BackTable / ENT / Podcast / Transcript #154

Podcast Transcript: Labyrinthitis Unpacked: Clinical Perspectives & Management

with Dr. Sujana Chandrasekhar

In this episode, Dr. Sujana Chandrashekar, neurotologist with New York City’s ENT and Allergy Associates, joins host Dr. Ashley Agan to discuss labyrinthitis. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) How the Surgeon Became the Patient: One ENT’s Experience with Labyrinthitis

(2) Differentiating Central & Peripheral Vestibular Lesions

(3) Assessing the Vestibular System

(4) Tests that Assess Balance & Coordination

(5) Medication for Labyrinthitis Symptoms

(6) Physical Therapy for Labyrinthitis

(7) Assessing Vergence Dysfunction

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Labyrinthitis Unpacked: Clinical Perspectives & Management with Dr. Sujana Chandrasekhar on the BackTable ENT Podcast)

Ep 154 Labyrinthitis Unpacked: Clinical Perspectives & Management with Dr. Sujana Chandrasekhar

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[Dr. Ashley Agan]
This week on the BackTable podcast.

[Dr. Sujana Chandrashekar]
One really key is to get them off the vestibular suppressants. That's a real crutch and there's a real fear of getting off of the Valium or the meclizine. Unfortunately, many of our colleagues in primary care and even in geriatrics leave people on particularly meclizine for much longer than they should. It's a real hassle to get them off, but it's very important because I think you really want them to be able to be at their best from a vestibular function perspective.

[Dr. Ashley Agan]
Hi, everybody. Welcome to the BackTable ENT podcast. We're a podcast that focuses on all things otolaryngology and we've got a really great show for you today. Thanks for stopping by. I'll be your host today. My name is Ashley Agan. I'm a general ENT and I'm joined today by Dr. Sujana Chandrasekhar. Welcome to the show, Sujana.

[Dr. Sujana Chandreshekar]
Thank you so much for having me back, Ashley.

[Dr. Ashley Agan]
Yes. You joined us for episode 87. We talked about sudden hearing loss. For those of you who have not heard that episode, go back and check it out. Today, we're going to talk about labyrinthitis. Before we get to that, let me introduce you for our listeners who don't know you yet. Dr. Sujana Chandrasekar is an otologist/neurotologist practicing at ENT and Allergy Associates in New York City. She has made many contributions to our field, serving as president and past chair of the Board of Governors of the AAO-HNS and serving as current president of the American Otological Society or AOS.

She is a past Eastern Section VP of the Trilogical Society and the Combined Sections Meeting Program Chair and Consulting Editor of Otolaryngologic Clinics of North America, where she records a podcast every issue with guest editors. She was the co-executive producer and co-host for She's On Call, a webcast of 59 shows from June 2020 to December 2021, covering COVID-19 and a breadth of other medical topics. All those shows are available on podcast as well. Welcome back to the show.

[Dr. Sujana Chandreshekar]
Thank you so much for having me. I really love BackTable. I love my BackTable t-shirt because it makes people ask me about it and I love to talk about it.

(1) How the Surgeon Became the Patient: One ENT’s Experience with Labyrinthitis

[Dr. Ashley Agan]
Awesome. Thank you for being a listener and thank you for being a guest, a contributor. I reached out to you today to talk about labyrinthitis, particularly because about six months ago, I had labyrinthitis and it was a pretty horrible experience and very eye-opening being on the patient side of it. I thought this would be a good opportunity to dive into it and talk more about it. I guess we can walk through it and I can add my patient experience as we talk about it. Just to set the stage. What is labyrinthitis?

[Dr. Sujana Chandreshekar]
I think you started setting the stage perfectly, right? This is so scary. You're one second ago, perfectly normal person. Then the next second, you're dizzy, spinning out of control, up is not up and down is not down. You're not really sure why your bed is swirling around, it's really, really scary. Generally, nobody has nothing to do that day. Whatever you were supposed to do that day, you're not able to do, which is also very frightening.

You can understand that acute onset of spinning vertigo takes people to the emergency room, right? This is the big one in our minds. It's really, really frightening. Even smart people with medical education and even people with medical education in this area, like you, are like, whoa, what's happening? I remember you and I talked about it at that time.

[Dr. Ashley Agan]
Yes, it was crazy. I had like a little URI, like minor, little sore throat, little runny nose, like probably something my daughter brought home from daycare, no big deal. Then, the next morning, my right ear, just started feeling a little stuffy, like I couldn't clear it. Then as the day progressed, it just felt like it was filling with fluid, it was starting to be more painful. By about 5pm, I had this little, almost like a little pop and a little drainage of fluid from my ear. I was like, oh, great, I ruptured my eardrum, maybe I have an otitis media, maybe I have an ear infection, whatever.

