Clinical Practice Guideline: Ménière's Disease

Current and Emerging Medical Therapies for Dizziness

Medical therapies for dizziness are aimed at vertigo reduction, secondary symptom management, or the root cause of the pathologic process. Acute peripheral vertigo pharmacotherapies include antihistamines, calcium channel blockers, and benzodiazepines. Prophylactic pharmacotherapies vary between causes. For Meniere disease, betahistine and diuretics remain initial first-line oral options, whereas intratympanic steroids and intratympanic gentamicin are reserved for uncontrolled symptoms. For cerebellar dizziness and oculomotor disorders, 4-aminopyridine may provide benefit. For vestibular migraine, persistent postural perceptual dizziness and mal de débarquement, treatment options overlap and include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants and calcium channel blockers.

Intraoperative Electrocochleography in Subjects Affected by Vestibular Schwannoma and Ménière's Disease: Comparison of Results

OBJECTIVES

Histologic reports of temporal bones of ears with vestibular schwannomas (VSs) have indicated findings of endolymphatic hydrops (ELH) in some cases. The main goal of this investigation was to test ears with VSs to determine if they exhibit electrophysiological characteristics similar to those of ears expected to experience ELH.

DESIGN

Fifty-three subjects with surgically confirmed VS aged ≥18 and with normal middle ear status were included in this study. In addition, a second group of adult subjects (n = 24) undergoing labyrinthectomy (n = 6) or endolymphatic sac decompression and shunt (ELS) placement (n = 18) for poorly controlled vestibular symptoms associated with Meniere's disease (MD) participated in this research. Intraoperative electrocochleography (ECochG) from the round window was performed using tone burst stimuli. Audiometric testing and word recognition scores (WRS) were performed preoperatively. ECochG amplitudes, cochlear microphonic/auditory nerve neurophonic (ANN) in the form of the "ongoing" response and summation potential, were analyzed and compared between the two groups of subjects. In addition, to evaluate any effect of auditory nerve function, the auditory nerve score was calculated for each subject. Pure-tone averages were obtained using the average air conduction thresholds at 0.5, 1, and 2 kHz while WRS was assessed using Northwestern University Auditory Test No. 6 word lists.

RESULTS

In the VS group the average pure-tone averages and WRS were 59.6 dB HL and 44.8%, respectively, while in the MD group they were 52.3 dB HL and 73.8%. ECochG findings in both groups revealed a reduced trend in amplitude of the ongoing response with increased stimulus frequency. The summation potential amplitudes of subjects with VS were found to be less negative than the MD subjects for nearly all test frequencies. Finally, the VS group exhibited poorer amounts of auditory nerve function compared to the MD group.

CONCLUSIONS

The current findings suggest cochlear pathology (e.g., hair cell loss) in both groups but do not support the hypothesis that VSs cause ELH.

Effects of hormone therapy containing 2 mg drospirenone and 1 mg 17β-estradiol on postmenopausal exacerbation of Meniere's disease: Preliminary study

The present study aimed to evaluate the effects of 2 mg drospirenone (DRSP) and 1 mg 17β-estradiol (E2) hormone therapy (HT) in combination with rehabilitation therapy for postmenopausal women with Meniere's disease (MD). The combined drug hormone treatment was denoted as DRSP/E2. A total of 65 postmenopausal female patients with MD and severe distress were enrolled in the present prospective study. A total of 31 women comprised the study group (group A), undergoing HT and rehabilitation therapy, whereas 34 women who opted for rehabilitation therapy alone comprised the control group (group B). Vestibular function and distress associated with MD were assessed by stabilometry and the Dizziness Handicap Inventory (DHI) questionnaire, respectively. The data were collected at baseline and during the 3- and 6-month follow-up visits. The areas of the stabilometric ellipses exhibited a higher reduction in group A compared with group B with regard to the baseline values at both follow-up assessments (P<0.001). At baseline, both groups exhibited severe self-perceived discomfort, with similar DHI scores of 72.3±3.7 (group A) and 70.6±3.9 (group B; P=0.07). At the 3-month follow-up, both groups underwent a gradual improvement, which was significantly higher in group A (47.5±3.7) compared with in group B (64.2±3.3; P<0.001). At the 6-month follow-up, the DHI scores were improved in group A (43.4±3.4) compared with in group B (58.5±3.1; P<0.001). Therefore, DRSP/E2 HT was effective in reducing the fluid overload, which is characteristic of MD. The findings of the present study demonstrated that integrated therapy based on the administration of DRSP/E2 HT and rehabilitation may be more effective compared with rehabilitation alone for the management of postmenopausal exacerbation of MD.

Advanced Imaging of the Vestibular Endolymphatic Space in Ménière's Disease

The diagnosis of "definite" Méniére's disease (MD) relies upon its clinical manifestations. MD has been related with Endolymphatic Hydrops (EH), an enlargement of the endolymphatic spaces (ES) (cochlear duct, posterior labyrinth, or both). Recent advances in Magnetic Resonance (MR) imaging justify its increasing role in the diagnostic workup: EH can be consistently recognized in living human subjects by means of 3-dimensional Fluid-Attenuated Inversion-Recovery sequences (3D-FLAIR) acquired 4 h post-injection of intra-venous (i.v.) Gadolinium-based contrast medium, or 24 h after an intratympanic (i.t.) injection. Different criteria to assess EH include: the comparison of the area of the vestibular ES with the whole vestibule on an axial section; the saccule-to-utricle ratio ("SURI"); and the bulging of the vestibular organs toward the inferior 1/3 of the vestibule, in contact with the stapedial platina ("VESCO"). An absolute link between MD and EH has been questioned, since not all patients with hydrops manifest MD symptoms. In this literature review, we report the technical refinements of the imaging methods proposed with either i.t. or i.v. delivery routes, and we browse the outcomes of MR imaging of the ES in both MD and non-MD patients. Finally, we summarize the following imaging findings observed by different researchers: blood-labyrinthine-barrier (BLB) breakdown, the extent and grading of EH, its correlation with clinical symptoms, otoneurological tests, and stage and progression of the disease.

