Transitory effect on endolymphatic hydrops of the intratympanic steroids for Ménière's disease

Click SP/AP Area Ratio Vesrus Tone Burst SP Amplitude to Diagnose Ménière's Disease Using Electrocochleography

OBJECTIVES

To evaluate the sensitivity and the specificity of summating potential (SP)/action potential (AP) area under the curve (AUC) ratio by a transtympanic electrode and a click stimulus (TT-CS), SP/AP AUC ratio by an extratympanic electrode and a click stimulus (ET-CS) and SP amplitude value by a transtympanic electrode and tone burst stimulus (TT-TBS) in regard of Ménière's disease (MD) diagnosis. This is the first study that compares SP amplitude value performed by a TT-TBS and the SP/AP AUC ratio performed by a TT-CS.

STUDY DESIGN

Retrospective comparative study.

SETTINGS

Ninety-five patients met the inclusion criteria for electrocochleography (ECochG) testing in a tertiary care center.

METHODS

The sensitivity and specificity of our different ECochG protocols were calculated in regard of the diagnosis of MD.

RESULTS

The patients' mean age was 54 years old (female predominance). The sensitivity and the specificity of SP/AP area ratio by a TT-CS were 88.5% and 70.0%, respectively. On the other hand, the sensitivity and specificity for the SP amplitude value by a TT-TBS were 60.0% and 55.6%, respectively. SP/AP area ratio by TT-CS was statistically better than SP amplitude value by TT-TBS to detect MD disease (P = .016). However, no difference was identified between SP/AP area ratio by ET-CS and SP amplitude value by a TT-TBS (P = .573).

CONCLUSION

SP/AP area ratio by click stimulation has higher sensitivity and specificity to detect MD compared to SP amplitude value by tone burst stimulation. ECochG would be extremely useful in the diagnosis of MD if we use the SP/AP area ratio (sensitivity: 88.5%); therefore, it changes the bad reputation of ECochG sensitivity using SP/AP amplitude ratio (sensitivity: 51.7%) for the diagnosis of MD.

Dexamethasone does not affect endolymphatic hydrops (EH) in patients with Meniere’s disease within 24 h, and intratympanic administration of gadolinium plus dexamethasone simplifies high-quality imaging of EH using a novel protocol of 7 minutes

Background

Intratympanic administration of gadolinium chelate allows for a better visualization of endolymphatic hydrops (EH) using MRI than intravenous injection and was recently further improved to facilitate high-quality imaging of EH in 7 min. The aim of the present study was to simplify the intratympanic administration protocol by mixing gadolinium chelate with therapeutic dexamethasone and to evaluate the effects of this mixture on the visualization of EH in MRI.

Materials and methods

In an in vitro study, the potential impact of gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) on the stability of dexamethasone was evaluated by analyzing dynamic changes in dexamethasone with high-performance liquid chromatography (HPLC) after mixing with Gd-DTPA. Ten patients with definite Meniere's disease (MD) were recruited to study the potential interference of dexamethasone on MRI visualization of EH, and 49 patients with MD were recruited to evaluate the effect of intratympanic injection of Gd-DTPA mixed with dexamethasone on MRI of EH using a 3T MR machine and a novel heavily T2-weighted 3-dimensional fluid-attenuated inversion recovery reconstructed using a magnitude plus zero-filled interpolation (hT₂FLAIR-MZFI) sequence.

Results

The retention times and peak area of dexamethasone in HPLC were not modified by the addition of Gd-DTPA. EH grading in the cochlea and vestibule was not influenced in any ear by intratympanic injection of dexamethasone. Excellent inner ear images were obtained from all patients, and EHs with various grades were displayed. There were significant correlations between diagnosis and cochlear EH (p < 0.01, Spearman's Rho), between diagnosis and vestibular EH (p < 0.01, Spearman's Rho), and between cochlear and vestibular EH (p < 0.01, Spearman's Rho). The distribution of Gd-DTPA plus dexamethasone negatively correlated with the grade of vestibular EH. Injury of the endolymph-perilymph barrier was detected in one cochlea and three vestibules of 59 inner ears with MD.

