate vestibular influences on posture, gaze control, vestibular influences on posture, gaze control, and autonomic function :and autonomic function : nausea, vomitingnausea, vomiting PallorPallor Respiratory/circulatory changesRespiratory/circulatory changes

Goal of treatment: restore balance between Goal of treatment: restore balance between different inputsdifferent inputs

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Medical TreatmentMedical Treatment

Symptomatic :Symptomatic :Relieve acute symptoms , autonomic Relieve acute symptoms , autonomic

complaints complaints Specific therapy :Specific therapy :

Targeting the underlying cause of vertigoTargeting the underlying cause of vertigo

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Symptomatic PharmacotherapySymptomatic Pharmacotherapy

Predominant targeted vestibular Predominant targeted vestibular neurotransmitters:neurotransmitters: CholinergicCholinergic HistaminergicHistaminergic GABA neurotransmitters - negative inhibitionGABA neurotransmitters - negative inhibition

Vomiting center transmitters:Vomiting center transmitters: Dopaminergic (D2)Dopaminergic (D2) Histaminergic (H1)Histaminergic (H1) Serotonergic (5-HT3)Serotonergic (5-HT3)

Multiple classes of drugs effectiveMultiple classes of drugs effective

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Main classes :Main classes :Antihistaminergic - dimenhydrinateAntihistaminergic - dimenhydrinateAnticholinergics - scopolamine, meclizineAnticholinergics - scopolamine, meclizineAnti-dopaminergic - droperidolAnti-dopaminergic - droperidol(gamma)-aminobutyric acid enhancing (gamma)-aminobutyric acid enhancing

(GABA-ergic) agents - lorazepam, valium(GABA-ergic) agents - lorazepam, valiumReduce the severity of vestibular Reduce the severity of vestibular

symptomssymptoms

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Suppressant agents :Suppressant agents :AnticholinergicsAnticholinergicsAntihistaminesAntihistaminesBenzodiazepinesBenzodiazepines

Anti-emetic drugsAnti-emetic drugs

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anticholinergicsanticholinergics

Inhibit stimulation ( exessive impulses ) Inhibit stimulation ( exessive impulses ) from peripheral organs – vestibular n.from peripheral organs – vestibular n.

Inhibit transmission in LVN ( lat. Vestibular Inhibit transmission in LVN ( lat. Vestibular Nucleus )Nucleus )

Non-specific muscarine receptor Non-specific muscarine receptor antagonistantagonist

Reversible overcompensationReversible overcompensation

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Agents not cross BBB are ineffectiveAgents not cross BBB are ineffective Ineffective after symptoms have appearedIneffective after symptoms have appearedScopalamine / atropine Scopalamine / atropine SE : SE :

Dry mouth dilated pupilsDry mouth dilated pupilsUrinary retention sedationUrinary retention sedationConstipation confusionConstipation confusion

C/I : BPH , closed angle glaucomaC/I : BPH , closed angle glaucoma

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antihistaminesantihistamines

Uncertain mechanismUncertain mechanism Central effect ( block H1-R)Central effect ( block H1-R) Inhibiton synaptic transmission on MVN ( medial Inhibiton synaptic transmission on MVN ( medial

vestibular nucleus )vestibular nucleus ) Anticholinergic and sedative effectsAnticholinergic and sedative effects Effective also after symptomes have appearedEffective also after symptomes have appeared Cinnarazine Cinnarazine promethazine / diphenhydramine - sedative promethazine / diphenhydramine - sedative prochlorperazine / miclizine - antiemeticprochlorperazine / miclizine - antiemetic

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benzodiazepinesbenzodiazepines

GABA modulatorsGABA modulatorsCentral suppression of vestibular responseCentral suppression of vestibular responseSedative , hypnotic, muscle relaxant , Sedative , hypnotic, muscle relaxant ,

reduce anxietyreduce anxietyClonazepam / lorazepam / alprazolamClonazepam / lorazepam / alprazolamSE : SE :

