Repeated courses of intratympanic dexamethasone injection are effective for intractable Meniere's disease

Intratympanic dexamethasone in Manières disease and symptom control

BACKGROUND

Manières disease (MD) is a chronic inner ear disease characterized by recurrent vertigo and fluctuation in auditory symptoms. Vertigo spells have a sudden onset and are difficult for patients to handle. Therefore, treating a patient with MD is still a challenge for clinicians.

AIMS

This study aims to analyse the short-term effects of intratympanic dexamethasone (ITD) on the various symptoms of unilateral MD.

MATERIALS AND METHODS

The study comprised 27 patients with unilateral MD and severe vertigo who failed medication therapy. Treatment was with ITD as an alternative to destructive therapy. Treatment is evaluated after four months.

RESULTS

Significant improvements were measured with Dizziness Handicap Inventory (DHI), Tinnitus Handicap Inventory (THI), frequency of vertigo attacks longer than 20 min, Functional Level Scale (FLS), and tinnitus sensation measured by the Analog Visual Scale (AVS). Patients with severe symptoms grading with DHI and THI experienced the most improvement. Patients have achieved substantial vertigo control in 73%.

CONCLUSION

ITD application shows improvement in controlling vertigo and tinnitus in patients under exacerbation in MD.

SIGNIFICANCE

It is a promising non-destructive addition to the 'stepwise treatment concept' in MD and can be used as a first-line treatment in vertigo control.

Comparison between audio-vestibular findings and contrast-enhanced MRI of inner ear in patients with unilateral Ménière’s disease

Objective

The diagnosis of Ménière’s disease (MD), characterized by idiopathic endolymphatic hydrops (ELH), remains a clinical priority. Many ancillary methods, including the auditory and vestibular assessments, have been developed to identify ELH. The newly emerging delayed magnetic resonance imaging (MRI) of the inner ear after intratympanic gadolinium (Gd) has been used for identifying ELH in vivo. We aimed to investigate the concordance of audio-vestibular and radiological findings in patients with unilateral MD.

Methods

In this retrospective study, 70 patients with unilateral definite MD underwent three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) sequences following intratympanic application of Gd. Audio-vestibular evaluations were performed, including pure tone audiometry, electrocochleogram (ECochG), glycerol test, caloric test, cervical and ocular vestibular evoked myogenic potentials (VEMPs), and video head impulse test (vHIT). The relationship between imaging signs of ELH and audio-vestibular results was investigated.

Results

The incidence of radiological ELH was higher than that of neurotological results, including the glycerol test, caloric test, VEMPs, and vHIT. Poor or slight agreement was observed between audio-vestibular findings and radiological ELH in cochlear and/or vestibular (kappa values <0.4). However, the pure tone average (PTA) in the affected side significantly correlated with the extent of both cochlear (r = 0.26795, p = 0.0249) and vestibular (r = 0.2728, p = 0.0223) hydrops. Furthermore, the degree of vestibular hydrops was also positively correlated with course duration (r = 0.2592, p = 0.0303) and glycerol test results (r = 0.3944, p = 0.0061) in the affected side.

Conclusion

In the diagnosis of MD, contrast-enhanced MRI of the inner ear is advantageous in detecting ELH over the conventional audio-vestibular evaluations, which estimates more than hydropic dilation of endolymphatic space.

Anatomical variation of inner ear may be a predisposing factor for unilateral Ménière's disease rather than for ipsilateral delayed endolymphatic hydrops

Objective

Radiological anatomical variations, measured by magnetic resonance imaging (MRI), were evaluated in patients with ipsilateral delayed endolymphatic hydrops (DEH) and unilateral Ménière’s disease (MD). The role of anatomical variations in different subtypes of hydropic ear disease was investigated.

Methods

Twenty-eight patients with ipsilateral DEH, 76 patients with unilateral MD, and 59 control subjects were enrolled. The radiological indices included the distance between the vertical part of the posterior semicircular canal and the posterior fossa (MRI-PP distance) and the visibility of vestibular aqueduct (MRI-VA). These variations among patients with DEH, MD, and control subjects were compared. The correlation between radiological anatomical variations and clinical features or audio-vestibular findings was also examined.

