Vertigo is one of the vestibular disorders and its prevalence is 20% among people over 65 Years of age.
Elderly people suffer from it when they lie down in bed, turn over in the bed or pick up something or with the head movement. These attacks go away after ten to fifteen seconds. Most patients have it again and again. In the morning they feel better and in the day it becomes less and less but restarts at night. There are many causative factors which includes infections to the vestibular nerve which is most important. It is severe vertigo which is accompanied with nausea and vomiting. It lasts for a week or so before its intensity reduces. Then it disappears but the problem remains and infection can destroy the nerve, he added.
Third type of vertigo is severe attacks which last for twenty minutes to several hours and then disappears. It comes back again and again and it is known as Meniere's disease. As regards its management the first and foremost is proper clinical history and to distinguish between these three types because policy for their management is different. There are some maneuvers with hand which brings the body organs back into correct position and it is quite successful. If you know it, almost 85% of these patients can be treated immediately. In case of Meniere's disease, before making diagnosis, it is always advisable to send the patient to an ENT surgeon to do audiometery, vestibular testing and generally he or she will prescribe Betahistine dihydrochloride (Serc). It should be used in high doses and it starts working immediately but the clinical picture will improve after two months therapy. Neuritis infection can be treated with high dose of methyl prednisolone or in combination with Betahistine dihydrochloride.
Tell the patient to get up as soon as possible and the patients need to be mobile.
Responding to a question whether vertigo falls in the domain of an ENT surgeon or a Neurologist, Prof. Herman Kingma said that if the signs and symptoms are related to neurology, refer the patient to a neurologist otherwise it should be managed by an ENT surgeon. Answering another question as to how the GPs, Family Physician go about diagnosing and treating vertigo, Prof. Kingma said that it is a very specialized field. However, there is lot of information available on the net. They should keep themselves update and it is worthwhile to go through the information on the net and learn precise diagnosis of Benign Paroxysmal Positioning Vertigo (BPPV). These are quite common disorders. It is a big group of patients which they can manage. Otherwise they should refer the patient to an ENT surgeon or Neurologist depending upon their symptoms. It is a worldwide problem and many patients do not know which complains can arise from vestibular disorders. They do not know where the balance organ is located in the body.
Replying to another question if there was any surgical treatment available, Prof.Kingma opined that in case of tumour of the nerve, surgical management is indicated. In the past these patients used to be operated immediately but now they are first sent for MRI to find out where the tumour is and whether it was growing fast or slowly. If it is growing fast, one can opt for either surgery or it can also be managed through Gama Knife. In case of Meniere's disease, if the patient is having three to four attacks per week, one can go for ablation. One way is by surgery to cut the nerve and take out the labyrinth or go for Gentamycin injection, since it is oto-toxic, it will kill the labyrinth. The later approach is more common now and Gentamycin application is growing.
Prof. Kingma also disclosed that they have developed a vestibular implant which is an artificial balance. If people lose bilateral function we put this organ in the brain. We implanted the first such implant on September 12th this year in a patient who was sixty five years of age. Our second patient was thirty seven years old. We had good results and so far the patients had no complication. It is just like cochlear implant. Of course it is a bit expensive but in Holland since it is all funded by the Government, we had no problem. For patients who lose both labyrinths, it is a new balance organ. Those who lose both labyrinths, they have no vertigo but their image is not stable. When they walk, everything is moving and people get very much tired. My other major interest is in improving diagnostics to measure vestibular system.
Talking about medical ethics, Prof.Kingma said that we have an Ethics Committee which deals with all these issues. We have very strict rules and monitoring by the government. Any cooperation, assistance from the industry has to be disclosed. No drug promotion is allowed in presentations at the scientific meetings. The Pharma industry does help and collaborate with the medical profession in academic activities but they cannot interfere in scientific programme in any way. I being a scientist will talk about science rather than promoting a drug. Prof. Kingma further added that Netherlands was the first country in the world which legalized euthanasia. Now we have gone a step further and facilitate those who wish to die since their quality of life is not good. Referring to a Japanese movie, he further stated that when the teeth of elderly starts moving, they are allowed to freeze to death in the mountains and they die n a decent way.
However, there is lot of debate on euthanasia and its ethical aspects all over the world, he remarked. My next question to Prof. Kingma was that it is believed that drug delivery is extremely difficult in the inner ear, its penetration is not good and it takes lot of time to have any effect to which he remarked that when one uses Betahistine dihydrochloride (Serc), blood flow in the ear improves. It acts fast but the clinical picture takes longer to improve. Though the drug acts fast but the patient will feel good only after a few weeks of therapy. Many patients with vestibular disorders have no vertigo. In these patients vision and balance problems are over looked. Hence control is always better.
Instructional session on Therapy of Vestibular Disorders
One of his presentations in the congress was an instructional session on Therapy for vestibular disorders which was chaired by Prof. M.Jalisi. Despite the fact that the session was late by two hours, Prof. Kingma kept the audience fully involved with his excellent presentation which was quite informative and extremely useful. He pointed out that most common vestibular syndrome is BPPV which is induced by change in position of head relative to gravity. Vertigo is induced after latency. If a patient gets up in the morning he or she will have same BPPV. With the passage of time in the day the symptoms are reduced and them eventually they disappear. But he will experience these symptoms at night again. We do not know what exactly causes it but it is related with aging, vascular problems, head trauma, long bed rest and neuritis. He then discussed the relative physical and patho physiological considerations in detail.
He also demonstrated the physical maneuvers in Meniere's disease which can be seen on I phone or I. Pad. Teaching, he felt is very critical. He then described the Settings and demonstration in detail and opined that credit for all this should go to Sydney people who have pioneered this progamme. It is mostly due to posterior canal due to their orientation of the canals in the head. There is natural remission when you wake up in the morning. It is less in the horizontal canal and seldom in the anterior canal.
Talking about therapy, he said that one should follow the policy of wait and see if there is a natural remission. But at times the patients do want you to do something. Ask the patient can you move your head and neck right and left? Rotate it to the healthy side but remember it is not so easy in the elderly. There are various maneuvers which ENT surgeons practice. In Italy they use different maneuvers. If a liberation maneuver does not work for various reasons, you may end up introducing another problem; hence one should be extremely careful during these maneuvers. Most common vestibular syndrome is fear of imbalance. He then talked about phobic postural vertigo, visual vertigo, panic and anxiety besides convulsions in detail.
Prof. Kingma also referred to motion sickness, dysfunction of vascular system, vestibular neuritis, peripheral versus central HINT, central and peripheral lesions and suggested mobilizing the patient and starting their rehabilitation as soon as possible. In Meniere's disease, if there is bilateral loss, use Betahistine dihydrochloride (Serc) in combination with prednisolone. Sometimes it is good. Almost 70% of patients show clear improvement. He also referred to the vestibular implants which they have developed and successfully implanted in two patients. We have developed surgical rules for that and there area different approaches like Geneva-Maastricht. One can use vestibular implants and also use drug therapy whichever is indicated and helps the patient.
In his concluding remarks Prof. Jalisi paid rich tributes to Prof.Kingma saying that he made an excellent presentation on a very difficult subject. Basically he is a scientist and it is extremely difficult to become a scientist than to be a clinician.
Prof. Kingma it may be mentioned here is also Professor in physics of the Vestibular Function at the faculty of Biomedical Physics at Technical University Eindhoven and Head of the Department of Balance Disorders at the ENT Department. His practice consists of patients suffering from complicated vestibular problems. He is Chief of Clinical Movement Laboratory and coordinator of the Master programme of Medical Engineering in the University Hospital.
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|Date:||Dec 31, 2012|
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