The Treatment Of Hearing Loss In Meniere’s Disease

Endolymphatic Mastoid Shunt: A Reevaluation of Efficacy

OBJECTIVES: The main goal of this paper was to statistically reevaluate the efficacy of the endolymphatic shunt procedure for Meniere's disease.

METHODS: Thomsen et al (Arch Otolaryngol 1981; 107:271–7) reported on the placebo effect in surgery for Meniere's disease in a controlled doubleblind study. Thirty patients with typical Meniere's disease in whom medical treatment failed participated in the study. A placebo-controlled blinded surgical study has not since been replicated. We performed a retrospective statistical analysis using data extracted from the published report and reanalyzed it using both the original and new statistical measures and techniques.

RESULTS: The original conclusions drawn by Thomsen et al differed considerably from ours in 5 key areas, including postoperative vertigo, nausea and vomiting, tinnitus, and combined score.

CONCLUSIONS: This analysis strongly supports the effectiveness of the endolymphatic shunt in the management of Meniere's disease and refutes the placebo effect previously proposed.

Hearing function after betahistine therapy in patients with Ménière's disease

Introduction

Objective

Methods

Results

Conclusion

Genetic investigations of Meniere's disease

Meniere's disease remains a disorder of unknown origin despite the collective efforts to determine the pathogenesis, although experts have long recognized that disease development likely has some heritable component. Although genetic studies of Meniere's disease have been inconclusive, increasing knowledge of human genetic structure and mutation and investigative techniques have potential to further understanding of this disorder.

Hearing loss

Hearing loss is one of the most common sensory impairments and affects almost 10% of the adult population. The percentage of adults with hearing loss markedly increases with advancing age. The differential diagnosis for patients presenting with hearing loss is extensive, but can often be narrowed with a directed hearing history and physical examination. The severity of the hearing loss may warrant additional diagnostic studies, including audiometry, and possible imaging in selected cases. Hearing aids, assistive listening devices, middle ear surgery, and cochlear implantation are potential therapeutic options available to patients depending on the type and severity of the hearing loss.

Clinical long-term effects of Meniett pulse generator for Meniere's disease

CONCLUSION

According to this long-term study, the Meniett pulse generator is a safe, effective, and non-destructive therapy that can reduce vertiginous symptoms and associated functional handicap and partly show an improvement of hearing in medically intractable and active Meniere's disease. Moreover, we recommend considering it before attempting any surgical or chemical vestibular ablation procedure.

OBJECTIVE

To evaluate the long-term efficacy and safety of transtympanic pressure treatment in the management of recalcitrant vertigo in Meniere's disease.

PATIENTS AND METHODS

This was a cross-sectional case study of 22 consecutive patients with medically active and intractable Meniere's disease who opted to try the Meniett pulse generator between July 2005 and March 2008. Eighteen of these patients were followed up for over 24 months. A standard ventilation tube was inserted in the affected ear. The treatment period with the Meniett pulse generator was 2 months in clinic, then the follow-up was a mean of 28 months. Patients indicated on the symptom report card and six-point functional scale the maximum level of vertigo, activity, and stress. Hearing was assessed utilizing pure tone average thresholds (PTAs) and the vestibular caloric test was performed.

RESULTS

For 18 patients, the changes on the vertigo visual analog scale (VAS) and six-point functional scale before and after treatment with the Meniett device were statistically significant (p<0.05). No changes in vestibular function were noted. In all, 13 and 10 of 18 patients, respectively, showed a significant PTA increase of 10 dB or more at 2 months and 12 months after treatment with the Meniett device. Nine of 17 patients showed a significant PTA increase of 10 dB or more at 24 months after the treatment. There were no complications during the 28-month follow-up.

Sequence variants in host cell factor C1 are associated with Ménière's disease

HYPOTHESIS

There is a genetic basis for the development of Ménière's (MD) disease.

BACKGROUND

The cause of MD is unknown, although many potential theories have been proposed. A genetic basis for the disease is suggested by greater prevalence in Caucasians and familial cases that display an autosomal dominant pattern of inheritance.

METHODS/DESIGN

Case-control association study of selected candidate genes among patients with MD and selected control individuals.

RESULTS

Several single-nucleotide polymorphisms (SNPs) within the host cell factor C1 (HCFCI) gene displayed a significant increase in prevalence of the major allele in subjects with MD disease. The most individually significant SNP is rs2266886. The minor allele at this site displays an odds ratio of 0.26 (95% confidence intervals, 0.010-0.65; p = 0.003) for disease development.

CONCLUSION

The minor allele at each SNP site was significantly more common in controls, suggesting that individuals bearing these alleles are at reduced risk of developing MD. The functional consequences of the SNPs in host cell factor C1 are unknown. A viable hypothesis for disease development is presented based on the known interaction between HCFC1 and the herpes simplex viral protein VP16.