I went to work the next day, had one of my colleagues, I was like, "Will you just look in my ear and see what's going on? I think maybe I ruptured my eardrum." She like looked in there and suctioned it out. She was like, "This looks really bad." I guess I had some like bullae on my eardrum. She's like, "It kind of looks like a bomb went out." She's like, "I think you probably need to get an audiogram. This seems bad."

My audio had, I had a little bit of a mixed loss in the high frequency. She's like, "I'm going to call you in some antibiotics and steroids." I went on lunch, I went to go pick that up, came back and finished my afternoon clinic. Then I looked over at her and I was like, "I think those steroids are upsetting my stomach. I'm feeling sick." She and I looked at each other and I was like, or this is turning into something much more than just an otitis media. From that moment, the spinning, it just boom. I just, I started throwing up and that lasted for like a solid three days maybe or more.

That was like the evolution of it. I remember vividly because it was almost like a play-by-play. It was like, Oh, great. Now this is happening. Then once that started happening, I was like, oh no. Because once that-

[Dr. Sujana Chandreshekar]
Oh, it sounds like you had a bullous myringitis, which is a viral inflammation. Luckily for you and luckily for the vast majority of people who get labyrinthitis, it's a viral phenomenon and not a bacterial phenomenon because bacterial labyrinthitis, which we should just talk about and put to a side is horrendous. It can take out your inner ear.

People who get bacterial labyrinthitis, often post-meningitic cases or chronic otitis media, cholesteatoma cases. Those are the people that we rush to put in a cochlear implant within a few months so that we don't end up trying to drill out an ossified cochlea. Those are the people that are going to lose their ear for hearing and for balance.

That timeline becomes very rapid in terms of imaging and intervention in order to end up with an ear that can hear something. Often very well. If you get that cochlear implant into those patients in a time when there is still a membranous labyrinth to introduce, they do much better than if you're drilling out bony channels.

Luckily the vast majority, well over 90% of labyrinthitis [is viral], which is interchangeably used with vestibular neuritis or vestibular neuronitis, there's like, as you and I talked about in the past, it seems like everything in otology has at least three names, if not more. These are often interchangeable because we don't really, we cannot tell you the site of lesion is in the labyrinth or along the vestibular nerve or even along the superior or inferior vestibular nerve. We just know that it's a peripheral vestibular itis.

The vast majority are viral, which means that they don't demolish the ear and they are recoverable. We start to see recovery, initial recovery in about three weeks. Most people have a full recovery by three months, like the outside limit. If you're older, if you have some underlying balance disorder, if you have peripheral neuropathy, if you have cataracts, if you have glaucoma, if you have something else that's going to affect your balance system, it may take you longer to recover. In general, even though it's absolutely horrific, and you remember every minute of that episode, as if it happened yesterday, the full recovery happens pretty well in these patients.

The bottom line is to identify that it is in fact a peripheral vestibular lesion, to give supportive care, and then to institute physical therapy, vestibular therapy, so that you can get back to normal. For you, Ashley, vestibular therapy was being a doctor, being a mom, running around, doing your things, which is fine. For people who maybe are a little bit older, maybe on blood thinners, somebody that you really don't want to fall down, a great exercise vestibular therapy for them is to take a shopping cart, go to the grocery store, push the cart up and down the aisles as their walker, and then look up and down.

I tell people, tell me how much the Cocoa Puffs are on the top shelf on the right, tell me how much the ramen costs on the bottom shelf on the left, and go up and down. What they'll find is they may be able to do one aisle or two aisles the first day, but by the end of the first week, they're really able to do like half the store. I think that's a really nice home exercise for them. Certainly engaging people in programmatic vestibular therapy really does help.

[Dr. Ashley Agan]
Yes. I went to physical therapy. I had an amazing therapist. Shout out to Egle Richards. She was amazing. I was in vestibular physical therapy the next week. I couldn't have walked in the grocery store looking up and down and all around for a while. It did finally get better. It's just, yes. Backing up, so you and I usually see patients outside of the acute phase. Because like you said, most of the time these patients are presenting to the emergency room because they're like, oh my God, I'm having a stroke or oh my God, something really bad is happening.

I feel like in my practice, patients will tell me about, yes, I had this horrible vertigo thing and I was in the ER and now I'm still dizzy. They're in that next phase of it. For the physician who just happens to be seeing the acute phase in that first 72 hours, what is your exam and workup? Is there anything that needs to be done as far as testing or otherwise? A lot of it is the history and just confirming that it's vertigo, spinning type of dizziness.

(2) Differentiating Central & Peripheral Vestibular Lesions

[Dr. Sujana Chandreshekar]
Right. I agree with you. I think the emergency room physicians see the acute vertigo, the acute labyrinthitis more frequently than we do. There are more and more integrated health systems where somebody who comes into the ER with something like this actually gets sent to ENT pretty rapidly. I think when that happens, that's a win for the patient because the ER's job, and I keep telling my patients this, who come and say, "Oh my God, I went to the ER and they didn't fill in the blank." Right? I'm like, "Well, their job is to make sure you're not having a heart attack or a stroke right that second. That's it. That's their job. They did their job very well."

