Endolymphatic Sac Enhancement

Functional outcomes and caloric response changes after endolymphatic sac decompression

OBJECTIVE

To evaluate caloric response changes after endolymphatic sac decompression (ESD), together with hearing outcomes and the functional benefit of the operation.

METHODS

A retrospective chart review of subjects who underwent endolymphatic sac decompression at a tertiary referral centre was performed. Data on audiological results, caloric testing, and functional level scale of the patients were analysed.

RESULTS

Twenty-eight patients who met our criteria were eligible for enrolment in the study. The average follow-up after surgery was 25 months (range, 13-41). Postoperative pure-tone threshold averages and reduced vestibular response values (RVR) were not significantly altered by ESD; whereas, functional level scores improved significantly.

CONCLUSION

Endolymphatic sac decompression is a surgical procedure that preserves hearing and vestibular function, and improves the daily functional level of patients with Ménière's disease. ESD can be preferred both in bilateral and unilateral disease because it does not alter vestibular function and preserves hearing.

A Comparison of Local Endolymphatic Sac Decompression, Endolymphatic Mastoid Shunt, and Wide Endolymphatic Sac Decompression in the Treatment of Intractable Meniere's Disease: A Short-Term Follow-Up Investigation

Background

Meniere's disease (MD) is an inner ear disorder, characterized by recurrent attacks of vertigo, low-frequency sensorineural hearing loss, tinnitus, and aural fullness. Endolymphatic sac surgery is an effective treatment to control vertigo attacks but without causing a hearing loss for intractable MD. However, the methods and effects of endolymphatic sac surgery have been controversial for many years, and the relationship between the vertigo control rates of different endolymphatic sac surgery methods is not well-documented.

Objectives

This study compared the vertigo control rate, hearing outcome, and quality of life (QOL) among different endolymphatic sac surgery, such as local endolymphatic sac decompression (LESD), endolymphatic sac mastoid shunt (ESMS), and wide endolymphatic sac decompression (WESD).

Materials and Methods

We retrospectively analyzed the patients who underwent endolymphatic sac surgery from January 2008 to June 2019. The control rate of vertigo and QOL scores were compared after 2 years of follow-up. The QOL was scored with validation of the MD patient-oriented symptom-severity index (MDPOSI). The pure tone thresholds of all patients at pre- and postoperation were also compared.

Results

In total, 83 MD patients with complete follow-up data were included in the study, i.e., 20 patients with LESD, 28 patients with ESMS, and 35 patients with WESD. Results showed a better vertigo control with WESD than the other groups (70% with LESD, 71.4% with ESMS, and 88.6% with WESD). The QOL was improved after surgery in all groups in which the difference was statistically significant (QOL, preoperative vs. postoperative, 38.2 vs. 10.1 with LESD, 37.8 vs. 9.6 with ESMS, and 37.6 vs. 8.3 with WESD), respectively. After endolymphatic sac surgery, the hearing was well-preserved in the three groups [pure tone averages (PTAs), dB, preoperative vs. postoperative, 41.0 ± 19.3 vs. 40.8 ± 17.9 with LESD, 39.7 ± 16.4 vs. 40.8 ± 18.2 with ESMS, and 38.5 ± 18.7 vs. 36.6 ± 19.5 with WESD].

Conclusion

Wide endolymphatic sac decompression has a higher vertigo control rate, better improvement of QOL, and relatively higher hearing stability or improvement rate after surgery in patients with MD compared with LESD and ESMS.

Clinical Practice Guideline: Ménière's Disease

OBJECTIVE

Ménière's disease (MD) is a clinical condition defined by spontaneous vertigo attacks (each lasting 20 minutes to 12 hours) with documented low- to midfrequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo. It also presents with fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear. The underlying etiology of MD is not completely clear, yet it has been associated with inner ear fluid (endolymph) volume increases, culminating in episodic ear symptoms (vertigo, fluctuating hearing loss, tinnitus, and aural fullness). Physical examination findings are often unremarkable, and audiometric testing may or may not show low- to midfrequency sensorineural hearing loss. Conventional imaging, if performed, is also typically normal. The goals of MD treatment are to prevent or reduce vertigo severity and frequency; relieve or prevent hearing loss, tinnitus, and aural fullness; and improve quality of life. Treatment approaches to MD are many and typically include modifications of lifestyle factors (eg, diet) and medical, surgical, or a combination of therapies.