The Effect of Different Round Window Sealants on Cochlear Mechanics Over Time

BACKGROUND

This project investigated the effects of round window membrane (RWM) sealants after surgical incision, with a focus on audiological thresholds, ossicular mechanics, and the impact upon cochlear function and pathology.

METHODS

Twenty-eight guinea pigs were randomly allocated to one of three sealant groups (muscle, n = 7; fascia, n = 7, Tisseel, n = 8) or an unsealed control group (n = 6). Preoperative hearing was measured using auditory brainstem responses (ABRs). The ossicular chain and RWM were exposed surgically, and Laser Doppler Vibrometry (LDV) measurements were obtained from the long process of the incus. The RWM was incised then sealed (or left unsealed) according to group. ABR testing and LDV measurements were repeated 4 and 12 weeks after surgery. At 12 weeks all cochleae were harvested.

RESULTS

ABR thresholds deteriorated over time in all groups. Overall, group was not statistically significant (p = 0.064). There was no significant effect by group on LDV measurements (p = 0.798). Histopathological analyses of the RWM showed that the fascia group had more extensive fibrosis than other groups (Independent-Samples Median Test, p = 0.001). However, there were minimal differences in the outer hair cell counts between the different intervention groups.

CONCLUSIONS

All the interventions appeared to be safe while none affected the cochlear mechanics or hearing thresholds in a statistically significant manner.

Outcomes of transtympanic dexamethasone perfusion using the MicroWickTM in patients with Ménière's disease: A cross-sectional study

PURPOSE

To assess the efficacy of a 4-week transtympanic dexamethasone perfusion using the Silverstein MicroWick^TM in patients with Ménière's disease.

MATERIALS AND METHODS

A self-reported questionnaire was designed and sent to patients who underwent transtympanic dexamethasone perfusion using the Silverstein MicroWick^TM from January 2017 to December 2020. A retrospective chart review was conducted to gather demographic and audiological data of those who responded.

RESULTS

Forty respondents were separated into Group 1 (n = 34), who required no further procedure, and Group 2 (n = 6), who required additional procedure for Ménière's disease. In Group 1, 50% reported subjective improvement in tinnitus, 59% in aural fullness, 79% in vertigo, and 21% in hearing loss after the MicroWick^TM treatment. A statistical analysis of the scores revealed that the improvement in aural fullness and vertigo met significance (p = 0.03 and p = 0.002, respectively). In Group 2, no significant change was seen in their symptoms. Audiological data showed no significant change in the pure tone average or the word recognition score after the treatment.

CONCLUSION

Transtympanic dexamethasone perfusion using the Silverstein MicroWick^TM is a well-tolerated treatment option for patients with Ménière's disease. Our survey data suggest its significant efficacy in reducing aural fullness and vertigo attacks in these patients. Prospective studies will be conducted to further establish its potential role in successfully managing patients with Ménière's disease.

Cochlear Implantation in the Setting of Menière's Disease After Labyrinthectomy: A Meta-Analysis

OBJECTIVE

Characterize the speech recognition and sound source localization of patients with unilateral Menière's disease who undergo labyrinthectomy for vertigo control with simultaneous or sequential cochlear implantation.

DATABASES REVIEWED

PubMed, Embase, and Cochrane databases.

METHODS

The search was performed on May 6, 2020. The keywords utilized included: "Menière's disease AND cochlear implant;" "cochlear implant AND single sided deafness;" "cochlear implant AND vestibular;" and "labyrinthectomy AND cochlear implant." Manuscripts published in English with a publication date after 1995 that assessed adult subjects (≥18 years of age) were included for review. Subjects must have been diagnosed with Menière's disease unilaterally and underwent labyrinthectomy with simultaneous or sequential cochlear implantation. Reported outcomes with cochlear implant (CI) use included speech recognition as measured with the consonant-nucleus-consonant (CNC) word test and/or sound source localization reported in root-mean squared (RMS) error. The method of data collection and study type were recorded to assess level of evidence. Statistical analysis was performed with Wilcoxon signed ranks test.

RESULTS

Data from 14 CI recipients met the criteria for inclusion. Word recognition comparisons between the preoperative interval and a postactivation interval demonstrated a significant improvement with the CI (p = 0.014), with an average improvement of 23% (range -16 to 50%). Sound source localization postoperatively with the CI demonstrated an average RMS error of 26° (SD 6.8, range 18.7-43.1°) compared to the 42° (SD 19.1, range 18-85°) in the preoperative or CI off condition, these two conditions were not statistically different (p = 0.148).

CONCLUSION

Cochlear implantation and labyrinthectomy in adult patients with Menière's disease can support improvements in speech recognition and sound source localization for some CI users, though observed performance may be poorer than traditional CI candidates.