Impaired vestibular compensationImpaired vestibular compensationImpaired memoryImpaired memoryaddictionaddiction

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Anti emeticsAnti emetics

Dopamine block activityDopamine block activityNot ideal for emesis from vestibular Not ideal for emesis from vestibular

imbalanceimbalanceAntihistamine effect – promethazine ( H1-Antihistamine effect – promethazine ( H1-

R block)R block)Metoclopramide – potent central Metoclopramide – potent central

antiemetic, speed gastric emptying is not antiemetic, speed gastric emptying is not effective antivertigo drugeffective antivertigo drug

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Sulpiride :Sulpiride :Selective dopamine (D2) antagonistSelective dopamine (D2) antagonistLow incidence of extrapyramidal Low incidence of extrapyramidal Antiemetic action Antiemetic action Improve blood flow, mucosal secretion in GIImprove blood flow, mucosal secretion in GIAntivertigo , anti-migraine headacheAntivertigo , anti-migraine headacheAntidepressant activity ( low doses )Antidepressant activity ( low doses )Antipsychotic activity ( high doses ) Antipsychotic activity ( high doses )

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New antiemetic – 5-HT3 antagonist New antiemetic – 5-HT3 antagonist

serotonin ( 5 hydroxytryptamine subtype 3 serotonin ( 5 hydroxytryptamine subtype 3 receptor ) antagonistreceptor ) antagonist

Ondensetron / granisetronOndensetron / granisetronNausea and vomiting associated with Nausea and vomiting associated with

chemotherapy , post. Operationchemotherapy , post. OperationLess effective for vestibular emesis Less effective for vestibular emesis High costHigh cost

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Other optionsOther options

Ca channel blockers :Ca channel blockers :Vestibular suppression on Ca channel in hair Vestibular suppression on Ca channel in hair

cellscellsFlurnarazine / cinnarazineFlurnarazine / cinnarazineAntihistamines and anticholinergic activityAntihistamines and anticholinergic activityEffective in menier’s and migraneEffective in menier’s and migraneSE : sedation , weight gain , parkinsonismSE : sedation , weight gain , parkinsonism

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Na channel blocker :Na channel blocker :Affect GABA NT , glutamate antagonistAffect GABA NT , glutamate antagonistPhenytoin / nerontin / tegretolPhenytoin / nerontin / tegretolCentral nystagmusCentral nystagmusAnticonvulsants are promising agents for Anticonvulsants are promising agents for

treatment vertigo ( uncertain mechanism )treatment vertigo ( uncertain mechanism )

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Histamine agonist :Histamine agonist :Betahistine – H1/H3 – R agonistBetahistine – H1/H3 – R agonistIncrease circulation to inner earIncrease circulation to inner earSuppress veastibular function Suppress veastibular function Facilitation of compensationFacilitation of compensationSE : nausea , headacheSE : nausea , headacheCaution ; peptic dis , pheochromocytomaCaution ; peptic dis , pheochromocytoma

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Steroids Steroids Reduce duration of vertigo episodesReduce duration of vertigo episodesEffective in meniere’s , vestibular neuritisEffective in meniere’s , vestibular neuritis

SypmpathomimeticsSypmpathomimeticsCounterbalance sedative effect of vestibular Counterbalance sedative effect of vestibular

suppressant - increase compensationsuppressant - increase compensationEphedrine / amphetamine – limitted use Ephedrine / amphetamine – limitted use

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Acetyl- leucineAcetyl- leucineVestibular suppresantVestibular suppresantRapid antivertigo effect ( IV)Rapid antivertigo effect ( IV)

Ginkgo-BilobaGinkgo-BilobaVestibular suppresantVestibular suppresantEffective in tinnitus , improve memoryEffective in tinnitus , improve memory

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Selective Ach antagonistSelective Ach antagonistM2-R antagonist M2-R antagonist Vestibular suppressant without SEVestibular suppressant without SELittle reaserchLittle reaserch

