logging in or signing up Meniere disease vedhachalamram Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1374 Category: Education License: All Rights Reserved Like it (5) Dislike it (0) Added: June 13, 2010 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... By: ravi.aslp1516 (8 month(s) ago) hi sir,i am in need of it please allow me to download it. i will be thankful to you Saving..... Post Reply Close Saving..... Edit Comment Close By: ss81375 (14 month(s) ago) This is a good material, can I download it please? Thanks. Saving..... Post Reply Close Saving..... 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Episodic vertigo : Episodic vertigo Sudden Spinning Diaphoresis,Pallor vomiting/nausea Normal consciousness No focal neurological deficits 15-60 minutes Aura Differential diagnosis for vertigo : Differential diagnosis for vertigo Labyrinthitis Acoustic neuroma BPPV -Postural -few mins Vestibular neuronitis -URI -Few days Hearing loss + No hearing loss Other Variants : Other Variants Sudden sensorineural hearing loss which improves during or immediately after the attack of vertigo Abrupt falling attacks of brief duration without loss of consciousness LERMOYEZ SYNDROME Tumarkin’s otolithic catastrophe Sensorineural hearing loss : Sensorineural hearing loss Fluctuating Progressive Low frequency Dysacusis-Tinny sounds Diplacusis binauralis Dysharmonica Loudness intolernce Unilateral initially Slide 9: Age: 30-60 yrs Women=Men Positive Family history-10-20% Pathophysiology : Pathophysiology Cochlear hydrops seen in all cases Saccular hydrops in more patients Utricular hydrops is rare. Bowing of reissner’s membrane ) Slide 11: 1 2 3 4 5 6 Slide 12: Endolymph=intracellular perilymph = extracellular Electrolytes & fluid balance ENDOLYMPHATIC CIRCULATION : ENDOLYMPHATIC CIRCULATION LONGITUDINAL PATTERN RADIAL PATTERN Hennebert’s sign : Hennebert’s sign False positive fistula sign Fibrous adhesion between the saccule and foot plate of stapes TULLIO’S PHENOMENON- : TULLIO’S PHENOMENON- Subjective imbalance & nystagmus in response to loud low frequency noise exposure. Possible Causes : Possible Causes Anatomical-abnormalities Genetic-autosomal dominant Immunological-immune complex deposition Viral-serum IgE to herpes simples virus types I and II, Epstein-Barr virus and CMV Vascular-associated with migraines Metabolic-potassium intoxication Slide 17: Endolymphatic malabsorption Hypoplasia of vestibular aqueduct Perisaccular fibrosis Immunoglobulins in sac wallsmaller blood vessels than normal controls Meniere’s syndrome : Meniere’s syndrome Syphilis Metabolic Autoimmunity(cogan’s syndrome) Viral infection otosclerosis Diagnosis : Diagnosis The diagnosis of Meniere disease is made based on a careful history and physical exam. If the work-up is normal and the classic symptoms continue, the diagnosis of Meniere disease is made. Physical Examination : Physical Examination Examination results vary, depending upon the phase of disease. During remission, physical examination findings may be completely normal, particularly if the patient is symptom free. Spontaneous nystagmus directed toward affected ear is typical during an acute attack-Irritative nystagmus Paretic nystagmus Recovery nystagmus Physical Examination (con’t) : Physical Examination (con’t) The Romberg test generally shows significant instability and worsening when the eyes are closed. The Weber tuning fork test usually lateralizes away from the affected ear. The Rinne test usually indicates that air conduction remains better than bone conduction. Complete neurologic evaluation is important. New-onset vertigo might be an early sign of stroke, migraine, or brainstem compression that may require emergent evaluation and care. Imaging Studies : Imaging Studies Magnetic resonance imaging - Brain scan should be done to rule out abnormal anatomy or mass lesions. Specifically, acoustic neuromas or other cerebellopontine angle lesions are sought. Other lesions, such as multiple sclerosis or Arnold-Chiari malformations, also can be ruled out. - Note that mass lesions rarely are found but are important to exclude. CT scans reveal dehiscent superior semicircular canals and/or widened cochlear and vestibular aqueducts Pure Tone Audiometry : Pure Tone Audiometry Typically, the lower frequencies are affected more severely. This is due to preferential sensitivity of the apex to the hydrops. Multiple hearing tests, which document fluctuating hearing loss, are helpful in diagnosing Ménière. Glycerol dehydration test : Glycerol dehydration test Oral or intravenous glycerol Orange juice 1-5 ml/kg body weight Before & after PTA >10 db improvement Nausea,headache,drowsiness Transtympanic electrocochleography (ECOG) : Transtympanic electrocochleography (ECOG) This is most accurate when Ménière