Treatment Of Vestibular Disorders Research Articles

Worldwide Survey on the Treatment of Peripheral Vestibular Disorders (P3-9.002)

<h3>Objective:</h3> The aim of this world wide survey was to evaluate the currently used treatment options of the six most frequent peripheral vestibular disorders: benign paroxysmal positional vertigo (BPPV), acute unilateral vestibulopathy (AUVP)/vestibular neuritis, Menière’s disease, bilateral vestibulopathy (BVP), vestibular paroxysmia and superior canal deshiscence syndrome (SCDS). <h3>Background:</h3> For the therapy of vestibular disorders, there are basically four treatment options: physiotherapy (liberatory maneuvers or balance training), pharmacotherapy, surgery and psychotherapy. Since there are very few state-of-the-art RCTs, the treatment of vestibular disorders is so far not standardized and various methods are applied with heterogeneous efficacy. <h3>Design/Methods:</h3> A web-based standardized survey questionnaire on the treatment of the six most frequent peripheral vestibular disorders was used to collect data. <h3>Results:</h3> 234 replies from five continents, 47 countries, 162 cities and 188 centers were received: (% from all 234 replies; multiple answers possible): BPPV: posterior canal: 71% Epley, 40% Sémont, and 12% others. Horizontal canal BPPV canalithiasis: 58% roll-maneuver, 33% Gufoni, 7% prolonged rest, and 9% others. Horizontal canal cupulolithiasis: 35% Gufoni, 27% roll-maneuver, 9% Zuma, and 7% head shaking: AUVP: 79% pharmacotherapy, namely 47% glucocorticoids, 39% antiemetics, and 24% betahistine; 67% physiotherapy. Menière’s disease: 85% pharmacotherapy, namely 65% betahistine, 21% diuretics, 20% steroids, 16% antiemetics, 14% gentamicin; 37% surgery. Vestibular paroxysmia: 65% pharmacotherapy, namely 57% anticonvulsants; 7% surgery. BVP: 77% physiotherapy. SCDS: 50% Surgery, namely 19% canal plugging, 12% capping, and 8% resurfacing. <h3>Conclusions:</h3> In this world wide survey with 234 replies from 188 centers widely heterogeneous applied treatment options were reported for the six most frequent peripheral vestibular disorders. For example, medication use is often not supported by evidence. Namely in AUVP, Menière’s disease and vestibular paroxysmia well designed controlled trials are needed with clinically meaningful endpoints are needed. <b>Disclosure:</b> Dr. Strupp has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for IntraBio. Dr. Strupp has received personal compensation in the range of $0-$499 for serving as a Consultant for AurisMedical. Dr. Strupp has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Springer. Dr. Strupp has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Frontiers. Dr. Strupp has stock in IntraBio. Mr. Kern has nothing to disclose. Prof. Laurell has nothing to disclose. Eva Grill has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for ELSEVIER. The institution of Eva Grill has received research support from German Federal Ministry of Education and Research. The institution of Eva Grill has received research support from AOK Bayern. Eva Grill has received personal compensation in the range of $500-$4,999 for serving as a Speaker with Apothekerkammer Bayern. Ralf Strobl has nothing to disclose.

Virtual reality set-up for studying vestibular function during head impulse test.

Virtual reality (VR) offers an ecological setting and the possibility of altered visual feedback during head movements useful for vestibular research and treatment of vestibular disorders. There is however no data quantifying vestibulo-ocular reflex (VOR) during head impulse test (HIT) in VR. The main objective of this study is to assess the feasibility and performance of eye and head movement measurements of healthy subjects in a VR environment during high velocity horizontal head rotation (VR-HIT) under a normal visual feedback condition. The secondary objective is to establish the feasibility of VR-HIT recordings in the same group of normal subjects but under altered visual feedback conditions. Twelve healthy subjects underwent video HIT using both a standard setup (vHIT) and VR-HIT. In VR, eye and head positions were recorded by using, respectively, an imbedded eye tracker and an infrared motion tracker. Subjects were tested under four conditions, one reproducing normal visual feedback and three simulating an altered gain or direction of visual feedback. During these three altered conditions the movement of the visual scene relative to the head movement was decreased in amplitude by 50% (half), was nullified (freeze) or was inverted in direction (inverse). Eye and head motion recording during normal visual feedback as well as during all 3 altered conditions was successful. There was no significant difference in VOR gain in VR-HIT between normal, half, freeze and inverse conditions. In the normal condition, VOR gain was significantly but slightly (by 3%) different for VR-HIT and vHIT. Duration and amplitude of head impulses were significantly greater in VR-HIT than in vHIT. In all three altered VR-HIT conditions, covert saccades were present in approximatively one out of four trials. Our VR setup allowed high quality recording of eye and head data during head impulse test under normal and altered visual feedback conditions. This setup could be used to investigate compensation mechanisms in vestibular hypofunction, to elicit adaptation of VOR in ecological settings or to allow objective evaluation of VR-based vestibular rehabilitation.

