What is the best approach to manage a patient with a vestibular disorder in an inpatient hospital setting, under the care of a physiatrist?

Management of Vestibular Disorders in Inpatient Rehabilitation Setting

The best approach to manage a patient with vestibular disorder in an inpatient hospital setting under a physiatrist's care should include prompt diagnosis, appropriate repositioning maneuvers for BPPV, vestibular rehabilitation therapy, limited use of vestibular suppressant medications, and comprehensive patient education. 1, 2

Diagnostic Approach

• Determine the specific type of vestibular disorder through careful history and diagnostic maneuvers, as management differs significantly based on etiology 1
• For suspected BPPV, perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV (vertigo with torsional, upbeating nystagmus) 1
• If Dix-Hallpike is negative but BPPV is still suspected, perform the supine roll test to assess for lateral semicircular canal BPPV 1
• Differentiate vestibular disorders from other causes of imbalance, dizziness, and vertigo including central disorders (stroke, migraine), other neurotologic conditions (cerebellopontine angle tumors), and systemic conditions 1
• Avoid unnecessary radiographic imaging in patients who meet diagnostic criteria for BPPV unless additional signs/symptoms inconsistent with BPPV are present 1
• Similarly, avoid routine vestibular testing in patients with clear BPPV unless additional vestibular signs/symptoms warrant further investigation 1

Treatment Algorithm

For Benign Paroxysmal Positional Vertigo (BPPV)

1. First-line treatment: Canalith Repositioning Procedures

   • For posterior canal BPPV: Perform the canalith repositioning maneuver (Epley maneuver) 1
   • For lateral canal BPPV: Perform the roll maneuver (Lempert maneuver or barbecue roll) 1
   • Postprocedural restrictions are not necessary after canalith repositioning 1

2. Vestibular Rehabilitation

   • Offer vestibular rehabilitation exercises either self-administered or with a clinician 1, 2
   • Include habituation exercises, adaptation exercises for gaze stabilization, and balance training 1
   • For chronic vestibular hypofunction, prescribe exercises 3-5 times daily for a total of 20-40 minutes 2

For Ménière's Disease

1. Acute Attack Management

   • Offer a limited course of vestibular suppressants only during acute Ménière's attacks 1
   • Avoid long-term use of vestibular suppressants due to risk of dependence and side effects 1

2. Preventive Measures

   • Educate patients on dietary modifications including sodium restriction, limiting caffeine, alcohol, and nicotine 1
   • Recommend well-balanced meals, adequate hydration, stress management, and regular exercise 1

Medication Management

• Meclizine is FDA-approved for treatment of vertigo associated with diseases affecting the vestibular system in adults 3
• Use vestibular suppressants (antihistamines, benzodiazepines) only for short-term symptomatic relief during acute vertigo attacks 1
• Be aware that centrally acting anticholinergic drugs (scopolamine, atropine) can suppress acute vertigo but have significant side effects including blurred vision, dry mouth, urinary retention, and sedation 1
• All benzodiazepines carry significant risk for drug dependence and should be used cautiously 1

Special Considerations in Inpatient Setting

• Assess for modifying factors including impaired mobility/balance, central nervous system disorders, lack of home support, and increased fall risk 1
• Implement fall prevention strategies as patients with vestibular disorders have significantly higher fall risk 1, 4
• Screen for comorbidities that may complicate management, including sleep apnea in patients with increased vertigo 1
• For patients with traumatic brain injury, be aware that post-traumatic BPPV may be more refractory to treatment and may require repeated physical treatments 1
• Consider the impact of medications prescribed for chronic pain or neurologic disorders, as these patients may have higher incidence of vestibular dysfunction 4

Patient Education and Follow-up

• Educate patients about their specific vestibular disorder, treatment options, and risk of recurrence 1
• Provide information about safety concerns, particularly fall risk 1
• Reassess patients within one month after initial treatment to document resolution or persistence of symptoms 1
• For persistent symptoms, evaluate for unresolved vestibular disorders or underlying peripheral/central nervous system disorders 1
• Consider referral to specialized vestibular therapy if symptoms persist despite initial interventions 2

Discharge Planning

• Ensure continuity of vestibular rehabilitation after discharge 2
• Provide written instructions for home exercise programs 1
• Educate patients and caregivers about potential disease recurrence and when to seek follow-up care 1
• Consider home safety assessment for patients with persistent balance issues 1