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Alternative medicine agents Alternative medicine agents Ambra grisea D6Ambra grisea D6Anamirta cocculus D4Anamirta cocculus D4Conium maculatum D3Conium maculatum D3Petroleum rectificatum D8Petroleum rectificatum D8

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Specific PharmacotherapySpecific Pharmacotherapy

Vestibular Neuritis *Vestibular Neuritis *Meniere’s Disease *Meniere’s Disease *Benign Paroxysmal Positional Vertigo *Benign Paroxysmal Positional Vertigo *OtosyphilisOtosyphilisVertebrobasilar InsufficiencyVertebrobasilar InsufficiencyMigraine (with vertigo)Migraine (with vertigo)

* * more common more common

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Vestibular NeuritisVestibular Neuritis

Sudden onset of peripheral vertigoSudden onset of peripheral vertigo Inflammation of vestibular nerve - Inflammation of vestibular nerve -

presumably of viral originpresumably of viral originSpontaneous, complete symptomatic Spontaneous, complete symptomatic

recovery with supportive treatmentrecovery with supportive treatmentTreatment aimed at stopping inflammationTreatment aimed at stopping inflammation

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Vestibular NeuritisVestibular Neuritis

Ariyasu et al. (1990)Ariyasu et al. (1990)20 patients: double-blinded, crossover20 patients: double-blinded, crossoverMethylprednisolone vs. placeboMethylprednisolone vs. placebo90% decrease in vertigo within 24 hours vs. 90% decrease in vertigo within 24 hours vs.

30% of placebo group30% of placebo groupPlacebo switched to steroid after 24 hours Placebo switched to steroid after 24 hours

with decrease in vertigo over next 24 hourswith decrease in vertigo over next 24 hours16 patients receiving steroid with resolution 16 patients receiving steroid with resolution

had normal ENG within one monthhad normal ENG within one month

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Meniere’s DiseaseMeniere’s Disease

Hallpike and Cairns - 1938 found Hallpike and Cairns - 1938 found endolymphatic hydrops by histologyendolymphatic hydrops by histology

Precise etiology is unknownPrecise etiology is unknown

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Widely accepted medical treatmentWidely accepted medical treatmentDietary salt restrictionDietary salt restrictionDiureticsDiuretics

Thiazide diureticsThiazide diureticsDecrease Na absorption is distal tubuleDecrease Na absorption is distal tubuleSide effects - hypokalemia, hypotension, Side effects - hypokalemia, hypotension,

hyperuricemia, hyperlipoproteinemiahyperuricemia, hyperlipoproteinemiaCombination potassium sparing agents Combination potassium sparing agents

spironolactone , thiazide + amiloridespironolactone , thiazide + amiloride

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At least 3 months of diuretic therapy At least 3 months of diuretic therapy recommended before discontinuingrecommended before discontinuing

Sulfa allergies - can try loop diuretics or Sulfa allergies - can try loop diuretics or alternate therapiesalternate therapies

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Carbonic anhydrase inhibitors Carbonic anhydrase inhibitors (acetazolamide)(acetazolamide)““inner ear glaucoma”inner ear glaucoma”Decreased Na-H exchange in tubuleDecreased Na-H exchange in tubuleDecreased CSF productionDecreased CSF productionDiuretic effect not as long-lastingDiuretic effect not as long-lastingSide effects - nephrocalcinosis, mild metabolic Side effects - nephrocalcinosis, mild metabolic

acidosis, GI disturbancesacidosis, GI disturbances

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VasodilatorsVasodilatorsBased on hypothesis - pathogenesis results Based on hypothesis - pathogenesis results

from ischemia of stria vascularisfrom ischemia of stria vascularisRationale - improve metabolic functionRationale - improve metabolic functionIV histamine, ISDN, cinnarizine (CA IV histamine, ISDN, cinnarizine (CA

antagonist), betahistine (oral histamine antagonist), betahistine (oral histamine analogue)analogue)

Anecdotal successAnecdotal successNo demonstrated beneficial effects in studiesNo demonstrated beneficial effects in studies