is active. cochlear microphonics summation potential action potential Slide 27: SP:AP ratio 1:3 Normal width of summation potential & action potential is 1.2-1.8 ms Treatment : Treatment Medical therapy is both symptomatic (ie, acute attacks) and prophylactic. If Ménière is due to a secondary cause (ie, Ménière syndrome), primary first-line management is the diagnosis and treatment of the primary disease (eg, thyroid disease). Vestibulosuppressants (eg, meclizine, prochlorperazine,cinnarizine) decrease symptoms, but generally only mask the vertigo by decreasing the brain's response to vestibular input. Treatment Cont’d : Treatment Cont’d Diuretics or diuretic-like medications (eg, hydrochlorothiazide) actually decrease the fluid pressure load in the inner ear. These medications help prevent attacks but do not help once an acute attack has started. Treatment Cont’d : Treatment Cont’d Anti-inflammatory properties of steroids are helpful in endolymphatic hydrops. This is probably due to reduced endolymphatic pressure. Steroids actually can reverse vertigo, tinnitus, and hearing loss. Slide 31: avoid Treatment Cont’d : Treatment Cont’d Surgical Care: Surgical therapy for Ménière disease is reserved for medical treatment failures and is otherwise controversial. Surgical procedures are divided into 2 major classifications as follows: Destructive surgical procedures Nondestructive surgical procedures surgical procedures Cont’d : surgical procedures Cont’d Destructive surgical procedures Rationale to control vertigo: Endolymphatic hydrops causes fluid pressure accumulation within the inner ear, which causes temporary malfunction and misfiring of the vestibular nerve. These abnormal signals cause vertigo. Destruction of the inner ear and/or the vestibular nerve prevents these abnormal signals. As long as the opposite inner ear and vestibular apparatus function normally, the brain eventually will compensate for the loss of one labyrinth. Destructive surgical procedures Cont’d : Destructive surgical procedures Cont’d Problems with destructive procedures: Destruction of one inner ear depends on the adequate function of the opposite ear. Unfortunately, Ménière disease can be bilateral (7-50%), in which case this method is contraindicated. Since balance and hearing are closely intertwined within the labyrinth, destruction of the balance portion carries a high risk of hearing loss. Note that destructive procedures are irreversible and reserved for severe cases. surgical procedures Cont’d : surgical procedures Cont’d Nondestructive surgical procedures: These are directed toward improving the state of the inner ear. They are less invasive than destructive procedures and do not preclude the use of other treatment modalities. Discussion here is limited to the 4 most generally accepted management options: endolymphatic sac decompression or shunt vestibular nerve section Labyrinthectomy transtympanic medication perfusion. surgical procedures Cont’d : surgical procedures Cont’d Endolymphatic sac decompression This procedure allows the reservoir sac to expand more freely, thus dissipating pressure. A drain or valve from the endolymphatic space to either the mastoid or subarachnoid space can be inserted as another means of further reducing pressure. . surgical procedures Cont’d : surgical procedures Cont’d Vestibular nerve section For patients with useful hearing in the affected ear, sectioning the diseased vestibular nerve can be the ultimate solution. Although the hearing and balance functions are housed in one common chamber within the inner ear, their neural connections to the brain separate into distinct nerve bundles as they course through the internal auditory canal. This anatomical separation allows balance function to be isolated and ablated without affecting hearing function. surgical procedures Cont’d : surgical procedures Cont’d Labyrinthectomy This management option for Ménière disease has the advantage of a high cure rate (>95%) and is useful in the patient whose hearing on the diseased side has been destroyed already by Ménière disease. Labyrinthectomy involves ablation of the diseased inner ear organs. This procedure is less complex than vestibular nerve section because labyrinthectomy does not require entry into the cranial cavity. Labyrinthectomy is less invasive than vestibular nerve section. Labyrinthectomy Cont’d : Labyrinthectomy Cont’d This procedure carries less danger of cerebrospinal fluid leak and meningitis since craniotomy is not required. Like those who undergo vestibular nerve section, patients require a few days of inpatient care. Accommodation to the surgical loss of one vestibular apparatus usually takes weeks or months. Vestibular rehabilitation during this time period is also helpful. Transtympanic perfusion of