We have the luxury, even with a sick patient, to say, okay, let's really look at your peripheral vestibular system. Let's see if I can make these distinctions based on clinical examination. You want to get the history and obviously, you want to do an ENT head and neck examination. You want to, at the very least, do tuning fork testing of their hearing if you don't have access to an audiogram. Sometimes they're just really too ill to have a formal audiogram. If you hadn't had an audiogram before that vertigo started, you would not have sat there. You would not have been able to be tested for four or five days. Right. It's just not possible.

You can do a nice 512 Hertz tuning fork test. Just do a Weber and a Rinne. Just make sure that there's some hearing in that ear. Then you want to, as best as possible, do some vestibular testing that you can do, that doesn't require really any machines. I must tell your listeners, the best article on this is written by JA Goebel, and it's, the ten-minute exam of the dizzy patient. It is excellent. He just breaks down really complicated vestibulo-ocular, vestibulo-spinal, central-peripheral vestibular disorders into, what are you looking for and what bucket can you put the patient in? Because you want to say, is this a central bucket or a peripheral bucket?

In this case, in an acute vestibulopathy situation, you're really looking at peripheral being vestibular or ear as opposed to oculomotor or something else. What you want to do is once you've examined the patient, and you happen to have what I think was bullous myringitis, which is very common after a URI, very common with the blebs, very common with a little bit of mixed, a little sensorineural component, like everything you're telling me sounds like that.

Often with serous labyrinthitis or viral labyrinthitis or viral neuronitis or vestibular neuritis, which are all the same thing, you actually don't see much of anything. Maybe they tell you they had a cold a couple of days ago. Maybe they didn't. You want to see if there's an acute otitis media. You want to see if there's something to give you a clue. Then you want to start looking at the eyes in particular.

If you're ready, we can dive into the thing that makes everybody really nervous. I remember when I was a resident, my chair, the late Dr. Noel Cohen, asked us to write an essay on nystagmus and like what it meant and how you look and this and that. I wrote and I wrote and I wrote because I am nothing if not a nerd and able to put lots of words on paper. He just returned that paper to me. He was left-handed with left-handed handwriting on top in red. It said, where'd you come up with this idea?

I don't know. I don't know. I guess I thought it made sense when I wrote it down. I think we have a tendency to make things seem more complicated than they are. It's beautiful to understand the complexity of the central and peripheral vestibular system. For the patient in front of you and for your own sanity, if you want to talk about not burning out, simple things that allow you to truly break it into buckets of central versus peripheral are very helpful.

You're going to first start by looking for a spontaneous nystagmus. You're just going to have the patient sitting in front of you. You're going to have them with their best corrected vision. If they wear glasses or contacts, they should be wearing them. Just look for, at rest, do they have nystagmus at zero degree with their glasses or their natural vision? Then you can put Frenzel glasses on them and see if you remove visual fixation. The Frenzel glasses, if nobody knows, are sort of like Coke bottle bottom glasses. They really just remove the visual fixation so that your eyes can't compensate for whatever baseline nystagmus is going on

You just say, is it present or is it absent? Normal people don't walk around with nystagmus. Then you're going to say, well, is it a jerk nystagmus or is it a pendular nystagmus? Is there a fast and slow phase or are both phases very similar to each other, which would be pendular nystagmus? Then you're going to say, is it directional? Is it a vertical nystagmus? Is it a horizontal nystagmus? Is it direction changing or direction fixed? If you have them look to the right, does it stay beating in the same direction or does it change directions when you have them look over to the left?

Is there an effect of fixation? If you put the Frenzel lenses on, does it change? Then is there an effect of eccentric gaze? If you have them look up and out or down and out, does something happen to the nystagmus? This is sort of, it sounds complicated, but if you make it almost a recipe for how to check, you can actually figure it out. What happens, either they have no nystagmus or, which is normal, or in peripheral pathologies, the nystagmus is an acute peripheral pathology, like labyrinthitis, spontaneous, it's direction fixed, meaning that it doesn't change direction when you look right or left. It's usually horizontal or rotary. It's usually a jerk nystagmus with the fast phase being away from the site of lesion.

If you think about it, it's jerking away and then slowly compensating back to the site of lesion. It's usually enhanced with gaze in the direction of the fast phase or when you remove visual fixation with a Frenzel lens, right? I'm going to say that again, just because this is the part where everybody gets crazy. Again, for peripheral, acute peripheral lesions, you're going to look for spontaneous, direction fixed, horizontal rotary nystagmus. It's going to be a jerk type of nystagmus with the fast phase away from the site of lesion, and it's going to be enhanced with gaze in the direction away from the site of lesion. In the fast phase, or if you put Frenzel lenses on.

If that person in front of you with the acute vertigo and acute dizziness and vomiting and so on and so forth has a central brainstem or cerebellum issue, they're going to have direction changing, horizontal or pure vertical or torsional nystagmus. It's going to be pendular. You're not going to be able to say, oh, there's a fast phase or a slow phase. They look like the same. Again, it's reduced with visual fixation.

