Surgical treatment of Ménièreʼs disease

Recent surgical options for vestibular vertigo

Vertigo is not a well-defined disease but a symptom that can occur in heterogeneous entities diagnosed and treated mainly by otolaryngologists, neurologists, internal medicine, and primary care physicians. Most vertigo syndromes have a good prognosis and management is predominantly conservative, whereas the need for surgical therapy is rare, but for a subset of patients often the only remaining option. In this paper, we describe and discuss different surgical therapy options for hydropic inner ear diseases, Menière's disease, dehiscence syndromes, perilymph fistulas, and benign paroxysmal positional vertigo. At the end, we shortly introduce the most recent developments in regard to vestibular implants. Surgical therapy is still indicated for vestibular disease in selected patients nowadays when conservative options did not reduce symptoms and patients are still suffering. Success depends on the correct diagnosis and choosing among different procedures the ones going along with an adequate patient selection. With regard to the invasiveness and the possible risks due to surgery, in depth individual counseling is absolutely necessary. Ablative and destructive surgical procedures usually achieve a successful vertigo control, but are associated with a high risk for hearing loss. Therefore, residual hearing has to be included in the decision making process for surgical therapy.

Meniett device in meniere disease: Randomized, double-blind, placebo-controlled multicenter trial

OBJECTIVE

To evaluate the efficacy of portable Meniett low-pressure pulse generator (Medtronic Xomed, Jacksonville, FL) in Meniere disease.

STUDY DESIGN

Randomized, double-blind, placebo-controlled, multicenter trial carried out in 17 academic medical centers.

METHODS

One hundred twenty-nine adults presenting Meniere disease (American Academy of Otolaryngology-Head and Neck Surgery criteria) not controlled by conventional medical treatment were included. The protocol included three phases: 1) placement of a transtympanic tube and evaluation of its effect (if resolution of symptoms, the patient was excluded); 2) randomization: 6-weeks treatment with Meniett (Medtronic Xomed) or placebo device; 3) removal of the device and 6-week follow-up period. The evaluation criteria were the number of vertigo episodes (at least 20 minutes with a 12-hour free interval) and the impact on daily life as assessed by self-questionnaires.

RESULTS

Ninety-seven patients passed to the second phase of the study: 49 and 48 patients received the Meniett (Medtronic Xomed) or the placebo device, respectively. In the placebo group, the number of vertigo episodes decreased from 4.3 ± 0.6 (mean ± standard error of the mean) during the first phase to 2.6 ± 0.5 after 6 weeks of treatment, and to 1.8 ± 0.8 after the removal of the device. Similar results were observed in the Meniett device (Medtronic Xomed) group: 3.2 ± 0.4 episodes during the first phase, 2.5 ± after 6 weeks of Meniett device (Medtronic Xomed) treatment, and 1.5 ± 0.2 after the third phase.

CONCLUSION

An improvement of symptoms was evidenced in all patients, with no difference between the Meniett (Medtronic Xomed) and the placebo device groups. The decrease in the number of vertigo episodes could be explained by an effect of the medical care.

LEVEL OF EVIDENCE

1b. Laryngoscope, 2016 127:470-475, 2017.

A Case of Post-Traumatic Meniere's Disease

There are only a few reports of post-traumatic Meniere's disease and there is few literature that contains detailed data associated with the disease. We report a case of post-traumatic Meniere's disease. He suffered from tinnitus, fluctuating sensorineural hearing loss, and recurrent vertigo. Symptomatic medical treatment was not helpful and neither was soft tissue plugging around the oval and round windows during exploratory tympanotomy. Three months after soft tissue plugging, endolymphatic sac decompression surgery was performed. The patient's symptoms improved markedly thereafter. The clinical significance of post-traumatic Meniere's disease is described and we present a brief review of the literature.

Does intratympanic gadolinium injection predict efficacy of gentamicin partial chemolabyrinthectomy in Menière's disease patients?

Using actual diagnostic criteria, the diagnosis of certain Menière's disease remains impossible during life without histopathologic confirmation. Assessing the value of a diagnostic test is difficult due to the lack of a gold standard. Recent studies reported on the use of MRI after intratympanic gadolinium injection to demonstrate endolymphatic hydrops in vivo. We evaluate whether MRI after intratympanic gadolinium administration is useful for predicting the effect and outcome of intratympanic gentamicin therapy. The correlation between transtympanic electrocochleographic (TT-ECoG) results and hydrops grade on MRI images is also investigated. Twelve definite Menière's disease patients with incapacitating vertigo attacks, not responding to drug and behavioral treatment, were selected for partial chemolabyrinthectomy with intratympanic gentamicin. All patients underwent transtympanic electrocochleography followed by surgical middle ear inspection, partial chemolabyrinthectomy (gentamicin solution 40 mg/ml applied during 60 min) and intratympanic gadolinium injection with clear exposure of the round window membrane. The MR images were reviewed and a hydrops grade was assigned. Correlation between the hydrops grade and the electrocochleographic data was assessed. Only 5 of 12 patients showed gadolinium enhancement in the inner ear. However, 6 of the 7 patients that did not show postoperative intracochlear or intralabyrinthine gadolinium distribution did report the clinical improvement after intratympanic gentamicin therapy. Hydrops grade correlated with the result of transtympanic electrocochleography in four of five cases that showed gadolinium enhancement. We conclude that the use of intratympanic gadolinium has no added value in predicting the clinical outcome of intratympanic gentamicin application. However, based on these data, a correlation between the result of TT-ECoG and hydrops grading on MRI images can be suggested.