PURPOSE

The primary purpose of this clinical practice guideline is to improve the quality of the diagnostic workup and treatment outcomes of MD. To achieve this purpose, the goals of this guideline are to use the best available published scientific and/or clinical evidence to enhance diagnostic accuracy and appropriate therapeutic interventions (medical and surgical) while reducing unindicated diagnostic testing and/or imaging.

Endolymphatic Sac Decompression With Intra-Sac Dexamethasone Injection in Menière's Disease

OBJECTIVE

Endolymphatic sac decompression surgery (ELSD) may be used to treat patients who have Menière's 's disease refractory to medical therapy. In this study, we investigated whether or not the injection of steroid into the endolymphatic sac at the time of ELSD provides additional benefit to patient outcomes.

STUDY DESIGN

Randomized prospective single-blinded placebo-controlled study.

SETTING

Tertiary center.

PATIENTS

Patients with Menière's disease with poorly controlled vertigo despite medical therapy and serviceable hearing that were offered ELSD.

INTERVENTION(S)

Patients randomized into two groups, with control group (n = 17) undergone ELSD without steroid injection and experimental group undergone ELSD with steroid injection (n = 18) MAIN OUTCOME MEASURE(S):: Audiogram, dizziness handicap inventory, tinnitus handicap inventory, frequency of vertigo spells, functional level scale, and quality of life were obtained at multiple intervals from preoperatively to 24 months postoperatively.

RESULTS

ELSD resulted in a statistically significant improvement in vertigo control whether or not steroid was injected into the endolymphatic sac at the time of surgery. However, no additional benefit was observed with the addition of intra-sac steroid injection. No statistical difference in pure-tone average, tinnitus handicap inventory, dizziness handicap inventory, or quality of life was observed between the steroid and nonsteroid surgical groups up to 24 months postoperatively.

CONCLUSION

ELSD is an effective treatment for Menière's disease refractory to medical therapy; however, the addition of intra-sac steroid injection at the time of surgery does not seem to result in a further improvement in patient outcomes.

Endolymphatic sac drainage for the treatment of Ménière's disease

OBJECTIVE

To describe the results obtained with endolymphatic sac drainage in patients with Ménière's disease.

METHOD

A retrospective case review study was conducted of 95 Ménière's disease patients who underwent endolymphatic sac drainage in a tertiary care referral centre, after failing a long course of medical management. The main outcome measures were vertigo control and hearing preservation.

RESULTS

In patients with unilateral disease, vertigo control was obtained in 94.3 per cent of patients. A significant improvement in cochlear function was seen in 14 per cent of patients, and hearing was preserved or improved in 88 per cent. For the bilateral group, vertigo control was obtained in 85.7 per cent of patients and cochlear function improved in 28 per cent. Hearing preservation was attained in 71 per cent of these patients.

CONCLUSION

Endolymphatic sac drainage is a good surgical option for patients with incapacitating endolymphatic hydrops, providing a high percentage of vertigo control and hearing preservation.

Surgical Management of Special Cases of Intractable Meniere's Disease: Unilateral Cases with Intact Canals and Bilateral Cases

If a clinician seeks to allow patients with vertigo to return to work as soon as possible, it is very important to determine the appearance of vestibular symptoms during convalescence just after treatment, as well as the long-term results. Apprehensive patients with vertigo may undergo severe psychological torment if treatment requires long-term rest in bed before they can return to daily life. In this paper, we observed postoperative vestibular symptoms (subjective sensation and objective nystagmus) in 50 patients with intractable Meniere's disease, including cases from our previous preliminary report, during the period of convalescence just after endolymphatic sac drainage and steroid instillation surgery (EDSS). All symptoms were eliminated within 8 days after EDSS. There was no significant difference in the duration of any vestibular symptoms between bilateral (n = 8) and unilateral cases (n = 42). This result indicates that EDSS could be as safe a treatment for bilateral Meniere's disease as for unilateral disease. In unilateral cases with intact semicircular canal function (n = 17), postoperative evoked vestibular sensation, positional, and positioning (Dix-Hallpike) nystagmus disappeared significantly earlier than in those with canal paresis (n = 25). This result indicates that EDSS could keep the vestibular peripheral function of patients with unilateral Meniere's disease with intact canals quite stable after surgery. Therefore, EDSS could be recommended as an initial, less-invasive surgical treatment for intractable Meniere's disease, especially in unilateral cases with intact canals and in bilateral cases.

