Menière's disease

INTRODUCTION

Menière's disease causes recurrent vertigo, hearing loss, tinnitus, and fullness or pressure in the ear, which mainly affects adults aged 40-60 years. Menière's disease is at first progressive but fluctuating, and episodes can occur in clusters. Vertigo usually resolves but hearing deteriorates, and symptoms other than hearing loss and tinnitus usually improve regardless of treatment.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for acute attacks of Menière's disease; and of interventions to prevent attacks and delay disease progression of Menière's disease? We searched: Medline, Embase, The Cochrane Library and other important databases up to January 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 17 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: anticholinergics, benzodiazepines, betahistine, cinnarizine, dietary modification, diuretics, phenothiazines, psychological support, trimetazidine, vestibular rehabilitation.

Changes in distortion of two-tone cochlear microphonic and otoacoustic emission signals during an acute endolymphatic hydrops in the guinea pig

An acute endolymphatic hydrops was induced by the injection of 1.1 mul of artificial endolymph into the scala media of guinea pig cochleas. This volume corresponds with an acute endolymphatic hydrops of 23%. During and after the injection, cochlear function was assessed by measuring the 2f(1)-f(2 )and f(2)-f(1) distortion products in cochlear microphonics (CMDP) and the 2f(1)-f(2) distortion product otoacoustic emission (DPOAE). A reversible pressure increase of 23 Pa and a relatively stable endocochlear potential (EP) were accompanied by a mean decrease in 2f(1)-f(2) DPOAE of only 3.4 dB. Similarly, the 2f(1)-f(2) CMDP amplitude change was minimal during and after the injection. The only substantial change was measured in the f(2)-f(1) CMDP amplitude. The measured range of distortion amplitudes during an acute endolymphatic hydrops can be related to small changes in the cochlear transducer operating point.

Drop attacks and vertigo secondary to a non-meniere otologic cause

BACKGROUND

Tumarkin falls are sudden drop-attack falls that occur in a subset of patients with Meniere syndrome (endolymphatic hydrops), an inner ear disorder characterized by vertigo spells and hearing loss.

OBJECTIVE

To describe the clinical features and quantitative audiovestibular testing results in a case series of patients with Tumarkin falls, episodic vertigo, and normal hearing.

SETTING

University referral center for disorders of balance and hearing.

METHODS

Case series (unselected) of all patients with Tumarkin falls and a normal audiogram at least 1 year after onset of vestibular symptoms (n = 6) from a retrospective analysis of the records of all patients with Tumarkin falls presenting to Neurotology Clinic at UCLA Medical Center, Los Angeles, Calif, from October 1, 1975, to February 1, 2001 (N = 55). Quantitative audiologic and vestibular function testing, neurologic history, and examination were performed.

RESULTS

Five of 6 patients had unilateral caloric paresis, and 1 had bilateral vestibulopathy. Five of 6 had a personal and/or family history of migraine headaches meeting International Headache Society criteria. All patients had a subjective sensation of feeling pushed by an external force, and half of the patients had a subjective tilt of the environment concurrent with the fall.

CONCLUSIONS

The incidence of migraine is high in this subgroup of patients with Tumarkin falls and normal hearing. The clinical description of the falls is similar to those associated with Meniere syndrome. Further studies are needed to understand the etiology of Tumarkin falls in these patients with normal hearing.

Intratympanic gentamicin in Menière's disease: the impact on tinnitus

Intratympanic administration of gentamicin for the treatment of intractable Menière's disease can achieve relief of vertigo. However, the effect of gentamicin on tinnitus has been less well identified. and conflicting results have been reported. Intratympanic gentamicin therapy was given to 25 patients with Menière's disease for the control of vertigo, and the effect of the therapy on tinnitus was evaluated by a 10-point scale and a modified tinnitus questionnaire. It was found that the tinnitus decreased in four patients (16%) and disappeared in three patients (12%) at follow-up. The effect of gentamicin on tinnitus presented intersubject variability, and no correlation was found between the amount of gentamicin injected and its effect on tinnitus.