Treatment of Vestibular Disorders (Inner Ear Balance Problems): How Does Your Physical Therapist Treat Dizziness Related to Inner Ear Balance Problems?

Dizziness is very common, but it is never normal. Dizziness can make performing daily activities, work, and walking difficult. Inner ear balance problems can make people dizzy when they turn their head, which can cause problems during walking and make people more likely to fall. Most of the time dizziness is not from a life-threatening disease. Often, dizziness is related to a problem of the vestibular (or inner ear balance) system. Vestibular disorders can be caused by infections in the ear, problems with the immune system, medications that harm the inner ear, and rarely from diabetes or stroke because of a lack of blood flow to the inner ear. Stress, poor sleep, migraine headaches, overdoing some activities, and feeling anxious or sad can increase symptoms of dizziness. Updated guidelines for the treatment of inner ear disorders are published in this issue of the Journal of Neurologic Physical Therapy. The guideline recommends which exercises are best to treat the dizziness and balance problems commonly seen with an inner ear problem.

The Importance of Otoneurological Evaluation in Brazilian Workers Exposed to Pesticides: A Preliminary Study.

Introduction Agrochemicals, also known as pesticides, are widely used in agriculture and in public health. They are organic and inorganic chemical substances with a high level of toxicity not only for the environment, but also for human health. Objective To verify findings on labyrinthine assessment in endemic disease control agents, and to recommend the inclusion of the vestibular exam in the set of tests for pesticide-exposed populations. Methods Descriptive, prospective, cross-sectional study with a sample comprising 15 endemic disease control agents, males, mean age of 51.6 years old (standard deviation [SD] = 5.9). All of the participants were submitted to anamnesis, otorhinolaryngological screening, and vestibular assessment. Results Regarding the most reported complaints, dizziness (73.4%), headache (60%), and tingling in the extremities (53.4%) were observed. The findings of the vestibular exams were normal in 53.3%, while 46.7% showed peripheral vestibular disorder, of which 26.7% were of deficitary type, and 20% of the irritative type. Conclusions: Alteration in the vestibular system was verified in 50% of the workers, with a greater prevalence in the caloric testing. Several disorders related to pesticides intoxication are scientifically known. Actions promoting knowledge and qualification of this population for the proper handling of chemicals are suggested, in addition to the elaboration and inclusion of protocols of vestibular assessment in hearing health programs for the prevention, diagnosis and treatment of vestibular disorders.

Neurophysiological approaches to the diagnosis and treatment of vestibular disorders in migraine and epilepsy

The review considers the results of domestic and foreign studies of modern neurophysiological diagnosis of vestibular disorders in migraine and epilepsy. Currently, there is a large number of physiological and clinical methods to evaluate the functions of the peripheral and central parts of the vestibular sensory system. However, among the tests, the samples for the assessment of the physiological state of horizontal semicircular canals and associated stem canals predominate. In recent years, neurophysiological techniques that reflect the work of the structures of the nervous system, previously inaccessible to direct study, are being actively introduced. Modern effective neurophysiological methods of rehabilitation of patients with migraine-associated and other various vestibular disorders have been developed. Further study of neurophysiological approaches to the diagnosis of vestibular disorders in migraine and epilepsy will significantly expands the current understanding of neurophysiological mechanisms of brain functions.