Endolymphatic duct blockage: a randomized controlled trial of a novel surgical technique for Ménière's disease treatment

OBJECTIVES

To compare the effectiveness of the endolymphatic duct blockage (EDB) and the endolymphatic sac decompression (ESD) to control Ménière's disease symptoms and to evaluate their effect on hearing level.

STUDY DESIGN

Prospective nonblinded randomized study.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Fifty-seven patients affected by a refractory Ménière's disease were included out of which 22 underwent an ESD and 35 underwent an EDB. Five periods of follow-up were considered: 0 to 1 week, 1 week to 6 months, 6 to 12 months, 12 to 18 months, and 18 to 24 months. Mean outcome measurements consisted of vertigo control, tinnitus, aural fullness, instability, and hearing level. Hearing level was evaluated using pure-tone average (PTA) and speech discrimination score (SDS).

RESULTS

There was no significant difference between the 2 groups in the number of vertigo spells per months preoperatively (P = .153). Twenty-four months postoperatively, 96.5% of the EDB group had achieved a complete control of vertigo spells against 37.5% of the ESD group with a statistically significant difference (P = .002). There was a better control of tinnitus and aural fullness with EDB (P = .021 and P = .014, respectively). There was no statistically significant difference in hearing level preoperatively (P = .976) and 24 months postoperatively (P = .287) between the 2 groups. Hearing level was preserved in each group with no significant difference between the preoperative and the postoperative levels (P > .05).

CONCLUSION

EDB is more effective than the traditional ESD in controlling the symptoms of Ménière's disease. It is a novel surgical technique with promising results for a complete treatment of Ménière's disease. There are no significant complications or adverse effect.

Long-Term Results of Endolymphatic Mastoid Shunt Surgery in Patients with Intractable Ménière's Disease

OBJECTIVE: To evaluate changes in vertigo and hearing from patients with Ménière's disease managed by endolymphatic mastoid shunt (EMS).

STUDY DESIGN: Case series with chart review.

SETTING: Tertiary referral center.

SUBJECTS AND METHODS: Data from 16 patients were analyzed using 1995 AAO–HNS criteria.

RESULTS: Among 16 patients, six had class A vertigo control two years after treatment, five had class B, one class C, three class D, and one class F. At four years after surgery, seven patients had class A, four class B, three class C, and two class F. The mean functional level before surgery was 4.8 and improved to 2.9 and 2.6 at two years and four years after surgery, respectively. The bone conduction pure-tone averages (four frequencies) were 43.3 before surgery and improved to 33.5 dB HL and 35.5 dB HL at three and six months after surgery, respectively. At two years of follow-up, the hearing level was 38.6 dB HL and was not different from the preoperative hearing level. Two years after surgery, the hearing level gradually decreased and was 42.0 dB HL at five years of follow-up.

CONCLUSION: EMS appears to be beneficial in the short term for the symptomatic patients.

Meniere's disease

Meniere's disease is a chronic illness that affects a substantial number of patients every year worldwide. The disease is characterised by intermittent episodes of vertigo lasting from minutes to hours, with fluctuating sensorineural hearing loss, tinnitus, and aural pressure. Although there is currently no cure, more than 85% of patients with Meniere's disease are helped by either changes in lifestyle and medical treatment, or minimally invasive surgical procedures such as intratympanic steroid therapy, intratympanic gentamicin therapy, and endolymphatic sac surgery. Vestibular neurectomy has a very high rate of vertigo control and is available for patients with good hearing who have failed all other treatments. Labyrinthectomy is undertaken as a last resort and is best reserved for patients with unilateral disease and deafness.

