Ultrasound treatment of Ménière's disease

This article reviews the technical data about ultrasonography devices, the mode of action of ultrasound waves on vestibular structures, when to use this technique, and the surgical procedure. It also presents the results of this treatment obtained during the last 10 years in the authors' various institutions.

Sensory interaction posturography in patients with peripheral vestibular disorders

The results of posturography, using all sensory inputs, are compared with recordings when one or more of the sensory inputs are altered by the test conditions. This gives an idea of the sensory interaction in central compensation in the vestibulospinal reflex. Positive and negative effects could be observed in patients with peripheral vestibular disorders.

[The surgery of the endolymphatic sac: a conservative or destructive procedure?]

A detailed analysis of different aspects relative to endolymphatic sac surgery employed as conservative surgical treatment in Menière's disease is presented. The presumed basic principles for this type of surgery, which have led several otologists to adopt this procedure in the therapeutical protocol followed in Menière's disease, are discussed along with the good symptomatological results obtained. Particular emphasis is put on the multiple functions which have been attributed to the endolymphatic sac in the functional dynamics of the entire inner ear environment. Among these functions, relevance is given to the secretory activity, which is presumed to be triggered by endolymphatic dysbarisms, which implies that macromolecules that are able to interact with fluid metabolism (glycosaminoglycans) might flow into the luminal endolymphatic space, a phenomenon which may well open new perspectives for the pathogenesis and treatment of Menière's disease. On the grounds of these premises, the conservative aspect of endolymphatic sac surgery, along with its mechanism of action, is reassessed.

Electrocochleography in endolymphatic hydrops using tone-pip and click stimuli

The use of electrocochleography (ECochG) in the identification of endolymphatic hydrops in Menière's disease, using either trans-tympanic or extra-tympanic recording techniques, has become very popular. The presence of an enhanced summating potential (SP) component is considered to be a diagnostic indicator of hydrops. The response evoked by a click stimulus is widely used in this investigation. The aim of this study was to assess the value of tone-pip stimuli for measurement of the SP component in patients with suspected Menière's disease. Extra-tympanic ECochG was recorded from a surface electrode positioned on the postero-inferior quadrant of the ear canal close to the tympanic annulus. Forty patients referred to the Evoked Potentials Clinic at the Queen's Medical Centre were studied. The combined summating potential and action potential waveform (SP/AP) were recorded using click and tone-pip stimuli. The pips had tone frequencies of 1 and 4 kHz and all stimuli were presented with alternating phase at a repetition rate of 10 per second. The percentage SP (%SP), width and latency characteristics of the SP/AP waveform were calculated for each stimulus condition. There were four patients (10%) with an enhanced tone-pip %SP when the click %SP was within normal limits. Width measurement of the tone-pip waveform at the onset point of the response was abnormal in 13 patients (33%) when a similar measurement of the click-evoked response was normal. There were nine of these patients identified by an abnormal width measurement at the 50% amplitude point of the SP/AP waveform. Both tone-pip frequencies were required in order to identify all these abnormal measurements.(ABSTRACT TRUNCATED AT 250 WORDS)

Intratympanic gentamicin in bilateral Menière's disease

Treatment of bilateral Menière's disease is a delicate task. Streptomycin has demonstrated its ability to successfully control the vertigo attacks, but in some cases it results in oscillopsia and transforms the periodic attacks to permanent instability. If the site of the active labyrinth can be determined, a more specific treatment can be tried. We have treated 14 patients with intractable bilateral Menière's disease with intratympanic gentamicin (Garamycin, 40 mg/ml) administered initially in either 1, 2, 3, or 4 injections. The patients were tested at frequent intervals and followed up for 2 years. The work capacity, severity of vertigo, and gait difficulties were scored before treatment and during each test occasion. The postural stability was evaluated on a force platform and sway velocity was analyzed. Before treatment, moderate or severe reduction of work capacity was experienced by all of the subjects, which correlated to severity of vertigo and gait problems. Two years after treatment, the vertigo attacks were eliminated in 11 subjects and controlled in three subjects. The work capacity of three subjects was still moderately or severely reduced. This reduction depended on gait disturbance and Tumarkin attacks. The average postural stability returned to pretreatment level 2 years after the treatment was begun. The outcome of the caloric responses did not correlate with the outcome of the treatment. Hearing was not significantly affected by the treatment. Intratympanic gentamicin treatment is a relatively safe and effective way to treat bilateral Meniere's disease when the symptoms can be localized to one ear.