Triple Semicircular Canal Occlusion Combined with Endolymphatic Sac Decompression: An Effective Surgical Strategy for Vertigo Control of Intractable Meniere's Disease

Triple semicircular canal occlusion is an efficient strategy for vertigo control in patients with intractable Meniere's disease The surgery can block the movement of endolymph in the canals to eliminate vertigo attacks induced by position changing Patients with advanced stage MD suffered more from hearing deterioration postoperatively The aural fullness remission was satisfactory postoperative Vestibular rehabilitation is important and effective for vestibular function compensation, it should be recommended to all patients postoperatively.

Effectiveness of endolymphatic duct blockage versus endolymphatic sac decompression in patients with intractable Ménière's disease: study protocol for a double-blinded, randomised controlled trial

INTRODUCTION

Outcomes of surgery for Ménière's disease (MD) remain discordant. Recently, a new surgical procedure in which the endolymphatic duct is clipped was proposed. To date, only one prospective trial assessing this technique was published, yielding promising results. This protocol describes a prospective, double-blinded, randomised controlled trial that will be carried out to assess the effectiveness of this surgical intervention.

METHODS

Eighty-four patients with intractable MD will be recruited from 13 hospitals in the Netherlands. Intraoperatively, randomisation will determine whether endolymphatic duct blockage (EDB) or endolymphatic sac decompression (ESD) will be performed. Randomisation will be 1:1 stratified for gender and duration of MD (recent-onset versus mature MD). All participants receive vestibular rehabilitation after surgery. Patients are followed up during 1 year after surgery. Follow-up visits will take place at 1 week, 3 months, 6 months and 12 months after surgery. The main study endpoint is proportion of patients who are free of vertigo spells at 12 months postoperatively. Secondary parameters include cumulative number of vertigo bouts, co-intervention, tinnitus, hearing, quality of life, cost effectiveness and a budget impact analysis. Total duration of the study is 4 years.

ANALYSIS

The primary analysis will follow the intention-to-treat principle. For the primary outcome, a χ² test will be performed. Secondary outcomes will be analysed using a linear mixed model (EDB versus decompression group) at the different time measurement point.

ETHICS AND DISSEMINATION

This study was reviewed and approved by a board of specialists before funding was obtained, as well as by the Medical Research Ethics Committee Leiden-The Hague-Delft and the boards of all participating centres. Results of this study will be published in international peer-reviewed scientific journals and will be presented on (inter)national scientific conferences and meetings.

TRIAL REGISTRATION NUMBERS

NL9095 and ISRCTN12074571; Pre-Results.

Vestibular Physical Therapy and Fall Risk Assessment

Vestibular physical therapy (VPT) is a specialized form of evidence-based therapy designed to alleviate primary (vertigo, dizziness, imbalance, gait instability, falls) and secondary (deconditioning, cervical muscle tension, anxiety, poor quality of life, fear of falling/fear avoidance behavior) symptoms related to vestibular disorders. This article provides an overview of VPT, highlighting various exercise modalities used to treat a variety of vestibular disorders. Patient safety and fall prevention are paramount; therefore, fall risk assessment and treatment are also addressed.

Progressive and Degenerative Peripheral Vestibular Disorders

Initial diagnosis of peripheral vestibulopathy requires a detailed history, physical examination, and, in some cases, audiovestibular testing, radiographic imaging, or serology. Differentiation of a peripheral vestibulopathy as progressive or degenerative is often nuanced and influenced by a characterization of a patient's symptoms or natural history over time. A diverse group of vestibular pathology may fit into this category, including Ménière's disease, autoimmune conditions, congenital pathologies, ototoxic medications, radiation therapy, and perilymphatic fistula. Differentiation among these entities may be guided by initial or subsequent symptomatology, with various combinations of audiovestibular testing, serology, and imaging. Treatment options are disparate and disease-specific, ranging from observation to medical management or surgical intervention, underscoring the need for astute investigation and diagnosis.

Usage Patterns of CT and MRI in the Evaluation of Otologic Disease

OBJECTIVE

To evaluate the current trends and usage patterns of radiographic imaging for otologic disease by specialty, length of practice, practice setting, geographic region, and pediatric volume.

STUDY DESIGN

Cross-sectional study.

SETTING

Survey of physicians.

SUBJECTS

General Otolaryngologists and Otologists/Neurotologists (O/N) of the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS).

METHODS AND OUTCOME MEASURES

An electronic questionnaire was distributed to AAO-HNS members. Respondents were separated into groups by specialty, length of practice, practice setting, region, and pediatric exposure. Chi-square tests were performed for the determination of significance.

RESULTS

The survey was sent to 5,168 members of AAO-HNS. The response rate was 10.6% (n = 546) and 18.1% for only O/N (n = 143). Most respondents were generalists (74%), in practice >20 years (51%), with a primarily adult practice (95%). O/N were more often academics (44 versus 17% combined, 40% private; p < 0.001) and saw fewer children (80 fewer than 25%; p < 0.001). Compared with generalists, O/N were more likely to respond with more frequent and earlier magnetic resonance imaging (MRI) utilization in the workup of the majority of otologic diseases. Significant differences in usage patterns for various conditions were demonstrated across all categories, but specialty training was the most common. Generalists (34 versus 12% of O/N; p < 0.001), physicians practicing >20 years (32 versus 18% of < 5 yrs; p = 0.006), and private practice physicians (34 versus 14-20% of others; p < 0.001) relied more heavily on the radiology report to interpret MRI scans.