Quality-of-life assessment of Ménière's disease patients after surgical labyrinthectomy

OBJECTIVE

To examine the impact of surgical labyrinthectomy on quality of life of Ménière's disease patients.

STUDY DESIGN

Cross-sectional survey.

SETTING

Otology subspecialty referral center.

PATIENTS

All patients with Ménière's disease who underwent surgical labyrinthectomy between 1998 and 2004 were selected. Fifty-three patients satisfied inclusion criteria. Completed questionnaires were obtained from 44 patients.

INTERVENTION(S)

The Ménière's Disease Outcomes Questionnaire is a disease-specific quality-of-life questionnaire. It was used to assess the quality of life of patients before and after surgical labyrinthectomy. The questionnaire encompasses physical, mental, and social well-being domains of quality of life.

MAIN OUTCOME MEASURE(S)

Change in total quality-of-life score was used to assess the overall impact of surgical labyrinthectomy on subjective patient outcome. Individual quality-of-life domains were also assessed.

RESULTS

Forty-three of 44 respondents (98%) had improvement in total score after surgery. The one patient who demonstrated deterioration developed latent contralateral disease. Average preoperative and postoperative scores were 34 +/- 14 and 67 +/- 15, respectively (p < 0.001). All questions showed significant improvement with surgery (p < 0.001) except questions pertaining to memory (no change) and hearing loss (nonsignificant decrease in score).

CONCLUSION

This study comprises the first patient-directed assessment of quality-of-life outcomes in Ménière's disease patients after labyrinthectomy. Despite the disadvantage of hearing loss, patients consistently reported significant improvement in all quality-of-life domains and do not report a significant loss of quality of life in terms of their hearing loss. Surgical labyrinthectomy remains a highly effective treatment for Ménière's disease patients.

Sac surgery results as a function of preoperative distress level

OBJECTIVE

To evaluate the postoperative status of the patients after endolymphatic sac decompression (ESD) for intractable unilateral definite Ménière's disease (MD) using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 1995 criteria and to discuss the current status of ESD in the management of MD, especially after the wide use of intratympanic administration of gentamicin for the treatment of intractable MD.

STUDY DESIGN

Retrospective questionnaire-based analysis.

METHODS

Thirty-nine patients who had undergone ESD between 1996 and May 2003 at Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India, were evaluated via a set format according to AAO-HNS 1995 guidelines. Their preoperative and postoperative data were compared.

RESULTS

We found significant improvement in functional level scales (FLSs) in 84.6%, Class A vertigo control in 82%, and improved disability outcome in 87% of cases after surgery at a median postoperative follow-up of 29 months. All the patients showing significant improvement in FLS were preoperatively in scale 4 or more, and all the patients whose treatment failed were in scale 3 or less.

CONCLUSION

We recommend continued use of ESD in indicated patients. We found a positive relation between preoperative distress level of the patient and postoperative improvement in FLSs; any such relationship should be investigated with a larger sample.

Endolymphatic Sac-Vein Decompression for Intractable Meniere's Disease: Long Term Treatment Results

OBJECTIVES: W e sought to determine the long-term efficacy of endolymphatic sac-vein decompression surgery on patients with classic Meniere's disease.

STUDY DESIGN AND SETTING: Using the 1995 American Academy of Otolaryngology–Head and Neck Surgery Committee on Hearing and Equilibrium criteria, starting stage, functional level, vertigo class, and hearing results were addressed. We studied 68 patients with classic Meniere's disease from a tertiary, private otology-neurotology practice. Patient data were gathered by retrospective chart review, questionnaire, and patient interview. All patients underwent endolymphatic sac-vein decompression with an average follow-up period of 55 months. RESULTS: Median functional level before surgery was level 4, improving to level 2 after surgery. Eighty-one percent of patients showed improvement in functional level, 12% remained stable, and 7% declined. Long-term vertigo control was 47% in class A, 25% in class B, 9% in class C, 3% in class D, and 16% in class F. Twenty percent of patients were in hearing stage I Meniere's disease; 31%, stage II; 44%, stage III; and 5%, stage IV. Eighteen percent of patients showed improvement in hearing class, 64% were stable, and 18% declined.