Then we have the patients with congenital nystagmus who do in fact walk around with nystagmus and they have variable waveforms. They're always horizontal and you can reduce that when you make the eyes converge or look at a null point. You can have them fixate on that. I think looking for nystagmus just by looking at their eyes is really important. Then there's more testing, but I'm going to let you chime in and then we can talk about that.

This is the part where everyone's like, oh my God, oh my God. The reality is if you're able to do these tests in the office or in the ER, you can really help the patient understand what's going on. You can understand what's going on and you can institute care in a very timely fashion.

[Dr. Ashley Agan]
Yes, because if the physical exam is pretty consistent with a peripheral lesion like a labyrinthitis, then you don't need the stroke workup, right? You can go down a different pathway. You can pretty confidently lean on this exam, yes?

[Dr. Sujana Chandreshekar]
Very much so. I think when the changes that look more central, I think that's really important to act upon that. For the most part, these are peripheral abnormalities.

[Dr. Ashley Agan]
Anything else that you, do you do the head thrust or?

(3) Assessing the Vestibular System

[Dr. Sujana Chandreshekar]
You can look for the alternate cover tests of ocular alignment. You have the patient just looking at you and you cover one eye, you cover the other eye and you look for skew. If it's an otolith lesion, so it's a vertical ocular misalignment. The vestibular tone is wrong.

If it's a peripheral lesion, you'll see a transient skew deviation with the lower eye on the side of the lesion. Acutely, that may be absent. You may not see that in the acute phase. With central lesions, this is usually associated with head tilt and an ocular counter-roll. You'll see the patient sort of compensating for it. You want to look for gaze-evoked nystagmus. We just talked about nystagmus at rest, right? Spontaneous nystagmus. We do take our finger and put it in front of people's eyes, right? What you don't want to do is stress the system.

When you're doing gaze-evoked nystagmus, you want to go 20 or 30 degrees horizontal and 10 or 20 degrees vertical. You don't want to go all the way to the end of the visual field because actually we have physiologic nystagmus at the end of our visual field. You're looking for gaze-evoked nystagmus, you're going to see direction fixed, which is more obvious in the direction of the fast phase, which we said was away from the site of lesion.

In central nystagmus, you're going to see that that gaze-evoked nystagmus is direction-changing. You could have rebound nystagmus. It's a little funny looking. Nystagmus that doesn't seem to point to either one side or the other, you really do have to think about central phenomenon there. On VNGs, when you guys order them or read them, you'll see all this saccades and smooth pursuit testing. For VNG, they do it with lights on a light bar in the office. You can again do it with your finger or you can have some dots on the wall.

Really, if these are abnormal, if they can't do smooth pursuit properly or have really jumpy saccade testing, like going from one dot to another dot to another dot, those are really central findings. If there are saccadic intrusions, they are sometimes reported with paraneoplastic syndrome, but often with anxiety. People who are just like weaked out by the test.

You can check for dynamic visual acuity. You have the patient hold a Snellen eye chart and you see where they can read the chart comfortably. Then you rotate their head at about two hertz constantly like this, while they continue to read the eye chart. Normal people lose less than two lines of visual acuity on the eye chart. With a unilateral vestibular lesion, they lose two or maybe three lines. With bilateral, they lose more than three lines. Then it's quite variable with central.

Think of how you felt that first few days. Yes, you're not doing this.

[Dr. Ashley Agan]
I would have refused to do that.

[Dr. Sujana Chandreshekar]
Yes, you'd be like, I'm just going to vomit on you if that's okay.

[Dr. Ashley Agan]
Pretty much.

[Dr. Sujana Chandreshekar]
Again, if you have, and again, if they're taking a vestibular suppressant, which is often given to help the patient overcome this, you're actually not going to have the findings manifest. As much as you can test them without vestibular suppression, it's really very helpful. I'll tell you, even if you can do only some of these at the acute injury, but then you see them five days or seven days later, and you can do the rest of the testing, it's actually very helpful. It gives them a sense of, look how much better you did on the eye chart. Look how much better you're able to track my dots or my finger.

You want them to do, if you're worried that it's a central phenomenon, right? None of us want to treat somebody for labyrinthitis when they're having a cerebellar ischemic event. There are cerebellar tests that we all learned on our neurology rotation in medical school. You have them finger-nose, right? You have them touch their nose, touch your finger, touch their nose, touch your finger, and you move your finger in a way. They should be able to do that really accurately. If they're shaking or they're quite not making your finger or their nose, that's a cerebellar finding.

Same thing, you can have them take one heel, start at their opposite knee and come down to their shin. Just that should be able to be done smoothly for the most part. If they cannot, and they have no peripheral, they have no leg issue, that's a cerebellar finding. Do you know what my favorite word in medicine is?

[Dr. Ashley Agan]
I don't.