CONCLUSION

Subspecialty training seems to be the main variable correlating with significant differences in the use of MRI and computed tomography imaging in patients with otologic disease.

Vestibular disorders in children: A retrospective analysis of vestibular function test findings

OBJECTIVE

This study was designed to describe the most common vestibular disorders in children and their associated findings on vestibular function testing.

METHOD

Data from 203 children with a mean age of 11.16 ± 3.87 (range, 1-17) years were collected from among 3400 patients who underwent vestibular assessment at a vertigo center in a tertiary hospital over a 3-year period. A retrospective data analysis was performed for 203 children.

RESULTS

Vestibular disorders were diagnosed in 78.3% (n = 159) of 203 children among 3400 patients, which revealed a 3-year incidence of 4.67% in our study. Benign paroxysmal positional vertigo (BPPV) was the most common diagnosis in our group of children (49%; n = 100), which involved both primary BPPV, and secondary BPPV that was associated with other vestibular pathologies. Vestibular migraine (VM) was the second most common diagnosis (41%; n = 83) followed by benign paroxysmal vertigo of childhood (BPVC; 4.5%, n = 9), vestibular neuritis (VN; 4.5%, n = 9), and psychogenic vertigo (4.5%, n = 9). Our study showed that Meniere's Disease (MD; 1.5%, n = 3) and central vertigo (1.5%, n = 3) were less commonly diagnosed in children. Perilymphatic fistula (PLF) was diagnosed and surgically confirmed in only one child.

CONCLUSION

BPPV and VM were the most common pediatric vestibular disorders in our study. Clinicians should be aware of the prevalence, signs, and symptoms of the most common vestibular disorders in children to enable diagnosis, treatment, and rehabilitation. Vestibular function testing with age-appropriate adaptations results in improved differential diagnosis, which guides medical treatment and rehabilitation.

Current Insights into Treating Vertigo in Older Adults

The number of older people has been increasing over recent decades in Western populations. Dizziness, imbalance, and vertigo constitute some of the most common complaints in older patients, and risk of falling is the most frequent and worrying consequence. It has been reported that 15–20% of the adult population experiences these debilitating symptoms. Among the diseases that may be associated with vertigo, the three classes of otological, central, and functional (psychological) dizziness may be distinguished. Overall, vestibular disorders account for 48% of vertiginous complaints in the older population. The main focus of this article is to review the forms of pharmacotherapy for vertigo, especially with regard to older patients, who may be treated simultaneously with other drugs for different comorbidities. Interactions with other drugs should be considered in the choice of a particular course of treatment. Moreover, overuse of pharmacotherapy for the management of vertigo in the elderly may prevent the development of the central compensatory mechanism that sustains both static and dynamic imbalance after a vertiginous crisis. In the majority of patients, vestibular and physical rehabilitation are strongly advised and rarely contraindicated.

Visualization of Endolymphatic Hydrops in Patients With Unilateral Idiopathic Sudden Sensorineural Hearing Loss With Four Types According to Chinese Criterion

Objective: The aim of this study is to evaluate the possible value of endolymphatic hydrops (EH) in patients with unilateral idiopathic sudden sensorineural hearing loss (UISSNHL) with four types according to audiometry.

Methods: Seventy-two patients (40 men and 32 women; age range, 28–78 years; mean age: 50.0 ± 12.9 years) with UISSNHL were admitted retrospectively into this study. Based on the pure tone audiometry before treatment, the hearing loss of all these patients were categorized into four types: low-frequency group (LF-G), high-frequency group (HF-G), flat group (F-G), and total deafness group (TD-G). The average time from symptom onset to the first examination was 6.9 ± 4.4 days (1–20 days). 3D-FLAIR MRI was performed 24 h after intratympanic injection of gadolinium (Gd) within 1 week after the UISSNHL onset. The incidence of EH in the affected ears based on four types of hearing loss were analyzed using the Chi-square test, and the possible relationship with vertigo and prognosis were also assessed.

Results: Eleven of 21 patients (52.4%) in LF-G had the highest EH-positive rate, followed by 18.2% in HF-G, 11.8% in F-G, and 17.4% in TD-G. The significant difference was found in the four groups (P = 0.018). The EH rate of LF-G was statistically significantly higher than that of F-G and TD-G (P = 0.009, P =0.014), respectively. After being valued by the volume-referencing grading system (VR scores), the EH level was represented by the sum scores of EH. In LF-G, no statistically significant difference was found in the prognosis of ISSNHL patients between with the EH group and the no EH group (P = 0.586). The symptom “vertigo” did not correlate with EH and prognosis.

Conclusions: EH was observed in UISSNHL patients by 3D-FLAIR MRI. EH may be responsible for the pathology of LF-G but not related to prognosis. It might be meaningless to assess EH in other hearing loss types, which might be more related to the blood-labyrinth dysfunction.

Diagnosis of Menière's disease according to the criteria of 2015: Characteristics and challenges in 96 patients

BACKGROUND

The diagnosis of Menière's disease (MD) is made according to diagnostic criteria, the last revision of which was in 2015. For diagnosis, symptoms are weighted with audiometric findings and this can be challenging in individual patients.

OBJECTIVE

To analyze patient's characteristics and symptoms in a real-life cohort of 96 patients with diagnosed MD regarding sociodemographic parameters, clinical specifics, and audiometry.

METHODS

Prospective clinical patient registry containing demographic and socioeconomic parameters, symptoms, as well as pure-tone audiometry data.

