Labyrinthectomy versus vestibular neurectomy: long-term physiologic and clinical outcomes

Determination of Recovery by Total Restitution or Compensation Using Multifrequency Vestibular Tests and Subjective Functional Scales in a Human Model of Vestibular Neuritis

BACKGROUND

Vestibular Neuritis (VN) can induce unilateral acute vestibular syndrome (AVS). This study aimed to identify predictive factors of recovery from vestibular neuritis considering total restitution and/or compensation.

METHODS

In this longitudinal study, 40 patients were included. The initial assessment, performed within 36 to 72 h from the onset (T0), included medical history taking (general and specific), including screening for cardiovascular risk factors (CVRFs), and a battery of diagnostic vestibular tests, comprising the bithermal caloric test (BCT), video head impulse test (VHIT), and skull vibration-induced nystagmus (SVIN) test. All patients also completed a Dizziness Handicap Inventory (DHI). All assessments were repeated 90 ± 15 days later (T3). Subjective compensation criteria were based on the DHI total score, and objective compensation criteria were based on laboratory test results. Four groups of patients (A, B, C, D) were delineated by combining patients with normal vs. abnormal vestibular tests and patients with normal vs. abnormal DHI.

RESULTS

CVRFs (but not age or body mass index (BMI)) were associated with a poorer recovery of symptoms. The BCT (lateral semicircular canal paresis %), VHIT (lateral semicircular canal gain), and SVINT (nystagmus slow phase velocity) recovered to normal values in 20%, 20%, and 27% of patients, respectively, at T3.

CONCLUSIONS

Vascular risk factors (hypercholesterolemia) are correlated with patients who do not recover their symptoms via either total restitution or compensation. There was no significant difference between high- and low-frequency vestibular tests in patients recovering from their symptoms. Some patients with objective recovery may continue to have persistent subjective symptoms.

Surgical labyrinthectomy in the treatment of unilateral Meniere disease: a Belgian retrospective study

PURPOSE

Meniere's disease (MD) is a disabling condition with symptoms, such as hearing loss, dizziness, and tinnitus. Surgery is the last resort option for managing MD when other treatments are not effective. Surgical labyrinthectomy (SL) is less commonly performed than vestibular neurectomy or chemical labyrinthectomy. We sought to assess the efficacy and safety of the SL procedure.

METHODS

A retrospective study was carried out involving a cohort of 25 patients with disabling and drug-resistant MD, who underwent SL performed by the same surgeon at University Hospital UCL Namur between 2009 and 2019. All patients considered their hearing non-functional and requested a radical therapeutic option. We compared subjective and objective measures before and after surgery, retrieved from patient medical records.

RESULTS

The difference between the Dizziness Handicap Inventory scores before and after surgery was statistically significant (p < 0.01). 81% of patients being satisfied with surgery. No post-operative complications occurred. Following SL, 14 patients evolved well, both subjectively and clinically, without any further vestibular workup required, which was offered to the other patients. All had a total deafness on the operated side, as expected, while four benefited from multidisciplinary rehabilitation because of persistent tinnitus. The scientific literature on this topic was reviewed, compared, and discussed.

CONCLUSIONS

Based on our results, SL represents an efficient and safe approach to achieve vestibular deafferentation in patients with unilateral, disabling, and treatment-resistant MD, with non-functional hearing.

Histaminergic System and Vestibular Function in Normal and Pathological Conditions

Most neurotransmitter systems are represented in the central and peripheral vestibular system and are thereby involved both in normal vestibular signal processing and the pathophysiology of vestibular disorders. However, there is a special relationship between the vestibular system and the histaminergic system. The purpose of this review is to document how the histaminergic system interferes with normal and pathological vestibular function. In particular, we will discuss neurobiological mechanisms such as neuroinflammation that involve histamine to modulate and allow restoration of balance function in the situation of a vestibular insult. These adaptive mechanisms represent targets of histaminergic pharmacological compounds capable of restoring vestibular function in pathological situations. The clinical use of drugs targeting the histaminergic system in various vestibular disorders is critically discussed.

