Balance Disorders (Vertigo)



Overview:

 

Treatments

There are many options for the treatment of vertigo. No one can reliably restore the normal function of the inner ear. We all depend upon our inner ear to provide information about where we are in our physical space. Some treatments and procedures offer the opportunity to stop disease in the inner ear. These procedures are few in number. They include taking oral steroids, injection of steroids and endolymphatic sac decompression surgery to reduce the pressure in the inner ear. Most operations are designed to eliminate the function from a damaged inner ear. The reason that they are recommended is that it is better for the brain to get no stimulus than it is to get wrong stimulus. Such procedures have varying levels of potential risk and benefits. They are usually recommended when only one ear is damaged and the other ear has normal balance function.

Oral steriods
In 1979 McCabe first described a process we call auto-immune inner ear disease. This disease process could be in part diagnosed and in part treated with steroids. At the time he originally described the disease he recommended the use of oral steroids. Oral steroids can have numerous side effects. Some patients may experience changes in personality and some can have frank psychosis. Many patients who have problems with their stomach such as heartburn can have a worsening of their symptoms. Some patients may also experience significant changes in their vision. The drug can uncover glaucoma. If one has acne, the skin problem can be made worse. Many people retain water and have difficulty in sleeping. The hip joint may also be damaged.

Steroid injection
Recently, some physicians have begun using steroids injected through the eardrum into the middle ear in an attempt to minimize the side effects of oral steroids. There is no agreed-upon dosage or schedule of injections. Some remarkable successes have been reported, but a very small number of patients have lost hearing completely. It is unclear what the long-term results will be like in most patients. While the procedure is usually performed in the clinic and is minimally invasive, complications such as an ear infection, temporary dizziness or a hole in the eardrum can occur.

Gentamicin injection
Gentamicin is an antibiotic which has been used to treat serious infections for many years. One of the side effects of this drug is that it damages portions of the inner ear including the cochlea which controls hearing and the labyrinth which controls balance. When the drug is given through the vein, it gets into all of tissues in the body. It is then cleared from the body by the kidney. Patients who experienced renal failure are more likely to have a toxic effect with this drug. Most physicians recommend that hearing and balance function be monitored if this drug is given systemically.

Recent experience has shown that when this drug is injected in the middle ear, it can be absorbed directly into the inner ear. Absorption is somewhat variable. Some patients are born with a deficiency of an enzyme which metabolizes the drug in the inner ear. These individuals may experience increased rates of hearing loss. Perhaps five percent of the population lacks this enzyme. While some centers have reported success with as little as one injection, most physicians recommend multiple injections over a longer period of time. Some failures have been identified. The exact failure rate is unclear. An estimate of the failure rate may be as high as 30 percent. Besides hearing loss, there are other potential complications. These are the same as for steroid injection.

Endolymphatic sac decompression
For patients who suffer from Meniere's disease an operation called an endolymphatic sac decompression procedure has been used for many years. This operation is successful in some patients but not all. The success rate has been reported as low as 50 percent and as high as 70 percent. Short-term results appear to be much more encouraging than long-term results. Some patients may have good results initially, but have return of their dizziness after several months to years and will require further treatment. The operation is performed under general anesthesia. Most patients can have the operation and go home the same day. Some patients experience dizziness immediately following the operation. They may require an overnight stay. The risk of hearing loss is low, but severe hearing loss can occur. There is a small risk of facial paralysis as a result of the operation. Other surgical risks are small.

Vestibular nerve section
Vestibular nerve section can be accomplished through different surgical approaches. The procedure involves opening the skull and moving aside a segment of the brain. This can usually be done without difficulty. The hearing and balance nerves are separated and the balance nerve is cut. This eliminates the abnormal function from the affected ear. The procedure is usually successful. Approximately 80 to 90 percent of those individuals who undergo the operation eliminate or substantially reduce their symptoms of vertigo. There is a chance of hearing loss and facial paralysis. Some patients can experience complete loss of hearing on the operated ear following this operation. Patients who have this surgery can experience one last severe attack of dizziness. Usually patients are hospitalized for approximately one week following the operation. Over the next three to six weeks most patients experience improvement in their symptoms. Many can return to part-time work in a few weeks. Complications from pulling the brain away from the nerves include seizures and bleeding into the brain. While these complications can be severe, they are also extremely rare.

Labyrinthectomy
The best method for vertigo control remains a labyrinthectomy. In this operation, the entire balance portion of the inner ear is opened and the contents are removed. The operation usually is short in duration. Following the operation many patients experience one last attack of dizziness. This attack may last between 24 hours and five days. When the patient is able to walk and eat, they are discharged from the hospital. Most patients find that they feel better in a period of two to six weeks. There is a small risk of facial paralysis with this operation. All patients who have a labyrinthectomy will lose the remaining hearing in the operated ear.

Vestibular rehabilitation
Our perception of orientation in space comes from our own experiences. Some of us are born with a greater ability to stay balanced. Whether we are born with skills or we learn them, all of us have the ability to improve our orientation in space. This can be summarized by the expression "a ballerina can be made and not just born." A ballerina can be taught to learn new techniques in order to maintain her balance. At the beginning of the space program many astronauts suffered from space sickness. Training helps to reduce the symptoms that most astronauts experience. Training to help a patient improve or even eliminate the dizziness and balance problems is available through physical therapists who specialize in vestibular rehabilitation. Some patients may benefit from vestibular exercises even after they undergo a procedure to improve the vertigo. If a patient is found to have problems with the balance function in both ears, vestibular rehabilitation is often the best treatment for the dizziness.

Conclusion
Control of vertigo can be achieved in most patients. The procedures all have risks but most risks are considered acceptable considering the severity of the problem. Each individual must customize their treatment plan with their physician.


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