medication : Transtympanic perfusion of medication Medications for Ménière disease are applied through a myringotomy within the middle ear cavity, where they presumably are absorbed through the round window membrane into the inner ear. Transtympanic perfusion is a relatively low-risk, simple procedure that applies a high concentration of medicine with minimal systemic effects. Diet Cont’d : Diet Cont’d Consult with a nutritionist to establish a rigid salt-restricted diet (1.5 g sodium per day). Avoiding other trigger substances (eg, caffeine, nicotine, alcohol, high-carbohydrate substances, high-cholesterol/triglyceride foods) also can help. Note that many preserved and smoked foods contain sodium nitrite, which can contribute to high sodium content. Treatment Cont’d : Treatment Cont’d Activity: Endolymphatic hydrops does not preclude regular activity. Exercise is recommended in moderation. Because of the unpredictable nature of the disease, balance-intensive, dangerous tasks (eg, especially climbing ladders) should be avoided. Prognosis : Prognosis Prognosis is variable, since the disease pattern of exacerbation and remission makes evaluation of treatment and prognosis difficult to predict. In general, Ménière symptoms tend to stabilize spontaneously with time. With regard to vertigo, about half of patients stabilize over several years. Patients tend to "burn out" over time and with residual poor balance and hearing. Prognosis Cont’d : Prognosis Cont’d Ménière disease can be classified into several stages of progression. Early stages involve cochlear hydrops, which proceeds to affect the vestibular system. Ménière disease is most bothersome during these early stages. As patients progress to later stages, the hydrops fills the vestibule so completely that no further room is available for pressure fluctuation and the vertigo spells disappear. The acute attacks are replaced by constant imbalance and progressive hearing loss. Electrocochleography : Electrocochleography a? b? Management ladder : Management ladder Slide 48: Tan q You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Meniere disease vedhachalamram Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1374 Category: Education License: All Rights Reserved Like it (5) Dislike it (0) Added: June 13, 2010 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... By: ravi.aslp1516 (8 month(s) ago) hi sir,i am in need of it please allow me to download it. i will be thankful to you Saving..... Post Reply Close Saving..... Edit Comment Close By: ss81375 (14 month(s) ago) This is a good material, can I download it please? Thanks. Saving..... Post Reply Close Saving..... Edit Comment Close By: drsila (15 month(s) ago) its a very good guide to the topic.i need to download plz Saving..... Post Reply Close Saving..... Edit Comment Close By: mooga (16 month(s) ago) please i need it Saving..... Post Reply Close Saving..... Edit Comment Close By: rajeshkk (22 month(s) ago) i am in need of it please allow me to download it. i will be thankful to you Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Slide 1: Meniere’s disease v.v.ramachandran Prosper Meniere : 1799-1862 Prosper Meniere Definition : Definition A disease of the membranous labyrinth characterised by deafness,vertigo & usually tinnitus which has as its pathologic correlate hydropic distension of the endolymphatic system. Episodic vertigo : Episodic vertigo Sudden Spinning Diaphoresis,Pallor vomiting/nausea Normal consciousness No focal neurological deficits 15-60 minutes Aura Differential diagnosis for vertigo : Differential diagnosis for vertigo Labyrinthitis Acoustic neuroma BPPV -Postural -few mins Vestibular neuronitis -URI -Few days Hearing loss + No hearing loss Other Variants : Other Variants Sudden sensorineural hearing loss which improves during or immediately after the attack of vertigo Abrupt falling attacks of brief duration without loss of consciousness LERMOYEZ SYNDROME Tumarkin’s otolithic catastrophe Sensorineural hearing loss : Sensorineural hearing loss Fluctuating Progressive Low frequency Dysacusis-Tinny sounds Diplacusis binauralis Dysharmonica Loudness intolernce Unilateral initially Slide 9: Age: 30-60 yrs Women=Men Positive Family history-10-20% Pathophysiology : Pathophysiology Cochlear hydrops seen in all cases Saccular hydrops in more patients Utricular hydrops is rare. Bowing of reissner’s membrane ) Slide 11: 1 2 3 4 5 6 Slide 12: Endolymph=intracellular perilymph = extracellular Electrolytes & fluid balance ENDOLYMPHATIC CIRCULATION : ENDOLYMPHATIC CIRCULATION LONGITUDINAL PATTERN RADIAL PATTERN Hennebert’s sign : Hennebert’s sign False positive fistula sign Fibrous adhesion between the saccule and foot plate of stapes TULLIO’S PHENOMENON- : TULLIO’S PHENOMENON- Subjective imbalance & nystagmus