Vestibular disorders are often overlooked in life care plans as well as in treatment. When vestibular disorders are treated, it can add quality of life as well as enhance a life care plan. The goal of this article is to allow vestibular disorders to be evaluated and opined in a life care plan in the same fashion as disorders and diseases of other bodily systems. It is important that the life care planner and medical professionals understand the evaluation of balance and vestibular disorders so that the life care plan and/or treatment plan accurately reflects what the individual needs. Another goal is to educate the medical professional and life care planner in projecting appropriate recommendations through understanding what to ask a neurotologist.
Fifty years ago, the differential diagnoses of patients with vestibular complaints included Meniere’s disease, positional vertigo, labyrinthitis, vestibular neuronitis, loss of vestibular function, and central vertigo. Vertigo was utilized as a general descriptive term for these disorders. It should be noted that, aside from loss of vestibular function, spinning was the presenting symptom in all of these disorders. It has been recognized that a straight-forward and careful examination of balance is crucial in the diagnosis and management of vestibular disorders.
During the 1960s, it was thought that all vertigo symptoms would resolve in six months. Later, it was realized that these cases required more attention, more careful examination, and a more precise diagnosis other than “vertigo.” The focus then changed to the examination of balance in all patients with complaints of dizziness and not limit the examination to patients with vertigo. If the patient could stand, the Romberg test was performed to look for a body sway or deviation. The Romberg test is preferred to be performed with the feet closely together and then observe the patient for at least 15 seconds while standing behind them to reassure the patient that so they do not fear falling. Currently, the Romberg test is performed in all patients if they are able to stand without provoking nausea or vomiting. A professional should look for shakiness or a sway. The body’s deviations on all of the tests that are performed are usually consistent being in the same direction when repeated at the time of the initial examination and in follow ups if the patient has not improved.
Patients with vestibular disorders are among the most difficult to diagnose and treat in otolaryngology and head and neck surgery. It does become essential to describe the symptoms of patients with non-spinning symptoms and to define which patients have a true vestibular disorder and not a cardiac, autonomic or psychogenic cause of their symptoms. Vestibular complaints include: spinning, dizziness, blurred vision, lightheadedness, motion sickness, ear or head fullness, feeling drunk, dizzy turning in bed or on getting out of bed, feeling spacey or disoriented in balance or disequilibrium, staggering, dizziness or imbalance in an elevator, on a escalator or treadmill, feeling tilted, feeling as if the floor is moving, swaying, feeling disoriented in stores or malls, and dizziness on standing up, bending or turning.
When a patient presents with any one or several of the vestibular complaints, a history of the onset, circumstances, and other factors that the patient feels would be relevant to obtain. The physical examination provides the key to the diagnosis. The patient with any of the vestibular complaints should have a complete examination of the ears, nose, throat, and neck as well as a complete evaluation of the cranial nerves. Middle ear or mastoid infection or tumor can be associated with the symptoms of inner ear extension.
Perilymphatic fistula syndrome (PLFS) has been described as following neck injury from acceleration/deceleration forces. Dr. Victor Goodhill in 1979 described the internal explosive forces and implosive forces, such as straining, as a causation of PLFS. Both airbag deployments and blast trauma have been cited as a cause of inner ear injury. The victims of the Boston Marathon bombers were noted to have tympanic membrane perforations and dizziness which would indicate that the trauma from the explosions affected both the middle and inner ears.
The management of PLFS can either be medical or surgical. The patients are informed that diuretic therapy provides medical management of the inner ear disorder (PLFS) and is not intended as a cure. Patients are informed that rejecting therapy for the imbalance can put their hearing at risk. Patients with an obvious case of bilateral PLFS can choose to have surgical management in order to achieve resolution of the disorder which is the case in over 90 percent of cases in the first procedure. Those that choose diuretic therapy may ultimately elect to have surgery if the diuretic therapy disrupts their daily routine because of frequent urination.
It has been noted that the symptoms of anxiety and dizziness are intermingled. Patients with symptoms originating from their head, be it dizziness, headache or tinnitus, have a fear of something that could threaten their life, such as a tumor, stroke or some other serious disease. The medical professional should analyze both the mind and the body because the resolution, or either the identification of a physical entity, will relieve the anxieties that are generally present in patients with vestibular disorders. It is important to note that the number of patients classified as unknown non-organic or psychogenic have decreased by the use of the new disorders such perilymphatic fistula syndrome.
What I have noted in his article is a small portion of vestibular disorders. It is important that patients with vestibular symptoms be evaluated by a medical professional in the early onset of symptoms. My hope in presenting the article is to share some tools to help manage vestibular disorders in order to project appropriate recommendations.
I offer my sincere thanks to Joel F. Lehrer, M.D., who provided permission for me to educate the public on this subject. Dr. Lehrer is one of the foremost ear and dizziness (balance) specialists in New Jersey, and he has lectured and published extensively in vestibular disorders.