General Management Goals

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General pharmacological management of conditions affecting hearing is nearly nonexistent, in spite of many attempts over the years using vasoactive agents, steroids, and agents for allergy. [io] When a specific etiology is known,

_TABLE 12-10 -- ON CAUSES OF CENTRAL VERTIGO_

Stroke and TIA Cerebellum AICA distribution PICA distribution Vertebrobasilar migraine Adult form

Childhood variant (benign paroxysmal vertigo of childhood) Seizure (temporal lobe)

Multiple sclerosis, postinfectious demyelination Arnold-Chiari malformation Tumors of eight nerve, brain stem, or cerebellum Paraneoplastic cerebellar degeneration Wernicke's syndrome

TIA, transient ischematic attack; AICA, anterior inferior cerebellar artery; PICA, posterior inferior cerebellar artery.

such as Meniere's disease, treatment directed at the cause may be used, but there is no effective pharmacological management of tinnitus or hearing loss.

Hearing aids are indicated when hearing loss is significant and "aidable," meaning that improvement in word recognition scores may be obtained with amplification. Hearing aids are expensive. They are often not covered by standard insurance policies, and there are considerable performance differences between basic and "deluxe" models. For these reasons, hearing aids should ideally be fit by an experienced audiologist who offers at least a 1-month tryout period.

For tinnitus, an assortment of medications may be empirically tried, including antidepressants, minor tranquilizers, and anticonvulsants. Hearing aids or "maskers" (devices that generate white noise) are helpful in a few patients.

With respect to symptomatic management of peripheral vestibular disorders (see T§.bles...l2.:4 and 12-5 ), vestibular suppressants and antiemetics are generally used. In patients with static and significant structural vestibular lesions, vestibular rehabilitation approaches including vestibular exercises are substituted. In patients with central vestibular disorders, treatment approaches are generally eclectic. Agents used in peripheral disorders are usually tried, followed by empirical trials of other medication groups, including benzodiazepines and anticonvulsants. Vestibular rehabilitation again may be quite useful in this group.

Certain medications should be used with caution in patients with disorders of the eighth cranial nerve. A surprisingly large number of frankly ototoxic medications are in common clinical use (see Table 1..2..-2 ). It is usually prudent to eliminate as many of these medications as possible in such patients. In addition, it is common practice to use potentially addictive medications, such as benzodiazepines, in the management of patients with vertigo or imbalance when other medications fail. Although these agents are indispensable in these settings, the doses should be kept low and patient use should be monitored.

Hearing protection is often indicated in patients with damage to the eighth cranial nerve, and patients need to be explicitly warned to avoid loud noises and use hearing protection devices in excessively noisy environments.

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