Intratympanic gentamicin for unilateral Meniere's disease: results of therapy

Patients with Meniere's disease that remains refractory to conservative treatment have traditionally been subjected to ablative surgery. The purpose of this prospective study was to evaluate the use of intratympanic gentamicin in eliminating incapacitating vertigo, while preserving hearing. Over the past 8 years, 83 patients have received between 1 and 6 intratympanic injections of gentamicin in an out-patient setting, with duration of therapy titrated to individual symptom response and effect on hearing. Using established AAO-HNS guidelines, we present data on 50 patients who have a minimum of 2 years follow-up. Control or significant improvement of definitive Meniere's attacks was achieved in 92% of patients and hearing preserved or improved in 76%. Only one patient experienced profound sensorineural hearing loss. We feel this treatment option should be considered and offered to patients in whom medical treatment has failed.

Continuous gentamicin therapy using an IntraEAR microcatheter for Meniere's disease: a retrospective study

OBJECTIVES

The study goals were to evaluate the safety and effectiveness of continuous gentamicin therapy (CGT) in the treatment of Meniere's disease and to evaluate the effect of flow rate.

STUDY DESIGN

In a retrospective study, physicians who were known to have used CGT in the treatment of Meniere's disease were asked to report patient information on a standardized data collection form.

RESULTS

In patients treated with low-flow CGT, vertigo was eliminated or substantially controlled in 90%, tinnitus was improved in 69%, pressure was improved in 77%, hearing was worse in 23%, and vestibular function was ablated in only 14% of patients.

CONCLUSION

On the basis of an average 10-month follow-up period, of the methods currently available to treat Meniere's patients with gentamicin, low-flow CGT seems to provide an excellent combination of vertigo control and tinnitus and pressure improvement, with a relatively low risk to hearing and vestibular function.

SIGNIFICANCE

The clinical use of low-flow CGT appears to be justified based on these data.

Patients' subjective evaluations of quality of life related to disease-specific symptoms, sense of coherence, and treatment in Ménière's disease

OBJECTIVE

To evaluate the self-rated quality of life associated with vertigo, hearing loss, and tinnitus in Ménière's patients, and to identify potential relationships between these findings, treatment regimens, and sense of coherence in comparison to the classification of the American Academy of Otolaryngology-Head and Neck Surgery (AAO/HNS).

STUDY DESIGN

Cross-sectional.

SETTING

Tertiary referral hospital centers.

PATIENTS

112 patients with Méniére's disease, who had undergone endolymphatic sac surgery or intratympanic gentamicin injections, or were surgically untreated.

MAIN OUTCOME MEASURE

Questionnaires concerning quality of life aspects and symptom-specific instruments: the Vertigo Symptom Scale (VSS), the Hearing Disability Handicap scale (HDHS), the Tinnitus Severity Questionnaire (TSQ), the AAO/HNS criteria for reporting results of treatment of Ménière's disease, and the Sense of Coherence Scale.

RESULTS

A majority of the patients reported their quality of life in general as very good or good. There was no difference in general quality of life, present hearing loss, or tinnitus between the three treatment groups, but the gentamicin-treated patients had less vertigo than did the other groups. Sense of coherence showed a strong correlation to reported quality of life in all measurements.

CONCLUSIONS

Even though the gentamicin-treated patients had less vertigo, no difference in overall quality of life was found between the surgically treated and untreated patients. The sense of coherence seems to be an important factor in the patient's experience of quality of life. Quality of life instruments can measure both specific symptoms and related aspects on quality of life and may give complementary information to the AAO/HNS classification in evaluating the treatment of patients with Ménière's disease.

Intratympanic therapy for Ménière's disease: effect of administration of low concentration of gentamicin

We present results at 2 years follow-up of a group of 15 patients with Ménière's disease treated with a low concentration of intratympanic gentamicin (IG group), compared with a group of 15 patients who refused any surgical treatment (NH group). IG was administered according to a predetermined and fixed schedule consisting of 2 doses of 0.5 ml gentamicin solution, pH 7.8, injected once a week, with a drug concentration of 20 mg/ml; the total dose of gentamicin was < or = 20 mg. Additional doses of IG were administered only in patients who had recurrence of vertigo. The results were evaluated following the American Academy of Otolaryngology Head and Neck Surgery 1995 criteria for reporting Ménière's disease treatment results by means of interviews, audiologic and vestibular evaluations, and a questionnaire based on a six-point functional level scale. Seven of the 15 IG patients had recurrence of vertigo after the second injection and received a third dose of IG. Four patients had recurrence of vertigo after the third infiltration; three subjects received a fourth dose and one refused additional injection. At 2 years follow-up, 93% of the IG patients had complete (class A) or substantial (class B) control of vertigo. Only 47% of the NH patients had no vertigo or were substantially improved. Hearing deteriorated in 7% of the IG group and in 40% of the NH group. Tinnitus disappeared or improved in 20% of the IG patients and in 27% of the NH patients; 40% of the IG patients and 27% of the NH patients reported that their aural pressure was abolished. The present study demonstrates that, in patients with Ménière's disease, 0.5 ml doses of gentamicin solution, with a concentration of 20 mg/ml, injected intratympanically once a week minimize the risk of hearing loss in the treated ear, permitting complete control of vertigo in more than half of cases after 2 doses and in almost all subjects (93%) after 4 doses.

