Given a description of feeling of imbalance when turning

Given the symptoms of episodic drops
in hearing, rotatory vertigo, aural fullness, tinnitus in the right ear, the
suspected diagnosis would be Meniere’s disease. But a description of feeling of
imbalance when turning in bed to the right side and looking up indicates an
associated Benign Paroxysmal Positional Vertigo (BPPV).

In
order to confirm the diagnosis of Meniere’s disease, the following tests would be performed:

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1.     
Full- hearing evaluation:
– Otoscope
-tympanometry
– otoacoustic emissions
– pure tone audiometry PTA
– Speech discrimination test

2.     
Vestibular system evaluation
– eye-movement examinations
– Caloric test
– vestibular evoked myogenic potentials VEMP will be beneficial in diagnosing
Meniere’s disease, because the increased pressure of endolymph will potentially
lead to degeneration of hair cells in saccule.

3.     
Electrocochleography EcochG. is a test used to record
the auditory-evoked responses of short latency from both cochleae and auditory
nerves.

The EcochG parameters tested are: Summating
Potential(SP), whole nerve Action Potential (AP) and SP/AP ratio are used in
the assessment of endolymphatic hydrops.

 

If the patient truly has Meniere’s disease, the
results of the previous tests would be:

1.     
Otoscope will show intact external canal and tympanic
membrane.

2.     
Tympanometry will show type A in both sides

3.     
Otoacoustic emissions will show slightly lowered
responses in frequencies ranging from 800 – 1100 Hz.

4.     
Pure tone audiometry will show rising audiogram,
because Meniere’s disease is suspected to be in its mid phase.
– if Audiogram showed an air- bone gap in lower frequencies, this would not be
a result of a conductive factor but due to pressure exerted on the stapedius
footplate
from endolymphatic hydrops. But this will be in the early stages of meniere’s
disease, and as the disease progresses, the gap will be diminished, and PTA
threshold will increase gradually resulting in a flat audiogram.

5.     
No reduced speech discrimination will be present in
contrast to what would be expected from the audiogram.

6.     
Eye movement examination such as saccades and smooth
pursuit will only be used to rule out any central involvement.

7.     
Caloric test will show a negative canal paresis above
20% indicating unilateral weakness in the right ear.
– If BPPV was in the horizontal semi-circular canal, the abnormal Caloric test
results would not necessarily be due to Meniere’s disease.

8.     
VEMPs will show abnormal response in both ears. The
unaffected ear will show elevated thresholds, prolonged latencies in p13 and
n23 will be seen in both affected and unaffected ears, but to a lesser degree
in the unaffected ear. The affected ear may show no response at all.

In a study, patients with Meniere’s disease
were divided into 4 stages according to their hearing loss. Based on the
information given in the case history concerning the patient’s hearing loss,
she would be in stage 2 or stage 3, which had either no VEMPs response or
prolonged p13 and n23 latencies. (citation)

9.     
Electrocochleography will show enhancement in
summating potential SP due to displacement of stereocilia as a result of
increased pressure of endolymph, which leads to a widened SP/AP waveform. 
                       

In order to confirm the diagnosis of BPPV, the following tests
would be performed:

1.     
Ordinarily
we would use Dix-Hall pike maneuver to confirm BPPV in posterior semi-circular
canal, but because of the patient’s neck problems, we will use side-lying test.
Posterior SCC will be tested first because it’s the most common site of BPPV.

2.     
VEMPs
can be beneficial for the diagnosis of BPPV because the degeneration of the
otolith organ that is usually found in the utricle, can involve the saccule.

 
If the patient truly has BPPV in the posterior SCC, previous tests will have
the following results:

1.     
Side
lying test will show torsional up-beating nystagmus to the right side. If this
is not the case, roll then rose test will be used to test horizontal and
anterior SCCs, respectively.

2.     
Abnormal
VEMP characterized by prolonged latencies and reduced amplitudes will be
observed regardless of the SCC involved.
if BPPC was cupuloithitis, VEMP will show normal results.

*Regarding
VEMP, more depressed and diminished responses are seen in Meniere’s disease
than BPPV, because the macula in the saccule do not degenerate sufficiently to
show no response at all at VEMP.

