[Follow-up of caloric test response after acute peripheral vestibular dysfunction]

Steroids for Acute Vestibular Neuronitis-the Earlier the Treatment, the Better the Outcome?

Objective:

To present findings that suggest steroid treatment within 24 hours of onset of vestibular neuronitis results in better restitution of vestibular function than treatment between 25 and 72 hours.

Patients:

Thirty-three consecutive patients (17 men, 16 women, mean age 57 yr, range 17–85 yr) with acute vestibular neuronitis and treated with steroids within 72 hours after symptom onset. Patients were divided into two groups depending on if they were treated within the first 24 hours or not.

Interventions:

Oral prednisolone 50 mg/d for 5 days with tapering of doses for the next 5 days, or combined with initial intravenous betamethasone 8 mg the first 1 to 2 days if the patient was nauseous.

Main Outcome Measures:

Proportion of patients with normal caloric test result (canal paresis value < 32%) at follow-up after 3 or 12 months.

Results:

All 9 patients (100%) treated within 24 hours from onset of vestibular neuronitis had normal caloric test results at follow-up after 3 months, as compared with 14 of 24 (58%) of the patients treated between 25 and 72 hours (p < 0,05, Fisher's exact test).

Conclusions:

The timing of steroid treatment of vestibular neuronitis may be of importance for subsequent vestibular restitution, and hence, for both time to recovery and late symptoms according to the literature.

Randomized trial of supervised versus unsupervised optokinetic exercise in persons with peripheral vestibular disorders

BACKGROUND

Visual vertigo (VV) symptoms improve only when customized vestibular rehabilitation (VR) integrates exposure to optokinetic stimuli (OK). However, equipment is expensive, biweekly sessions are not standard practice, and therapy is often unsupervised.

METHODS

A controlled, parallel-group comparison was made of patients' responses to an 8-week customized program incorporating OK training via a full-field visual environment rotator (group OKF) or DVD (an optokinetic disc or drum rotating at 40° or 60° s(-1)), supervised (group OKS) or unsupervised (group OKU). A total of 60 participants with chronic peripheral vestibular symptoms were randomly allocated to 1 of 3 treatment groups: group OKF (n = 20) or OKS (n = 20), in which participants attended weekly sessions and were prescribed customized home exercises incorporating the DVD, or group OKU (n = 20) who practiced customized exercises and the DVD unsupervised. Treatment response was assessed at baseline and at 8 weeks with dynamic posturography, Functional Gait Assessment (FGA), and questionnaires for symptoms, symptom triggers, and psychological state.

RESULTS

No significant between-group differences were present at baseline or at post interventions. All groups showed significant within-group improvements for vestibular (ie, lightheadedness), VV, and autonomic symptoms (P < .05). Posturography and FGA improved significantly for groups OKF and OKS (P ≤ .01) as well as anxiety scores for group OKS (P < .05) and depression for group OKF (P < .05). Migraine significantly affected VV improvement (migraineurs improved more; P = .01). The drop-out rate was 55% for group OKU and 10% for each supervised group (P < .01).

CONCLUSIONS

The DVD may be an effective and economical method of integrating OK into VR. However, rehabilitation should be supervised for greater compliance and improvements, particularly for postural stability and psychological state.

Recovery of vestibular ocular reflex function and balance control after a unilateral peripheral vestibular deficit

This review describes the effect of unilateral peripheral vestibular deficit (UPVD) on balance control for stance and gait tests. Because a UPVD is normally defined based on vestibular ocular reflex (VOR) tests, we compared recovery observed in balance control with patterns of recovery in VOR function. Two general types of UPVD are considered; acute vestibular neuritis (AVN) and vestibular neurectomy. The latter was subdivided into vestibular loss after cerebellar pontine angle tumor surgery during which a vestibular neurectomy was performed, and vestibular loss following neurectomy to eliminate disabling Ménière's disease. To measure balance control, body-worn gyroscopes, mounted near the body's center of mass (CoM), were used. Measurement variables were the pitch (anterior-posterior) and roll (lateral) sway angles and angular velocities of the lower trunk/pelvis. Both patient groups showed balance deficits during stance tasks on foam, especially with eyes closed when stable balance control is normally highly dependent on vestibular inputs. Deficits during gait were also present and were more profound for complex gait tasks such as tandem gait than simple gait tasks. Major differences emerged between the groups concerning the severity of the deficit and its recovery. Generally, the effects of acute neuritis on balance control were more severe but recovered rapidly. Deficits due to vestibular neurectomy were less severe, but longer lasting. These results mostly paralleled recovery of deficits in VOR function. However, questions need to be raised about the effect on balance control of the two modes of neural plasticity occurring in the vestibular system following vestibular loss due to neuritis: one mode being the limited central compensation for the loss, and the second mode being some restoration of peripheral vestibular function. Future work will need to correlate deficits in balance control during stance and gait more exactly with VOR deficits and carefully consider the differences between insufficient central compensation compared to inadequate peripheral restoration of function.

Treatment of acute vestibular neuronitis with glucocorticoids

OBJECTIVE

To report the effects of glucocorticoid treatment of acute vestibular neuronitis on recovery of vestibular function and length of hospital stay.

STUDY DESIGN

Prospective, consecutive case series compared with historic controls.

SETTING

Secondary referral academic hospital.

PATIENTS

Patients with acute vestibular neuronitis. One group treated with glucocorticoids within 3 days after symptom onset (n = 33) and 2 historic untreated control groups (n = 41 and n = 67).

INTERVENTIONS

Oral prednisolone 50 mg/d for 5 days with tapering of doses for the next 5 days, alternatively with intravenous betamethasone 8 mg on the first 1 to 2 days if nauseated.

MAIN OUTCOME MEASURES

Extent of unilateral vestibular paresis (%) in the caloric test at presentation and at 12 months of follow-up. Length of hospital stay (days).

RESULTS

The initial vestibular paresis value did not differ between the treatment group and the control group. At follow-up, the treatment group showed a lower value (22.8% versus 47.2%, p = 0.0003) and greater improvement (53.4% versus 35.6%, p = 0.002). At follow-up, 70% of the treatment group had a normal caloric test result compared to only 34% of the control group. The mean hospital stay of the treatment group was significantly shorter than that of the control group (1.8 versus 3.0 d, p = 0.001).

CONCLUSION

Glucocorticoids administered within 3 days after onset of vestibular neuronitis improves long-time recovery of vestibular function and reduces length of hospital stay.

Peripheral vestibular disorders with acute onset of vertigo

Disorders of the vestibular nerve and end organs are the most common causes of vertigo. The advances in recognizing different forms of canalolithiasis and cupulolithiasis, which sometimes present with continuous positional nystagmus, have revealed a peripheral vestibular aetiology in which central nervous system lesions were previously suspected. Treatments using repositioning manoeuvres are also successful in cases in which nystagmus does not appear, and when administered by less specialized physicians. In acute vestibulopathy, suspicions of the activation of herpes virus infections as a causative agent are increasing, but no reports on the treatment of such infections are yet available. New treatments are in development for use in Ménière's disease.