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Surgery for vertigo
The document discusses the evaluation and management of vertigo, emphasizing the importance of accurately diagnosing its underlying etiology through comprehensive patient history, physical exams, and various auditory-vestibular tests. It details potential causes including peripheral and central disorders, and suggests rehabilitation or surgical interventions based on the stability and progression of symptoms. Additionally, it highlights the necessity of individualized treatment plans while considering the entire clinical presentation of patients.
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Surgery for vertigo
- 1. AMIR ALAM HOSPITAL SasanDabiri, MD, MSc, Associate Professor Department of Otorhinolaryngology – Head & Neck Surgery Amir Alam Hospital – Tehran University of Medical Sciences S e p t e m b e r 2 0 2 0
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- 5. The accurate diagnosisof the underlying etiology is th e crucial step in th e man agement of vertigo
- 6. History ➢ True orpseudo-vertigo ➢ One attack or more ➢ Episodic or continuous ➢ Duration of each episode ➢ Chronology of symptoms ➢ How does start at first time (straining, trauma) ➢ Associated symptoms (oto, neuro, ocular) ➢ Associated histories (medico-surgical, family, drug, psychologic) ➢ Effect of lifestyle ➢ environment ➢ Effect of head movement ear pressure changes
- 7. ➢ Ear Exam(inspection) ➢ Eye Exam (position & Nystagmus) ➢ Neurologic Exam (R/O ataxia) ➢ Sound or Pressure (3rd window) ➢ Vibration (SSCD, MD, VS) ➢ Hyperventilation (phobia, central) demyelination: MS, VS, Vascular ➢ Positional testing (Hallpike , roll test) ➢ H I T test (canal dysfunction) ➢ Head shaking test Physical Exam. History
- 8. Audio- Vestibular Tests Physical Exam. History ➢ VNG (saccade, pursuit , nystagmus ) ➢ Evoked evaluation • Caloric Test ( lower freq. ) • Head Shaking ( 1-2 Hz ) • V-HIT ( 3-5 Hz ) ➢ PTA-SRT-WRS, AR ➢ ECoG ➢ VEMP (cervical, ocular) ➢ Rotatory chair test ➢ Posturography ( C D P )
- 9. Imaging Audio- Vestibular Tests Physical Exam. History ➢ C T: • Otic capsule involvement • SSCD Sx. / any other 3rd window • Large vestibular aqueduct Sx. ➢ M R : • Meniere’s Disease • CP Angle lesions • Other central disorders
- 10. Imaging Audio- Vestibular Tests Physical Exam. History 2 - Concurrentdisorders may p res ent at th e s ame time 1 - Patients with vertigo h ave s ome d egree of pseudo-vertigo 3 - T h e etiology of vertigo might change over time
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- 14. Supporting labyrinthine instability: •Acute vestibular crisis and repeating similar symptoms • Presence of other otologic findings (symptom/sign) Supporting compensation problems: • Persistent spontaneous nystagmus • Post–head-shaking nystagmus Supporting central pathology • Nystagmus type and fixation • Saccade and pursuit abnormalities Clinical Points
- 15. Supporting labyrinthine instability: •Fluctuate or progressive SNHL (serial audiogram is important) • Rapid positional nystagmus provoked by the Dix-Hallpike • Unilateral caloric weakness • ECoG abnormalities • VEMP abnormalities Supporting compensation problems: • Rotational chair asymmetry • Persistent asymmetry in VOR responses • Sensory organization test abnormalities on CDP Clinical Points Audiovestibular Points
- 16. Supporting labyrinthine instability: Diagnosticuncertainty → A program of supervised vestibular rehabilitation (4 to 6 wks) → No improvement Clinical Points Audiovestibular Points Rehabilitation Trial
- 17. In unstable orrapidly progressive lesion → central compensation is not possible So, the goal is stabilizing the ear (by medical or surgical management) • Correcting the defect or • Ablating the function
- 18. • An asymmetrichearing loss (the best indicator) • Reproducible unilateral reduction in caloric • Less reliable lateralizing features: • Tinnitus • Aural fullness • Direction of nystagmus • Audiovestibular results Tests should always be interpreted in the light of the entire clinical presentation (sometimes, the worse ear is not the source ear)
- 19. • Surgery isalways elective • MRI in all patients are mandatory • Residual hearing is always important (completely patient-based) • Start from less invasive to more aggressive (Transtympanic injections have priority)
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- 23. • Singular Neurectomy •Canal Occlusion BPPV Otologic Surgery, Brackmann, 2016
- 24. • Canal Occlusion(not repair) • Middle fossa approach • Transmastoid approach SSCCD Sx Otologic Surgery, Brackmann, 2016
- 25. • Closure ofthe fistula • Oval window • In iatrogenic footplate manipulations • In idiopathic etiologies (anterior to OW) • Round window • In Hyrtl’s fissure (inferior to RW) • In idiopathic etiologies (RW occlusion) Perilymphatic Fistula
- 26. • Tenotomy (tensor tympaniand stapedius) Meniere’s Disease C D Oper Tech Otolaryngol, 2016, 27:240
- 27. Meniere’s Disease Otologic Surgery, Brackmann, 2016 OtolNeurotol, 2007, 28:641 • Tenotomy • Cochleosacculotomy
- 28. Meniere’s Disease Otologic Surgery, Brackmann, 2016 TemporalBone, Sanna, 2006 • Tenotomy • Cochleosacculotomy • Endolymphatic Sac Surgery
- 29. • Middle fossa •Retrolabyrinthine • Retrosigmoid • Infralabyrinthine • Tenotomy • Cochleosacculotomy • Endolymphatic Sac Surgery • Vestibular Neurectomy (Only Hearing Preservation) Meniere’s Disease CummingsOtolaryngology, Flintetal,2021
- 30. • Labyrinthectomy • Transcanal •Transmastoid (GOLD Standard) • Facial nerve • Irrigation • Drill direction • Neuroepithelium Ablative Surgery Endoscopic Ear Surgery, Marchioni and Presutti, 2014 IAC
- 31. • Labyrinthectomy • VestibularNeurectomy (added to labyrinthectomy) Ablative Surgery • Translabyrinthine (cutting the vestibular nerve) • Transcochlear (cutting the cochleovestibular nerve) Endoscopic Ear Surgery, Marchioni and Presutti, 2014 Intradural dissection
- 32. • Labyrinthectomy • VestibularNeurectomy (added to labyrinthectomy) Ablative Surgery • Translabyrinthine (cutting the vestibular nerve) • Transcochlear (cutting the cochleovestibular nerve) Cummings Otolaryngology, Flint et al, 2021 Intradural dissection TranslabyrinthineTranscochlear
- 33. • Labyrinthectomy • VestibularNeurectomy (added to labyrinthectomy) Ablative Surgery • Translabyrinthine (cutting the vestibular nerve) • Transcochlear (cutting the cochleovestibular nerve) Endoscopic Ear Surgery, Marchioni and Presutti, 2014 Intradural dissection TranslabyrinthineTranscochlear
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