 

 

Management:

Management of BPPV

 Liberatory maneuver (Semont) will be due to
the contraindication of neck pain.
 In this maneuver, the patient will be in
a sitting position, she will tilt her head away from the right affected side,
and then she will lie down on her right side with her head turned up.
After five minutes she is moved quickly to the opposite side with her head
looking down, she will be in this position for 5-10 minutes, then she returns
to sitting position.

Management of MD:

Researches proving the efficiency of
various therapeutic interventions for Meniere’s are very limited due to  Meniere’s unsteady natural, Therefore there is
no agreed upon therapy strategy for Meniere’s.

” Absence of robust prospective,
randomized, placebo-controlled studies has led to a variety of medical and
surgical therapeutic interventions of uncertain value”.(citation)

There are two types of managements
to be provided depending on the purpose of intervention, acute and chronic. Acute
management is provided during the first 48 hours after an attack happened again
, and chronic management is intended to improve the overall quality of life,
since the symptoms of Meniere’s may become severe enough to cause a handicap.

Acute Management:

This type focuses on suppression of
symptoms and reducing frequency and severity of attacks:

It may involve drugs, mainly
vestibular suppressors (eg. Benzodiazepines) and antiemetic (eg meclizine).
Also hydration and rest are very important specially for eliminating vertigo.

Chronic management:

this includes life-style
adjustments, Pharmacologic Therapy, Complementary and Alternative Medicines,
multiple devices, rehabilitation therapy and surgical intervention.

Audiologists play a major role in
the rehabilitation therapy which focuses in eliminating tinnitus , hearing and
vestibular symptoms.

1)     
In
many cases, simple directive counseling can be helpfull in managing tinnitus. (citation)
Feenstra

2)     
Hearing
aids can also be used for eliminating tinnitus and hearing symptoms.
However, due to the fluctuating nature of the Minere’s hearing loss, care
should be taken in the fitting process.

3)     
For
eliminating vestibular symptoms , Vestibular rehabilitation therapy can be used.
This kind of rehabilitation rely mainly on neural plasticity and compensation
of the vestibular dysfunction achieved training the central nerves system.

A study testing the efficiency of
vestibular rehabilitation to eliminate symptoms of Meinere’s disease, patients
showed significiant improvement in balance function on both objective and
self-report tests (citation.)

4)     
Life-style
adjustments aiming to avoid the triggers of attacks such as: caffiane, alcohol,
anxiety and salt.
– Anxiety can be managed by behavior therapy and  proper counseling for the patient.
– salt reduction can be achieved by changing the diet of the patient and using
herbs and spices instead of salt in food.

Many studies reported on reduction
of salt in managing Meniere’s symptoms, no study support that sodium
restriction alone is efficient in managing MD, but a study by Claes and Van de
Heyning, suggests that patients should maintain a no more than 1gram of salt
per day. (citation)

 

5)     
Pharmacologic
Therapy such as giving  Diuretics, Steroids
and Amino glycoside Ablation.
– Intratympanic gentamicin (ITG) is one of the most used Aminoglycoside
Ablation.
 “The large number of published
reports on the efficacy of ITG has led to near abandonment of surgical
intervention.” (citation in text )

–         
Patient’s
with unilateral MD, such as our case would be recommended to follow the low-
dose method described by (Harner. et al)

 

6)     
Devices
such as:
– The Meniett which is a  low-intensity
pressure generator that is worn in the external auditory canal, can be used to
reduce vertigo’s severity and frequency specially on the short-term.
– p-100 is also used as a less-expensive replacement for the Meniett. However,
studies that proves it’s efficiency are rare.

 

7)     
Surgical
interventions (eg. Vestibular nerve section and endolymphatic sac surgery) are
used to eliminate the symptoms of MD, but such surgeries result in no
improvement in hearing.

In a study, no difference was found
in the overall improvement between patients treated conservatively, medically
or surgically.

For this patient, we will refer her
to an ENT for any medical/ surgical interventions.
As audiologists, we can provide her with hearing aids and vestibular
rehabilitation exercises, such as: Cawthorne-Cooksey Exercises, these exercises