On the classification of hydropic ear disease (Menière's disease)

[Psychosomatic medicine for patients with Meniere's disease]

BACKGROUND

Unpredictable attacks of vertigo with or without emesis, unilateral hearing loss, and tinnitus characterize the inner ear disorder that is classified as part of Meniere's disease (MD). While the pathological final stage with cochleovestibular hydrops seems to be certain as a component of MD, there are many uncertainties with respect to the multifactorial pathogenesis. It is certain that the disease can have effects in addition to the attack, which questions the treatment of things that were previously taken for granted. Persistent perceptual and postural dizziness [19] and reactive psychogenic dizziness [18] can occur, so that during the course of the disease, a mixed picture of organic and psychogenic dizziness can develop. In addition, there is an increased anxiety and depression comorbidity. The course, suffering, and experience of the disease depend essentially on the processing and the active acquisition of coping strategies as well as-also the medical-treatment of the patient(s), who in their distress seek and need a knowledgeable and reliable practitioner at their side.

OBJECTIVE

The effects on the affected persons and suggestions for the most helpful treatment of Meniere's disease sufferers shall be described here in detail.

Assessing the optimal MRI descriptors to diagnose Ménière's disease and the added value of analysing the vestibular aqueduct

OBJECTIVES

To evaluate the diagnostic performance and reliability of MRI descriptors used for the detection of Ménière's disease (MD) on delayed post-gadolinium MRI. To determine which combination of descriptors should be optimally applied and whether analysis of the vestibular aqueduct (VA) contributes to the diagnosis.

MATERIALS AND METHODS

This retrospective single centre case-control study evaluated delayed post-gadolinium MRI of patients with Ménièriform symptoms examined consecutively between Dec 2017 and March 2023. Two observers evaluated 17 MRI descriptors of MD and quantified perilymphatic enhancement (PLE) in the cochlea. Definite MD ears according to the 2015 Barany Society criteria were compared to control ears. Cohen's kappa and diagnostic odds ratio (DORs) were calculated for each descriptor. Forward stepwise logistic regression determined which combination of MRI descriptors would best predict MD ears, and the area under the receiver operating characteristic curve for this model was measured.

RESULTS

A total of 227 patients (mean age 48.3 ± 14.6, 99 men) with 96 definite MD and 78 control ears were evaluated. The presence of saccular abnormality (absent, as large as or confluent with the utricle) performed best with a DOR of 292.6 (95% confidence interval (CI), 38.305-2235.058). All VA descriptors demonstrated excellent reliability and with DORs of 7.761 (95% CI, 3.517-17.125) to 18.1 (95% CI, 8.445-39.170). Combining these saccular abnormalities with asymmetric cochlear PLE and an incompletely visualised VA correctly classified 90.2% of cases (sensitivity 84.4%, specificity 97.4%, AUC 0.938).

CONCLUSION

Either absent, enlarged or confluent saccules are the best predictors of MD. Incomplete visualisation of the VA adds value to the diagnosis.

CLINICAL RELEVANCE STATEMENT

A number of different MRI descriptors have been proposed for the diagnosis of Ménière's disease, but by establishing the optimally performing MRI features and highlighting new useful descriptors, there is an opportunity to improve the diagnostic performance of Ménière's disease imaging.

KEY POINTS

• A comprehensive range of existing and novel vestibular aqueduct delayed post-gadolinium MRI descriptors were compared for their diagnostic performance in Ménière's disease. • Saccular abnormality (absent, confluent with or larger than the utricle) is a reliable descriptor and is the optimal individual MRI predictor of Ménière's disease. • The presence of this saccule descriptor or asymmetric perilymphatic enhancement and incomplete vestibular aqueduct visualisation will optimise the MRI diagnosis of Ménière's disease.

[Validity of the German Menière's Disease Patient-Oriented Symptom Severity Index]

BACKGROUND

The MD POSI is a disease-specific questionnaire to determine the health-related quality of life (HRQoL) of patients with Menière's disease (MD).

OBJECTIVES

Validity and reliability of the German translation of the MD POSI.

MATERIAL AND METHODS

Prospective data analysis of a patient group with vertigo (n = 162), which was treated in the otorhinolaryngology of a University Hospital from 2005-2019. A clinical selection was made according to the new Bárány classification in a "definite" and "probable" Menière's disease. HRQoL was assessed using the German translation of the MD POSI, the Vertigo Symptom Score (VSS) and the Short Form (SF-36). Reliability was measured by Cronbach's α and test-retesting after 12 months and again 2 weeks later. Content and agreement validity were examined.

RESULTS

Cronbach α values greater than 0.9 indicated good internal consistency. There was no statistically significant difference from baseline to 12 months, except for the subscore "during the attack". There were significant positive correlations between the VSS overall/VER/AA and the overall index of the MD POSI and negative significant correlations with the SF-36 domains physical functioning, physical role functioning, social functioning, emotional role functioning, mental well-being. There were low SRM (standardized response mean) values below 0.5.

CONCLUSIONS

The German translation of the MD POSI is a valid and reliable instrument to evaluate the impact of MD on patients' disease-specific quality of life.