Ablation of luteal phase symptoms of Menière's disease with leuprolide

Symptoms of Menière's disease in women may be exacerbated during the luteal phase of the menstrual cycle. This suggests a role for progesterone production and subsequent fluid redistribution as a predisposing factor for Menière's symptoms. We report the use of leuprolide acetate, a gonadotropin-releasing hormone agonist, in a woman with cyclic Menière's symptoms. This drug, which abolishes gonadotropin-dependent ovarian sex steroid production, alleviated the patient's symptoms during therapy. This observation offers further support to the hypothesis of sex hormone-related exacerbations of Menière's symptoms and provides a possible future treatment option for this debilitating disease.

[Clinical application of the visual suppression test]

200 cases of peripheral and central vestibular disorder patients were examined by caloric test and visual suppression test (VS) simultaneously. The results with ENG recording showed: (1) VS score > 50% indicates normal function. (2) VS score 50%-10% is function decreased. (3) VS score < 10% shows function failure. (4) Patients with negative VS score accompanies nystagmus strengthen with eye open when in the light also, the clinical application of the VS test for diagnosis of several kinds of vestibular disorder were discussed.

Electronystagmographic findings in a case of Lermoyez's syndrome

A 40-year-old female patient with Lermoyez's syndrome is presented. Prior to the vertiginous attack, right low-tone hearing loss and tinnitus were noted. During the vertiginous attack, spontaneous nystagmus was directed to the right (lesioned) side, with improvement of cochlear symptoms. After the vertiginous attack, nystagmus was positional rather than spontaneous, and was directed to the left (opposite) side, with the subsidence of cochlear symptoms. One week later, follow-up audiometry revealed bilateral normal hearing.

[Investigation on vertigoes in childhood]

This paper analysed the pathogenesis and the vestibular test results of 87 cases of vertigo in the childhood below the age of 13 years old. 83 cases (95.4%) were vestibular peripheral lesions, and 4 cases were vestibular central lesions. 34.5% of them were benign paroxysmal vertigo and 14.9% were the Meniere's disease which all occurred at the age more than 9 years old. The appearances of ENG were semicircular canal hypofunction in 57 cases (65.5%). The function of ocular movement was abnormal in a few cases. The posturography results were compared with an age-matched control group. Posturographic recording showed length of locus and velocity increased in the thirteen patients of semicircular canal hypofunction.

Human summating potential to tone bursts: observations on tympanic membrane versus promontory recordings in the same patients

Electrocochleographic responses to tone bursts and clicks were recorded from the tympanic membranes (TMs) and promontories of six suspected Meniere's patients. Although the majority of ears had normal summating potentials (SPs), regardless of recording site and stimulus type, some displayed amplitude-enlarged SPs at both sites and to both types of stimuli. The following observations were made from these patients regarding the choice of recording approaches and stimuli for ECochG: (1) Although SP amplitudes at the promontory were approximately four times larger than corresponding TM values, response "patterns" leading to diagnostic interpretation were the same at both sites; (2) the majority of patients who displayed enlarged SP amplitudes to tone bursts also had enlarged SPs to clicks; and (3) with tone-burst stimuli, the amplitude of the SP alone was sufficient for diagnostic interpretation of the ECochG waveform.

Acceleration registrography of head movement during alternating inclination of the support platform

The righting reflex, essential for maintaining equilibrium, keeps the head and trunk in a state of balance with regard to gravity. Because patients suffering from vestibular disorders almost always complain of dizziness during everyday movements such as rising and walking, the righting reflex should be evaluated within the context of these dynamic states. A new method of acceleration registrography was designed to enable the testing of this reflex as the subject stands upon a moving platform. Participating in the study were 49 normal control subjects and 80 patients with peripheral vestibular disorders. The test we devised proved to be more successful in detecting labyrinthine righting reflex dysfunction in patients than the tests of righting reflex and deviation evaluations used thus far, such as Romberg's, Mann's and the stepping test, and to more accurately represent the disequilibrium and/or dizziness experienced by patients in everyday movements.