in response to loud low frequency noise exposure. Possible Causes : Possible Causes Anatomical-abnormalities Genetic-autosomal dominant Immunological-immune complex deposition Viral-serum IgE to herpes simples virus types I and II, Epstein-Barr virus and CMV Vascular-associated with migraines Metabolic-potassium intoxication Slide 17: Endolymphatic malabsorption Hypoplasia of vestibular aqueduct Perisaccular fibrosis Immunoglobulins in sac wallsmaller blood vessels than normal controls Meniere’s syndrome : Meniere’s syndrome Syphilis Metabolic Autoimmunity(cogan’s syndrome) Viral infection otosclerosis Diagnosis : Diagnosis The diagnosis of Meniere disease is made based on a careful history and physical exam. If the work-up is normal and the classic symptoms continue, the diagnosis of Meniere disease is made. Physical Examination : Physical Examination Examination results vary, depending upon the phase of disease. During remission, physical examination findings may be completely normal, particularly if the patient is symptom free. Spontaneous nystagmus directed toward affected ear is typical during an acute attack-Irritative nystagmus Paretic nystagmus Recovery nystagmus Physical Examination (con’t) : Physical Examination (con’t) The Romberg test generally shows significant instability and worsening when the eyes are closed. The Weber tuning fork test usually lateralizes away from the affected ear. The Rinne test usually indicates that air conduction remains better than bone conduction. Complete neurologic evaluation is important. New-onset vertigo might be an early sign of stroke, migraine, or brainstem compression that may require emergent evaluation and care. Imaging Studies : Imaging Studies Magnetic resonance imaging - Brain scan should be done to rule out abnormal anatomy or mass lesions. Specifically, acoustic neuromas or other cerebellopontine angle lesions are sought. Other lesions, such as multiple sclerosis or Arnold-Chiari malformations, also can be ruled out. - Note that mass lesions rarely are found but are important to exclude. CT scans reveal dehiscent superior semicircular canals and/or widened cochlear and vestibular aqueducts Pure Tone Audiometry : Pure Tone Audiometry Typically, the lower frequencies are affected more severely. This is due to preferential sensitivity of the apex to the hydrops. Multiple hearing tests, which document fluctuating hearing loss, are helpful in diagnosing Ménière. Glycerol dehydration test : Glycerol dehydration test Oral or intravenous glycerol Orange juice 1-5 ml/kg body weight Before & after PTA >10 db improvement Nausea,headache,drowsiness Transtympanic electrocochleography (ECOG) : Transtympanic electrocochleography (ECOG) This is most accurate when Ménière is active. cochlear microphonics summation potential action potential Slide 27: SP:AP ratio 1:3 Normal width of summation potential & action potential is 1.2-1.8 ms Treatment : Treatment Medical therapy is both symptomatic (ie, acute attacks) and prophylactic. If Ménière is due to a secondary cause (ie, Ménière syndrome), primary first-line management is the diagnosis and treatment of the primary disease (eg, thyroid disease). Vestibulosuppressants (eg, meclizine, prochlorperazine,cinnarizine) decrease symptoms, but generally only mask the vertigo by decreasing the brain's response to vestibular input. Treatment Cont’d : Treatment Cont’d Diuretics or diuretic-like medications (eg, hydrochlorothiazide) actually decrease the fluid pressure load in the inner ear. These medications help prevent attacks but do not help once an acute attack has started. Treatment Cont’d : Treatment Cont’d Anti-inflammatory properties of steroids are helpful in endolymphatic hydrops. This is probably due to reduced endolymphatic pressure. Steroids actually can reverse vertigo, tinnitus, and hearing loss. Slide 31: avoid Treatment Cont’d : Treatment Cont’d Surgical Care: Surgical therapy for Ménière disease is reserved for medical treatment failures and is otherwise controversial. Surgical procedures are divided into 2 major classifications as follows: Destructive surgical procedures Nondestructive surgical procedures surgical procedures Cont’d : surgical procedures Cont’d Destructive surgical procedures Rationale to control vertigo: Endolymphatic hydrops causes fluid pressure accumulation within the inner ear, which causes temporary malfunction and misfiring of the vestibular nerve. These abnormal signals cause vertigo. Destruction of the inner ear and/or the vestibular nerve prevents these abnormal signals. As long as the opposite inner ear and vestibular apparatus function normally, the brain eventually will compensate for the loss of one labyrinth. Destructive surgical procedures Cont’d : Destructive surgical procedures Cont’d Problems with