Conclusions

Intratympanic administration of Gd-DTPA plus dexamethasone yielded high-quality MRI images of EH in patients with MD using a novel 7-min protocol and simplified the clinical application. Intratympanic administration of Gd-DTPA plus dexamethasone might be used to test its therapeutic effect in future work.

Level of evidence

3.

Cyclophosphamide inhibits the progression of Meniere's disease by reducing the generation of circulating immune complex

Endolymphatic hydrops is a characteristic pathological manifestation of Meniere's disease (MD) that has been previously associated with autoimmunity. Interest in the circulating immune complex (CIC) has increased due to its reported role in the occurrence of MD. The present study aimed to investigate the potential value of serum CIC concentration in the diagnosis of MD and the therapeutic potential of cyclophosphamide (CTX) for the treatment of MD. In the present study, guinea pigs were immunized with isologous crude inner ear antigens to establish an autoimmune MD model. Pure tone audiometry, Vestibular-evoked myogenic potential test, electrocochleography test and auditory brainstem response was applied in this study for assessing the severity of MD in guinea pigs. ELISA was applied to measure CIC, tumor necrosis factor α (TNF-α) and heat shock protein 70 (HSP70) expression levels in the serum samples of different groups of patients. Western blotting was applied to detect the protein expression of HSP70 in inner ear tissues in guinea pigs. Hematoxylin and eosin staining was applied to visualize the spiral ganglions in spiral ganglions models. CIC expression in the inner ear was detected by immunohistochemistry. In vivo experiments were performed to confirm the therapeutic effects of CTX in MD. Serum concentrations of CIC, TNF-α and HSP70 were found to be significantly higher in patients with MD, which were also associated with increases in hearing classification and the severity of endolymphatic hydrops. Using a guinea pig MD model, ELISA results revealed significantly increased serum CIC, TNF-α and HSP70 concentrations compared with those in the control group. ABR results showed that the thresholds in the CTX group were notably decreased compared with that in the dexamethasone group, whereas CIC concentrations in the serum were reduced following dexamethasone and CTX treatments compared with those after saline treatment. In the inner ear tissues, the CIC concentration in CTX group was lower than that in the dexamethasone group. Similarly, reductions in HSP70 and TNF-α concentrations was also observed in a similar manner. Immunohistochemistry staining found notably lower CIC deposition in the inner ear tissues following CTX treatment than that in dexamethasone group. Taken together, higher CIC expression can be used as a biomarker for MD diagnosis. The efficacy of CTX in MD was found to be higher compared with that in dexamethasone, which may be associated with the effective inhibition of CIC, HSP70 and TNF-α generation.

Evaluation of vestibular function following endolymphatic sac surgery

PURPOSE

To evaluate objective vestibular function after endolymphatic sac surgery (ELSS) for Menière's disease (MD), using comparative vestibular function tests: videonystagmography (VNG), vestibular evoked myogenic potentials (VEMP) and video head-impulse test (VHIT) METHODS: Patients with definite MD using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) of 1995 criteria modified in 2015 and treated with ELSS (sac decompression or sac opening) were included. The primary outcome was the preservation of vestibular function, comparing pre- and postoperative vestibular function tests: VNG, VEMP, VHIT. Secondary outcomes were control of episodes of vertigo, hearing outcome using AAO-HNS criteria, and QoL using the Menière's disease outcome questionnaire.

RESULTS

73 patients were included in the study. We found a significant preservation of vestibular function as measured by VNG and VHIT. There was no statistical difference in the presence or absence of cervical and ocular (P13/N23 and N1/P1) waves on VEMP pre- and postoperatively. 67% of patients had good control of episodes of vertigo post-operatively, with significantly better results in the sac opening group (75%). There was no significant change in hearing postoperatively, and QoL scores were significantly improved after surgery (p < 0.0001).