Treatment of vestibular disorders with weak asymmetric base-in prisms: An hypothesis with a focus on Ménière's disease.

BACKGROUND:Regular treatments of Ménière’s disease (MD) vary largely, and no single satisfactory treatment exists. A complementary treatment popular among Dutch and Belgian patients involves eyeglasses with weak asymmetric base-in prisms, with a perceived high success rate. An explanatory mechanism is, however, lacking.OBJECTIVE:To speculate on a working mechanism explaining an effectiveness of weak asymmetric base-in prims in MD, based on available knowledge.METHODS:After describing the way these prisms are prescribed using a walking test and its effect reported on, we give an explanation of its underlying mechanism, based on the literature.RESULTS:The presumed effect can be explained by considering the typical star-like walking pattern in MD, induced by a drifting after-image comparable to the oculogyral illusion. Weak asymmetric base-in prisms can furthermore eliminate the conflict between a net vestibular angular velocity bias in the efferent signal controlling the VOR, and a net re-afferent ocular signal.CONCLUSIONS:The positive findings with these glasses reported on, the fact that the treatment itself is simple, low-cost, and socially acceptable, and the fact that an explanation is at hand, speak in favour of elaborating further on this treatment.

Advances in the diagnosis and treatment of vestibular disorders: psychophysics and prosthetics.

Although vestibular disorders are common and often disabling, they remain difficult to diagnose and treat. For these reasons, considerable interest has been focused on developing new ways to identify peripheral and central vestibular abnormalities and on new therapeutic options that could benefit the numerous patients who remain symptomatic despite optimal therapy. In this review, I focus on the potential utility of psychophysical vestibular testing and vestibular prosthetics. The former offers a new diagnostic approach that may prove to be superior to the current tests in some circumstances; the latter may be a way to provide the brain with information about head motion that restores some elements of the information normally provided by the vestibular labyrinth.

New insights into vestibular neuropharmacology: From bench to bedside

Recent epidemiological investigations have highlighted the high prevalence of vestibular dysfunctions in the adult population and its association with aging. Despite a large and unmet medical need, the pharmaceutical options of targeted and efficient drugs to reduce the symptoms associated with vestibular deficits remains largely insufficient. This special issue of the Journal of Vestibular Research is devoted to the session: New insights on vestibular neuropharmacology: From bench to bedside, that was organized at the 2012 Midwinter Meeting of the Association of Research in Otolaryngology. This special issue intends 1. to emphasize the current state of the medical need for potent pharmacological treatments of vestibular deficits while highlighting questions regarding the molecular targets, the therapeutic window and the role of pharmacological treatment versus physiotherapy; 2. to give an overview of the fundamental mechanisms of vestibular system function and the mechanism of action of the drugs currently used in the treatment of vestibular disorders and 3. to present recent discoveries in basic research, that may lead to future drug identification to efficiently alleviate the vertigo crisis and protect the vestibule. This theme should target a broad audience ranging from ENT clinicians to scientists, including pharmacologists and pharmacists.