Delayed post gadolinium MRI descriptors for Meniere's disease: a systematic review and meta-analysis

OBJECTIVES

Delayed post-gadolinium magnetic resonance imaging (MRI) detects changes of endolymphatic hydrops (EH) within the inner ear in Meniere's disease (MD). A systematic review with meta-analysis was conducted to summarise the diagnostic performance of MRI descriptors across the range of MD clinical classifications.

MATERIALS AND METHODS

Case-controlled studies documenting the diagnostic performance of MRI descriptors in distinguishing MD ears from asymptomatic ears or ears with other audio-vestibular conditions were identified (MEDLINE, EMBASE, Web of Science, Scopus databases: updated 17/2/2022). Methodological quality was evaluated with Quality Assessment of Diagnostic Accuracy Studies version 2. Results were pooled using a bivariate random-effects model for evaluation of sensitivity, specificity and diagnostic odds ratio (DOR). Meta-regression evaluated sources of heterogeneity, and subgroup analysis for individual clinical classifications was performed.

RESULTS

The meta-analysis included 66 unique studies and 3073 ears with MD (mean age 40.2-67.2 years), evaluating 11 MRI descriptors. The combination of increased perilymphatic enhancement (PLE) and EH (3 studies, 122 MD ears) achieved the highest sensitivity (87% (95% CI: 79.92%)) whilst maintaining high specificity (91% (95% CI: 85.95%)). The diagnostic performance of "high grade cochlear EH" and "any EH" descriptors did not significantly differ between monosymptomatic cochlear MD and the latest reference standard for definite MD (p = 0.3; p = 0.09). Potential sources of bias were case-controlled design, unblinded observers and variable reference standard, whilst differing MRI techniques introduced heterogeneity.

CONCLUSIONS

The combination of increased PLE and EH optimised sensitivity and specificity for MD, whilst some MRI descriptors also performed well in diagnosing monosymptomatic cochlear MD.

KEY POINTS

• A meta-analysis of delayed post-gadolinium magnetic resonance imaging (MRI) for the diagnosis of Meniere's disease is reported for the first time and comprised 66 studies (3073 ears). • Increased enhancement of the perilymphatic space of the inner ear is shown to be a key MRI feature for the diagnosis of Meniere's disease. • MRI diagnosis of Meniere's disease can be usefully applied across a range of clinical classifications including patients with cochlear symptoms alone.

Assessing the usefulness of inner ear contrast-enhanced magnetic resonance imaging and pure-tone audiometry in estimating the prognostic value of hearing improvement in patients with definite Meniere's disease

PURPOSE

Meniere's disease (MD) is characterized by combined cochlear and vestibular symptoms. However, its underlying cause remains unclear, with low-to-mid-tone hearing impairment being predominantly reported. Moreover, predicting hearing improvement after disease onset is not possible. This study aimed to assess whether hearing improvement in patients with definite MD (DMD) could be predicted using inner ear contrast magnetic resonance imaging (IEC-MRI) and pure-tone audiometry (PTA) at disease attack.

MATERIALS AND METHODS

Between April 2020 and March 2022, seven outpatients with DMD were enrolled based on the Bárány Society DMD criteria. The patients were divided into two groups: low-tone hearing loss (LTL) group and low-to-mid-tone hearing loss (LMTL) group. Hearing improvement rates as well as the possible inter-relation between endolymphatic hydrops and hearing improvement were evaluated.

RESULTS

Endolymphatic hydrops was found in two of four LTL cases. One of three LMTL cases had prominent lymphedema. All patients with LTL but only one patient with LMTL had hearing improvement. Endolymphatic hydrops was not found to be correlated with hearing improvement.

CONCLUSIONS

Estimating hearing improvement in patients with DMD using IEC-MRI was not possible. However, PTA showed better hearing prognosis in LTL than in LMTL. Therefore, estimating hearing improvement using PTA was possible at disease attack.

Subjective Visual Vertical and Vestibular Evoked Myogenic Potential in Meniere's disease

OBJECTIVE

To evaluate otolith function by comparing the findings of the Subjective Visual Vertical, the cervical Vestibular Evoked Myogenic Potential and the ocular Vestibular Evoked Myogenic Potential tests in patients in the inter-crisis period of unilateral definite Meniere's disease.

METHODS

The sample consisted of an experimental group (n=22; 10 men and 12 women, mean age 47.32±12.82 years) with definite unilateral Meniere's disease and a control group (n=14; 5 men and 9 women, with a mean age of 41.64±13.45 years). They all underwent vestibular evaluation by means of Subjective Visual Vertical with the bucket method and, cervical and ocular Vestibular Evoked Myogenic Potential tests. The data were collected and subjected to statistical analysis.

RESULTS

The results of the comparison of the Subjective Visual Vertical, the cervical Vestibular Evoked Myogenic Potential, the ocular Vestibular Evoked Myogenic Potential and, the association of cervical Vestibular Evoked Myogenic Potential with the ocular Vestibular Evoked Myogenic Potential showed no significant difference, indicating concordance among the tests.

