Faculty of Pharmacy, Nursing and Health professionsDepartment of Audiology and Speech Therapy.
Balance DisordersSPAU 4380 Assignment Case study reportInstructorMrs.Amal Abu Kteish Made byAnwar Jolany 1142344Ahd Dagharah 1141930Manar Siory 1142232 Citation styleABA Date: January 18,2018 According to the information in thecase history, this patient will be given the diagnosis of Meniere’s disease (stage3) associated with posterior canal Benign Paroxysmal Positional Vertigo(BPPV)in the right ear. We gave her this diagnosis for the following reasons:Meniere’s diagnosis: During the last24 months she reports four episodes of drop in hearing on the right side,associated right sided tinnitus, and aural fullness. She also reports rotatoryvertigo, lasting from 2-6 hours. Also, we estimated that she has stage 3 ofMeniere’s disease because she reported that is sincethe last attack 3 months ago, her hearing loss has persisted and not feel stablein the dark, which are hall marks in the stage 3.
BPPV diagnosis: In the last 6 weeksshe reports a new symptom of short lived rotatory vertigo on turning to herright side in bed, and looking up. This occurs most times she makes thesemovements.v Tests and results:ü For Meniere’s disease diagnosis we can perform the following tests:Ø Audiologic tests § Pure tone audiometry: Due to her diagnosis of stage 3 the resultswill show flattening sensorineural hearing loss in the right ear.§ Speech audiometry: The result will revel reducedor possibly worsening speech discrimination.§ Otoacoustic emissions(OAE): The result willrevel lowered main frequencies, the frequency of emission may providelocalizing information.
§ Brainstem-evoked auditory responses(BEAR): The result will revelnormal, shorter or delayed wave 5 latency in the right ear.§ Traveling-wave velocity(TWV): The result will revel fastertraveling waves (masked wave 5 latency difference b0.6 ms).§ Low-frequency masking(LFM): The result will revel absent phasedependence of masking, reduced modulation depth of audiometric threshold (b28dB) and impaired masking of BEAR.§ Immittance tests: The result will revel increased conductancewidth, decreased resonance frequency and lowered threshold of the cochleostapedialreflex.§ Electrocochleography (ECoG): The test measures the electricalpotentials produced in the inner ear in response to sound. It will record alarge waveform, which results from providing sound stimulation to the innerear.
This waveform contains two components, the summating potential (SP) andthe action potential (AP). The summating potentials reflect the cochlearbioelectric activity, while the action potentials reflect the activity ofdistal afferent fibers of the 8th nerve. ECoG results for MD will show enhancednegative SP, enlarged SP/AP ratio (N0.34), increased AP/N1 latency differenceto clicks of opposing polarity (N0.
38 ms), increased SP/AP area curve ratio(N1.34), and increased SP/AP width (N1.89).
(N1 means firstnegative peak of the ECoG recording).Ø Vestibular tests§ Instrumental-aided study of nystagmus (e.g., by electronystagmographyand rotatory chair protocols): Often spontaneous nystagmus toward theunaffected ear and canal paresis of the affected ear, occasionally vestibularhyperactivity of the affected ear.
§ Vestibular-evoked myogenic potentials (VEMP): Measures thesternocleidomastoid muscle contraction in response to loud sound. It alsomeasuring the otolith (saccule and utricle) function and both branches of thevestibular nerve and the vestibulospinal tract. VEMP results for MD will show decreasedor absent amplitude in the infected ear.Ø Imaging§ Computed tomography(CT): The result will revel narrower, shorter,or nonvisualized vestibular aqueduct, smaller external aperture, and abnormallydecreased periaqueductal pneumatization. § Magnetic resonance(MR): The result will revel narrowedendolymphatic duct, obstructed endolymphatic sac, direct visualization of theendolymphatic hydrops. ü For the diagnosis of posterior BPPV we can perform the Side Lyingmanoeuvre not the Dix– Side lying testwill show that in first 2-3 seconds there is no nystagmus. Then up-wardvertical nystagmus (with torsional component towards the downward ear). Thenreversal of nystagmus upon sitting.