CONCLUSION: Endolymphatic sac-vein decompression surgery is a safe, nondestructive surgical option for Meniere's disease that offers durable control of vertigo and stabilization of hearing for the majority of symptomatic patients.

SIGNIFICANCE: The beneficial long-term outcome of the endolymphatic sac-vein decompression supports its continued use as a first-line treatment option in intractable Meniere's disease.

Meniere's disease: overview, epidemiology, and natural history

Meniere's disease is a disease of the inner ear characterized by a triad of symptoms: vestibular symptoms, auditory symptoms, and pressure. The pathologic correlate of Meniere's disease is endolymphatic hydrops and the etiopathogenesis involves a deficiency in the absorption of endolymph. The pathophysiology of the symptoms is still disputed: membranous ruptures, pressure and mechanical displacement of the end organs, or obstruction followed by an abrupt clearance of the endolymphatic duct. The course of the disease may be progressive or nonprogressive and, in addition to the typical presentation of Meniere's disease, two variations of the disorder have been identified: cochlear Meniere's disease, and vestibular Meniere's disease. It can be further broken into two subsets: Meniere's syndrome, with a known and well-established cause, and Meniere's disease, in which the cause seems to be idiopathic. It is likely that there are racial (genetic) as well as environmental factors that influence differences in incidence among countries and among various sections of countries. The disease is much more common in adults, with an average age of onset in the fourth decade, the symptoms beginning usually between ages 20 and 60 years. Meniere's disease is (grossly) equally common in each sex, and right and left ears are affected with fairly equal frequency. The diagnosis of Meniere's disease is by exclusion, and a careful history is the most important guide to a correct diagnosis. Its medical treatment is largely empiric. Surgery can be considered when, even after medical therapy, the disease progresses and the symptoms become intractable. Surgery may be either conservative or destructive. Bilaterality must be considered when deciding the best surgical option for a patient with Meniere's disease. It is the authors' opinion that endolymphatic sac surgery is an extension of conservative treatment.

Endolymphatic sac enhancement: reversal of pathogenesis

As this article and many other publications have indicated, many thousands of patients with incapacitating intractable progressive Meniere's disease have had their lives restored through endolymphatic sac enhancement surgery. This is the only nondestructive procedure for Meniere's disease that has stood the test of time. Destructive procedures such as labyrinthectomy (chemical or physical) and vestibular nerve section are reserved for rare cases of failure or recurrence after sac enhancement, despite revision of the enhancement. There is much evidence to support the concept that endolymphatic sac enhancement reverses or enhances the pathogenesis of Meniere's disease. With additional clinical and molecular biologic research, endolymphatic sac enhancement will continue to improve and become more efficacious in the new millennium.

Medical management of Meniere's disease

Medical therapy of Meniere's disease is geared not only toward the differential diagnosis that has led to Meniere's disease and the supportive therapy for the physical manifestations of the disease but also for the psychologic sequelae of the disease such as mild-to-moderate situational depression and even chronic depression. Overall, with adequate medical therapy, allergy workup, and immunotherapy for patients with known diagnoses of allergies, the author's clinic has been able to help more than 85% of its patients who present with symptoms of Meniere's disease. For intractable cases where autoimmune phenomena can be suspected with a strong degree of suspicion, the author's clinic has also treated patients with immunosuppressive medications such as azathioprine and/or methotrexate in a low dose.

Intratympanic dexamethasone, intratympanic gentamicin, and endolymphatic sac surgery for intractable vertigo in Meniere's disease

OBJECTIVE

To compare the efficacy of intratympanic dexamethasone (ID), intratympanic gentamicin (IG), and decompression of the endolymphatic sac (ESD) for intractable vertigo in Meniere's disease.

STUDY DESIGN AND SETTING

This prospective study was conducted at Hacettepe University Medical Faculty, a tertiary care center. Dexamethasone was applied through a ventilation tube in 24 patients, intratympanic gentamicin (also through a ventilation tube) to 16 patients, and 25 patients underwent ESD.

RESULTS

Satisfactory control of vertigo was 72%, 75%, and 52%, respectively for the ID, IG, and ESD. Two patients in the gentamicine group had total hearing loss. In the dexamethasone group, hearing level remained the same in 46% of the patients with 16% increase and 38% decrease (30% 10dB and 8% 20 dB).