CONCLUSION

The identified abnormalities and the concordance between the combined proportion of the Subjective Visual Vertical, the cervical Vestibular Evoked Myogenic Potential and the ocular Vestibular Evoked Myogenic Potential findings indicate that the association of these three tests contributes to the identification of sustained and transient otolith dysfunction in the inter-crisis of unilateral definite Meniere's disease.

LEVEL OF EVIDENCE: 2

Consensus on MR Imaging of Endolymphatic Hydrops in Patients With Suspected Hydropic Ear Disease (Meniere)

Endolymphatic hydrops (EH) is considered the histological hallmark of Meniere's disease. Visualization of EH has been achieved by special sequences of inner ear magnetic resonance imaging (MRI) with a gadolinium-based contrast agent via intravenous or intratympanic administration. Although it has been applied for more than 10 years since 2007, a unified view on this technique has not yet been achieved. This paper presents an expert consensus on MRI of endolymphatic hydrops in the following aspects: indications and contra-indications for patient selection, methods of contrast-agent administration (intravenous or intratympanic), MRI sequence selection, the specific scanning parameter settings, and standard image evaluation methods and their advantages and disadvantages. For each part of this consensus, a comment is attached to elucidate the reasons for the recommendation.

Hydropic Ear Disease: Correlation Between Audiovestibular Symptoms, Endolymphatic Hydrops and Blood-Labyrinth Barrier Impairment

Research Objective: To investigate the correlation between clinical features and MRI-confirmed endolymphatic hydrops (EH) and blood-labyrinth barrier (BLB) impairment. Study Design: Retrospective cross-sectional study. Setting: Vertigo referral center (Haga Teaching Hospital, The Hague, the Netherlands). Methods: We retrospectively analyzed all patients that underwent 4 h-delayed Gd-enhanced 3D FLAIR MRI at our institution from February 2017 to March 2019. Perilymphatic enhancement and the degree of cochlear and vestibular hydrops were assessed. The signal intensity ratio (SIR) was calculated by region of interest analysis. Correlations between MRI findings and clinical features were evaluated. Results: Two hundred and fifteen patients with MRI-proven endolymphatic hydrops (EH) were included (179 unilateral, 36 bilateral) with a mean age of 55.9 yrs and median disease duration of 4.3 yrs. Hydrops grade is significantly correlated with disease duration (P < 0.001), the severity of low- and high-frequency hearing loss (both P < 0.001), and the incidence of drop attacks (P = 0.001). Visually increased perilymphatic enhancement was present in 157 (87.7%) subjects with unilateral EH. SIR increases in correlation with hydrops grade (P < 0.001), but is not significantly correlated with the low or high Fletcher index (P = 0.344 and P = 0.178 respectively). No significant differences were found between the degree of EH or BLB impairment and vertigo, tinnitus or aural fullness. Conclusion: The degree of EH positively correlates with disease duration, hearing loss and the incidence of drop attacks. The BLB is impaired in association with EH grade, but without clear contribution to the severity of audiovestibular symptoms.

The Additional Value of Endolymphatic Hydrops Imaging With Intratympanic Contrast for Diagnostic Work-Up-Experience From a Neurotology Center in Austria

Objective: To illustrate the merit of hydrops imaging during clinical workup of dizziness and balance disorders. Background: Ever since the first description of in-vivo endolymphatic hydrops imaging in 2007, this diagnostic tool has been implemented in an increasing number of centers. The more experience in its clinical application is gathered, the more it is possible to critically assess its potential value for the diagnostic workup. This article intends to provide information about the experience of handling and utilization of endolymphatic hydrops imaging in one of the first centers in Austria. Methods: Retrospective analysis and review of clinical cases. Results: Based on our experience of endolymphatic hydrops imaging (EHI), which was established in cooperation between our departments of radiology and otorhinolaryngology in 2017, we have exclusively used intratympanic application of a contrast agent prior to magnetic resonance imaging, as this approach provides high quality imaging results. In 42.6% of cases, EHI could lead to the diagnosis of MD or HED. Since precise vestibular examination is still necessary, EHI is not a tool to replace the clinical examination but rather to add significantly to the interpretation of the results. Conclusion: Endolymphatic hydrops imaging represents a valuable, safe and well-applicable tool for evaluating cases with inconclusive clinical results. However, its potential additional diagnostic benefits rely on a correct indication based on prior thorough vestibular investigations.