CONCLUSION

Endolymphatic sac surgery (ELSS) is a conservative surgical treatment, which does not negatively impact vestibular function. It was associated with improved control of episodes of vertigo, preservation of hearing, and a clear improvement in QoL scores. Despite its pathophysiology not being fully understood, it remains a first-line procedure preserving vestibular function, for MD refractory to medical management.

A comparison of endolymphatic shunt surgery and intratympanic gentamicin for meniere's disease

OBJECTIVE

To report audiovestibular outcomes following endolymphatic shunt surgery (ELS) and intratympanic gentamicin injections (ITG) in patients with Meniere's disease (MD).

STUDY DESIGN

Retrospective matched cohort study METHODS: Patients with MD refractory to medical management between 2004 and 2017 were reviewed: 44 patients underwent ELS and had outcomes available, while 27 patients underwent ITG and had outcomes available. Mean follow-up durations for the ELS and ITG groups were 39.1 and 43.3 months, respectively. Twenty-six patients from the ELS group and 24 patients from the ITG group were then included in a pretreatment hearing- and age-matched analysis. Main outcome measures were successful control of vertigo, pure-tone average (PTA; 0.5, 1, 2 and 4 kHz), word recognition score (WRS), and treatment complications.

RESULTS

A matched analysis showed vertigo control rates of 73.1% in the ELS group and 66.8% in the ITG group, which were not significantly different (P = .760). The change in PTA following treatment was statistically similar between the ELS group (6.2 dB) and ITG group (4.6 dB) (P = .521), while the change in WRS for the ELS group (+3.9 %) was significantly more favorable than the ITG group (-13.6 %) (P = .046). Chronic post-treatment unsteadiness was reported in 25.0% of the ITG group and was not encountered in the ELS group (P = .009).

CONCLUSION

ELS provided successful vertigo control at least as well as ITG with a lower incidence of audiovestibular complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2455-2460, 2020.

A systematic review and meta-analysis of extratympanic electrocochleography in Ménière's disease diagnosis

Objective: Determine whether a combination of electrocochleography determined summating/action potential (SP/AP) ratio and other audiological measurements has greater sensitivity and specificity than that achieved with electrocochleography SP/AP ratio alone in diagnosing definite Ménière's Disease. Design: Systematic review and meta-analysis. Study sample: Pubmed, Cochrane Library, and Web of Science were searched using search terms "electrocochleography", "ECochG, ,"ECoG", "Ménière's Disease", and "Idiopathic Endolymphatic Hydrops". Inclusion criteria were extratympanic electrocochleography methodology, English language publication between January 2002 and December 2017, and the 1995 American Academy of Otolaryngology and Head and Neck Surgery Ménière's disease diagnostic criteria. Five articles satisfied inclusion criteria and were sufficiently detailed for aggregate quantitative analysis of SP/AP ratio (315 subjects) and combination audiological measures (113 subjects). Results: The diagnostic sensitivity and specificity of the SP/AP amplitude ratio was 47.6% and 83.8% and of combination diagnostic measures 63.5% and 89.3%, respectively. Point estimates of sensitivity (p = 0.248) and specificity (p = 0.969) and the summary Receiver Operator Characteristic Curve (p = 0.407) were not statistically significant. Conclusion: Statistically, combination diagnostic measures do not result in greater accuracy of definite Ménière's disease diagnosis compared to the SP/AP amplitude ratio alone. However, given the small sample size further studies are recommended to arrive at a definitive conclusion.

Intratympanic (IT) Therapies for Menière's Disease: Some Consensus Among the Confusion

Purpose of Review

Aminoglycosides and corticosteroids are commonly used to treat Menière's disease. Intratympanic (IT) administration of these medications allows high inner ear concentrations without significant adverse systemic effects. As a direct result, IT therapy has grown in popularity. Recent studies have compared patient outcomes between IT aminoglycosides and corticosteroids. This review summarizes these findings.