Triple Semicircular Canal Plugging versus Labyrinthectomy for Meniere Disease: A Retrospective Study

OBJECTIVES

The study goals were to compare the long-term efficacy of semicircular canal plugging (SCP) with labyrinthectomy in the treatment of advanced Meniere's disease (MD).

STUDY DESIGN

A retrospective study.

SETTING

Single tertiary medical center.

METHODS

A total of 116 MD patients (TSCP group of 90; labyrinthectomy group of 26) with complete medical documents in Shandong Provincial ENT Hospital, from March 2017 to March 2019 were retrospectively analyzed, including a battery of auditory and vestibular function tests, recovery time from imbalance and function level scores (FLS).

RESULTS

The total control rate of vertigo in the TSCP group was 96.7% (87/90). The rate of hearing loss was 23.3% (21/90). The control rate of vertigo in the labyrinthectomy group was 100% (26/26). All patients lost their auditory function after labyrinthectomy with a 100% hearing loss rate. There was no significant difference in the vertigo control rate between the two groups (P > 0.05). The hearing loss rate in the TSCP group was significantly lower than that in the labyrinthectomy group (P < 0.00). The median time recovered from imbalance was 15 days in TSCP group and 21 days in labyrinthectomy group, which is significantly different (P < 0.05). There was no significant difference in the FLS between the two groups (P > 0.05).

CONCLUSIONS

Compared to labyrinthectomy, TSCP can preserve hearing at a high probability; meanwhile, otolith organ function preservation benefits patients from faster vestibular compensation.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3178-3184, 2023.

Long-Term Balance Outcomes in Vestibular Ablative Surgeries

Objective:

To evaluate the long-term balance outcomes of vestibular nerve section (VNS) and labyrinthectomy (L) operations. The indirect outcomes will be the correlation of objective and subjective test results and an analysis of anterior-posterior versus medial-lateral computerized posturography (CP) scores.

Methods:

This retrospective study evaluated objective CP and subjective Dizziness Handicap Inventory (DHI) results of patients who underwent VNS and L surgeries for Ménière’s disease.

Results:

A total of 55 (31 VNS and 24 L) patients were included in the study. The two operation groups were similar in terms of age, and mean time between surgery and the tests (p=0.465 and p=0.616) respectively. The vestibular and global scores at anterior-posterior CP showed statistically significant differences between the groups (p=0.000 and p=0.007) respectively in favor of the VNS group. In addition, the comparison of the vestibular CP scores of anterior-posterior and medial-lateral evaluations of the entire study population was lower in the medial-lateral evaluation (p=0.000). The mean DHI scores did not show statistically significant differences (p=0.359) between operation groups, nor did the correlation analysis between CP and DHI scores reveal statistical significance (p values >0.05).

Conclusion:

In the long term, objective balance outcomes are better for VNS patients than for L patients. Additionally, medial-lateral balance outcomes are more affected than anterior-posterior balance outcomes from unilateral ablative surgeries. Subjective balance perception is not different between the two surgery groups, and DHI scores do not show a correlation with CP scores.

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.

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.

Labyrinthectomy and Vestibular Neurectomy for Intractable Vertiginous Symptoms

Introduction Labyrinthectomy and vestibular neurectomy are considered the surgical procedures with the highest possibility of controlling medically untreatable incapacitating vertigo. Ironically, after 100 years of the introduction of both transmastoid labyrinthectomy and vestibular neurectomy, the choice of which procedure to use rests primarily on the evaluation of the hearing and of the surgical morbidity.

Objective To review surgical labyrinthectomy and vestibular neurectomy for the treatment of incapacitating vestibular disorders.

Data Sources PubMed, MD consult and Ovid-SP databases.

Data Synthesis In this review we describe and compare surgical labyrinthectomy and vestibular neurectomy. A contrast between surgical and chemical labyrinthectomy is also examined. Proper candidate selection, success in vertigo control and complication rates are discussed on the basis of a literature review.

