Translabyrinthine vestibular neurectomy and simultaneous cochlear implant for Ménière's disease

Long-term outcome of patients with Ménière's disease following cochlear implantation: a comprehensive outcome study with validated assessment tools

PURPOSE

Patients suffering from Ménière's disease (MD) experience vertigo, and impairments in hearing and quality of life (QoL). This study aims to investigate the impact of cochlear implantation (CI) on various aspects affecting patients with MD.

METHODS

A single tertiary centre's CI database for CI recipients with MD between 2014 and 2022 was screened retrospectively. Hearing, vertigo, tinnitus symptoms, and hearing-related QoL were assessed. Pre- and postoperative hearing tests in conjunction with subjective outcome measures by visual analogue scale (VAS) and validated tools such as the Dizziness Handicap Inventory (DHI), Tinnitus Handicap Inventory (THI) and Nijmegen Cochlear Implant Questionnaire (NCIQ), as well as the assessment of the pre- and postoperative Functional Level Scale (FLS) were examined.

RESULTS

Eleven ears were included (median age: 59 years at implantation). Following implantation, there was a significant enhancement in Word Recognition Scores at sound levels of 65 dB and 80 dB compared to before treatment (preop vs. 12 months postop: p = 0.012). However, no significant enhancement was observed for 50 dB. MD-related impairments improved significantly postoperatively, as measured by the VAS (vertigo: p = 0.017; tinnitus: p = 0.042), DHI (p = 0.043), THI (p = 0.043) and NCIQ (p < 0.001). The FLS improved significantly (p = 0.020).

CONCLUSION

CI has positive effects on all areas examined in our cohort. However, discrimination of speech at low sound pressure levels remained problematic postoperatively. In patients suffering from MD, the prioritized treatment goals include not only improved hearing but also the rehabilitation of vertigo and tinnitus, as well as the enhancement of QoL. Validated instruments are useful screening tools.

Cochlear implantation in patients with Meniere's disease: A systematic review

BACKGROUND

Meniere's disease (MD) is an idiopathic disorder of the inner ear, which manifests as cochleo-vestibular dysfunction. Hearing loss will progress to a profound levelin a subset of patients with MD, and vestibular interventions can independently cause loss of hearing. The aim of this study was to systematically review the published literature describing the safety and efficacy of CI in patients with MD.

MATERIALS AND METHODS

A systematic literature review was conducted in accordance PRISMA guidelines to identify articles that assessed at least one functional outcome in patients with MD who underwent CI. Demographic information, disease history, MD symptoms, outcomes measures, and complications related to CI were extracted from included studies.

RESULTS

In total, 17 studies were included, and 182 patients with MD underwent CI. The weighted-mean age was 61.9 years (range 27-85). Study objective and methodology varied, and there was significant heterogeneity in CI outcome measures reported. In total, 179 (98.3%) of 182 patients reported objective improvements in at least one hearing metric after CI. A total of 69 patients (37.9%) reported vertigo or severe dizziness prior to CI, compared to 22 patients (15.4%) postoperatively. Two studies reported significant reductions in postoperative Tinnitus Handicap Inventory score (THI). Quality of life assessments varied between studies. Complications rates were low with only nine patients (4.9%) reporting a serious CI-related complication.

CONCLUSIONS

This systematic review evaluated 17 studies describing the safety and efficacy of CI in patients with MD and encountered many challenges due to small sample sizes, and heterogeneity in study design and outcomes measured. Despite these limitations, this study of 182 patients is to the best of our knowledge the largest systematic review evaluating the safety and efficacy of CI in MD. The results of this study support the need for a standardized approach to evaluating outcomes of CI in patients with MD in future studies.

The role of cochlear implant positioning on MR imaging quality: a preclinical in vivo study with a novel implant magnet system

Purposes

To investigate the effects for Ultra 3D cochlear implant (CI) positioning on MR imaging quality, looking at a comprehensive description of intracranial structures in cases of unilateral and bilateral CI placement.

Methods

Four CI angular positions (90°, 120°, 135° and 160°) at 9 cm distance from the outer-ear canal were explored. The 1.5 T MRI assessment included our institutional protocol for the investigation of brain pathologies without gadolinium application. Three investigators (two experienced neuroradiologists and one experienced otoneurosurgeon) independently evaluated the MR findings. A 4-point scale was adopted to describe 14 intracranial structures and to determine which CI positioning allowed the best image quality score and how bilateral CI placement modified MRI scan visibility.