Recent Findings

Trials comparing IT corticosteroids to IT placebo or oral therapy have had conflicting results. Most recently, Lambert et al. investigated the effect of IT dexamethasone in a sustained-release formulation compared to placebo. Their findings demonstrated improvement in some secondary measures of vertigo with the sustained-release formulation.IT gentamicin is known to be effective in controlling vertigo in Menière's disease. In a recent study from 2016, Patel et al compared IT gentamicin and IT methylprednisolone in a double-blind, randomized controlled trial and identified no significant differences between the two in vertigo control.

Summary

IT injections of aminoglycosides and corticosteroids can improve vertigo control. Hearing and vestibular loss however may result with IT aminoglycosides. Corticosteroids demonstrate limited hearing loss but may not have the same efficacy in controlling vertigo. Further investigation in the etiology of Menière's disease is needed to tailor the proposed treatment to suit the disease mechanism.

The Short- and Long-Term Outcome of Intratympanic Steroid Therapy as a Salvage Treatment for Acute Low-Tone Sensorineural Hearing Loss without Episodes of Vertigo

OBJECTIVES

To evaluate the hearing outcomes of intratympanic steroid (ITS) treatment for patients with acute low-tone sensorineural hearing loss (ALHL) after failure of initial therapy and to investigate the recurrence and progression to definite Ménière's disease (MD) during a long-term follow-up.

METHODS

We retrospectively reviewed the medical records of 90 patients with refractory ALHL who were followed up for at least 1 year between January 2000 and April 2014. Patients who responded poorly to initial medical treatment received intratympanic dexamethasone injections (ITS group) or isosorbide administration for 4 weeks (diuretic group) as salvage treatment options according to their choice of management. The control group did not receive ITS or the diuretic, due to their refusal of both medical treatments. The hearing outcomes were evaluated 1 month, 1 year and 5 years after the completion of the second-line therapy, and the rates of recurrence and progression to MD were measured during a follow-up period of at least 1 year.

RESULTS

Twenty-seven patients in the ITS group, 39 patients in the diuretic group and 24 patients in the control group were enrolled. Of these, 12 patients in the ITS group, 15 patients in the diuretic group and 12 patients in the control group were followed up for over 5 years. We found that the recovery rates and the audiometric functional values after 1 month and 1 year in the ITS group were significantly higher than those in the diuretic and control groups. However, there were no significant differences in the recovery rates or the audiometric functional values after 5 years, or in the rates of recurrence and progression to MD between the groups.

CONCLUSIONS

Salvage ITS therapy can provide a relatively good short-term hearing outcome for ALHL patients who have persistent hearing loss despite conventional treatment. However, both recurrence and progression to MD after treatment were observed in some patients during the long-term follow-up.

The effect of intra-tympanic dexamethasone on the vestibular function in patients with recurrent vertigo

CONCLUSION

The low clinical efficacy of the treatment for patients included in this work correlates with no noticeable effect on the vestibular function.

OBJECTIVE

To assess follow-up in patients with idiopathic and secondary Ménière's disease after treatment with intra-tympanic dexamethasone and correlate clinical findings with changes in the vestibular-ocular reflex elicited after stimulation of each of the six semicircular canals.

METHODS

This is a single center retrospective review of patients presenting the clinical symptomatology of Meniérè's disease treated with intra-tympanic dexamethasone. An audiometric evaluation was performed in each patient before and after treatment. The study cohort was divided into two groups: those evaluated after a short period of time and after a long period of time.

RESULTS

The study included 30 patients, mean age = 61 years. Differences in mean pure-tone average before and after treatment were non-significant for both treated (0.61 dB, p = 0.723) and untreated (0.59 dB, p = 0.609) ears. Vestibular-ocular reflex gain averages in the treated ear after treatment were 0.73 (superior semicircular canal), 0.86 (horizontal semicircular canal), and 0.69 (posterior semicircular canal). The gain did not vary significantly in the Superior (p = 0.194), the Horizontal (p = 0.646), or the Posterior Semicircular Canal (p = 0.820). Similar were obtained for the untreated ear.