Conclusions Vestibular nerve section and labyrinthectomy achieve high and comparable rates of vertigo control. Even though vestibular neurectomy is considered a hearing sparing surgery, since it is an intradural procedure, it carries a greater risk of complications than transmastoid labyrinthectomy. Furthermore, since many patients whose hearing is preserved with vestibular nerve section may ultimately lose that hearing, the long-term value of hearing preservation is not well established. Although the combination of both procedures, in the form of a translabyrinthine vestibular nerve section, is the most certain way to ablate vestibular function for patients with no useful hearing and disabling vertigo, some advocate for transmastoid labyrinthectomy alone, considering that avoiding opening the subarachnoid space minimizes the possible intracranial complications. Chemical labyrinthectomy may be considered a safer alternative, but the risks of hearing loss when hearing preservation is desired are also high.

Surgical management of Meniere's disease in the era of gentamicin

OBJECTIVE

For many years, surgery was the mainstay of therapy for medically refractory patients, but recently, transtympanic gentamicin perfusion has attracted increasing interest and is a method frequently used for treating Meniere's disease. Many otologists question the relevance of surgical treatments, and traditional options are rarely discussed or offered to patients. The purpose of this study is to describe results of labyrinthectomy, vestibular nerve section, and endolymphatic mastoid shunt surgery for patients with Meniere's disease and to compare them with published results for gentamicin perfusion.

STUDY DESIGN AND SETTING

Retrospective chart review. Two hundred twenty-nine patients underwent surgery for management of Meniere's disease between January 1, 1995 and December 31, 2001. One hundred eighty-nine patients' charts had sufficient data for review. Thirty-two patients had translabyrinthine labyrinthectomies, 83 underwent suboccipital vestibular nerve sections, and 74 elected for an endolymphatic mastoid shunt. Hearing results, dizziness classification, and functional level score were determined from patient charts and telephone conversations. All results were in accordance with the guidelines of the AAO-HNS Committee on Hearing and Equilibrium for evaluation of Meniere's disease therapy.

RESULTS

Audiologic results, functional level score, and dizziness classification are reported for the preoperative period and for the 18- to 24-month postoperative period for all surgical patients. These data are also reported individually for each of the 3 surgical procedures. Early postoperative data and most recent follow-up data are presented if available.

CONCLUSIONS

Surgical management of Meniere's disease is a safe and viable option for patients with medically refractory disease.

EBM RATING

C.

First trial response to sudden support surface displacement: the effect of vestibular compensation

CONCLUSION

The effect of visual condition is more intense in the first trial response in normal subjects and patients and in last trial response only in patients. The first trial effect is more evident in compensated patients in the eyes open condition with any type of perturbation, and in non-compensated patients with the angular displacements in either visual condition.

OBJECTIVE

The study of body reaction to FTR can help to understand the complex mechanisms involved in the postural response and to develop new therapies to improve stability and prevent falls in unilateral vestibular deficit (UVD). This work describes the adaptation effect and the visual influence on the postural response to repetitive balance perturbation stimulus in normal subjects, compensated, and uncompensated UVD patients.

METHODS

The magnitude of displacement has been measured when the support surface is linearly or angularly displaced. The differences between results in the first and late trial, and the differences between the eyes open and eyes closed situation have been compared.

RESULTS

Compensated patients recover the adaptation ability to unexpected changes on the support surface through visual preference mechanism. Not compensated patients present hypermetric postural response with greater instability in the eyes open and eyes closed situations.

Dizziness is more prevalent than autophony among patients who have undergone repair of superior canal dehiscence

OBJECTIVE

Studies have reported high early success rates in rectifying dizziness and autophony after primary repair of superior canal dehiscence (SCD). We sought to identify the prevalence of dizziness and autophony at later time points in patients who had undergone SCD repair. We also assessed any problems with hearing in this population, along with prevalence of headaches and decreases in overall quality of life.

STUDY QUALITY DESIGN

Identification of patients via retrospective chart review, followed by administration of multiple validated surveys.