RESULTS

31 patients with definite MD, and 36 with probable MD were identified. 29 patients showed typical clinical signs of MD, but did not meet the full diagnostic criteria, and were considered separately. Mean duration of symptoms prior to presentation was 3.9±4.6 years. Significant differences between categories were found regarding aural fullness, tinnitus, and fluctuating hearing. If multiple audiograms were available, 28.6 %(6/21) documented fluctuating hearing.

CONCLUSIONS

Current diagnostic criteria probably do not represent patients with monosymptomatic presentation or an early stage very well. Long-term follow-up with repeated audiometry is advisable.

Quality Indicators for the Diagnosis and Management of Menière's Disease

OBJECTIVE

Menière's disease (MD) is a clinical disorder that often provides challenges in diagnosis and management. High-quality evidence to guide care providers is sparse, which can result in significant practice variations. Quality indicators (QIs) are one method that can be used to standardize and measure accepted care practices to improve healthcare quality and patient outcomes. Here, we developed practical, high-yield QIs that serve to measure and inform the quality of care provided to patients with MD.

STUDY DESIGN

Modified RAND Corporation University of California, Los Angeles appropriateness methodology for QI development.

SETTING

Multicenter nine-member expert panel.

PATIENTS

NA.

INTERVENTIONS

NA.

MAIN OUTCOME MEASURE

Final QIs deemed appropriate measures of quality care with agreement by the expert panel.

RESULTS

Twenty-seven candidate indicators were identified after literature review. After the first round of evaluations, the panel agreed on three candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss disagreements. Two agreed-upon QIs were revised during this discussion before final evaluations. The expert panel ultimately agreed upon five QIs as appropriate measures of high-quality care after completing final evaluations and reviewing updated literature. The five quality indicators measure audiometric documentation, minimization of electrocochleography, use of intratympanic dexamethasone, use of intratympanic gentamycin, and rate of labyrinthectomy/vestibular neurectomy in refractory MD patient.

CONCLUSIONS

This study proposes five QIs that cover key aspects of care for MD, such as accurate diagnosis and management options including initial destructive therapies. These QIs can serve multiple purposes, the most important of which is to galvanize quality improvement initiatives.

Altered mapping of sound frequency to cochlear place in ears with endolymphatic hydrops provide insight into the pitch anomaly of diplacusis

A fundamental property of mammalian hearing is the conversion of sound pressure into a frequency-specific place of maximum vibration along the cochlear length, thereby creating a tonotopic map. The tonotopic map makes possible systematic frequency tuning across auditory-nerve fibers, which enables the brain to use pitch to separate sounds from different environmental sources and process the speech and music that connects us to people and the world. Sometimes a tone has a different pitch in the left and right ears, a perceptual anomaly known as diplacusis. Diplacusis has been attributed to a change in the cochlear frequency-place map, but the hypothesized abnormal cochlear map has never been demonstrated. Here we assess cochlear frequency-place maps in guinea-pig ears with experimentally-induced endolymphatic hydrops, a hallmark of Ménière’s disease. Our findings are consistent with the hypothesis that diplacusis is due to an altered cochlear map. Map changes can lead to altered pitch, but the size of the pitch change is also affected by neural synchrony. Our data show that the cochlear frequency-place map is not fixed but can be altered by endolymphatic hydrops. Map changes should be considered in assessing hearing pathologies and treatments.

[Betahistine in vestibular disorders: current concepts and perspectives]

The goal of this paper is to review the pharmacological profile of betahistine and evidence for using it in the treatment of common vestibular disorders. Betahistine is a weak agonist for histamine H1 receptors and strong antagonist for histamine H3 receptors. It demonstrates the maximum benefit in different types of peripheral vertigo, especially in Meniere's disease. The best results in decreasing intensity of vertigo, frequency of attacks and stimulation of vestibular compensation were obtained in daily dose 48 mg during 3 months. In benign paroxysmal positional vertigo betahistine is used to treat residual dizziness after successful treatment of otolithiasis and to reduce the severity of vertigo during repositioning maneuvers. In vestibular neuritis betahistine stimulates central compensation during vestibular rehabilitation. A new once-daily drug formulation of modified-release betahistine is non-inferior to traditional and has a comparable safety profile, and could improve patient adherence. The implication of betahistine in the treatment of central vestibular disorders is under-researched. The efficacy of betahistine in increasing of vestibular compensation in post-stroke central vestibular disorders, persistent postural-perceptual dizziness and its role in vestibular migraine need further investigation.

Clinical Decision Support Systems in Otolaryngology-Head and Neck Surgery: A State of the Art Review

OBJECTIVE

To offer practical, evidence-informed knowledge on clinical decision support systems (CDSSs) and their utility in improving care and reducing costs in otolaryngology-head and neck surgery. This primer on CDSSs introduces clinicians to both the capabilities and the limitations of this technology, reviews the literature on current state, and seeks to spur further progress in this area.

DATA SOURCES

PubMed/MEDLINE, Embase, and Web of Science.

REVIEW METHODS

Scoping review of CDSS literature applicable to otolaryngology clinical practice. Investigators identified articles that incorporated knowledge-based computerized CDSSs to aid clinicians in decision making and workflow. Data extraction included level of evidence, Osheroff classification of CDSS intervention type, otolaryngology subspecialty or domain, and impact on provider performance or patient outcomes.