[Establishment of the animal model of triple semicircular canal occlusion]

OBJECTIVE

To establish the animal model of triple semicircular canal occlusion(TCO) in guinea pigs.

METHODS

TCO was performed on 20 guinea pigs. Electronystagmography, auditory brainstem responses (ABR) and distortion product otoacoustic emissions(DPOAE) were recorded pre- and post-operatively. The non-operated ear was used as control.

RESULTS

There was spontaneous nystagmus towards non-operated side on the 1st postoperative day and no nystagmus to stimuli of sinusoidal angular acceleration in operated side. On the 30th postoperative day, left and right nystagmus returned symmetrical. Pre-operation, ice-water stimulation induced normal symmetric nystagmus in both sides. On the 30th postoperative day, ice-water stimulation only induced normal nystagmus in non-operated ear and failed in operated one. ABR thresholds increased approximately 10 dB post-operation. There were no significant changes of the amplitudes of DPOAE before and after surgery. Histologic examination revealed complete occlusion in the three semicircular canals with newly formed bone and connective tissue.

CONCLUSION

This study showed that the animal model of TCO was successfully established. These findings suggests that TCO might be a safe and simple procedure for the treatment of intractable peripheral vertigo.

Audiogram fine structure and spontaneous otoacoustic emissions in patients with Menière's disease

The incidence of and inter-relationship between audiogram fine structure and spontaneous otoacoustic emissions (SOAEs) was investigated in patients with Menière's disease. This project is a part of a comprehensive longitudinal study in which a range of tests of cochlear and vestibular function in patients who suffer from Menière's disease, is carried out and repeated over time. In this paper we present preliminary data from both ears (in most cases an affected and an unaffected ear) of 13 patients. The thresholds in these 26 ears ranged from normal to 80 dB HL. SOAEs could be measured in only four ears; these ears had near-normal thresholds. Data from seven ears had to be excluded because of the possibility of cross-over effects. In 16 out of the 19 remaining ears, audiogram fine structure was found. Our data confirm that (1) SOAEs correspond to behavioural sensitivity peaks. (2) There is no simple relationship between SOAE level and height of sensitivity peaks. (3) Sensitivity peaks may occur at frequencies without measurable SOAEs. In addition, our data show that: (1) Audiogram fine structure may occur in ears without observable SOAEs. (2) Fine structure can be present in ears without normal thresholds. (3) There is a weak tendency for fine structure to be more pronounced in ears with milder hearing loss.

Middle ear instillation of gentamicin and streptomycin in chinchillas: morphologic appraisal of selective ototoxicity

OBJECTIVE

To determine selective cochlear and vestibular ototoxicity of two aminoglycoside antibiotics (gentamicin and streptomycin) in the chinchilla model. Middle ear application of these agents mirrors the clinical practice of chemical vestibular ablation used in Meniere's disease.

BACKGROUND

Middle ear instillation of gentamicin or streptomycin has become a popular form of vestibular ablative treatment for disabling Meniere's disease. The vestibular selectivity of these two drugs applied in this fashion has clinical support but is not fully established in humans. Our understanding in this regard has largely been limited to animal models exposed to systemic infusion of aminoglycosides.

METHOD

Ten chinchillas underwent left middle ear instillation of one of three agents using variable dosing schedules: gentamicin (n = 6), streptomycin (n = 2), and saline (n = 2) as control. Animals were sacrificed for temporal bone studies using scanning electron microscopy. Morphologic changes in the cochlear and vestibular neuroepithelia were identified.

RESULTS

Widespread cochlear and vestibular neuroepithelial injuries were observed with both gentamicin and streptomycin. Contralateral ototoxicity was variable and not related to the total dose of drug delivered. The effect of these two aminoglycosides on the dark cells of the vestibular system appeared negligible.

CONCLUSION

We were unable to confirm the selective damage of vestibular end-organ in the chinchilla by either gentamicin or streptomycin, a phenomenon that is generally perceived to occur in humans. Chinchillas, like other small mammals, may not be an ideal model for the study of human ototoxicity.