ABR amplitude and dispersion variables. Relation to audiogram shape and click polarity

ABR amplitude behaviour to condensation (C) and rarefaction (R) clicks was investigated in normal ears, ears affected by Ménière's disease and ears with high-frequency hearing loss (HF ears). The wave IV-V amplitude-intensity function was steeper in ABRs evoked by R than by C clicks. This may suggest that two different cochlear generator components, one intensity-dependent as well as one polarity-dependent, contribute to click-evoked ABRs. Wave IV-V amplitude was significantly higher in Ménière ears compared to HF ears in spite of comparable 2-4 kHz hearing loss in the two groups. Hence, audiometric steepness (which is lower in Ménière ears than in HF ears) seems to predict the wave IV-V amplitude decline more precisely than the 2-4 kHz perception threshold. The wave IV-V dispersion variable (SR IV-V) was close to normal in Ménière ears, while wave IV-V was more dispersed in HF ears. In general, C click ABRs were less affected than R click ABRs by 'peripheral' factors (i.e. intensity and audiometric steepness).

Immunological approach to Ménière's disease: vestibular immune injury following immune reaction of the endolymphatic sac

Following direct antigen challenge to the endolymphatic sac (sac), the relation of caloric test results and spontaneous nystagmus to the histological changes of the sensory epithelium of the vestibular organ and perilymph antibody levels was investigated in the guinea pig. In a secondary keyhole limpet hemocyanin (KLH) challenge to the sac, irritative nystagmus was followed by paralytic nystagmus and a suppression of caloric reaction. These findings correlated well with the degree of degeneration of the sensory epithelium of the vestibular organ and the levels of perilymph antibody. On the other hand, neither phosphate-buffered saline inoculation nor primary KLH challenge to the sac nor a secondary KLH challenge to the intradural space resulted in a disturbance of the vestibular function. These results suggest that the immune response of the sac may possibly be an important key to the pathogenesis of Ménière's disease.

Plain radiological findings in Ménière's disease

In order to investigate the characteristics of plain radiography of Ménière's disease, the degree of the pneumatization and the distance between the sigmoid plate and the bony wall of the vestibule in Schüller's view were examined in patients with unilateral and bilateral Ménière's disease, non-Ménière vertiginous disease and healthy subjects. There was no difference of the degree of pneumatization and the distance among the patients with Ménière's disease, the non-Ménière inner ear disease group and in healthy subjects. The distance of the unaffected ear was significantly shorter in patients showing a shorter distance of the affected ear. There was no relationship between the distance and age of onset of the disease, and duration of the disease. Therefore, it is concluded that the dysfunction of endolymphatic sac does not always reflect poor mastoid pneumatization and/or shorter distance in the plain radiography and that other etiological mechanisms such as autoimmune disease should be considered in some patients having evidence of endolymphatic hydrops.

Recovery from unilateral vestibular nerve section in human subjects evaluated by physiological, psychological and questionnaire assessments

Patients undergoing vestibular nerve section for vertigo or acoustic neuroma surgery were compared pre- and post-operatively and during long-term follow-up using a range of tests including: nystagmography, impulsive rotational testing of the vestibulo-ocular reflex (VOR), ability to estimate and reproduce imposed rotational displacements, validated questionnaires rating vertigo, imbalance, autonomic reactivity and somatisation, and clinical and self-assessment scales of overall outcome in terms of symptoms and disability. Correlations were found between rating scale assessments, questionnaire scores and estimates of self-rotation. Neither nystagmography nor VOR tests correlated with the presence or severity of vertigo or imbalance. Post-operatively, vertigo patients reported that they had received significant relief, although they had higher incidences of residual complaints of imbalance and vertigo than patients after acoustic neuroma surgery. Factors impeding rehabilitation in patients with vertigo are discussed.