Treating the Signature Injury

Treating the Signature Injury

Vestibular disorders among adults in a tertiary hospital in Lagos, Nigeria

Dizziness is not an uncommon complaint in the Otolaryngological clinics among other symptoms. To a large number of practitioners, the treatment of dizziness remains the same irrespective of the etiology, i.e., anti-vertiginous drugs. The objective of this study was to document the evaluation, causes and treatment of vestibular disorders among our patients. The design includes descriptive prospective study conducted in the Oto-rhino-laryngology and Orthopedic Clinics of Lagos University Teaching Hospital, Lagos and Nigerian Army Audiological Centre, 68 Nigerian Army Reference Hospital, Yaba, Lagos, Nigeria. Adult patients referred to the audiology clinic for dizziness had detailed history obtained by using structured questionnaire. General physical and neuro-otological examinations were done. Clinical diagnoses were made on standardized criteria. The patients had hearing evaluation, videonystagmography (VNG) evaluation using infrared videonystagmography system. X-ray of the cervical spine and computerized tomogram scan of internal auditory meatus and brain when indicated were done. A total of 102 patients were seen with age range between 21 and 90 years. Thirty patients (29.4%) recorded average duration of episode of vertiginous attacks in seconds, 69 (67.6%) recorded within minutes to hours and 3 (2.9%) with no definite pattern. Clinical signs on neuro-otological examination were elicited on 39 (38.2%) of the patients while on VNG the vestibular subtest mainly caloric test was abnormal unilaterally and bilaterally in 47 (46.1%) while with the oculomotor subtests, smooth pursuit tests were abnormal in 5 (6.9%), saccade tests were abnormal in 8 (7.8%) and OPK were abnormal in 9 (8.8%). Peripheral vestibular disorders are common of which benign paroxysmal positional vertigo (BPPV) was seen in 29 (28.4%), Meniere's disease in 22 (21.6%), recurrent vestibulopathy in 20 (19.6%), cervical vertigo in 18 (17.6%), psychogenic vertigo in 2 (2%), vestibular schwannoma, barotraumas and drug-induced vertigo in 1 (1%), respectively, central vestibular disorders of vascular origin 2 (2%), vertebrobasilar insufficiency in 1 (1%), post-traumatic vertigo in 3 (3%) and unknown in 2 (2%). In conclusion, peripheral vestibular disorders are common of which BPPV is the most prevalent. Pre-referral anti-vertiginous medication is common among general practitioners. The practising ORL/Head neck surgeon and orthopedic surgeons must be conversant with the tools of diagnosis, differential diagnosis and treatment.

Neuropharmacology of vestibular system disorders.

This work reviews the neuropharmacology of the vestibular system, with an emphasis on the mechanism of action of drugs used in the treatment of vestibular disorders. Otolaryngologists are confronted with a rapidly changing field in which advances in the knowledge of ionic channel function and synaptic transmission mechanisms have led to the development of new scientific models for the understanding of vestibular dysfunction and its management. In particular, there have been recent advances in our knowledge of the fundamental mechanisms of vestibular system function and drug mechanisms of action. In this work, drugs acting on vestibular system have been grouped into two main categories according to their primary mechanisms of action: those with effects on neurotransmitters and neuromodulator receptors and those that act on voltage-gated ion channels. Particular attention is given in this review to drugs that may provide additional insight into the pathophysiology of vestibular diseases. A critical review of the pharmacology and highlights of the major advances are discussed in each case.

Medical treatment of vestibular disorders

Background: The lifelong prevalence of rotatory vertigo is 30%. Despite this high figure, patients with vertigo generally receive either inappropriate or inadequate treatment. However, the majority of vestibular disorders have a benign cause, take a favorable natural course, and respond positively to therapy. Objective: This review puts special emphasis on the medical rather than the physical, operative, or psychotherapeutic treatments available. Methods: A selected review of recent reports and studies on the medical treatment of peripheral and central vestibular disorders. Results/conclusions: In vestibular neuritis, recovery of the peripheral vestibular function can be improved by oral corticosteroids; in Menière's disease, there is first evidence that high-dose, long-term administration of betahistine reduces attack frequency; carbamazepine or oxcarbamazepine is the treatment of first choice in vestibular paroxysmia, a disorder mainly caused by neurovascular cross-compression; the potassium channel blocker aminopyridine provides a new therapeutic principle for treatment of downbeat nystagmus, upbeat nystagmus, and episodic ataxia type 2.

Effects of betahistine on the spatiotemporal response properties of vestibulospinal neurons to labyrinthine volleys

Betahistine, a drug used in the treatment of vestibular disorders, speeds-up the recovery from hemilabyrinthectomy in experimental animals, likely through the activation of histamine receptors. In order to better understand the mechanism of action of this drug we investigated, in adult, urethane anesthetized rats, whether betahistine modifies the spatial (directional) and temporal response properties of vestibular nuclear neurons to the labyrinthine input, as well as the convergence of different labyrinthine signals on single units. Extracellular single-unit activity was recorded from the caudal, spinal-projecting region of the vestibular nuclei during tilt of the animal, before and after i.p. injection of betahistine. The two orthogonal directions of maximal and minimal response to tilt, as well as the corresponding gains were determined for each neuron. Betahistine reduced the maximal response gain of units showing larger basal values of this parameter and increased it in neurons with smaller basal values, while the minimal response gain was on the average raised. These changes led to a significant decrease in the spatial specificity of the neurons, suggesting that betahistine affects the process of spatiotemporal convergence on vestibular units, likely through a rearrangement of the various inputs. This could be related to the effect of the drug on vestibular compensation.