Immediate effects of middle ear pressure changes on the electrocochleographic recordings in patients with Menière's disease: a clinical placebo-controlled study

OBJECTIVE

The aim of the study was to evaluate effects of middle ear pressure changes on the electrocochleographic responses in patients with well-defined Menière's disease. STUDY DESIGN AND INTERVENTIONS: The investigation was conducted as a placebo-controlled, randomized clinical study. Electrocochleographic measurements were performed before and after the insertion of a transtympanic ventilation tube and immediately after the exposure to active or placebo treatment.

SETTING

The study was carried out in one secondary referral center and one tertiary referral center on an ambulatory basis.

PATIENTS

Thirty-nine patients with well-defined Menière's disease were included in the study.

MAIN OUTCOME MEASURES

The summating potential/action potential ratio of the electrocochleographic response complex was chosen as the main variable for statistical evaluation of results. Other parameters of the recordings such as responses to low-frequency burst stimulation also were evaluated. Subjective symptoms (e.g., vertigo, tinnitus, and aural pressure) were assessed before and after insertion of the ventilation tube and before and after exposure to treatment.

RESULTS

A statistical difference was shown in the electrocochleographic response in the active group before and after exposure to middle ear pressure changes. In the placebo group, no change was found. Changes in electrocochleographic parameters in the active group indicated an improvement in inner ear electrophysiology. No significant changes were found in subjective symptoms in the active or the placebo group. Evaluation before and after insertion of the ventilation tube showed no significant improvement in any variable.

CONCLUSIONS

This is the first study in which electrophysiologic parameters were evaluated in a placebo-controlled clinical trial of overpressure treatment in Menière's disease. The results show that electrophysiologic parameters can be improved by the application of positive pressure pulses of low amplitude in the middle ear.

Clinical forum: a review of intratympanic therapy

OBJECTIVE

This article provides an overview of the rational basis for the appropriate clinical use of intratympanic aminoglycosides and steroids.

DATA SOURCES

The data sources were relevant English language clinical and basic science publications.

STUDY SELECTION

The most recent publication available for each author or group of original, human, clinical reports about the technique were included.

DATA EXTRACTION

The techniques and results for control of vertigo and hearing loss were compared.

CONCLUSIONS

At least 11 articles have been published that indicate that intratympanic gentamicin treatments control vertigo well and provide acceptable rates of hearing loss. Intratympanic gentamicin should be the initial treatment of choice for unilateral disabling Meniere's disease that has failed medical therapy. The use of intratympanic steroids should remain investigational until more favorable data are available.

Clinical importance of the Korner's septum

OBJECTIVE

To evaluate the clinical importance of the petrosquamosal lamina (Korner's septum [KS]), which is not only a bony plate dividing the mastoid cells at the level of antrum, but is also a lamina starting from the posterior aspect of the glenoid fossa that extends above the middle ear cavity and courses in an inferior direction lateral to the facial canal and proceeds to the mastoid apex.

STUDY DESIGN AND SETTING

A retrospective review of 688 mastoidectomies performed in University Hospital from 1987 to 1992.

PATIENTS

The study group consisted of 389 males and 299 females (mean age 30.85 +/- 12.80, the youngest being 8 and the oldest being 67 years of age).

MAIN OUTCOME MEASURES

The main outcome measures were the prevalence of KS encountered during mastoidectomies and comparison of prevalence of retraction pockets (RPs) or retraction and/or adhesion of the whole tympanic membrane (R/A-TM) between ears with KS and without KS.

RESULTS

The prevalence of KS was 30.4% among the ears with RP or R/A-TM, 6.58% in normal ears, and 17.4% in ears with chronic otitis media without RP or R/A-TM.

CONCLUSIONS

KS is an important anatomic handicap predisposing the individual to chronic otitis media, particularly when it is characterized by attic retraction pockets and cholesteatoma, and adhesive otitis media, because KS contributes to attic blockage. This statement is in accordance with the original articles written by Cheatle (1910, 1923) and Williams (1966), and recently published data related to supratubal recess and the cog (Tono et al., 1996).