Computerized tomography of the petrous bone in Menière's disease

High resolution transverse axial computerized tomograph (CT) encompassing the lateral semicircular canal (LSC) was used to measure the size of the petrous bone in ears with bilateral (n = 13) and unilateral (n = 38) Menière's disease, and in ears with unilateral chronic otitis media (n = 25) as a control group. Measurements were made of the following 4 distances in the petrous bone; A: the distance between the posterior semicircular canal (PSC) and the posterior petrous surface (PPS) (P-P distance), B: the distance between the PSC and the LSC (P-L distance), C: the distance between the vestibule and the PPS (V-P distance), and D: the distance between the PSC and the anterior margin of the sigmoid sinus (P-S distance). The P-P and the V-P distances were significantly shorter in ears with Menière's disease, especially in ears with bilateral Menière's disease compared to the nonaffected ears in unilateral Menière's disease or ears with chronic otitis media. This tendency was clearer in the P-P distance than in the V-P distance. The P-L and P-S distances did not show any statistical difference between groups. The results indicate that bone development between the PSC and the PPS and between the vestibule and the PPS, which usually contains the endolymphatic duct and sac, is significantly poorer in ears with Menière's disease than in ears with chronic otitis media. Hypoplasia of the retrolabyrinthine region may be an important factor in the pathogenesis of endolymphatic hydrops.

Frequency characteristics of summating potential in Menière's disease

SP iso-response functions in 9 patients with Menière's disease were examined for differences in the properties between +SP and -SP. The iso-response functions of +SP and -SP exhibited a large difference. The iso-response function for +SP was centered at high frequencies (around 9 kHz in most cases) with fairly steep slopes on both sides towards both higher and lower frequencies, whereas -SP showed a low-pass function. The tendency was found for patients with normal hearing at high frequencies to have a larger Q10dB than patients with a hearing loss. The difference in properties between +SP and -SP suggests the possibility that +SP may provide different information on the pathophysiology of Ménière's disease from that obtained from -SP.

Three-dimensional audiogram

We used a three-dimensional audiogram which displays duration of the disease on the X-axis, frequency on the Y-axis, and hearing level on the Z-axis, to aid observation of hearing changes during the course of various otologic diseases. An overall, quantitative view of the changes in a patient's hearing level with time was easily obtainable with this technique, as the temporal element is shown on the X-axis. The basal view position of the three-dimensional audiogram displays most of the information necessary to form a diagnosis, determine treatment, and evaluate is efficacy in various otologic diseases. The three-dimensional audiogram was found to be most useful in observing changes in hearing level in sudden deafness, with its often rapid recovery period, and Meniere's disease, with its long-term fluctuating hearing loss. In some patients, a better understanding of the hearing changes could be obtained from a view angle other than the basal view position.

A ventilation capacity test for the Eustachian tube using a soundproof pressure chamber

Using a soundproof pressure chamber, we performed Békésy air conduction audiometry at 1000 Hz under the following pressure conditions: 1) from atmospheric pressure (AP) to 200 mmH2O below AP, 2) AP to 200 mmH2O above AP, 3) AP to 700 mmH2O below AP, and 4) AP to 700 mmH2O above AP. In conditions 1) and 2), the patient was instructed not to swallow until the pressure change was complete, then to swallow once every 15 seconds. The number of swallows required for hearing to return to the baseline level was counted. In conditions 3) and 4), the patient was told to swallow as many times as possible both before and after completion of the pressure change; maximum hearing level and the time needed for return to the baseline level were measured. Although all except one of the seven patients with suspected tubal dysfunction showed normal results with catheter insufflation and tympanometry, six of the seven showed abnormality and one reported the disappearance of ear stuffiness after the ventilation capacity test. We concluded that this test is useful not only for the diagnosis of tubal dysfunction but also as a possible therapy for aiding adaptation to changing environmental pressure.