CONCLUSIONS

Of 3191 studies retrieved, 11 articles met formal inclusion criteria. CDSS interventions included guideline or protocols support (n = 8), forms and templates (n = 5), data presentation aids (n = 2), and reactive alerts, reference information, or order sets (all n = 1); 4 studies had multiple interventions. CDSS studies demonstrated effectiveness across diverse domains, including antibiotic stewardship, cancer survivorship, guideline adherence, data capture, cost reduction, and workflow. Implementing CDSSs often involved collaboration with health information technologists.

IMPLICATIONS FOR PRACTICE

While the published literature on CDSSs in otolaryngology is finite, CDSS interventions are proliferating in clinical practice, with roles in preventing medical errors, streamlining workflows, and improving adherence to best practices for head and neck disorders. Clinicians may collaborate with information technologists and health systems scientists to develop, implement, and investigate the impact of CDSSs in otolaryngology.

Correlation between magnetic resonance imaging classification of endolymphatic hydrops and clinical manifestations and audiovestibular test results in patients with definite Ménière's disease

OBJECTIVES

The purpose was to evaluate magnetic resonance imaging (MRI) classification of endolymphatic hydrops with clinical features, audiological and vestibular tests in patients with definite unilateral Ménière's disease (MD).

METHODS

Thirty-eight patients were enrolled in this study. The severity of the main clinical symptoms, audiovestibular tests, and MRI, performed 4 hours after intravenous injection of gadobutrol to visualize inner ear compartments, were evaluated. Endolymphatic space dilatation was assessed using Barath and Bernaerts grading systems, and the correlation between the grade of the hydrops and clinical features was evaluated.

RESULTS

Using the Barath system, cochlear hydrops was visualized in 81.6% of affected ears, while vestibular was 63.2%. Sensitivity increased to 94.7% using Bernaerts' modification. Vestibular hydrops involving the utricle was present only among patients with cochlear and saccular endolymphatic space dilatation. There was a significant relationship between the hearing level and the vestibular hydrops degree in the Bernaerts scale. The grade of the hydrops correlated neither with the duration of MD nor with the severity of main clinical symptoms. Our study proved MRI to be a sensitive diagnostic tool in MD. The endolymphatic hydrops' grade correlates with the hearing level, which confirms endolymphatic space dilatation's role in hearing loss.

CONCLUSIONS

In our study, two similar MRI grading systems were used; however, several differences were found compared to one another. The Bernaerts scale was more sensitive than the Barath scale, and several relationships between the radiological and clinical data were found. Therefore, several MRI evaluating scales and correlating them with the clinical features are needed. The increased perilymphatic enhancement of the cochlea and an extra low-grade vestibular hydrops distinguished in the Bernaerts scale may increase MD diagnosis sensitivity. Magnetic resonance findings in MD support the clinical diagnosis and may help to understand MD pathophysiology better. This study adds to the knowledge and diagnostics in MD for healthcare to improve patients' treatment.

Spin the Abstracts of Systematic Reviews and Meta-Analyses Regarding the Treatment of Ménière's Disease

OBJECTIVES

To identify, quantify, and characterize the presence of spin-specific strategies leading to misrepresentation of study results-in the abstracts of systematic reviews and meta-analyses of Ménière's disease treatment.

METHODS

Using a cross-sectional design, we searched MEDLINE and Embase on May 28, 2020, for systematic reviews and meta-analyses focused on Ménière's disease treatment. Returned searches were screened, and data were extracted in a masked, duplicate fashion.

RESULTS

Our sample included 36 systematic reviews and meta-analyses. Of the 36 included studies, 22 (61.1%) abstracts contained spin while 14 (38.9%) did not. The most common spin types were selective reporting of benefit (10/36, 27.8%) or harm (8/36, 22.2%). Other types of spin occurred when findings were extrapolated to the global improvement of the disease (5/36, 13.9%), beneficial effects were reported with high risk of bias in primary studies (3/36, 8.3%), and when beneficial effects were extrapolated to an entire class of interventions (1/36, 2.8%). No instances of other spin types occurred. Abstracts containing spin were substantively associated with studies of critically low methodological quality compared with studies with low and moderate quality. No studies had a methodological rating of high quality. No associations were observed between spin and intervention types, journal recommendation of adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or funding. We found a negative correlation (r = -.31) between abstract word limit and presence of spin.

CONCLUSIONS

Our study highlights that spin in the abstracts of systematic reviews of Ménière's disease is common, and it further enhances the discussion surrounding spin in abstracts of scientific research. Spin in an abstract does not discredit a study's findings; however, its occurrence should be eliminated.

Positional Nystagmus after Acute Vertiginous Attack in Meniere's Disease

There have been no reports regarding nystagmus observed immediately after the end of an acute vertiginous attack in patients with Meniere’s disease. The aim of this study was to demonstrate positional direction-changing nystagmus in patients with Meniere’s disease, and to discuss the mechanism that underlies this nystagmus. Video-nystagmography was recorded in two patients with definite Meniere’s disease, who showed positional direction-changing nystagmus during the period immediately after a vertigo attack. In one patient, video-nystagmographic recording was conducted 5 h after an episode of vertigo attack, and it showed very weak, persistent positional geotropic direction-changing nystagmus. In the other patient, video-nystagmographic recording was conducted 23 h after an episode of vertigo attack, and it showed very weak, persistent positional apogeotropic direction-changing nystagmus. Our patients exhibited very weak, persistent positional direction-changing nystagmus, which was geotropic in one and apogeotropic in the other. This type of positional nystagmus has been reported in other inner ear disorders and it cannot be clearly explained by typical benign paroxysmal positional vertigo. The change in chemical composition and/or electrolyte concentration of the inner ear fluid, although still unclear, may underlie the production of this characteristic nystagmus in these patients.