destructive procedures: Destruction of one inner ear depends on the adequate function of the opposite ear. Unfortunately, Ménière disease can be bilateral (7-50%), in which case this method is contraindicated. Since balance and hearing are closely intertwined within the labyrinth, destruction of the balance portion carries a high risk of hearing loss. Note that destructive procedures are irreversible and reserved for severe cases. surgical procedures Cont’d : surgical procedures Cont’d Nondestructive surgical procedures: These are directed toward improving the state of the inner ear. They are less invasive than destructive procedures and do not preclude the use of other treatment modalities. Discussion here is limited to the 4 most generally accepted management options: endolymphatic sac decompression or shunt vestibular nerve section Labyrinthectomy transtympanic medication perfusion. surgical procedures Cont’d : surgical procedures Cont’d Endolymphatic sac decompression This procedure allows the reservoir sac to expand more freely, thus dissipating pressure. A drain or valve from the endolymphatic space to either the mastoid or subarachnoid space can be inserted as another means of further reducing pressure. . surgical procedures Cont’d : surgical procedures Cont’d Vestibular nerve section For patients with useful hearing in the affected ear, sectioning the diseased vestibular nerve can be the ultimate solution. Although the hearing and balance functions are housed in one common chamber within the inner ear, their neural connections to the brain separate into distinct nerve bundles as they course through the internal auditory canal. This anatomical separation allows balance function to be isolated and ablated without affecting hearing function. surgical procedures Cont’d : surgical procedures Cont’d Labyrinthectomy This management option for Ménière disease has the advantage of a high cure rate (>95%) and is useful in the patient whose hearing on the diseased side has been destroyed already by Ménière disease. Labyrinthectomy involves ablation of the diseased inner ear organs. This procedure is less complex than vestibular nerve section because labyrinthectomy does not require entry into the cranial cavity. Labyrinthectomy is less invasive than vestibular nerve section. Labyrinthectomy Cont’d : Labyrinthectomy Cont’d This procedure carries less danger of cerebrospinal fluid leak and meningitis since craniotomy is not required. Like those who undergo vestibular nerve section, patients require a few days of inpatient care. Accommodation to the surgical loss of one vestibular apparatus usually takes weeks or months. Vestibular rehabilitation during this time period is also helpful. Transtympanic perfusion of medication : Transtympanic perfusion of medication Medications for Ménière disease are applied through a myringotomy within the middle ear cavity, where they presumably are absorbed through the round window membrane into the inner ear. Transtympanic perfusion is a relatively low-risk, simple procedure that applies a high concentration of medicine with minimal systemic effects. Diet Cont’d : Diet Cont’d Consult with a nutritionist to establish a rigid salt-restricted diet (1.5 g sodium per day). Avoiding other trigger substances (eg, caffeine, nicotine, alcohol, high-carbohydrate substances, high-cholesterol/triglyceride foods) also can help. Note that many preserved and smoked foods contain sodium nitrite, which can contribute to high sodium content. Treatment Cont’d : Treatment Cont’d Activity: Endolymphatic hydrops does not preclude regular activity. Exercise is recommended in moderation. Because of the unpredictable nature of the disease, balance-intensive, dangerous tasks (eg, especially climbing ladders) should be avoided. Prognosis : Prognosis Prognosis is variable, since the disease pattern of exacerbation and remission makes evaluation of treatment and prognosis difficult to predict. In general, Ménière symptoms tend to stabilize spontaneously with time. With regard to vertigo, about half of patients stabilize over several years. Patients tend to "burn out" over time and with residual poor balance and hearing. Prognosis Cont’d : Prognosis Cont’d Ménière disease can be classified into several stages of progression. Early stages involve cochlear hydrops, which proceeds to affect the vestibular system. Ménière disease is most bothersome during these early stages. As patients progress to later stages, the hydrops fills the vestibule so completely that no further room is available for pressure fluctuation and the vertigo spells disappear. The acute attacks are replaced by constant imbalance and progressive hearing loss. Electrocochleography : Electrocochleography a? b? Management ladder : Management ladder Slide 48: Tan q