CONCLUSION

If the vertiginous symptoms still persist after 6 months of medical treatment, ID can be started. If there is no further improvement after 3 months with ID, patients with profound sensorineural hearing loss undergo treatment with IG, ESD is reserved for patients with good hearing. If ESD also fails, patients with good hearing may undergo vestibular nerve section; patients with nonservicable hearing become candidates for labyrinthectomy.

Effects of exposing the opened endolymphatic sac to large doses of steroids to treat intractable Meniere's disease

To enhance the effect of treatment for intractable Meniere's disease, we exposed the opened endolymphatic sac to high concentrations of steroids. This technique--endolymphatic sac drainage and steroid instillation surgery--involves the application of a mass of prednisolone followed by absorbable gelatin sponges soaked in a high concentration of dexamethasone into a sac lumen opened and expanded with a bundle of absorbable gelatin film. These sponges are also placed around the sac and coated with biochemical adhesive so that the medicine is slowly delivered into the sac over a prolonged period of time by means of a natural sustained-release vehicle. The short-term results (6 to 14 months) in 12 patients with Meniere's disease, including those in stage IV, treated by the above techniques showed that definitive spells were completely controlled in all cases. Hearing was improved, and annoyance due to tinnitus was decreased in all cases except one.

Innovar treatment for Meniere's disease

Patients with intractable vertigo due to clinical Meniere's disease were offered treatment with Innovar, a neurolept analgesic. The patients were from a single clinical practice, had failed conventional dietary and medical treatment and were eligible on clinical grounds for endolymphatic sac surgery. After a follow-up of 2-8 years, 58% of patients had long-lasting relief of vertigo. Hearing was not affected. Risk factors for a favorable response were male gender, fluctuating hearing, and early stage of the disorder. Innovar is a safe, cost-effective second-line therapy for patients with Meniere's disease who have failed conventional first-line medical therapy.

Sac-vein decompression for intractable Meniere's disease: two-year treatment results

Surgical intervention has been offered to patients with Meniere's disease who have failed medical treatment and have disabling symptoms. Surgical options have included labyrinthectomy (mechanical and chemical), vestibular neurectomy, and endolymphatic sac surgery with or without shunting. We present a modification of endolymphatic sac decompression surgery that includes wide decompression of the sigmoid sinus, posterior cranial fossa dura, and endolymphatic sac (sac-vein decompression). Thirty-five patients underwent 37 primary procedures with 2 years of follow-up. Patients were evaluated according to the 1985 American Academy of Otolaryngology-Head and Neck Surgery criteria for assessing Meniere's disease. Vestibular symptom severity was resolved or mild in 92% and disability severity was none or mild in 95% of patients at 2 years after surgery. Vertigo control was complete or substantial in 85% and 100% of patients at 1 and 2 years after surgery. Audiologic data showed stable or improved hearing in 86% and 85% of patients at 1 and 2 years after surgery. In summary, wide decompression of the sigmoid sinus, posterior cranial fossa dura, and endolymphatic sac offers improved control of vertigo and hearing stabilization for intractable Meniere's disease compared with simple endolymphatic sac decompression or shunt surgery.

Outcome-based assessment of endolymphatic sac surgery for Meniere's disease

This study reports the preliminary results of an outcomes approach to analysis of the effectiveness of endolymphatic sac decompression (ELSD). Using the medical outcomes survey's 36-item, short-form health survey (SF-36), we assessed the quality of life in 33 patients with disabling Meniere's disease undergoing ELSD for medically intractable vertigo. Results indicate that patients with 1995 American Academy of Otolaryngology--Head and Neck Surgery (AAO/HNS) class A or B outcomes showed no significant difference from population norms on the SF-36, whereas patients with AAO/HNS classes C to E outcomes scored significantly below norms. Six patients who were given the SF-36 preoperatively scored consistently below population norms. Postoperatively, they showed a statistically significant improvement and were statistically equal to norms. These findings suggest that the SF-36 is a good measure of the quality of life impairment in patients with disabling Meniere's disease. In addition, SF-36 scores correlated well with the 1995 AAO/HNS classification.