Cortical Activity During an Attack of Ménière's Disease-A Case Report

Background: Ménière's disease (MD) is a chronic peripheral vestibular disorder with recurrent episodes of vertigo accompanied by fluctuating hearing loss, tinnitus and aural fullness in the affected ear. There are several unanswered fundamental questions regarding MD, one of these being cortical activity during a MD attack. However, it is not possible to plan an investigation in an episodic disease as MD. Objective: To visualize cortical activity during an attack of MD. Method: ¹⁸F-FDG PET scans were used to visualize cortical activity in a 62 years old male suffering from definite MD. Two ¹⁸F-FDG PET scans were performed. One to show activity during the attack and one to show normal baseline brain activity 7 days after the attack. Results: A number of low-magnitude fluctuations in the ¹⁸F-FDG FDG uptake were found in ¹⁸F-FDG PET examination following the MD attack compared to the patient's own baseline ¹⁸F-FDG FDG scan. Across both hemispheres no significant changes were seen. However, reduced activity was observed in most of the orbitofrontal, frontal cortices as well as Heschl's gyrus and insula. Conclusion: This is the first neuroimaging showing alteration of brain activity during an attack in a patient with MD. No strong focal alterations was seen. It is noteworthy that the decreased activity observed was in the insula and Heschl's gyrus that seems to be core areas for processing information from the labyrinth. It is also of interest that decreased activity rather than hyperactivity was observed.

MR Imaging of Cochlear Modiolus and Endolymphatic Hydrops in Patients With Menière's Disease

Background: Menière's disease (MD) is an inner ear disorder characterized by recurrent episodes of spontaneous vertigo, unilateral low-frequency sensorineural hearing loss, tinnitus, and aural fullness. Current diagnosis still often has to rely on subjective and audiometric criteria only, although endolymphatic hydrops is recognized as the pathophysiological substrate of the disease, having been demonstrated in anatomical pathological studies and by magnetic resonance (MRI). The modiolus has a close functional and anatomical relationship with the cochlear nerve and membranous labyrinth and can be evaluated with MRI but no data exist on the modiolar size in MD.

Purpose: Our purpose is to examine the following hypothesis. Is cochlear modiolus smaller in symptomatic ears in MD?

Methods: We used a retrospective 3 Tesla MR study (heavily T2-weighted 3D fast asymmetric spin-echo images and 0.5 mm slice thickness) comparing the mean modiolar area (MMA) in the index and best ears of eight patients with definite MD based on audiometric data. The obtained MMA values were compared against the audiometric data and the presence of vestibular endolymphatic hydrops.

Results: No differences were seen in MMA between best and worst ears. Ears with a pure tone average (PTA) ≥25 dB and more pronounced endolymphatic hydrops showed lower MMA (not statistically significant). Two patients with extreme endolymphatic hydrops showed a noteworthy ipsilateral decrease in the cochlear modiolus area.

Conclusion: No differences were seen in MMA between best and worst ears in definite MD. Worse hearing function (PTA ≥ 25dB) and more pronounced endolymphatic hydrops seem to be associated with lower MMA. This might be related to bone remodeling as a consequence of endolymphatic hydrops. Further research is needed to corroborate and explore these findings.

Magnetic resonance imaging and Ménière's disease-unavoidable alliance

Ménière's disease (MD) is a clinical syndrome characterized by recurrent episodes of spontaneous vertigo, unilateral fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Endolymphatic hydrops is recognized as the pathophysiological substrate of the disease, having been demonstrated in anatomical pathological studies and more recently by magnetic resonance imaging (MRI). The current criteria of the disease, however, remain symptom based and do not include the demonstration of endolymphatic hydrops. The authors review MRI techniques and diagnostic criteria of endolymphatic hydrops and the role of MRI in MD is discussed.

Endolymphatic Hydrops in Fluctuating Hearing Loss and Recurrent Vertigo

Background: Endolymphatic hydrops (EH) is the histopathological hallmark of Ménière's disease (MD) and has been found by in vivo magnetic resonance imaging (MRI) in patients with several inner ear syndromes without definite MD criteria. The incidence and relevance of this finding is under debate.

Purpose: The purpose of the study is to evaluate the prevalence and characteristics of EH and audiovestibular test results in groups of patients with fluctuating audiovestibular symptoms not fulfilling the actual criteria for definite MD and compare them with a similar group of patients with definite MD and a group of patients with recent idiopathic sudden neurosensory hearing loss (ISSNHL).

Material and Methods: 170 patients were included, 83 with definite MD, 38 with fluctuating sensorineural hearing loss, 34 with recurrent vertigo, and 15 with ISSNHL. The clinical variables, audiovestibular tests, and EH were evaluated and compared. Logistic proportional hazard models were used to obtain the odds ratio for hydrops development, including a multivariable adjusted model for potential confounders.

Results: No statistical differences between groups were found regarding disease duration, episodes, Tumarkin spells, migraine, vascular risk factors, or vestibular tests; only hearing loss showed differences. Regarding EH, we found significant differences between groups, with odds ratio (OR) for EH presence in definite MD group vs. all other patients of 11.43 (4.5–29.02; p < 0.001). If the ISSNHL group was used as reference, OR was 55.2 (11.9–253.9; p < 0.001) for the definite MD group, 9.9 (2.1–38.9; p = 0.003) for the recurrent vertigo group, and 5.1 (1.2–21.7; p = 0.03) for the group with fluctuating sensorineural hearing loss.

Conclusion: The percentage of patients with EH varies between groups. It is minimal in the ISSNHL group and increases in groups with increasing fluctuating audiovestibular symptoms, with a rate of severe EH similar to the known rate of progression to definite MD in those groups, suggesting that presence of EH by MRI could be related to the risk of progression to definite MD. Thus, EH imaging in these patients is recommended.