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Newer theoriesNewer theoriesMultifactorial inheritanceMultifactorial inheritanceImmune-mediated phenomenaImmune-mediated phenomenaAssociation of allergiesAssociation of allergies

Study by Gottschlich et al.Study by Gottschlich et al.50% meeting criteria have antibodies to 70-kD 50% meeting criteria have antibodies to 70-kD

heat-shock proteinheat-shock protein70-kD HSP implicated in AI-SNHL70-kD HSP implicated in AI-SNHL

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Immunosuppressive agents gaining favorImmunosuppressive agents gaining favorSystemic and intra-tympanic glucocorticoidsSystemic and intra-tympanic glucocorticoidsCyclophosphamideCyclophosphamideMethotrexateMethotrexate

Shea study - intractable Meniere’sShea study - intractable Meniere’s48 patients IT dexamethasone 48 patients IT dexamethasone 66.7% elimination of vertigo66.7% elimination of vertigo35.4% improvement in hearing (>10dB and/or 35.4% improvement in hearing (>10dB and/or

15% change in word recognition score) 15% change in word recognition score)

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Chemical labyrinthectomyChemical labyrinthectomyDisabling vertigoDisabling vertigoAfter trial of adequate medical therapyAfter trial of adequate medical therapy

Intratympanic aminoglycoside (ITAG)Intratympanic aminoglycoside (ITAG)Allows treatment of unilateral diseaseAllows treatment of unilateral diseaseGentamicinGentamicin

Primarily vestibulotoxicPrimarily vestibulotoxic may impair vestibular dark cells (endolymph)may impair vestibular dark cells (endolymph)

Inherent hearing loss risk - 30%Inherent hearing loss risk - 30%

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ITAGITAG

Stock solution - 40mg/mL gentamicinStock solution - 40mg/mL gentamicin10 to 20 mg injected over round window10 to 20 mg injected over round windowPatient supine, ear up for 30 minutesPatient supine, ear up for 30 minutes Instructed not to swallowInstructed not to swallowBolus injections - weekly or bi-weeklyBolus injections - weekly or bi-weeklyEnd point variable - vestibular hypofunctionEnd point variable - vestibular hypofunctionAudiometry monitoring between injectionsAudiometry monitoring between injectionsTotal vestibular ablation not necessaryTotal vestibular ablation not necessary

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ITAGITAG

MinorMinor91% control of vertigo91% control of vertigo3% rate of profound SNHL (usually sudden)3% rate of profound SNHL (usually sudden)22% recurrence rate22% recurrence rate

Continuous deliveryContinuous deliveryMicrowickMicrowickRound Window MicrocatheterRound Window Microcatheter

Direct injection (labyrinthotomy)Direct injection (labyrinthotomy)Significant hearing lossSignificant hearing lossOut of favorOut of favor

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BPPVBPPV

Most common causeMost common cause Dysfunction of posterior SCCDysfunction of posterior SCC Cupulolithiasis vs. CanalithiasisCupulolithiasis vs. Canalithiasis

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BPPVBPPV

Treatment approachesTreatment approaches Liberatory maneuversLiberatory maneuvers Particle repositioningParticle repositioning Habituation exercisesHabituation exercises

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BPPVBPPV

EpleyEpley CanalithiasisCanalithiasis Canalith repositioningCanalith repositioning Move into vestibuleMove into vestibule Cure ratesCure rates

80% - one treatment80% - one treatment 100% - multiple100% - multiple

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OtosyphilisOtosyphilis

Penicillin established treatmentPenicillin established treatment IM and IV routes acceptableIM and IV routes acceptable IM - 2.4 million units benzathine PCN IM - 2.4 million units benzathine PCN

weekly x 3 consecutive weeks is minimal weekly x 3 consecutive weeks is minimal treatment (some advocate up to 1 year)treatment (some advocate up to 1 year)