Measurement of cochlear basilar membrane traveling wave velocity by derived ABR

Auditory brainstem response (ABR) can be used to measure the basilar membrane traveling wave velocity (TWV). Traveling wave velocity was calculated from the latency difference between wave V of different derived ABR and the cochlear location distance between the appropriate derived band center frequency. The latency of wave V of derived ABR produced by 6 noise-masked ABR using high pass filtered noise and the location of the corresponding cochlear partition (distance from the stapes foot-plate) were measured, and five traveling wave velocities were estimated based on this parameter. Ten subjects with normal hearing, 7 patients with Meniere's disease, and 8 patients with sensorineural hearing loss were used in this study. The traveling wave velocity in the sensorineural hearing loss group was within normal limits at all frequencies, whereas the traveling wave velocity at 8 kHz in the Meniere group greatly exceeded that of the normal and sensorineural hearing loss group.

Frequency analysis of transiently evoked otoacoustic emissions in sensorineural hearing disturbance

Transiently evoked otoacoustic emissions (TEOAE) are present in nearly all normal hearing ears and recognized as useful for objective auditory screening. In the spectral analysis of TEOAE with click stimuli, the normal power spectrum of TEOAE has yet to be obtained. In this study, the normal range of the power spectrum was determined for 42 adults with normal hearing and compared with sensorineural hearing disturbance data. The power spectrum of TEOAE in normal hearing adults sloped down at high frequencies and was the same for right and left ears in both males and females. For comparison with sensorineural hearing disturbance, a significant correlation between the audiogram and power spectrum of TEOAE was sought. Frequency specificity was noted in the power spectrum of TEOAE with click stimulation.

Tinnitus evaluation using the tinnitus grading system

We developed a system to help evaluate the likelihood of a particular patient requiring intensive tinnitus treatment. The system is based on Vernon's tinnitus grading system, in which patients assign values from 1 to 5 to each of the three subjective complaints of loudness, annoyance, and interference with life activities. In our study, we collected data from 346 of our tinnitus patients and analyzed the relationship between the three values. On the basis of these results the patients were divided into five tinnitus-type groups. Scores on a tinnitus severity scale were also determined by adding the three values together. We similarly evaluated 87 patients whose tinnitus was severe enough to require hospitalization. It was found that patients who had high values for annoyance and life interference and who showed tinnitus severity scores of 9 or more tended to require careful observation and intensive treatment. These patients also tended to have physical and psychological problems in addition to their tinnitus.

Pressure test for the diagnosis of Menière's disease

In the last 15 years, a pressure chamber able to generate negative air pressure has been used to treat patients with Menière's disease. In this study we sought to clarify whether the underpressure chamber can be used to diagnose Menière's disease. We studied 45 ears from patients with neurotological diseases. The subjects were placed supine in a soundproof pressure chamber. The pressure was first decreased to -500 mmH2O, and after 5 min to -700 mmH2O. The pressure was kept at this level for another 5 min and then increased to 0 mmH2O. This procedure was done three times in succession. While the chamber pressure was below 0 mmH2O, the subjects were instructed to abstain from actively equilibrating middle ear pressure. When the chamber pressure was raised to 0 mmH2O, they were instructed to equilibrate middle ear pressure, and if necessary Politzerization or catheterization of the Eustachian tube was done. As a result, hearing was improved after this procedure only in patients with Menière's disease (50%) and/or cochlear Menière's disease (32%) in which endolymphatic hydrops was suspected.

Effect of atmospheric pressure on hearing in patients with Menière's disease

Hearing in patients with Menière's disease improved when they were treated in an underpressure chamber. In this study 46 patients with neurotological diseases, including 32 cases of Menière's disease, were tested in an overpressure chamber. As a result, hearing in 32% of the patients with Menière's disease improved, although this was lower than the 50% rate of improvement in Menière's disease patients tested in an underpressure chamber.

Menière's disease

Menière's disease is one of the most common etiologies for dizziness in the United States. The mainstay of therapy for Menière's is medical therapy. Symptomatic treatment is employed, but long-term prophylaxis is emphasized, with salt restriction and diuretic administration as needed. A prophylactic approach can prevent many attacks and ameliorate those that do occur. Patients with moderate to severe symptoms who fail medical therapy may be candidates for endolymphatic sac surgery, since this procedure is successful in a majority of patients and has low morbidity. Those patients in whom an endolymphatic shunt fails and who continue to have severe symptoms may undergo selective sectioning of the vestibular nerve, while patients with no residual hearing may be offered translabyrinthine nerve section.