Also, the Videonystagmograghy (VNG) can use to diagnose theposterior BPPV and the estimate results will be as the same as the positiveSide Lying test. However, the Electronystagmography (ENG) and the Caloric testcan’t be used in the diagnosis of the posterior BPPV because they can’tdiagnose the torsional nystagmus that result from this disease. In addition,VEMP test can be used in the diagnosis of BPPV and the result will show reducedor absent amplitude at the infected side and delayed peak latency (P13 or N1). Treatment for each of MD and BPPVshould be considered independently. Treatments of Meniere’s disease mayinclude: § Medications- Motion sickness medications: such asmeclizine or diazepam (Valium) to reduce vertigo and help control nausea and vomiting.- Anti-nausea medication: suchas promethazine to control nausea andvomiting during vertigo.- Diuretics: such astriamterene to reduce the amount of fluid pressure in the inner ear, high Na?²which helps to prevent attacks, should be used with caution because ofototoxicity potential.
– Middle ear injections:Medications injected into the middle ear and is absorbed into the inner ear,can help improve vertigo symptoms such as Gentamicin Steroids. § Noninvasivetherapies – Vestibular rehabilitation exercises: canbe taught by a physical therapist and occupational therapist. It is performedby repetitive balance exercises. Those exerciseshelp patients to habituate to their vestibularloss helping them compensate for the effects of the inner ear disorder. VRE canhelp in teaching patients to cope with vertigo and imbalance. Those exercisesare habituation exercise, gaze stabilization and balance exercise.
– Hearing aids or cochlear implantshould be used with this patient because she has severe unilateral hearingloss. – Meniett device: used when it is hardto treat vertigo. It applies pulses of pressure to the ear canal through aventilation tube to improve fluid exchange. Using this device will show improvement in symptoms of vertigo, tinnitus and auralpressure. § Dietary agents(triggers) to avoidthe attacks, such as salt, caffeine, chocolate and alcohol.
§ Lifestyle adjustments to avoid orreduce the occurrence of attacks symptoms (e.g. Sitor lie down when she feels dizzy). § Surgery: is used when a patient hassevere attacks and has not had success with other treatment options. Proceduresinclude: – Endolymphatic Shunt procedure to decrease fluidproduction or increase fluid absorption which may alleviate vertigo. – Vestibular neurectomy to reduce vertigo whilepreserving hearing in the affected ear. – Labyrinthectomy is done when there are hearingand balance problems to control vertigo attack.
Treatment of BPPVIn order to treat BPPV, the patientat first should wait for it to resolve. As the symptoms may resolve bythemselves within six months. The same medications of MD can be helpful duringthis period to control the severe symptoms. As she has neck pain, the Semont maneuver willbe used to move the calcium particles out of thesemicircular canals of the inner ear to a place where they will not causevertigo. It is done by seating her on the bench and turning her head to theleft side, then lowers her quickly to the right side for 30 seconds. Thenrapidly move her to the opposite side, maintaining alignment of neck and headand wait for 30 seconds. Then return her to a seated position slowly.
After Semont maneuver, she is instructed to wait for 10 minutes after themaneuver before going home. After the following two days, she should sleep withthe head between flat and upright at an angle of 45 degrees.Brandt-Daroffexercise is performed at home when the Semont maneuver fails.
She is instructedby the clinician to do the following: during sitting, turn her head a 45 degreeto the left and lie on the opposite side for 30 seconds. Then she gets up tothe sitting position for 30 seconds. Then turn her head a 45 degree to the right,and lie on the opposite side for 30 seconds. Then return to the sittingposition.Ifthe symptoms persist for a year and more, it means that the maneuver orexercise do not help in controlling the symptoms of BPPV. In this case,surgical treatment may be recommended. The most common surgery is posteriorsemicircular canal plugging or occlusion. In this surgery, the surgeon occludesmost of the posterior canal’s function but without affecting the other canalsor parts of the affected ear.
Thereis another surgery called singular neurectomy. This is done by a section of theampullary nerve. This nerve job is to send impulses from the posteriorsemicircular canal to the balance part in the brain. It has been replaced bythe posterior semicircular canal occlusion as it is simpler as it demands lesstechnology.
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