Results

A high positive correlation was found between the three blinded observers. Structures situated contralateral from the CI showed high-quality values in all four placements. Structures situated ipsilaterally provided results suitable for diagnostic purposes for at least one position. At 90°, artifacts mainly involved brain structures located cranially and anteriorly (e.g., temporal lobe); on the contrary, at 160°, artifacts mostly influenced the posterior fossa structures (e.g., occipital lobe). For the bilateral CI condition, MR imaging examination revealed additional artifacts involving all structures located close to either CI, where there was a signal void/distortion area.

Conclusions

Suitable unilateral CI positioning can allow the visualization of intracranial structures with sufficient visibility for diagnostic purposes. Bilateral CI positioning significantly deteriorates the anatomical visibility. CI positioning might play a crucial role for patients who need post-operative MRI surveillance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-07005-y.

Quality of Life Following Cochlear Implantation in Patients With Menière's Disease

Background: Menière's disease (MD) is a disorder characterized by auditory and vestibular dysfunction that significantly deteriorates patients' quality of life (QoL). In addition to the management of vestibular symptoms, some patients with bilateral hearing loss meet criteria for cochlear implantation (CI).

Objectives: (1) To assess hearing results and QoL outcomes following CI in patients with MD. (2) To compare these results to a matched control group of patients who had undergone CI. (3) To analyse differences in MD patients who have undergone simultaneous or sequential labyrinthectomy or previous neurectomy.

Methods: A retrospective analysis of a study group of 18 implanted patients with MD and a matched control group of 18 implanted patients without MD, who had CI at a tertiary referral center. Hearing and speech understanding were assessed via pure-tone audiometry (PTA) and disyllabic perception tests in quiet. QoL was assessed via the Nijmegen Cochlear Implant Questionnaire (NCIQ), the Glasgow Benefit Inventory (GBI), the Speech, Spatial and Qualities of Hearing Scale (SSQ₁₂), and the Hearing Implant Sound Quality Index (HISQUI₁₉). The impact of MD ablative surgeries was analyzed in the study group (MD group).

Results: Mean pre-operative PTA thresholds were significantly lower in the MD group (103 vs. 121 dB). A significant improvement in hearing outcomes was observed following CI in both groups (p < 0.001), with a maximum Speech Discrimination Score of 64 and 65% disyllables at 65 dB for the MD and control group, respectively. Subjective outcomes, as measured by the NCIQ, GBI, SSQ₁₂, and HISQUI₁₉ did not significantly differ between groups. In the MD group, despite achieving similar hearing results, QoL outcomes were worse in patients who underwent simultaneous CI and labyrinthectomy compared to the rest of the MD group. Post-operative NCIQ results were significantly better in patients who had undergone a previous retrosigmoid neurectomy when compared to those who had undergone only CI surgery in the subdomains “basic sound perception” (p = 0.038), “speech” (p = 0.005), “activity” (p = 0.038), and “social interactions” (p = 0.038).

Conclusion: Patients with MD and severe hearing loss obtain hearing results and QoL benefits similar to other CI candidates. Delayed CI after labyrinthectomy or vestibular neurectomy can be performed with similar or better results, respectively, to those of other cochlear implanted patients. Patients who undergo simultaneous CI and labyrinthectomy may achieve similar hearing results but careful pre-operative counseling is needed.

Gangliformis Intumescentia and Beyond: Antonio Scarpa and His Core Contribution to Neuroanatomy, Neurosurgery, and Otoneurosurgery

Nearly 250 years ago, Antonio Scarpa became a professor of anatomy and surgery only 2 years after he graduated from the University of Padua. The young lecturer soon became one of the most renowned anatomists in Italy and a director of the Faculty of Medicine at the University of Pavia. He worked in the fields of general surgery and ophthalmology. Several anatomic structures have been named after him, mainly Scarpa fascia and Scarpa triangle. His interest in neuroanatomy was ardent, despite being occasionally neglected. Scarpa's contributions to the fields of neurosciences have been significant. He was the first to describe the round window and the secondary tympanic membrane, and he eventually focused on the auditory and olfactory organs. Notably, the vestibular ganglion is now known as Scarpa ganglion. Scarpa's magnum opus was the book Tabulae Neurologicae, in which he described the path of several cranial nerves including the vagus nerve and innervation of the heart. Since his death in 1832, Scarpa's head has been preserved at the University History Museum of the University of Pavia. In this historical vignette, we aim to describe Antonio Scarpa's troubled life and brilliant career, focusing on his core contributions to neuroanatomy, neurosurgery, and otoneurosurgery.