(4) Tests that Assess Balance & Coordination

[Dr. Sujana Chandrashekar]
It's dysdiadochokinesis. It's like the coolest word ever. It has a Y, it has a CH, it has a K. It's awesome. I remember learning it from a neurology professor on a rotation up at the Harlem Hospital. I'm like, that is, patty cake is basically the test of dysdiadochokinesis. I love that. That's where you have the patient sort of essentially play patty cake with themselves and make sure that they can do palm down, palm up in an alternating fashion. If they can't do that, that's a significant peripheral sign.

Then you're going to look also for fine finger movement. You're going to basically have them take their thumb and touch their fingers in alternating, just have them do this, where they're just basically finger to four, three, two, one, one, two, three, four. That should be able to be done without difficulty.

If you have a dizzy patient without a really significant unilateral ear pathology, and all of these findings look abnormal, you're really looking at a central dysfunction, an acute central dysfunction. I think that's a really important bucket. You really want to very much know. Then you want to look for Romberg testing. This is later on, right? This was you maybe two weeks later. Okay. Can you do a sharpened Romberg?

What's a sharpened Romberg? Put your feet as together as possible, cross your arms so that you're essentially hugging yourself and just stand straight. Then you as the examiner should stand on either side of the person with your hands out, not touching them, but ready to catch them should they start tipping over. Then you say, okay, now close your eyes. You will find that as a young person like you, Ashley, compensated, you would find that you swayed more maybe week one and a lot less week two. By week three, you really didn't sway at all. Sometimes people do fall over because they're so bad. You really, unless you like picking people up off the floor, you should probably catch them.

There are in fact, posturography is a great way to identify people who may have a physiologic sway. Because we know how much is physiologic sway. If there's a secondary gain or there's some other reason, you will find that it's a very, if you test enough people in your office, or in the clinic, you will find that you can recognize physiologic versus aphysiologic very readily.

You can find that with the Romberg. You can find that with a Fukuda step test, which is where you have them stand with their feet sort of shoulder length apart, just normal stance. Their arms are now at their side. They're not making themselves as small as possible. Or, you can make the Romberg a little bit more challenging by having them put one foot in front of the other or cross their feet. I know that you're supposed to do that. I have never really found that helps more than anything other than it freaks everybody out that they're going to fall down.

For the Fukuda, they're very comfortable stance. Then you have them just march in place. You say to them, okay, when you're good and ready, and again, your arms are at either side, you ask them to close their eyes. If within about 15 to 20 seconds, if they turn, they are turning toward the weaker side, the strong side is pushing them. They will turn towards the weaker side. If they just sway, or if they just feel very off balance, it's just sort of an uncompensated vestibular dysfunction, but it doesn't tell you a side.

You can look at gait testing. One of the really good tests that we've incorporated from the physical therapy literature is something called the timed up-and-go test. What you do with that, it's a great test for falls risk. This is really important, as we're treating an older population and a population that's often on some sort of blood thinner. This is now later on in the course. This is not the acute phase.

Later on in the course, you have the patient sitting in an armchair, and you have about 10 feet or three meters marked off. You say, Okay, get up from your chair, walk over to that distance, turn around, and walk back and sit down. There are timings of how long that should take. The risk for falls is twice or thrice, or even five times, depending on how long it takes them to do that, if they can do that effectively. That's actually a great test for even an intake nurse to do in an admission to see if there's a risk for falls of this patient.

There are some other cool tests. If you're thinking that this is a superior canal dehiscence, you can take a 512 Hertz tuning fork, you can vibrate it on their mastoid, and see if you induce nystagmus or dizziness. You can put them on their medial malleolus in their leg. On the ipsilateral side, you can induce nystagmus and or vertigo with ipsilateral significant superior canal dehiscence. That's a cool thing to do. If you think that's there, you should try it. Kind of fun.

Then the last thing I want to say is, you could have somebody hyperventilate for about 90 seconds, have them put Frenzel lenses on. If it's a peripheral, non-irritated lesion, you're going to have nystagmus with the fast phase to the unaffected ear, to the normal ear. If it's a peripheral, irritative lesion, you're going to have fast phase towards the affected ear. That's actually a very helpful test, if they don't pass out.

[Dr. Ashley Agan]
Yes. It's like 90 seconds. Long time.

[Dr. Sujana Chandreshekar]
Then if it's a central lesion, it's not a, it could be a variable finding. These sound, literally, these tests take less than 10 minutes to do. They are so beneficial in helping you understand what's going on with the patient.

(5) Medication for Labyrinthitis Symptoms

[Dr. Ashley Agan]
Yes. For your patients who you've determined that this is a labyrinthitis, what, if you do happen to see them in the acute phase, what do you give them? I think I had Zofran and I had Valium. We had started steroids because my, that mixed loss. What else do you, I just remember during those first few days, I just was just laying there perfectly still, because anytime I moved, I would throw up.