Heat shock protein 70 delays gentamicin-induced vestibular hair cell death

In this study, geranylgeranylacetone (GGA) was shown to induce heat shock protein (HSP)70 in the vestibular end organs of the guinea pig and to alleviate gentamicin (GM) ototoxicity. This was accomplished without thermal preconditioning. In isolated guinea pig vestibular end organs we demonstrated possible prophylactic (preventive) effects of GGA on GM ototoxicity by actively inducing HSP70. When HSP70 was pre-incubated with GGA, its content in sensory cell cytoplasm and transitional dark cells was increased. Pre-incubation of vestibular end organs with GGA gave sensory cells partial protection from GM toxicity. These findings show that administration of GGA can protect vestibular sensory cells from GM ototoxicity and suggest that induction of HSP70 by GGA may be a useful adjunct for the treatment of vestibular disorders.

Results of magnetic resonance imaging in dogs with vestibular disorders: 85 cases (1996-1999).

To determine results of magnetic resonance (MR) imaging in dogs with vestibular disorders (VD) and correlate results of MR imaging with clinical findings. Retrospective study. 85 dogs. Information on signalment, clinical signs, and presumptive lesion location was obtained from the medical records, and MR images were reviewed. 27 dogs had peripheral VD, 37 had central VD, and 21 had paradoxical VD. Of the 27 dogs with peripheral VD, 11 (41%) had MR imaging abnormalities involving the ipsilateral tympanic bulla compatible with otitis media (6 also had abnormalities involving the petrous portion of the ipsilateral temporal bone compatible with otitis interna), 7 (26%) had MR imaging abnormalities compatible with middle ear neoplasia, 2(7%) had an ipsilateral cerebellopontine angle lesion, and 7 (26%) did not have MR imaging abnormalities. All dogs with central and paradoxical VD had abnormalities evident on MR images. Of the 37 dogs with central VD, 13 (35%) had an extra-axial lesion, 6 (16%) had an intra-axial lesion, and 18 (49%) had multiple intra-axial lesions. In 23 (62%) dogs with central VD, lesions on MR images corresponded with location suspected on the basis of clinical signs. Of the 21 dogs with paradoxical VD, 12 (57%) had an extra-axial lesion, 5 (24%) had an intra-axial lesion, and 4 (19%) had multiple intra-axial lesions. Location of lesions on MR images agreed with location suspected on the basis of clinical signs in 19 (90%) dogs. Results suggest that MR imaging may be helpful in the diagnosis and treatment of VD in dogs.

Pharmacology of the vestibular system.

In the past year significant advances have been made in our understanding of the neurochemistry and neuropharmacology of the peripheral and central vestibular systems. The recognition of the central importance of excitatory amino acids and their receptors at the level of the hair cells, vestibular nerve and vestibular nucleus has progressed further, and the role of nitric oxide in relation to activation of the N-methyl-D-aspartate receptor subtype is becoming increasingly clear. Increasing evidence suggests that excessive N-methyl-D-aspartate receptor activation and nitric oxide production after exposure to aminoglycoside antibiotics is a critical part of hair cell death, and new pharmacological strategies for preventing aminoglycoside ototoxicity are emerging as a result. Conversely, the use of aminoglycosides to lesion the peripheral vestibular system in the treatment of Meniere's disease has been studied intensively. In the vestibular nucleus, new studies suggest the importance of opioid, nociceptin and glucocorticoid receptors in the control of vestibular reflex function. Finally, the mechanisms of action and optimal use of antihistamines in the treatment of vestibular disorders has also received a great deal of attention.

The effects of flunarizine and pentoxifylline on vestibular blood flow in the guinea pig.