Endolymphatic mastoid shunt: a reevaluation of efficacy

OBJECTIVES

The main goal of this paper was to statistically reevaluate the efficacy of the endolymphatic shunt procedure for Meniere's disease.

METHODS

Thomsen et al (Arch Otolaryngol 1981;107:271-7) reported on the placebo effect in surgery for Meniere's disease in a controlled double-blind study. Thirty patients with typical Meniere's disease in whom medical treatment failed participated in the study. A placebo-controlled blinded surgical study has not since been replicated. We performed a retrospective statistical analysis using data extracted from the published report and reanalyzed it using both the original and new statistical measures and techniques.

RESULTS

The original conclusions drawn by Thomsen et al differed considerably from ours in 5 key areas, including postoperative vertigo, nausea and vomiting, tinnitus, and combined score.

CONCLUSIONS

This analysis strongly supports the effectiveness of the endolymphatic shunt in the management of Meniere's disease and refutes the placebo effect previously proposed.

Intratympanic therapy for Ménière's disease. High-concentration gentamicin with round-window protection

Many therapeutic options exist for the management of patients with Ménière's disease. In the last few years, the use of intratympanic gentamicin has been investigated as an alternative treatment to vestibular nerve section or labyrinthectomy. In humans, the concentration of gentamicin used for intratympanic treatment of vertigo ranges from 10 mg/mL to 40 mg/mL, and the number of doses from 2 to 14, with a total administered amount between 6 and 2.400 mg. Here lower doses of gentamicin were used, usually had the lowest incidence of hearing loss, but more injections were needed to ablate vestibular function. The purpose of this study was to evaluate the acute and chronic ototoxic effects of intratympanic high-concentration gentamicin after having obliterated the round-window niche with connective tissue in 11 subjects' ears with Ménière's disease. Intratympanic gentamicin was administered according to a predetermined and fixed schedule consisting of two doses of 0.5 mL gentamicin solution, injected once a week with a drug concentration of 80 mg/mL. The total dose of gentamicin was < or = 80 mg. The charts of the patients were surveyed in accordance with the 1995 AAO-HNS guidelines. Three patients had recurrence of vertigo between 3 and 6 months after the second injection and went on to one additional dose of gentamicin. At 2 years follow-up, 10 patients (91%) had complete and 1 (9%) substantial control of vertigo; 3 subjects (27%) had hearing decreased. Tinnitus disappeared or decreased in 3 patients (27%); eight subjects (73%) reported their aural pressure abolished or decreased. The present study demonstrates that in patients with Ménière's disease, 0.5 mL gentamicin solution, with a concentration of 80 mg/mL (total dose < or = 80 mg), injected intratympanically once a week after having obliterated the round-window niche, permits complete or substantial control of vertigo in two-thirds of cases after two doses and in all subjects after three doses. This vertigo control rate is compared to that observed after vestibular nerve section. Hearing results are not different from those with natural control, with endolymphatic sac surgery, and with vestibular nerve section.

Inner ear transgene expression after adenoviral vector inoculation in the endolymphatic sac

Gene transfer has been performed in a variety of organs. In the mammalian inner ear, viral vectors have been used to introduce exogenous reporter genes via the scala tympani into the cochlea. While scala tympani inoculation is clinically feasible, it is not without risks. Moreover, transgene expression has so far been restricted to the cochlear tissues in the perilymphatic spaces that are contiguous with the scala tympani. To achieve gene transfer of vestibular organs and cells surrounding the endolymphatic space, and to extend the clinical utility of inner ear gene therapy, we developed a new surgical approach for vector inoculation. A replication-deficient adenoviral vector, Ad.RSVntlacZ, was injected into the guinea pig endolymphatic sac. A large number of blue (LacZ-positive) cells was observed in the endolymphatic sac and duct, the vestibule, and the ampulla. Blue cells were also detected in the cochlea, mainly in cells bordering the endolymphatic space: marginal cells in the stria vascularis and supporting cells in the organ of Corti. These findings indicate that inoculation of viral vectors into the endolymphatic sac can provide efficient gene transfer into a variety of cell types that are not accessible via scala tympani inoculation.