[Dr. Sujana Chandreshekar]
Yes. Supportive measures are the most important thing. The Ondansetron or Zofran is really beneficial, because what you don't want is now to compound this with some dehydration, malnutrition acute picture, because it is not at all unreasonable to stick an IV in somebody who's not able to keep anything down and just get them hydrated up because that really does help. I think Ondansetron, and I like the orally disintegrating tablets, because it's really impossible to vomit those up, right? You just stick them on your tongue and just lie there. Within about five, 10 minutes, it's absorbed into your body. It's working no matter what happens afterwards.

I tell my patients to take the Ondansetron first, wait about 10-15 minutes, and then take their Valium. Valium or diazepam is really an ideal vestibular suppressant. What you really want to do is rest the vestibular system and allow the compensation to start. Then as the compensation begins, you want to dial down and off the vestibular suppressant because the longer you stay on a Valium or a meclizine, the longer it's going to take you for full recovery.

The acute phase, extremely beneficial. I like the diazepam much better than the meclizine. Most of my patients will tell me that all the meclizine seems to do is make them sleepy and dull, whereas the Valium really suppresses the vestibular response.

[Dr. Ashley Agan]
What dose do you give of that Valium?

[Dr. Sujana Chandreshekar]
It depends how sensitive people are. Five milligrams is actually a very nice dose and it puts most people to sleep anyway, which is what you want. You'll find that the patients find the one position where the world is spinning the least, and they just stay there. If you see them, they are just sitting like a mummy with their head tilted in a certain way. They're just sitting there and they're talking to you like out of the corner of their mouth, because there's no way they're going to move their head or their eyes to look at you.

I've had patients who are tiny little people, like they're like my height, five, four and a quarter if I stand up tall, and they're half my weight, and they're taking 10, 20 milligrams of Valium. Each person is very different. I think if you gave me five of Valium, you could, on a Saturday morning, maybe you could wake me up on Monday, I don't know. I think five is a very good number. They could actually break those in half. If it's too much, they can take two and a half. What you don't want is you don't want them to keep taking it because then they really do fail to benefit from our vestibular system's ability to compensate. You want them off when it is feasible, so that they can start compensating well.

Steroids, absolutely. I think I've mentioned a few times that we often see viral neuritis or vestibular neuronitis or vestibular neuronitis or viral labyrinthitis in older individuals or people on blood thinners. You want to be really careful, because the steroid will definitely help them get better faster, but also can contribute to some bleeding and some injury. You want to really work with their physicians, their diabetics.

Nowadays, with people being able to monitor with that new device that they put on their arm, and really be able to manage their glucose better, it's actually easier for otolaryngologists to prescribe systemic steroids to these people, because we're not running a real risk of really throwing them into a diabetic crisis. You want to really remember that we're doctors and we need to care about the whole thing.

[Dr. Ashley Agan]
What dose of steroids do you like to do?

[Dr. Sujana Chandreshekar]
I'm a big steroid girl, like if you had nothing going on, in terms of your ear exam, or your audiogram, I probably still would have given you around a milligram per kilogram per day of prednisone. I would have given you between 40 and 60 milligrams of prednisone, at least for the first three days, four days, the sudden hearing loss dose, as we talked about is like seven days, and then you taper, some people give it for 10 days. Often you just need that acute jolt of anti-inflammatory to get people down. Then you can start tapering that off.

I think again, a Medrol dose pack doesn't do it for this degree of inner ear dysfunction. I would stick with the higher dose, but I probably tapered off more quickly than I would for a sudden hearing loss patient. Ondansetron, we talked about vestibular suppressants, and the Ondansetron is amazing. You could give it three times a day for the nausea. You could actually give it as often as you feel like. Some people take eight, most people are fine on four milligrams of the orally disintegrating tablets.

There are some old fashioned remedies that your grandmother knew, like ginger candy, ginger teas, things like that that settle your stomach. I often will tell people take the Ondansetron, take the Valium, and then eat something and drink something because that's the ideal time when you can keep things down and then just be. I tell them, this is not the time to really watch TV. This is the time to watch a blank TV. You don't want to stimulate your vestibular system in any possible way.

Then as soon as possible you want to get up and at 'em as soon as possible. If it's just when that Valium and Ondansetron have kicked in when you've eaten something, try to maybe walk to the table and sit down and eat something and then walk back and assume the position that you're most comfortable in. There's a lot of data about 24 hours in bed deconditions, all of us, about five to seven days worth. Now we're not only suffering from our vestibular dysfunction but we also get acutely deconditioned.

The more that the patient is able to do something, the better. I absolutely am so glad that you got into vestibular PT because that really, really helps that immediate compensation. Then it helps the activities in daily living compensation because the fear of falling makes you more likely to fall. If you can't cross a street in a crosswalk looking both ways as you're moving forward, you're going to be stuck just like living on your block. I think these are things where our physical therapy colleagues are just outstanding in terms of compensation and full recovery.

