Disability perception in Menière's disease: when, how much and why?

Posterior Semicircular Canal Plugging Relieves Tumarkin's Crisis in Ménière's Disease Patients

(1) Background: Patients affected by Ménière's disease can experience Tumarkin's syndrome, which is characterized by postural instability, gait abnormalities, and, occasionally, an abrupt loss of balance known as vestibular drop attack or Tumarkin's crisis. In this study, semicircular canal plugging is proposed as the definitive treatment for this condition. The outcomes of this type of surgery are discussed. (2) Methods: A total of 9 patients with a confirmed diagnosis of Ménière disease suffering from Tumarkin crisis underwent posterior semicircular canal plugging. These patients were assessed with Video Head Impulse Tests, vestibular evoked myogenic potentials, and Pure Tone Audiometry preoperatively and postoperatively. (3) Results: VHIT showed a postoperative decrease in PSC gain median (Preop. 0.86 and postop. 0.52; p < 0.009). No statistically significant differences were described for the anterior semicircular canal and the lateral semicircular canal. No patient experienced new Tumarkin crisis after the surgical treatment. (4) Conclusions: Our ten years of experience with posterior semicircular canal plugging in Ménière disease patients with Tumarkin's syndrome has shown that this type of surgical procedure is successful in controlling Tumarkin's crisis, with high patient satisfaction and little worsening in hearing level.

Long-term efficacy of vestibular neurotomy in disabling Ménière's disease and Tumarkin drop attacks

OBJECTIVE

When Ménière's disease (MD) becomes disabling due to the frequency of attacks or the appearance of drop attacks (i.e., Tumarkin otolithic crisis) despite "conservative" medical and surgical treatments, a radical treatment like vestibular neurotomy (VN) is possible. An ideal MD treatment would relieve symptoms immediately and persist after the therapy. The aim of this study was to identify if VN was effective after 10 years of follow-up regarding vertigo and drop attacks, and to collect the immediate complications.

METHODS

The authors report a retrospective, single-center (i.e., in a single tertiary referral center with otoneurological surgery activity) cohort study conducted from January 2003 to April 2020. All patients with unilateral disabling MD who had received a VN with at least 10 years of follow-up were included. The therapeutic efficacy was defined by complete disappearance of vertigo and drop attacks. The postoperative complications (CSF leak, total deafness, meningitis, death) were determined immediately after the surgery, and the hearing thresholds were determined during the patient follow-up with the pure tone average (PTA).

RESULTS

A total of 74 patients (of 85 who were eligible), average age 51.9 ± 11.1 years, including 38 men (51.4%), with disabling MD and/or Tumarkin drop attacks (24.3%) received VN, with at least 10 years of follow-up after surgery. After an average follow-up of 12.4 ± 1.7 years (range 10.0-16.3 years), 67 patients (90.5%) no longer presented any vertiginous attacks, and no patient experienced drop attack. The mean variation in early pre- and postoperative PTA was not statistically significant (n = 64, 2.2 ± 10.3 decibels hearing level [range -18 to 29], 95% CI [-0.4 to 4.37]; p = 0.096), and 84.4% of the patients evaluated had unchanged or improved postoperative PTA. Three significant complications were noted, including two surgical revisions for CSF leak. There was no permanent facial paralysis, meningitis, or death.

CONCLUSIONS

In case of disabling MD (disabling vertigo refractory to conservative vestibular treatments-Tumarkin drop attacks), VN via the retrosigmoid approach must be the prioritized proposal in comparison to intratympanic gentamicin injections, because of the extremely low complication rate and the immediate and long-lasting effect of this treatment on vertigo and falls.

A New Proposal for Severity Evaluation of Menière's Disease by Using the Evidence From a Comprehensive Battery of Auditory and Vestibular Tests

To date, no widely accepted criteria exist to quantify the severity of Menière's disease (MD) by using vestibular tests. This study aimed to compare association of hearing loss and vertigo severity with association of accurate assessments of vestibular function and the vertigo severity. The severity of vertigo was documented by a comprehensive medical history with number of vertigo attacks in the past 6 months and a Dizziness Handicap Inventory (DHI) questionnaire. The involvement of vestibular organs was verified by audio-vestibular tests in 80 definite MD patients. Correlations between DHI scores, number of vertigo attacks in the past 6 months, audio-vestibular function, and the number of involved vestibular end organs were evaluated. We show that there are no significant differences in either severity of vertigo or laboratory results across the degree of hearing loss. Furthermore, the number of involved vestibular end organs was significantly correlated with vestibulo-ocular reflex gain in anterior and posterior canal video head impulse test (vHIT), interaural asymmetry ratio in vestibular-evoked myogenic potentials (VEMPs), and number of vertigo attacks in the past 6 months and DHI score. The vestibulo-ocular reflex gain in the rotatory chair test (RCT) was significantly correlated with the DHI Physical scores and number of involved vestibular end organs at 0.08 Hz. These results indicate that hearing loss is a poor indicator of vertigo severity in MD whereas the number of involved vestibular end organs may serve as an objective measure for MD progress. A battery of vestibular tests targeting different sensor organs is a complementary method for evaluating inner ear deficits and may aid in "grading" the severity of MD.

Dizziness handicap and clinical characteristics of posterior and lateral canal BPPV

PURPOSE

Benign paroxysmal positional vertigo (BPPV) is diagnosed and divided into subtypes based on positioning vertigo and nystagmus. Whether these subtypes entail any significant differences in patient-reported symptoms; is yet not known. Such differences may have clinical and therapeutic consequences. Our aim was to assess dizziness handicap and clinical characteristics of posterior and lateral canal BPPV.

METHODS

This prospective observational multicentre study analysed consecutive patients with BPPV, confirmed by standardized procedures including videonystagmography under diagnostic manoeuvres in a biaxial rotational chair. Patients were screened for other neurological and otological disorders.

OUTCOMES

Dizziness handicap inventory (DHI), posterior vs. lateral canal involvement.

FACTORS

age, gender, positional nystagmus intensity (maximum slow-phase velocity), symptom duration, 25-hydroxyvitamin D-level and traumatic aetiology.

RESULTS

132 patients aged 27-90 (mean 57, SD 13) years were included. Higher DHI scores were associated with lateral canal BPPV [95% CI (1.59-13.95), p = 0.01] and female gender [95% CI (0.74-15.52), p = 0.03]. Lateral canal BPPV was associated with longer symptom duration [OR 1.10, CI (1.03-1.17), p = 0.01] and lower 25-hydroxyvitamin D-levels [OR 0.80, CI (0.67-0.95), p = 0.03]. There was no correlation between DHI scores and nystagmus intensity.

CONCLUSIONS

This study suggests that patients with lateral canal BPPV have increased patient-perceived disability, lower vitamin D-levels and longer duration of symptoms. This subtype might therefore require closer follow-up. Patient-perceived disability is not related to positional nystagmus intensity.