On the Relationship Between Menière's Disease and Endolymphatic Hydrops

: The relationship between Menière's disease and endolymphatic hydrops is ambiguous. On the one hand, the existence of cases of endolymphatic hydrops lacking the classic symptoms of Menière's disease has prompted the assertion that endolymphatic hydrops alone is insufficient to cause symptoms and drives the hypothesis that endolymphatic hydrops is a mere epiphenomenon. Yet, on the other hand, there is considerable evidence suggesting a relationship between the mechanical pressure effects of endolymphatic hydrops and resultant disordered auditory physiology and symptomatology. A critical appraisal of this topic is undertaken, including a review of key histopathologic data chiefly responsible for the epiphenomenon hypothesis. Overall, a case is made that A) the preponderance of available evidence suggests endolymphatic hydrops is likely responsible for some of the auditory symptoms of Menière's disease, particularly those that can be modulated by mechanical manipulation of the basilar membrane and cochlear microphonic; B) Menière's disease can be reasonably considered part of a larger spectrum of hydropic inner ear disease that also includes some cases that lack vertigo. C) The relationship with endolymphatic hydrops sufficiently robust to consider its presence a hallmark defining feature of Menière's disease and a sensible target for diagnostic detection.

The Importance of the Temporal Bone 3T MR Imaging in the Diagnosis of Menière's Disease

BACKGROUND

The aim of this study was to evaluate endolymphatic hydrops using the 3T temporal bone magnetic resonance imaging (MRI), performed according to the chosen protocol, and determine whether it could be applied as an objective diagnostic tool for Menière's disease.

METHODS

105 participants diagnosed with probable (n = 50) and definite (n = 55) Menière's disease were included in this prospective study at Vilnius University Hospital, Santaros Clinics. Audiometry, vestibular function tests, videonystagmography, and computer posturography were performed before MRI. The 3T MRI with gadolinium contrast was performed to evaluate the endolymphatic hydrops. Imaging protocol consisted of 3D-FLAIR and 3D T2DRIVE sequences. Vestibular endolymphatic sac was interpreted as enlarged if occupied more than 50% of the vestibular area.

RESULTS

78.1% of subjects had abnormal MRI findings other than hydrops, and it was more than 90% (50/55) of patients in the definite MD group (p < 0.001). Changes in caloric test were observed in 63.8% of subjects in general, and in 76.4% of patients with a definite Menière's disease. The side of the endolymphatic hydrops observed on MR imaging corresponded to the clinical diagnosis of the Menière's disease based on the results of audiometry (p < 0.001) and unilateral weakness (p < 0.001). Endolymphatic hydrops on MRI and directional preponderance in caloric test were two independent predictors of the definite Menière's disease.

CONCLUSIONS

Temporal bone 3T MRI with gadolinium contrast is clinically superior to confirm the diagnosis of Menière's disease. Grade II endolymphatic hydrops on MRI, directional preponderance, and unilateral weakness on caloric test were independent predictors for the definite Menière's disease.

Laterality of Audiovestibular Symptoms Predicts Laterality of Endolymphatic Hydrops in Hydropic Ear Disease (Menière)

BACKGROUND

For clinical confirmation of the diagnosis of hydropic ear disease (HED) (Menière) by MR imaging, two routes of contrast enhancement of the perilymphatic space are currently being used: intratympanic and intravenous. While unilateral intratympanic contrast application generally enables a higher perilymph signal intensity and image quality, the intravenous route allows for imaging of both inner ears simultaneously. It is conceivable that intratympanic contrast application to one ear would result in a failure to detect endolymphatic hydrops in a given patient if the hydrops is present only in the other ear. Therefore, in this study we examined the question whether the ear with the greater degree of endolymphatic hydrops may be predicted based on clinical features.

METHODS

Retrospective study of 50 patients with HED confirmed on MR imaging. Three tesla MR imaging with 3D fluid attenuated inversion recovery 4 hours after intravenous gadolinium contrast application was used to detect endolymphatic hydrops. The index ear was defined by auditory symptoms during attacks, low frequency hearing loss, and caloric canal paresis.

RESULTS

In all patients the ear with more severe symptoms corresponded with the ear showing the more severe hydrops on MR imaging.

CONCLUSION

In summary, in this study population the degree of low-frequency hearing loss (250 Hz-1 kHz) in combination with auditory symptoms during attacks identified the ear with the greater extent of endolymphatic hydrops in all patients. In conclusion, intratympanic contrast application to the index ear seems to be sufficient to confirm the diagnosis of HED (Menière) on MR imaging.