Results

(1) MRI-PP distance in the affected side of unilateral MD was shorter than that in ipsilateral DEH (Z =  − 2.481, p = 0.013) and control subjects (Z =  − 2.983, p = 0.003), while the difference of MRI-PP distance between the affected side of ipsilateral DEH and control subjects was not statistically significant (Z =  − 0.859, p = 0.391). (2) There was no significant interaural difference of MRI-PP distance in patients with unilateral MD (Z =  − 0.041, p = 0.968) and ipsilateral DEH (t =  − 0.107, p = 0.915) respectively. (3) No significant interaural difference of MRI-VA visibility was observed in patients with unilateral MD (χ² = 0.742, p = 0.389) and ipsilateral DEH (χ² = 0.327, p = 0.567) respectively. (4) No correlation was found between these anatomical variables and clinical features or audio-vestibular findings in patients with unilateral MD and ipsilateral DEH respectively (p > 0.05).

Conclusions

Anatomical variations of inner ear may be a predisposing factor in the pathogenesis of unilateral MD rather than ipsilateral DEH.

Key Points

• Patients with ipsilateral delayed endolymphatic hydrops showed normal distance between the vertical part of the posterior semicircular canal and the posterior fossa.

• Compared to patients with ipsilateral delayed endolymphatic hydrops and control subjects, patients with unilateral Ménière’s disease exhibited shorter distance between the vertical part of the posterior semicircular canal and the posterior fossa.

• Anatomical variations of inner ear may be a predisposing factor in the pathogenesis of unilateral Ménière’s disease rather than ipsilateral delayed endolymphatic hydrops.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08430-7.

Differences in responsiveness of intratympanic steroid injection for intractable vertigo in Meniere's disease

OBJECTIVES

The efficacy of intratympanic steroid (ITS) injection for intractable Meniere's disease has been reported; however, its differences in responsiveness are not fully understood. This study investigated the clinical characteristics of patients who responded to ITS injection treatment.

METHODS

This retrospective study included 32 patients with Meniere's disease who were unable to control frequent vertigo attacks despite conservative treatment for at least 3 months. They received an intratympanic injection of dexamethasone (3.3 mg/mL) in the affected side at least three times. We measured hearing threshold, subjective symptom scores, cervical and ocular vestibular evoked myogenic potential (cVEMP and oVEMP), and performed glycerol and bithermal caloric tests.

RESULTS

Satisfactory control of vertigo for 1 year after the first round of injection was found in 18 patients (56.3%; the response group). However, the injections failed to control vertigo in the other 14 patients (43.8%; the non-response group), and they were then treated with middle ear micropressure therapy. The response group showed improvement in low-frequency hearing, whereas hearing acuity did not change in the non-response group. Significantly reduced amplitude of cVEMP on the affected side was found in 62.5% of patients in the response group; however, no patients in the non-response group showed reduced amplitude of cVEMP.

CONCLUSIONS

ITS injection significantly improved the subjective symptoms for intractable Meniere's disease; however, the long-term effects were heterogeneous. Our results suggest that reduced amplitude in cVEMP is associated with the effectiveness of ITS injection treatment.

Biologics for Immune-Mediated Sensorineural Hearing Loss

Immune-mediated hearing losses include autoimmune inner ear disease, sudden sensorineural hearing loss, and Meniere's disease. Standard therapy for an acute decline in hearing is timely use of corticosteroids. Although 60% to 70% of patients are initially corticosteroid-responsive, that responsiveness is lost over time. In corticosteroid-resistant patients, increased expression of interleukin (IL)-1 is observed, and these patients may benefit from IL-1 inhibition. Autoinflammatory diseases are characterized by dysregulation of the innate immune response, clinically include sensorineural hearing loss, and benefit from IL-1 inhibition, thereby further establishing the relationship of IL-1 with immune-mediated sensorineural hearing loss.

Effectiveness of intratympanic dexamethasone for the treatment of vertigo attacks in patients with Ménière's disease compared with betahistine pharmacotherapy

OBJECTIVE

This study analyzed the possible effects of intratympanic steroid (ITS) therapy in the symptomatic treatment of vertigo attacks in patients with Ménière's disease.

METHODS

Thirty-five patients treated with ITS (dexamethasone) plus betahistine (Group A) and 35 patients treated with betahistine alone (Group B) were enrolled in this investigation. Complaints were analyzed using medical records and vertigo diaries. Statistical analysis was conducted using IBM SPSS V24 software.