Methods for Testing the Subjective Visual Vertical during the Chronic Phase of Menière's Disease

The subjective visual vertical (SVV) evaluates the function of the utricle, which, in patients with Menière’s disease (MD), can be affected by endolymphatic hydrops. This study aimed to determine the SVV in MD patients during the chronic phase of illness compared to healthy participants. The second aim was to compare the SVV measurement tools: the analog bucket test, digital bucket test, and C-SVV© goggles. The SVV scores differed significantly between MD patients and the control group for the analog bucket test (p < 0.001) and the C-SVV^® goggles (p = 0.028), but no significance was shown when using the digital bucket test (p = 0.062). When comparing the analog bucket test and the C-SVV^® goggles applying the calculated threshold (1.125° in analog bucket test, 2.5° in C-SVV^® goggles), the bucket test showed higher accuracy (bucket test 73.84%, C-SVV^® goggles 69.23%). When examining the influence of betahistine on SVV scores, there were no statistically significant differences in both the analog bucket test and C-SVV© goggles. We conclude that SVV test can be used as an additional tool to evaluate utricle function during the chronic phase of MD and that the analog bucket test produces the most reliable results. The intake of betahistine does not influence the perception of SVV.

Identification of Potential Meniere's Disease Targets in the Adult Stria Vascularis

The stria vascularis generates the endocochlear potential and is involved in processes that underlie ionic homeostasis in the cochlear endolymph, both which play essential roles in hearing. The histological hallmark of Meniere's disease (MD) is endolymphatic hydrops, which refers to the bulging or expansion of the scala media, which is the endolymph-containing compartment of the cochlea. This histologic hallmark suggests that processes that disrupt ion homeostasis or potentially endocochlear potential may underlie MD. While treatments exist for vestibular symptoms related to MD, effective therapies for hearing fluctuation and hearing loss seen in MD remain elusive. Understanding the potential cell types involved in MD may inform the creation of disease mouse models and provide insight into underlying mechanisms and potential therapeutic targets. For these reasons, we compare published datasets related to MD in humans with our previously published adult mouse stria vascularis single-cell and single-nucleus RNA-Seq datasets to implicate potentially involved stria vascularis (SV) cell types in MD. Finally, we provide support for these implicated cell types by demonstrating co-expression of select candidate genes for MD within SV cell types.

Long-term efficacy of triple semicircular canal plugging in the treatment of patients with ipsilateral delayed endolymphatic hydrops

This study aims to explore the long-term efficacy of triple semicircular canal plugging (TSCP) in the treatment of intractable ipsilateral delayed endolymphatic hydrops (DEH), so as to provide an alternative therapy for this disease. Forty-eight patients diagnosed with ipsilateral DEH referred to vertigo clinic of our hospital between Dec. 2010 and Dec. 2017, were included in this study for retrospective analysis. All patients were followed up for 2 years. Vertigo control and auditory functions were measured and analyzed. Pure tone audiometry, caloric test, and vestibular evoked myogenic potential (VEMP) were performed in two-year follow-up. Forty-five patients who accepted intratympanic gentamicin (26.7 mg/mL) twice given one week apart were selected as a control group. The total control rate of vertigo in TSCP group was 97.9% (47/48) in the two-year follow-up, with complete control rate of 83.3% (40/48) and substantial control rate of 14.6% (7/48). The rate of hearing loss was 22.9% (11/48). The total control rate of vertigo in intratympanic gentamicin group was 80.0% (36/45), with complete control rate of 57.8% (26/45) and substantial control rate of 22.2% (10/45), and the rate of hearing loss was 20.0% (9/45). The vertigo control rate of TSCP was significantly higher than that of intratympanic gentamicin (χ² = 6.01, p < 0.05). There was no significant difference of hearing loss rate between two groups. (χ² = 0.12, p > 0.05). TSCP, which can reduce vertiginous symptoms in patients with intractable ipsilateral DEH, represents an effective therapy for this disorder.

Cochlear Implantation in Meniere's Disease: A Systematic Review and Meta-Analysis

OBJECTIVES/HYPOTHESIS

Meniere's disease (MD) is a debilitating condition characterized by hearing loss, vertigo, and tinnitus. The objective of this study was to systematically investigate outcomes in MD after cochlear implantation (CoI), with and without labyrinthectomy.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of articles in Medline and Embase was performed to identify all studies of patients with MD who underwent CoI. This analysis evaluates outcomes of speech recognition, pure tone audiometry, vertigo, tinnitus, and quality of life.

RESULTS

Of 321 studies identified, 37 were included, involving 216 patients. Mean age at implantation was 61.4 years (range 27-85 years) with average length of follow-up at 1.7 years (range 0-9 years). Forty-four (20.4%) patients underwent labyrinthectomy. Meta-analysis demonstrated significant improvements in audiometric outcomes following CoI. There was a statistically significant improvement in Hearing in Noise Test performance, with a mean difference improvement of 44.7 (95% confidence interval [CI] [8.8, 80.6]) at 6 months and 60.1 (95% CI [35.3, 85.0]) at 12 months. The Freiburger Monosyllabic Test (FMT) and Consonant-Nucleus-Consonant (CNC) also improved significantly, with mean difference improvements of 46.2 (95% CI [30.0, 62.4]) for FMT and 19.3 (95% CI [8.1, 30.4]) for CNC. There was a statistically significant decrease in tinnitus, as measured by a mean difference reduction of 48.1 (95% CI [1.0, 95.2]) in the Tinnitus Handicap Index.

