Once the cause of the vertigo has been established, appropriate treatment should be initiated as soon as possible.
Treating vertigo involves:
1) Promptly treating the attacks and alleviating the symptoms.
2) Treating the cause.
1. Treating the symptoms
This consists of administering vertigo medications and antiemetics. These medications can be given intravenously if the patient suffers from nausea and vomiting. The patient should be placed somewhere quiet to rest. Rapid head movements must be avoided.
2. Treating the cause
When the diagnosis has been made, the cause must be treated to prevent recurrences.
This is treated by the Semont or Epley liberatory manoeuvre, which is performed carefully when the diagnosis is certain after an otoneurological assessment.
The manoeuvre is designed to reposition the otoconia or “small crystals of calcium carbonate” in the labyrinthine cavity, where they may have deteriorated.
Over the following week, rapid head movements should be avoided, especially up/down movements. The patient should not sleep on the affected side and must keep their head slightly raised at 30° during sleep, for example using two pillows. A consultation takes place one week later to ensure that the positional vertigo has healed. Sometimes a second manoeuvre is necessary, but rarely more than that.
The treatment involves administering corticosteroids and possibly antivirals. The patient should not remain lying down, despite the effort this requires, but move around to rapidly generate the central compensation mechanisms that will allow them to retrieve sufficient balance despite the unilateral lesion in the vestibular nerve. Vestibular rehabilitation therapy can be helpful, especially in the elderly.
Long-term treatment uses H1 and H3 antihistamines, a salt-free diet, diuretics and medications that decrease endolymphatic hypertension. If the patient is refractory to medical treatment and continues to suffer from frequent dizziness, a chemical labyrinthectomy can be offered. This is performed by intratympanic injections of an ototoxic antibiotic, Gentamicin, under local anaesthesia. The number of injections varies between one and six depending on the patient and must be given one week apart. The patient’s hearing is totally preserved. The destruction of dysfunctional vestibular receptors cures the patient’s vertigo permanently. Central vestibular compensation takes place the first week following the effect of the Gentamicin. This treatment must be administered by following the progression by videonystagmography and otolithic evoked potentials. The EquiTest is used to see how well balance function has been restored.
An eighth nerve Schwannoma can cause tinnitus, dizziness or balance disorders. It is diagnosed by imaging.
It can be treated simply by monitoring progression or by Gamma Knife microradiosurgery, a type of surgery usually involving both a neurosurgeon and a specialized ENT doctor.
Once the diagnosis is established, medical treatment can be offered to reduce the sensation of unsteadiness. Surgical treatment can be offered to compensate for the dehiscence. Several international authors have demonstrated an improvement in symptoms.
The Equitest is vital: the sensory test assesses how well the inputs from the inner ear and the visual and proprioceptive inputs are used. In general, patients rely heavily on their visual input. Vestibular rehabilitation therapy using visual optokinetic stimuli, the Equitest and rotary chair with the help of a specialized therapist significantly improve balance and greatly reduce the risk of falls.
Treating the episodes can alleviate the patient’s symptoms and stop the vertigo attack.
The constitutional treatment must be adapted to the cause. All patients see an improvement with the treatments currently available. The key is to determine the cause. With any dizziness or unsteadiness, the inner ear function must be assessed by way of a full otoneurological assessment, studying all the receptors of the inner ear. It may be necessary to rule out a central cause by MRI or scan of the petrous temporal bones.
Medical treatment and vestibular rehabilitation can usually enable the patient to regain normal activity.