(6) Physical Therapy for Labyrinthitis

[Dr. Ashley Agan]
I think when you have an appointment on your calendar, it makes you do it. It's like you have to because you just don't feel like doing it.

[Dr. Sujana Chandreshekar]
You have to do your home exercise program. I have dialogues about home exercise program with my patients all the time. I'm like, it's pointless to go twice a week if the other five days you're doing nothing. You really have to do it. You have to push yourself. It's like any other PT. The more you do it in a normal fashion, the better you'll be. For somebody like you who's running, whose life is full of vestibular exercise, you can almost incorporate those home exercises into your daily living. But, there are people who really do shut down and get so scared and they really have to be encouraged to do their PT.

[Dr. Ashley Agan]
Yes, it's pretty humbling where the exercise is, okay, stare at this dot and move your head back and forth side to side for a minute, three times a day. It's just so uncomfortable to do that, that I remember having to like work, I'd be like, okay, got to go do my physical therapy. Over time, now we're six months out and I don't think about it anymore. It was the increments of improvement, just teeny tiny every-- That was another nice thing about going to physical therapy is that they were able to really show me like, Look, how much you couldn't do this last week. They were great.

In follow-up for these patients. For me, I saw my colleague and dear friend Walter Kutz took care of me. I saw him about five days after the initial onset. I came into clinic and we went ahead and repeated the audiogram because I was noticing that my hearing had really dropped. At that time, I was around 50, 55 all the way across purely sensory neuron at that time. We went ahead and treated it like a sudden loss. I got three rounds of IT steroid injections once a week for three weeks. Just because of the amount of loss, how quickly would you bring someone back in after an acute labyrinthitis?

[Dr. Sujana Chandreshekar]
I think a week timeframe makes a lot of sense. Probably one to two weeks. If they notice that their hearing is not getting better or getting worse, obviously, they need to come in sooner. This is a place where if they're really not feeling well, the mobile phone testing is actually very beneficial. Out of all bad things come a couple of good things. During COVID, when people were homebound and access to care was limited, we identified that people really could do a home hearing test enough to let us know if they needed intervention or not. I think that can be very beneficial, even with a tele-visit if they're really struggling to come in and they're not sure they need to.

I think Walter did the right thing for you. Then you just treat it like that sudden hearing loss because we'd like to recover your hearing and your balance as best as we possibly can. We know that between 40 and 60 DB, particularly mid frequency, but across the board losses are very steroid responsive.

About a 4:1 odds ratio of improving that hearing if steroids are introduced. That could be oral, but you were already on oral so then correct thing is to add intratympanic to that. I think if in the normal course of events where perhaps you're not seeing that sensory neural component because I think you had a cause. Some often we don't see a cause for the viral labyrinthitis particularly. As long as they are improving and you can touch base with them and yes, they're getting better and now they're able to go to PT. I think seeing them at intervals is very helpful.

I will tell you that more than any other inner ear insult, viral labyrinthitis leads to subsequent benign paroxysmal positional vertigo more often than does Meniere's or any other type of labyrinthine insult. It's not unreasonable that several months later they say, oh my God, now if I turn over in bed to the right, everything spins. Just be aware that you may have to treat BPPV in these individuals in the future.

Again, once they know where to go for their vestibular dysfunction, the anxiety component is much less. If you give people a little bit of power over their symptoms that they know, oh yes, now I have to call Dr. Chandrasekhar because now I'm having vertigo again and I want to get better. She said, if this happened, I'm supposed to come back and see her. I think that's very beneficial.

I'll just tell you as an aside, we don't really write about it, but there's some small number or small percentage of post-stapes patients who will develop a little viral findings and then a few months later, they're like, present with this BPPV stuff and you're like, oh yes, sorry I did that to you. You just like, sorry I gave you your hearing, but I also made you come back so I could shake your head.

They do very well. Again, understanding the different compensatory mechanisms, the different inflammatory mechanisms in the inner ear and vestibular system end up being very, very important.

[Dr. Ashley Agan]
I got a kick out of talking to Walter Kutz. I was texting with Jake Hunter a little bit, and they're just like, "How's your hearing? How's your hearing?" I'm like, "I'm so dizzy." I could care less about my hearing. I was so dizzy and uncomfortable. They're like, "Yes, yes, you'll be fine. You're going to compensate." They're like, "But how's your hearing? How's your hearing?" It was just funny. My hearing did basically fully recover. I have a little bit of a weird diplacusis sometimes where when I'm listening to music, that ear, I'll hear almost like it's a second sound, but it's so minor. Again, I don't even think about it hardly.

One thing that I do remember with my balance and working through physical therapy was the exhaustion. At 1:00 or 2:00 PM, I would just be mentally exhausted. I would have to like take a nap. My physical therapist, she was like, "Yes, your brain is working a lot harder to do the things that you normally would just do and so you're going to be tired." I was legit exhausted every day around early afternoon, which was I didn't expect.