CONCLUSIONS

CoI with and without simultaneous labyrinthectomy is a viable treatment option for patients with MD, yielding high rates of tinnitus suppression and vertigo control. Post-CoI MD patients demonstrate similar postoperative speech perception outcomes to non-MD implant recipients. Laryngoscope, 131:1845-1854, 2021.

Meniere's disease: Medical management, rationale for vestibular preservation and suggested protocol in medical failure

Meniere's disease is a peripheral audiovestibular disorder characterized by vertigo, hearing loss, tinnitus, and aural fullness. Management of these symptoms includes medical and surgical treatment. Many patients with Meniere's disease can be managed using nonablative therapy, such as intratympanic steroids and endolymphatic shunt surgery, prior to ablative techniques such as intratympanic gentamicin. Recognition of concurrent migraine symptoms may aid in medical therapy and also underscore the importance of preserving vestibular function where possible. The goal of this review is to explain the importance of nonablative therapy options and discuss treatment protocols after medical failure.

Magnetic resonance imaging of the inner ear in the diagnostics of Ménière's disease

Ménière's disease is characterized by sudden episodes of vertigo accompanied by tinnitus and/or feeling of fullness in the ear as well as fluctuating sensorineural hearing loss. Despite numerous studies, the etiology of this disease remains unknown. However, the enlargement of the inner ear's endolymphatic spaces, referred to as endolymphatic hydrops, is considered the underlying condition. Thanks to recent advances in magnetic resonance (MR) technology, it is now possible to obtain in vivo imaging of endolymphatic hydrops in patients presenting with Ménière's disease symptoms. Visualization of the inner ear fluid compartments is achieved after gadolinium contrast is administered into the tympanic cavity or via the intravenous route. Evaluation of endolymphatic hydrops is possible as the contrast agent selectively penetrates the perilymph, and endolymph is visualized as contrast defects. The currently used radiological hydrops grading systems include qualitative, semi-quantitative, and volumetric scales. The methods are subject to ongoing modifications to increase their sensitivity and specificity. Numerous studies describe correlations between clinical symptoms and audiological and otoneurological examination results with the endolymphatic hydrops grade. MRI is also applicable in patients' diagnostics with an incomplete or atypical course of the Ménière's disease. In the course of the treatment, follow-up MRI scans enable assessing individual treatment modalities' efficacy in terms of the severity of lesions and the further course of the disease within the inner ear.

Is Vestibular Meniere's Disease Associated With Endolymphatic Hydrops?

Background: Vestibular Meniere's disease (American Academy of Ophthalmology and Otolaryngology, 1972) also known as possible Meniere's disease (American Academy of Otolaryngology Head and Neck Surgery, 1995) or vestibular type of atypical Meniere's disease (V-AMD) (Japan Society for Equilibrium Research, 2017) is characterized by an episodic vertigo without hearing loss. Though named as Meniere's disease (MD), this entity may not be caused solely by endolymphatic hydrops (EH).

Objective: To estimate the role of EH in vestibular Meniere's disease in comparison with definite Meniere's disease.

Methods: Thirty patients with unilateral definite MD and 16 patients with vestibular Meniere's disease were included. Those who met the criteria for definite or probable vestibular migraine were excluded. All patients underwent vestibular assessments including inner ear MRI 4 h after intravenous gadolinium injection, bithermal caloric testing, directional preponderance of vestibulo-ocular reflex in rotatory chair test, cervical- and ocular-vestibular evoked myogenic potential, stepping test, dizziness handicap inventory (DHI), and hospital anxiety and depression scale (HADS). All above tests and frequency/duration of vertigo spells were compared between vestibular Meniere's disease and MD.

Results: Even in unilateral MD, cochlear and vestibular endolymphatic hydrops (c-, v-EH) were demonstrated not only in the affected side but also in the healthy side in more than half of patients. Positive rate of v-EH in vestibular Meniere's disease (68.8%) was as high as that of MD (80%). In vestibular Meniere's disease, the number of bilateral EH was higher in the vestibule (56.3%) than that in the cochlea (25.0%). There were no differences in vestibular tests and DHI between vestibular Meniere's disease and MD; however, the frequency of vertigo spells was lower in vestibular Meniere's disease (p = 0.001). The total HADS score in the MD group was significantly higher than that in the vestibular Meniere's disease group.

Conclusions: MD is a systemic disease with bilateral involvement of inner ears. V-EH is a major pathophysiology of vestibular Meniere's disease, which would precede c-EH in the development of vestibular Meniere's disease, a milder subtype of MD. MRI is useful for differentiating MD from other vertigo attacks caused by different pathologies in bringing EH into evidence.

Plain Language Summary: Ménière's Disease

This plain language summary explains Ménière's (pronounced men-yerz) disease (MD) to patients. The summary applies to patients aged 18 years and older with a suspected diagnosis of definite or probable MD. It is based on the 2020 "Clinical Practice Guideline: Ménière's Disease." This guideline uses published research to best advise health care providers and patients on the history and physical examination of patients with MD and how to diagnose and treat them. The guideline includes recommendations that are explained in this summary. Recommendations may not apply to every patient but can be used to facilitate shared decision making between patients and their health care providers.