Keyword
vestibule of the labyrinth - cardiac catheterization - emergencies
Palavras-chave
vestíbulo do labirinto - cateterismo cardíaco - emergências
Introduction
The corporal balance depends on the integration of the vestibular systems, visual
and proprioceptive[1]
[2]. Two factors become related with the alterations of balance in the aged one: the
gradual increase of the population aging and the proper illnesses of age[2]. Amongst them, they are distinguished it vertebral-basilar insufficiency, being
able to be represented by ischemic injuries, embolics, desiccants or traumatics[3], alterations of the central nervous system, the metabolic syndrome of disequilibrium
of the aged one, hormones alterations/and benign paroxysmal postural vertigo (VPPB)[4]. Clinically, the alterations of the balance are characterized for giddiness, vertigo,
disequilibrium and fall and are esteem that the prevalence in the aged population
arrives the 85%[5]
[6].
The objective of this story of case is to describe an uncommon cause of associated
peripheral vestibulopathy to the unilateral auditory loss in aged patient after catheterism
of urgency.
Case Report
Patient of the masculine sort, 82 years, with antecedents of systemic arterial hypertension
and dyslipidaemia in medicated treatment, was submitted to the cardiovascular surgery
in September of 2000 due the abdominal ragged aneurism of aorta. In the intra-operative
it suffered heart attack acute from the myocardium needing primary angioplasty. Since
then, it presented history of vertigo to the fast movements of the head and disequilibrium
to the changes of decumbency as to seat and to raise and to the deambulation. It remained
fifteen days in UTI and it after received high one month hospital from internment
with the described complaints and without focal neurological signals. It made use
of dihydrocloride of flunarizine per 5 years guided by the cardiologist and kept the
complaint of disequilibrium and hyperacusis. To the otorhinolaryngological clinical
examination it presented: Test of Weber lateralized for the left, spontaneous nystagmus
for the left, marches rocking, has taken normal disbasia and ataxia, index-nose and
diadochokinesia, Test of Romberg with oscillation without fall and Fukuda with lateral
shunting line for the right.
The audiometric examination evidenced anacusis to the right and sensorineural loss
to the left in frequencies 4, 6 and 8 kHz, and the Otolaryngologic Neurological examination
evidenced horizontal presence of nystagmus spontaneous for the right with VACL of
3 degrees, oculomotor tests without alterations and vestibular areflexia to the right
in the caloric test. It was carried through computed tomography of the secular bones
and brainstem, that presence of metallic connecting rod showed crossing the right
secular bone, from the vein internal jugular vein and bulb jugular vein, crossing
the canals semicircular posterior, superior and vestibule, projecting itself in secular
wolf ([Figures 1] and [2]). The radiological diagnosis was traumatic injury for guide to endovascular metallic
during catheterization of urgency and the behavior, considering that the patient had
not compensated the balance, it was vestibular rehabilitation. After 40 days of therapy
the patient related 90% improvement and after 3 months of therapy, presented complete
remission of the disequilibrium symptoms. Actually we found in radiological accompaniment
has 3 years without mobilization of the metallic rod.
Figure 1. Sequence of images from computed tomography of the temporal bone showing a metal
rod (guide wire) injuring the posterior semicircular canals, vestibule and upper,
projecting into the temporal lobe.
Figure 2. Metal rod through the right temporal bone from the internal jugular vein and the
jugular bulb.
Discussion
The majority of the authors agrees that, in if treating to alterations of the balance
in the aged population, it must be remembered the multifactorial etiology, a time
that exist innumerable competing factors of risk, as the presence of neurological
illnesses, muscle-skeletal, diabetes, syncope of idiopathic origin, use of different
classrooms of drugs, including diuretics, anticonvulsants, antihypertensive, anxyolitics
and antidepressant[7]
[8], cardiovascular illnesses and metabolic riots. These two last ones are main the
responsible ones for the attack of the system initial[9]
[10].
The cardiovascular illnesses are the main causes of mortality in Brazil being that,
approximately, 23% of these are represented by heart attack acute of myocardium (IAM)[11]. The cardiac catheterism of urgency is one of the therapeutically possibilities
in IAM, with rare complicações[12] as for example, vascular injury for the wire guides.
Front to the vertigo complaint, the otolaryngologist doctor must be attempted against
to carry through a good clinical history and to investigate causes, of systematic
form that justify such symptomatology. In this manner, it is obtained to stipulate
reasonable diagnostic hypotheses that can direct, effectively, the treatment. The
patient was submitted to the Otolaryngology Neurological clinical evaluation, that
included anamneses and otolaryngologist physical examination, audiometry, immittance
testing and examination initial, carried through for intermediary of the vectoelectronystagmography,
in accordance with the described criteria in literatura[13].
Ahead of findings of anacusis and areflexia initial to right, what it configures a
severe cochlea-vestibular that could involve alterations of the internal ear, nerves
cochlea-vestibular contests or same brainstem, is essential the request of nuclear
magnetic resonance for adjusted diagnóstico[14]. One opted to the computed tomography (TC) of secular bones and brainstem since
the patient presented phobia when entering in the device of magnetic resonance. The
TC was of extreme value therefore closed the injury diagnosis to endovascular catheterism
of urgency after. The evaluation for image is used when the clinical inquiry suggests
possibility of some responsible central commitment for the symptomatology. The computed
tomography is advantageous to bone amendments and the magnetic resonance is optimum
method to investigate alterations of soft parts, as for example tumors and degenerações[15].
The patient was submitted the medical evaluations vascular and neurosurgery and guided
the radiological control of the picture therefore the withdrawal of the rod could
extremely be harmful and it apparently it was presented steady in the bone not generating,
at the moment, risks of new endovascular or intra-cranial injuries. Of the otorhinolaryngological
point of view, considering that the patient one was aged and presented an unilateral
initial areflexia of traumatic origin, with predisposition to the fall, it was opted
to therapy of global initial whitewashing (RVG) based in the protocol of Cawthorne and Cooksey associated to the exercises of adaptation of the reflected vestibule-oculomotor.
These activities are developed through walked in the street, march with opening and
closing of the eyes, object persecution and soccer games[16]
[17]. The procedure was successful in view of that the patient got complete remission
of the symptoms to the end of 3 months of treatment. Pedalini et al.[18] had studied 116 patients amongst which 109 had been analyzed how much to the average
time of treatment for attainment of the improvement. The biggest number of patients
(n = 61) needed 2 months of treatment to relate improvement of the symptoms. Popper
[19] affirms that the RVG is an efficient method, adjusted and innocuous; and that the
results gotten in its study had varied since suppression of pathological symptoms,
restoration of the balance until the probable “objective cure” of the vestibulopathy.
Final Considerations
Complaints of disequilibrium in the aged patient must be critically evaluated of its
pathological clinical description therefore the antecedents of illnesses and previous
treatments, in general, direct the diagnostic hypotheses however they can bring unexpected
alterations.