RESULTS

Based on the analysis, there were no significant differences in baseline features between the two groups. When the occurrence of vertigo attacks was compared using the Kaplan-Meier method, no significant difference was detected between Groups A and B (odds ratio [OR] = 1.051, 95% confidence interval [CI] = 0.965-1.067; p = 0.972). In addition, no difference in the incidence of vertigo attacks was noted in group A between the periods of treatment with betahistine alone and betahistine plus ITS when the groups were analyzed via logistic regression (OR = 1.07, 95% CI = 0.065-1.467; p = 0.614).

CONCLUSION

It can be concluded that the addition of ITS therapy to betahistine did not improve outcomes in patients with Ménière's disease. Further prospective studies should be conducted to analyze the results in a more detailed manner.

1D Convolutional Neural Networks for Detecting Nystagmus

Vertigo is a type of dizziness characterised by the subjective feeling of movement despite being stationary. One in four individuals in the community experience symptoms of dizziness at any given time, and it can be challenging for clinicians to diagnose the underlying cause. When dizziness is the result of a malfunction in the inner-ear, the eyes flicker and this is called nystagmus. In this article we describe the first use of Deep Neural Network architectures applied to detecting nystagmus. The data used in these experiments was gathered during a clinical investigation of a novel medical device for recording head and eye movements. We describe methods for training networks using very limited amounts of training data, with an average of 11 mins of nystagmus across four subjects, and less than 24 hours of data in total, per subject. Our methods work by replicating and modifying existing samples to generate new data. In a cross-fold validation experiment, we achieve an average F1 score of 0.59 (SD = 0.24) across all four folds, showing that the methods employed are capable of identifying periods of nystagmus with a modest degree of accuracy. Notably, we were also able to identify periods of pathological nystagmus produced by a patient during an acute attack of Ménière's Disease, despite training the network on nystagmus that was induced by different means.

Vestibulo-ocular reflex tests may reflect unilateral Ménière disease progression: A cross-sectional study

Vestibular disorders can manifest several patterns of horizontal vestibulo-ocular reflex (VOR) impairment, which can be detected by caloric test and video head impulse test (vHIT). Several studies have examined the patterns of caloric-vHIT response in Ménière disease (MD). The purpose of this study was to investigate the diversity of caloric-vHIT response and its related factors in unilateral MD patients. We also explore the possibility of assessing the progression of unilateral MD by using the horizontal VOR tests.Ninety-eight patients with unilateral MD were enrolled and underwent a battery of audio-vestibular evaluations, including the pure tone audiogram, caloric test, and horizontal vHIT. Some patients received the electrocochleography and glycerol test. The combined results of caloric test and horizontal vHIT were categorized qualitatively into 4 patterns: Pattern I: normal caloric and vHIT responses; Pattern II: abnormal caloric and normal vHIT responses; Pattern III: normal caloric and abnormal vHIT response; and Pattern IV: abnormal caloric and vHIT responses. The abnormal caloric results were semi-quantitatively subdivided into sub-patterns as mild, moderate, and severe abnormality. The associations between these patterns/sub-patterns and related factors were analyzed.Pattern I was found in 35 cases (35.7%), Pattern II in 57 (58.2%), and Pattern IV in 6 (6.1%). No patient had Pattern III. No significant differences were found between the patterns/sub-pattern distribution and age, electrocochleography, and glycerol test results. Disease duration was not associated with the pattern distribution, while remained a relation with sub-pattern distribution. The pattern/sub-pattern distribution varied significantly across MD stages. The proportion of pattern II or pattern IV increased with the stage of unilateral MD.MD can manifest several patterns of horizontal VOR impairment, of which the impaired caloric response with normal vHIT is the most common pattern. With the progression of unilateral MD, the caloric-vHIT pattern tends to shift, which may reflect the deterioration of endolymphatic hydrops and vestibular hair cells impairments.

A comparison of endolymphatic shunt surgery and intratympanic gentamicin for meniere's disease

OBJECTIVE

To report audiovestibular outcomes following endolymphatic shunt surgery (ELS) and intratympanic gentamicin injections (ITG) in patients with Meniere's disease (MD).

STUDY DESIGN

Retrospective matched cohort study METHODS: Patients with MD refractory to medical management between 2004 and 2017 were reviewed: 44 patients underwent ELS and had outcomes available, while 27 patients underwent ITG and had outcomes available. Mean follow-up durations for the ELS and ITG groups were 39.1 and 43.3 months, respectively. Twenty-six patients from the ELS group and 24 patients from the ITG group were then included in a pretreatment hearing- and age-matched analysis. Main outcome measures were successful control of vertigo, pure-tone average (PTA; 0.5, 1, 2 and 4 kHz), word recognition score (WRS), and treatment complications.