Clinical high-resolution imaging and grading of endolymphatic hydrops in Hydropic Ear Disease at 1.5 T using the two-slice grading for vestibular endolymphatic hydrops in less than 10 min

BACKGROUND

Hydropic Ear Disease (Menière) is one of the most common inner ear disorders and one of the most common causes of vertigo attacks. The underlying pathology is a distension of the endolymphatic space of the inner ear, termed endolymphatic hydrops. However, the unequivocal morphologic confirmation of ELH has been restricted to post-mortem histologic analysis until 2007, when the first clinical MR imaging report demonstrated ELH in living patients with Menière's disease at 3 T combined with intratympanic application of contrast. Imaging techniques have since then evolved further. However, a high magnetic field strength of 3 T has consistently been mandatory for reliable clinical imaging of ELH. This limitation has significantly prevented ELH imaging from being widely available across different health care systems around the world. With the aim of filling this gap, in the present study, we aim to describe the feasibility of ELH imaging at 1.5 T in clinical practice and to develop a dedicated grading system for cochlear and vestibular ELH for MR imaging at 1.5 T.

METHODS

In this retrospective study, we examined 30 patients with suspected hydropic ear disease undergoing diagnostic MR imaging. Contrast agent was diluted eightfold in saline solution and unilaterally applied by intratympanic injection as described previously. MRI scanning was performed using a 16-channel head coil on a 1.5 T Achieva Philips Medical Systems Scanner using a 3D FLAIR sequence. For the cochlea, a 3-stage grading was developed. For the vestibulum, a 4-stage grading based on two axial slices was developed by analysing both the superior and the inferior part of the vestibulum. The presence of hydropic herniation of the endolymphatic space into the posterior crus of the horizontal semicircular canal was evaluated.

RESULTS

In all 30 patients, the perilymphatic fluid spaces of the inner ear showed clear and high signal intensity, while the endolymphatic space was not enhanced. In all patients, the vestibular endolymphatic space could be clearly delineated and differentiated from the perilymphatic space. Analysis of the cochlear endolymphatic space revealed no evidence of ELH in 7 patients, a grade 1 cochlear ELH in 11 patients and a grade 2 cochlear ELH in 12 patients. Analysis of the vestibular endoylmphatic space revealed no evidence of ELH in 8 patients, a grade 1 vestibular ELH in 5 patients, a grade 2 vestibular ELH in 9 patients and a grade 3 vestibular ELH in 8 patients. Three patients showed a clear hydropic herniation of the vestibular endolymphatic space into the posterior non-ampullated crus of the horizontal SCC.

CONCLUSION

In summary, the findings presented in this study offer an easy, reliable and universally available technique of ELH imaging for diagnostic management of patients with suspected Hydropic Ear Disease.

The "hype" of hydrops in classifying vestibular disorders: a narrative review

Background

Classifying and diagnosing peripheral vestibular disorders based on their symptoms is challenging due to possible symptom overlap or atypical clinical presentation. To improve the diagnostic trajectory, gadolinium-based contrast-enhanced magnetic resonance imaging of the inner ear is nowadays frequently used for the in vivo confirmation of endolymphatic hydrops in humans. However, hydrops is visualized in both healthy subjects and patients with vestibular disorders, which might make the clinical value of hydrops detection on MRI questionable.

Objective

To investigate the diagnostic value of clinical and radiological features, including the in vivo visualization of endolymphatic hydrops, for the classification and diagnosis of vestibular disorders.

Methods

A literature search was performed in February and March 2019 to estimate the prevalence of various features in healthy subjects and in common vestibular disorders to make a graphical comparison between healthy and abnormal.

Results

Of the features studied, hydrops was found to be a highly prevalent feature in Menière’s disease (99.4%). Though, hydrops has also a relatively high prevalence in patients with vestibular schwannoma (48.2%) and in healthy temporal bones (12.5%) as well. In patients diagnosed with (definite or probable) Menière’s disease, hydrops is less frequently diagnosed by magnetic resonance imaging compared to the histological confirmation (82.3% versus 99.4%). The mean prevalence of radiologically diagnosed hydrops was 31% in healthy subjects, 28.1% in patients with vestibular migraine, and 25.9% in patients with vestibular schwannoma. An interesting finding was an absolute difference in hydrops prevalence between the two diagnostic techniques (histology and radiology) of 25.2% in patients with Menière’s disease and 29% in patients with vestibular schwannoma.

Conclusions

Although the visualization of hydrops has a high diagnostic value in patients with definite Menière’s disease, it is important to appreciate the relatively high prevalence of hydrops in healthy populations and other vestibular disorders. Endolymphatic hydrops is not a pathognomic phenomenon, and detecting hydrops should not directly indicate a diagnosis of Menière’s disease. Both symptom-driven and hydrops-based classification systems have disadvantages. Therefore, it might be worth to explore features “beyond” hydrops. New analysis techniques, such as Radiomics, might play an essential role in (re)classifying vestibular disorders in the future.

Electronic supplementary material

The online version of this article (10.1007/s00415-020-10278-8) contains supplementary material, which is available to authorized users.

State of the Art Imaging in Menière’s Disease. Tips and Tricks for Protocol and Interpretation

Purpose of Review

Menière’s disease (MD) is a burdensome and not well understood inner ear disorder that has received increasing attention of scientists over the past decade. Until 2007, a certain diagnosis of endolymphatic hydrops (EH) required post-mortem histology. Today, dedicated high-resolution magnetic resonance imaging (MRI) protocols enable detection of disease-related changes in the membranous labyrinth in vivo. In this review, we summarize the current status of MR imaging for MD.