IV - 10 million units PCN G qD in divided IV - 10 million units PCN G qD in divided doses x 10 days, followed by 2.4 million doses x 10 days, followed by 2.4 million units benzathine PCN x 2 weeksunits benzathine PCN x 2 weeks

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Vertebrobasilar insufficiencyVertebrobasilar insufficiency

Vertigo, diplopia, dysarthria, gait ataxia Vertigo, diplopia, dysarthria, gait ataxia and bilateral sensory & motor disturbanceand bilateral sensory & motor disturbance

Transient ischemia - low stroke riskTransient ischemia - low stroke riskAntiplatelet therapy - aspirin 325mg qDAntiplatelet therapy - aspirin 325mg qDTiclid Ticlid

Platelet aggregate inhibitorPlatelet aggregate inhibitorRisk of life-threatening neutropeniaRisk of life-threatening neutropeniaOnly in patients unable to tolerate aspirinOnly in patients unable to tolerate aspirin

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MigraineMigraine

Concomitant vertigo and disequilibriumConcomitant vertigo and disequilibriumHeadache control improves vertigoHeadache control improves vertigoDiagnostic criteriaDiagnostic criteria

Personal/family historyPersonal/family historyMotion intoleranceMotion intoleranceVestibular symptoms - do not fit other causesVestibular symptoms - do not fit other causes

Theories - vascular origin, abnormal Theories - vascular origin, abnormal neural activity (brainstem), abnormal neural activity (brainstem), abnormal voltage-gated calcium channel genesvoltage-gated calcium channel genes

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MigraineMigraine

TreatmentTreatmentModifying risk factorsModifying risk factors

Exercise and dietExercise and dietAvoid nicotine, caffeine, red wine and chocolateAvoid nicotine, caffeine, red wine and chocolate

Abortive medical therapyAbortive medical therapyErgotsErgotsSumatriptinSumatriptinMidrinMidrin

Prophylactic medical therapyProphylactic medical therapyB blockers, Ca channel blockers, NSAIDs, B blockers, Ca channel blockers, NSAIDs,

amitryptiline, and lithiumamitryptiline, and lithium

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Vestibular RehabilitationVestibular Rehabilitation

Promoting vestibular compensationPromoting vestibular compensationHabituationHabituationEnhancing adaptation of VOR & VSREnhancing adaptation of VOR & VSRMay have initial exacerbationMay have initial exacerbation

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Cawthorne - CookseyCawthorne - CookseyDeveloped in 1940sDeveloped in 1940sHead movementsHead movementsBalance tasksBalance tasksCoordination of eyes with headCoordination of eyes with headTotal body movementsTotal body movementsEyes open & closedEyes open & closedNoisy environmentsNoisy environments

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Habituation of pathologic responsesHabituation of pathologic responsesPostural control exercisesPostural control exercisesVisual-vestibular interactionVisual-vestibular interactionConditioning activitiesConditioning activitiesB.I.D., most improve after 4-6 weeksB.I.D., most improve after 4-6 weeks

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VRT - ElderlyVRT - Elderly

Multifactorial causes of balance difficultyMultifactorial causes of balance difficultyNeed 2 of 3 systems functionalNeed 2 of 3 systems functional

vestibular, visual, proprioceptivevestibular, visual, proprioceptive

Good outcome measures with longer timeGood outcome measures with longer time Impact on complications of fallsImpact on complications of falls

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ConclusionsConclusions

Vestibular complaints common to ENTVestibular complaints common to ENTThorough evaluation and understandingThorough evaluation and understandingDx and treat acute symptomsDx and treat acute symptomsWean vestibular suppressantsWean vestibular suppressantsSpecific pharmacotherapy institutedSpecific pharmacotherapy institutedChronic, uncompensated disease benefits Chronic, uncompensated disease benefits

from early VRTfrom early VRT

1 medical management of vestibular disorders dr. w. watad

Documents

vestibular influences

pathophysiology slide

watad slide

pathophysiology balance

scarpas ganglion slide

management strategies

medical treatment symptomatic

acute symptoms