RESULTS

A matched analysis showed vertigo control rates of 73.1% in the ELS group and 66.8% in the ITG group, which were not significantly different (P = .760). The change in PTA following treatment was statistically similar between the ELS group (6.2 dB) and ITG group (4.6 dB) (P = .521), while the change in WRS for the ELS group (+3.9 %) was significantly more favorable than the ITG group (-13.6 %) (P = .046). Chronic post-treatment unsteadiness was reported in 25.0% of the ITG group and was not encountered in the ELS group (P = .009).

CONCLUSION

ELS provided successful vertigo control at least as well as ITG with a lower incidence of audiovestibular complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2455-2460, 2020.

Long Term Outcomes of Intratympanic Dexamethasone in Intractable Unilateral Meniere's Disease

To evaluate the long term effect of Intratympanic dexamethasone in intractable Meniere's disease. 30 patients with refractory Meniere's disease which did not respond to the standard medical management, were treated with Intratympanic dexamethasone injections. Post treatment hearing outcome and dizziness scores were compared with the pretreatment values respectively. The mean dizziness handicap inventory (DHI) score was reduced from 91.58 (range 80-100) to be 31.00 (p = 0.00) at 3 months of treatment. With the successive follow-up periods, the mean DHI scores were reduced to 51.50, 46.6, and 50.90 at the end of, 6, 12, and 24 months (p = 0.04, 0.35, and 0.49 respectively). Again at the end of 24 months, 23.80% of patients were free of vertigo (p = 0.01). No patient had improvement in the hearing (> 10 dB) in any of the follow-up periods and 6.6% demonstrated deterioration in hearing. There were no major intraoperative or postoperative complications detected. Intratympanic injection of steroid is a safe and effective method for treating intractable Meniere's disease. Although short term improvement in the vertigo is well documented, still in 23% of the patients were found to be free of vertigo at even the end of 24 months. There was no significant improvement in hearing noticed, either in short term or in long term.

Intratympanic corticosteroids in Ménière's disease: A mini-review

This article reviews the effectiveness of intratympanic corticosteroids for vertigo control in Ménière's disease at 2-years follow-up according to the guidelines expressed by the American Academy of Otolaryngology-Head & Neck Surgery. Despite the increased use of intratympanic corticosteroids for vertigo control in Ménière's disease there is debate as to their effectiveness, particularly compared to gentamicin. Even so, after just a single course of injections, corticosteroids can reliably provide complete vertigo control (Class A) at 2-years in about 50% of cases as indicated in a recent double-blind randomized controlled clinical trial (Patel et al., 2016). But the effectiveness of intratympanic corticosteroids truly increases when treatment is provided 'as-needed', whereby complete vertigo control is established in up to 91% of cases. On the basis of available literature, there is good evidence to recommend the use of intratympanic steroid treatment for vertigo control in Ménière's disease, but patients must be monitored for non-response. The rationale for treating patients as-needed and the possible reasons for corticosteroid non-response are discussed.

Intratympanic steroids injection is effective for the treatment of drop attacks with Ménière's disease and delayed endolymphatic hydrops: A retrospective study

Drop attack (DA) associated with Ménière's disease (MD) and delayed endolymphatic hydrops (DEH) is not common and may cause life-threatening clinical problems. The intratympanic dexamethasone (ITD) is one of primary treatments for MD or DEH. Our study investigated the effect of ITD on the DA associated with endolymphatic hydrops (EH).We retrospectively reviewed 10 patients with MD- and DEH-associated DA between January 2009 and December 2013 in Outpatient Department of Otolaryngology, Union Hospital, Wuhan, China. Among them, 7 patients (5 cases with MD, 2 cases of DEH) received ITD (4 times, on weekly basis). Further repeated ITD courses or intratympanic gentamicin (ITG) were given if the vertigo was not satisfactorily controlled. The number of DA and status of vertigo control after intratympanic injection were evaluated. After a follow-up study lasting from 19 to 35 months, DA in 5 cases (71.4%) disappeared after initial ITD course. In 2 cases, DA was altogether controlled after an additional intratympanic injection (repeated ITD or/and ITG).This study showed that ITD promises to be a first-line conservative treatment for MD- or DEH-related DA since the steroid possesses no inner-ear toxicity. Furthermore, for MD- or DEH-related DA refractory to ITD, ITG can be an effective alternative.