Several authors have proposed that complications arising from vestibular disorders are the result of compromised circulation. The purpose of the current study was to assess the ability of flunarizine and pentoxifylline to increase peripheral vestibular blood flow (VBF), since flunarizine is a selective calcium-channel entry blocker that inhibits calcium-related contraction of smooth muscle, while pentoxifylline is a xanthine derivative that promotes microcirculation by affecting red blood cell malleability. Both of these treatment strategies have received considerable attention in clinics and laboratory, but their effects on blood flow are unclear. Changes in VBF were evaluated from the posterior semicircular canal ampulla in guinea pigs using a laser Doppler flowmeter. One group of animals was infused with pentoxifylline at concentrations of 10-40 mg/ml, while a second group was treated with 0.3-1.5 mg/kg flunarizine. VBF, blood pressure (BP) and heart rate (HR) were monitored continuously. Findings showed that pentoxifylline induced a concentration-dependent increase in VBF. In contrast, no increase in VBF occurred in response to flunarizine infusions. These studies suggest that the effectiveness of pentoxifylline in the clinical treatment of vestibular disorders may be the result of improved blood flow.

The Effects of Steroids on Vestibular Compensation and Vestibular Nucleus Neuronal Activity in the Guinea Pig

Recent studies have suggested that steroids such as dexamethasone and methylprednisolone might be useful in the treatment of vestibular disorders, irrespective of whether inflammatory processes are involved. The aim of this study was to investigate the effects of systemic administration of dexamethasone on vestibular compensation of spontaneous nystagmus (SN) in guinea pig, and the effects of dexamethasone and methylprednisolone on extracellularly recorded spontaneous activity of medial vestibular nucleus (MVN) neurons in brainstem slices in vitro. In the behavioral study, none of the 3 doses of dexamethasone (5, 10, or 40 mg/kg i.p., delivered at 0, 12, 24, and 36 h following a unilateral surgical labyrinthectomy (UL)) resulted in a significant change in the frequency or compensation of SN, relative to the vehicle control group. In the in vitro study, only a minority of MVN neurons showed any response to 1 microM dexamethasone (1 out of 9 neurons), or 10 nM (3 out of 13), or 0.1 microM methylprednisolone (3 out of 7). These results suggest, contrary to previous evidence, that dexamethasone may not accelerate compensation of SN following surgical UL and that dexamethasone and methylprednisolone may have a direct action only on a minority of MVN neurons.

Physiological Principles of Vestibular Function on Earth and in Space

Physiological mechanisms underlying vestibular function have important implications for our ability to understand, predict, and modify balance processes during and after spaceflight. The microgravity environment of space provides many unique opportunities for studying the effects of changes in gravitoinertial force on structure and function of the vestibular system. Investigations of basic vestibular physiology and of changes in reflexes occurring as a consequence of exposure to microgravity have important implications for diagnosis and treatment of vestibular disorders in human beings. This report reviews physiological principles underlying control of vestibular processes on earth and in space. Information is presented from a functional perspective with emphasis on signals arising from labyrinthine receptors. Changes induced by microgravity in linear acceleration detected by the vestibulo-ocular reflexes. Alterations of the functional requirements for postural control in space are described. Areas of direct correlation between studies of vestibular reflexes in microgravity and vestibular disorders in human beings are discussed.

Physiological principles of vestibular function on earth and in space

Physiological mechanisms underlying vestibular function have important implications for our ability to understand, predict, and modify balance processes during and after spaceflight. The microgravity environment of space provides many unique opportunities for studying the effects of changes in gravitoinertial force on structure and function of the vestibular system. Investigations of basic vestibular physiology and of changes in reflexes occurring as a consequence of exposure to microgravity have important implications for diagnosis and treatment of vestibular disorders in human beings. This report reviews physiological principles underlying control of vestibular processes on earth and in space. Information is presented from a functional perspective with emphasis on signals arising from labyrinthine receptors. Changes induced by microgravity in linear acceleration detected by the vestibulo-ocular reflexes. Alterations of the functional requirements for postural control in space are described. Areas of direct correlation between studies of vestibular reflexes in microgravity and vestibular disorders in human beings are discussed. (Otolaryngol Head Neck Surg 1998;118:S5-S15.)