MRI-induced artifact by a cochlear implant with a novel magnet system: an experimental cadaver study

Purposes

To primarily evaluate MRI-induced effects for Ultra 3D cochlear implantation in human cadavers in terms of artifact generation and MR image quality.

Methods

Three human cadaveric heads were submitted to imaging after unilateral and bilateral cochlear implantation. The 1.5 T MR examination protocol was chosen in accordance with our institutional protocol for the assessment of brain pathology. The maximal signal void size was measured according to each sequence and plane. Two experienced neuro-radiologists and one experienced otoneurosurgeon independently evaluated the MR image quality findings. A 4-point scale was used to describe the diagnostic usefulness of 14 brain structures.

Results

Shape and size of the artifacts were found to be highly related to MRI sequences and acquisition planes. MRI sequences and processing algorithms affected the ability to assess anatomical visibility. Image quality appeared either high or assessable for diagnostic purposes in 9 out of 14 of the ipsilateral structures, in at least one plane. Anatomical structures contralateral to the cochlear implant were highly visible in all conditions. Artifact intrusion clearly improved after application of metal artifact-reduction techniques. In the case of bilateral cochlear implant, a mutual interaction between the two implant magnets produced an additional artifact.

Conclusions

We performed the first cadaver study aimed at systematically evaluating the MRI-induced artifacts produced by a cochlear implant with a novel four bar magnet system. Specific brain structures can be assessable for diagnostic purposes under 1.5 T MRI, with the cochlear implant magnet in place.

Cochlear implantation in Ménière's disease: a systematic review of literature and pooled analysis

Objective: The aim of this study was to evaluate the effect of cochlear implantation (CI) in advanced Ménière's disease (MD).Design: The initial search on PubMed, EMBASE, and Cochrane databases yielded 171 articles; no language restriction was applied.Study sample: A total of 11 articles met the inclusion criteria and were included in this systematic review. Six articles provided patient-level data on improvement in speech recognition testing after CI.Results: The methodological quality of included studies was assessed by examining the study design, level of evidence, method of measurement and adequacy of outcome reporting. A random-effect model was fitted for calculating weighted means. Post-operative improvement in word recognition score (WCS) was 50.8% (95% confidence interval: 34.6-67.1%); general improvement of vestibular symptoms after CI was found in 67% of the pooled patients; when reported in the studies, quality of life (QoL) and tinnitus were also generally improved after CI.Conclusions: CI in advanced MD is a valid option providing good outcomes in terms of speech performances, regardless of the disease duration, uni- or bilaterality, age at implantation, previous therapeutic procedures and stage of activity of MD.

Quality-of-Life Outcomes following Surgical Treatment of Ménière’s Disease: A Systematic Review and Meta-analysis

Objective

Several surgical interventions are offered to patients with Ménière’s disease (MD) who fail medical management. Although outcomes have historically been reported according to American Academy of Otolaryngology—Head and Neck Surgery guidelines, patient-reported outcome measures (PROMs) are increasingly used to evaluate treatments. This study reviews PROMs used to assess surgical treatments for MD and compares the effect of each intervention based on PROM scores.

Data Sources

PubMed, EMBASE, CINAHL, and Web of Science.

Review Methods

This is a systematic review and meta-analysis of English-language studies that reported PROMs for surgical treatments of MD. Two independent investigators assessed study eligibility, rated the quality using Methodological Index for Non-Randomized Studies (MINORS), and abstracted data for comparative analysis. A random-effects model was used for meta-analysis of pooled data.

Results

Of 148 unique studies identified, 11 satisfied inclusion criteria. The Ménière’s Disease Outcome Questionnaire (MDOQ) was the most commonly used survey. Interventions included intratympanic gentamicin, vestibular nerve section, endolymphatic sac surgery, and labyrinthectomy. Pooled analysis of 8 studies that used the MDOQ instrument demonstrated statistically significant improvements in quality of life but did not identify a difference between destructive and nondestructive procedures.

Conclusion

Although our review shows significant improvements in PROM scores for both destructive and nondestructive interventions, there was no significant difference noted between treatment types. We cannot draw conclusions regarding the comparative effectiveness of specific interventions, and the results do not account for placebo effects or the natural history of the disease. Further investigation with randomized controlled trials should be considered in future studies.