Recent Findings

The mainstays of hydrops imaging are inversion recovery sequences using delayed acquisition after intravenous or intratympanic contrast administration. Based on these techniques, several methods have been developed to detect and classify EH. In addition, novel imaging features of MD, such as blood-labyrinth barrier impairment, have recently been observed.

Summary

Delayed contrast enhanced MRI has emerged as a reliable technique to demonstrate EH in vivo, with promising application in the diagnosis and follow-up of MD patients. Therefore, familiarity with current techniques and diagnostic imaging criteria is increasingly important.

Diagnostic Value of the Magnetic Resonance Imaging With Intratympanic Gadolinium Administration (IT-Gd MRI) Versus Audio-Vestibular Tests in Menière's Disease: IT-Gd MRI Makes the Difference

OBJECTIVE

Our aim was to evaluate the validity and reliability of clinically relevant tests in the diagnosis of Menière's disease (MD) according to the criteria formulated during 2015 as well as their efficacy in detecting endolymphatic hydrops (EH). The focus was on: three-dimensional fluid-attenuated inversion recovery-SPectral Attenuated Inversion Recovery (3D-FLAIR-SPAIR) sequences using 3 Tesla magnetic resonance imaging (3T MRI) performed 24 hours after intratympanic Gadolinium injection (IT-Gd) in comparison with the functional tests pure tone audiometry (PTA), caloric test, video head impulse test (vHIT), and cervical-vestibular-evoked-myogenic-potentials (cVEMP).

STUDY DESIGN

Retrospective study.

SETTING

Tertiary care center.

PATIENTS

Primary eligibility criteria were given clinical suspicion of MD and the performance of an IT-Gd MRI leading to a group of 31 patients and 52 ears to be analyzed separately.

MAIN OUTCOME MEASURE (S)

Reanalysis of the raw diagnostic data leading to comparability of IT-Gd MRI, PTA, caloric test, vHIT, and cVEMP concerning their valency for clinically diagnosed MD and quantifiability of EH.

RESULTS

Considering sensitivity, specificity, and the likelihood-ratio only the IT-Gd MRI displayed results qualifying it as a viable device for MD-diagnostics in regards to the criteria of 2015 (p = 0.01), it even provides direct imaging evidence for the underlying pathology of the disease. Furthermore, the comparison between MRI images and test results of caloric test, vHIT and cVEMP revealed that neither of these diagnostic functional tests serves as a reliable indicator for EH.

CONCLUSIONS

It appears that the diagnosing process of MD would benefit from turning IT-Gd MRI into a standard diagnostic procedure in cases of suspected MD, displaying better results than caloric test, vHIT, and cVEMP.

Value of Endolymphatic Hydrops and Perilymph Signal Intensity in Suspected Ménière Disease

BACKGROUND AND PURPOSE

Ménière disease is characterized by endolymphatic hydrops, whereas perilymphatic enhancement on MR imaging has been suggested to be of additional value in diagnosing Ménière disease. This study evaluates the presence of endolymphatic hydrops and perilymphatic enhancement in patients with Ménière disease and with other vertigo-associated inner ear pathology.

MATERIALS AND METHODS

A 3D-FLAIR sequence 4 hours after intravenous gadolinium injection was performed to visualize the endolymph and perilymph in 220 patients suspected of having Ménière disease. Patients' ears were retrospectively categorized as having Ménière disease (probable or definite) or other vertigo-associated inner ear pathology not attributable to Ménière disease. Endolymphatic hydrops was evaluated using a visual classification system, and perilymphatic enhancement was scored both visually and quantitatively.

RESULTS

Endolymphatic hydrops was present in 137 (91.9%) of the definite Ménière disease ears and in 9 (7.0%) of the ears with other vertigo-associated inner ear pathology (P < .001). The combination of endolymphatic hydrops and visually increased perilymphatic enhancement was present in 122 (81.9%) definite Ménière disease ears compared with 4 (3.1%) ears with other vertigo-associated inner ear pathology (P < .001). This combination increases the positive predictive value from 0.94 for endolymphatic hydrops and 0.91 for perilymphatic enhancement to 0.97. The addition of measured perilymphatic enhancement leads to a moderate decrease in sensitivity from 0.92 for endolymphatic hydrops to 0.86.

CONCLUSIONS

The combination of perilymphatic enhancement and endolymphatic hydrops in patients suspected of having Ménière disease increases the positive predictive value in the diagnosis of definite Ménière disease.

MRI detection of endolymphatic hydrops in Meniere's disease in 8 minutes using MIIRMR and a 20-channel coil after targeted gadolinium delivery

Background

Endolymphatic hydrops (EH) become visible in vertigo patients, particularly in those with Meniere's disease (MD), in vivo using gadolinium-enhanced MRI. However, the image quality is not satisfying after intravenous injection of gadolinium chelate (GdC), and occasional failure in GdC uptake has been noticed after traditional intratympanic injection. In the present report, targeted delivery of GdC and using a cost-effective MRI system to obtain high quality images of EH in only 8 min will be introduced.

