Management of Vestibular Symptoms in Chemotherapy Patients
For patients undergoing chemotherapy who develop vestibular symptoms, referral to an audiologist or vestibular specialist is the primary recommendation, with meclizine as an appropriate symptomatic treatment option while awaiting specialist evaluation. 1, 2
Initial Assessment and Differential Diagnosis
When evaluating vestibular symptoms in chemotherapy patients, you must distinguish between several distinct etiologies:
Chemotherapy-induced vestibulotoxicity: Platinum-based agents (particularly cisplatin) cause direct damage to vestibular end organs, with abnormal vestibular function tests occurring in 0-50% of patients, though objective findings don't always correlate with symptoms 3, 4
Benign paroxysmal positional vertigo (BPPV): This is surprisingly common in cancer survivors post-cisplatin, occurring in approximately 9.2% of patients, making it the most frequent balance symptom reported 5
Vestibular dysfunction as a cause of chemotherapy-related nausea: The NCCN antiemesis guidelines explicitly list vestibular dysfunction as a potential cause of emesis in cancer patients, separate from chemotherapy-induced nausea 1
Peripheral neuropathy-related imbalance: Patients with chemotherapy-induced peripheral neuropathy (detected by vibration sense testing) are significantly more likely to report balance symptoms and falls 5
Immediate Symptomatic Management
Meclizine hydrochloride is FDA-approved for treatment of vertigo associated with diseases affecting the vestibular system, with recommended dosing of 25-100 mg daily in divided doses. 2 This provides symptomatic relief while diagnostic workup proceeds.
Key prescribing considerations for meclizine:
- May cause drowsiness; counsel patients about operating machinery 2
- Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 2
- Avoid concurrent CNS depressants including alcohol 2
- Be aware of potential CYP2D6 drug interactions 2
Specialist Referral and Diagnostic Workup
The American Cancer Society Head and Neck Cancer Survivorship Care Guideline (Level IIA evidence) explicitly recommends referring cancer survivors to appropriate specialists (audiologists) for loss of hearing, vertigo, or vestibular neuropathy related to treatment. 1 While this guideline addresses head and neck cancer specifically, the principle applies to all chemotherapy-related vestibular symptoms.
The specialist evaluation should include:
Video head impulse testing (vHIT) of all semicircular canals to assess horizontal canal function, though note that adult cisplatin survivors may have normal vHIT despite symptoms 5, 4
Vestibular evoked myogenic potential (VEMP) testing for otolith organ assessment, as this shows significant changes after cisplatin-based chemoradiation even when audiometry remains normal 4
Modified Clinical Testing of Sensory Interaction and Balance (CTSIB-m) as a bedside test to identify high fall risk—abnormal results correlate strongly with reported falls 5
Vibration sense testing to detect peripheral neuropathy, which significantly associates with balance symptoms 5
Treatment Based on Specific Diagnosis
For BPPV (Most Common Presentation)
Canalith repositioning maneuvers are the primary treatment, with vestibular rehabilitation as an alternative or adjunctive option. 1 The Epley maneuver and similar particle repositioning techniques show superior short-term outcomes compared to vestibular rehabilitation alone, though long-term effectiveness becomes comparable 1
For Cisplatin-Induced Vestibulotoxicity
Early initiation of vestibular physiotherapy is recommended once vestibular loss is detected. 4 The rationale is that:
- Cisplatin causes demonstrable vestibulotoxicity with reduced VOR gain and increased refixational saccades 6 weeks post-treatment 4
- Patients often don't spontaneously report dizziness despite objective vestibular dysfunction 4
- Early intervention may improve compensation and reduce fall risk 5
Vestibular rehabilitation (habituation exercises) can be self-administered or clinician-supervised, with no clear superiority of formal outpatient therapy over home programs. 1 Programs should include:
- Gaze stabilization exercises 1
- Balance and postural control training 1
- Fall prevention strategies, particularly for patients with concurrent peripheral neuropathy 5
Critical Clinical Pitfalls
Do not assume normal vestibular function based on absence of patient complaints—patients frequently have objective vestibular dysfunction without spontaneously reporting dizziness, particularly after cisplatin-based regimens 4. This represents a significant gap between objective findings and subjective symptoms.
Do not rely solely on vHIT for vestibular assessment in adult cancer survivors—all patients in one study had normal vHIT results despite 17% reporting balance symptoms 5. VEMP testing and clinical balance assessments provide complementary information 4.
Screen specifically for BPPV with positional testing, as this treatable condition is disproportionately common (9.2%) in cisplatin-treated patients and responds well to repositioning maneuvers 5.
Monitoring and Prevention
For patients receiving platinum-based chemotherapy, particularly cisplatin:
Baseline vestibular testing before chemotherapy initiation is recommended, followed by testing at 6 weeks and 3 months post-treatment to detect vestibular loss early 4
Patients with pre-existing vestibular loss may be at higher risk for additional vestibular toxicity after cisplatin dosing, though evidence is tentative 3
Consider cumulative dose effects, as the relationship between total platinum exposure and vestibular toxicity requires further study but appears clinically relevant 3