[Dr. Sujana Chandreshekar]
I think that's great advice from your physical therapist. If you think about it, I'm watching you, you're watching me. We're moving our head in a certain way and we're nodding, we're shaking, we're this, we're that. Oh my God, imagine you doing these simple little head movements, eye movements in that time. I will often tell my patients as they are recovering because that three weeks to three months, that's a pretty gosh darn long period of time when you are in it.

I'll often say to them, why don't you divide your day into two days? Have your first half of the day, have a lie down, 20 minutes, recharge, reset, and then start your day again an hour or two after that. Then you have basically two half days where you can actually accomplish things rather than one long day where you're just totally wiped out and you almost go backwards by the end of that day. It's almost like having a siesta. It's almost like, why don't we just become Spaniards and have a siesta right in the middle of the day?

It really, really helps people particularly if you have an evening event. Now you're maybe four weeks, five weeks out, and you're okay, but you're not great. You're okay, but you're not yourself. Rather than what you would normally do, which is work all day and then go into the evening event, that's when you really need to make that break happen, do the recharge, and then go out for the evening. Even if it's a school event in the evening where you might in the past have rushed there, finish up your office hours, I'll do my charts, in the night, blah, blah blah all that stuff, you really literally have to say, no, I have to give myself a little bit of grace, I have to go, I have to lie down, I have to be able to function from that whatever six to eight or seven to nine period at night.

What happens when you do that, when you realize that, yes, this is part of my recovery, is that supratentorial component of why am I not perfect yet, doesn't bother you so much. You're like, yes, this is my recovery, and this is how I'm going to recover. If you and your family understand, and by you I mean your patient. Your patient and their family understand that, yes, this is why your relative is so tired at the end of the day, and this is how you can help them be less tired. Then you'll notice that your days can get back to being long over time.

[Dr. Ashley Agan]
Yes, I leaned on my husband a lot because we had a toddler. He, thank God, he picked up the slack a lot. Yes, but it was a very humbling experience. It's definitely given me greater empathy for my dizzy patients. As we round this out, I think it's been a really excellent discussion and deep dive. Any other final pearls or other things that we need to know about this?

[Dr. Sujana Chandreshekar]
I think the final pearl I'll say, or maybe I'll say two pearls. What do you think?

[Dr. Ashley Agan]
We'll give you two pearls.

(7) Assessing Vergence Dysfunction

[Dr. Sujana Chandreshekar]
Two, like a pair of earrings. One really key is to get them off the vestibular suppressants when possible. That's a real crutch, and there's a real fear of getting off of the Valium or the meclizine. Unfortunately, many of our colleagues in primary care and even in geriatrics leave people on particularly meclizine for much longer than they should. It's a real hassle to get them off, but it's very important because I think you really want them to be able to be at their best from a vestibular function perspective. That's one.

The other pearl is, there is an eye test that I did not describe, which is looking for vergence dysfunction. All the testing that we talked about was either at rest or in the X or Y plane. Either in the X plane or the Y plane, which is horizontal or vertical. There is a Z plane, right? When you're walking up and down those grocery store aisles, you're actually using all three planes to maintain your balance. What you want to do is you want to bring a pen from far and say, focus on my pen or my finger with both eyes, and then bring it near and ask them, when do they see two? Right there, about two to four inches from the nose, their eyes should cross and uncross real quick. That's where that single object becomes two.

With people with vergence dysfunction that can be unlocked or uncompensated for by either head trauma or viral labyrinthitis or some other vestibular insult, they will either never see two because their eyes one skews over, or they get so dizzy that they just close their eyes and they can't do it. You can do that also with near-far. You have an object near, you have an object far, and have them look at the near object, far object, and their eyes should be very tight. They should be able to converge and diverge and converge and diverge without a skew deviation. If you see that that is a problem, our friends in neuro optometry are amazing at helping them with vision therapy to correct these things.

I think that is something that can persist and get missed because we really do only test in X and Y plane and I think we shouldn't forget the Z plane.

[Dr. Ashley Agan]
That's a very good point.

[Dr. Sujana Chandreshekar]
One earring and two earrings.

[Dr. Ashley Agan]
Thank you so much for taking the time. This was fun. Again, if you guys missed episode 87, we talk about sudden hearing loss, go check that one out. Check out She's On Call podcast and webcast. What else? We'll post your socials as well if people want to follow you or you can also plug them.

[Dr. Sujana Chandreshekar]
Thank you. I love the podcast. I get to be Ashley and I get to record podcasts with the guest editors of every single issue of otolaryngologic clinics in North America. It's really a fun way to do a deep dive into various subjects in otolaryngology. If you get a chance to listen to them, please do and let me know what I can do to make them better.

Podcast Contributors

Dr. Sujana Chandrasekhar

Dr. Sujana Chandrasekhar is an otologist / neurotologist practicing at ENT and Allergy Associates in New York City.

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2024, January 16). Ep. 154 – Labyrinthitis Unpacked: Clinical Perspectives & Management [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.