Methods

39 MD patients were recruited in the study. First, 0.1 ml of 20-fold diluted gadolinium-diethylenetriamine acid (Gd-DTPA) was delivered onto the posterior upper part of the tympanic medial wall using a soft-tipped micro-irrigation catheter through an artificially perforated tympanic membrane. Inner ear MRI was performed 24 h after Gd-DTPA administration using a 3T MR machine and a 20-channel head/neck coil with an 8 min sequence of medium inversion time inversion recovery imaging with magnitude reconstruction (MIIRMR). The parameters were as follows: TR 16000 ms, TE 663 ms, inversion time 2700 ms, flip angle 180°, slices per slab 60.

Results

Efficient inner ear uptake of Gd-DTPA was detected 24 h after delivery and it created excellent contrast in the inner ear of all cases. High quality images demonstrating EH in the vestibule and cochlea were obtained.

Conclusion

Targeted delivery of minimum Gd-DTPA (0.1 ml, 20-fold dilution) onto the posterior upper portion of the tympanic medial wall and MRI with MIIRMR in a 3T machine and 20-channel head/neck coil are clinically practical to obtain high quality images displaying EH.

Tone burst electrocochleography disproves a diagnosis of Meniere's disease treated aggressively

Reliable confirmation of the presence or absence of endolymphatic hydrops is essential to avoid confusing vestibular migraine with Meniere's disease. MRI inner ear imaging is a promising new method to confirm hydrops, avoiding both unnecessary invasive or destructive inner ear treatments, but it is not universally available. Tone burst electrocochleography is an older simple, quick, safe, and sensitive test that is potentially available, with existing (or minorly upgraded) equipment at most tertiary medical centers. In Meniere's disease hydrops remains after intratympanic treatments. A case is presented of a 45 year-old man with a long history of recurrent vertigo attacks who, due to an erroneous diagnosis of Meniere's disease, was given five intratympanic treatments with no effect. He was subsequently found by tone burst electrocochleography to have no hydrops and was differentially diagnosed with probable vestibular migraine. Response to treatment confirms this diagnosis. This patient's electrocochleographic findings are compared with two other patients with definite Meniere's disease, one of whom had demonstrable hydrops despite intratympanic gentamycin treatments.

Response of the inner ear to lipopolysaccharide introduced directly into scala media

In an attempt to develop an animal model of immune mediated Meniere's disease, we have injected lipopolysaccharide (LPS) directly into scala media of guinea pigs and monitored functional and morphological changes over a period of 6 weeks. Depending on the concentration of LPS, changes ranged from moderate-to-severe hearing loss and endolymphatic hydrops with minimal cellular infiltrate or fibrosis, to dense cellular infiltration that filled the scalae. Interestingly, higher concentrations of LPS not only induced severe cellular infiltration, hydrops, and hearing loss, but also a substantial enlargement of the endolymphatic duct and sac. Moreover, LPS injections into perilymph failed to induce hydrops, yet still resulted in cellular infiltration and fibrosis in the cochlea. This suggests that chronic hydrops resulting from an immune challenge of the cochlea may not be due to blockage of the endolymphatic duct and sac, restricting fluid absorption. Furthermore, injecting antigen into endolymph may produce chronic immune-mediated hydrops, and provide a more promising animal model of Meniere's, although animals did not display signs of vestibular dysfunction, and the hearing loss was relatively severe.

Clinical manifestations of hydropic ear disease (Menière's)

INTRODUCTION

Hydropic ear disease, initially described by and named after Prosper Menière, is one of the most frequent vertigo disorders and one of the most frequent inner ear disorders. It is the syndrome of endolymphatic hydrops which until 2007 could be diagnostically confirmed only by post-mortem histology. In the past, various attempts to formulate clinical diagnostic criteria have been undertaken but were hampered by the inability to ascertain the diagnosis in living patients. With the milestone achievement of endolymphatic hydrops imaging, today the pathology can be ascertained. In this study, we have performed a detailed analysis of the clinical features of hydropic ear disease for the first time by examining a large cohort of patients with morphologically confirmed endolymphatic hydrops using a detailed physician-administered neurotologic face-to-face interview.

RESULTS

During a hydropic vertigo attack, the patients report nausea, vomiting, sweating, urge to defecate, urge to urinate, phosphenes, headache, photophobia, phonophobia and even transient loss of consciousness. A third of the patients does not experience auditory symptoms during the vertigo attacks. Vertigo attacks last less than 20 min in more than one-fourth of the patients. Audiometric hearing loss has its greatest diagnostic value at the frequencies of 1 kHz and below. Cochleovestibular symptom onset simultaneity is associated with a high frequency of drop-attacks. Migraine and autoimmune disorders are not associated with hydropic ear disease.

CONCLUSION

This study marks the beginning of the clinical characterization of hydropic ear disease. The findings have important implications for the future formulation of clinical diagnostic criteria.