SETTING

Tertiary, hospital-based neurotology practice.

PATIENTS

All 62 patients who had undergone primary SCD repair at Massachusetts Eye and Ear Infirmary with follow-up time of at least 3 months were contacted, with 38 responses from 22 women and 16 men. The average follow-up was 34 months (range, 3-155 mo).

INTERVENTIONS

Patient surveys.

MAIN OUTCOME MEASURES

Dizziness Handicap Inventory and Autophony Index.

SECONDARY OUTCOME MEASURES

Hearing Handicap Survey, MIDAS headache survey, and Short Form-36 Quality of Life Survey.

RESULTS

Twenty patients reported low DHI scores, whereas 18 patients reported elevated DHI scores corresponding to moderate-to-severe dizziness. Autophony was less prevalent, as 3 patients experienced autophony in the operated ear, whereas 3 patients experienced "unmasking" of autophony in the contralateral ear. HHI scores were not significantly different between the low DHI and high DHI group. There were significantly more female subjects in the high DHI group, which was also characterized by significantly more severe MIDAS grades and significantly worse SF-36 scores.

CONCLUSION

Dizziness is more prevalent than autophony among patients who have undergone SCD repair, although the majority of these patients are satisfied with their decision to undergo surgery. Female sex and migraine headaches are associated with dizziness in this patient population. Further work is necessary to determine causal relationships among these associations.

Early adaptation and compensation of clinical vestibular responses after unilateral vestibular deafferentation surgery

OBJECTIVE

To describe vestibulo-ocular function in the immediate postoperative period after unilateral vestibular deafferentation from vestibular schwannoma resection.

STUDY DESIGN

Prospective longitudinal study.

SETTING

Tertiary medical center.

PATIENTS

Five patients who underwent vestibular schwannoma resection via retrosigmoid approach.

INTERVENTIONS

Bedside video-oculography and video head impulse testing (HIT).

MAIN OUTCOME MEASURES

Static and dynamic measures of vestibulo-ocular reflex (VOR) function including spontaneous nystagmus, skew deviation, VOR gain during HIT, and presence of saccades related to HIT.

RESULTS

Mean ipsilesional horizontal VOR gain decreased from 0.88 ± 0.09 preoperatively to 0.27 ± 0.20 on POD 2 (p = 0.004). Mean contralesional VOR gain declined from 0.95 ± 0.1 preoperatively to 0.79 ± 0.17 on POD 2 (p = 0.032). By POD 4, ipsilesional VOR gain remained low, whereas contralesional VOR gain returned to baseline. Initially on POD 1 to 3, compensatory saccades occurred exclusively after the head stopped moving (overt) with latency of 192.8 ± 36.1 ms; by POD 5, saccade latency decreased to 134.5 ± 23.5 ms (p = 0.026), and saccades were occurring during the head rotation. Skew deviation was present and remained abnormal through POD 5 in 3 of the 5 patients.

CONCLUSION

In the postoperative period, gaze stability seems to improve from contralesional VOR gain restoration and reduced latency of compensatory saccades.

Responses of central vestibular neurons to sinusoidal yaw rotation in compensated macaques after unilateral labyrinthectomy

After vestibular labyrinth injury, behavioral measures of vestibular function partially recover through the process of vestibular compensation. The present study was performed to improve our understanding of the physiology of macaque vestibular nucleus neurons in the compensated state (>6 wk) after unilateral labyrinthectomy (UL). The responses of neurons to sinusoidal yaw rotation at a series of frequencies (0.1-2.0 Hz) and peak velocities (7.5-210°/s) were examined to determine how the behavior of these cells differed from those in animals with intact labyrinths. The sensitivity of neurons responding to ipsilateral rotation (type I) did not differ between the intact and injured sides after UL, although this sensitivity was lower bilaterally after lesion than before lesion. The sensitivity of neurons that increase firing with contralateral rotation (type II) was higher ipsilateral to the UL than before lesion or in the nucleus contralateral to the UL. UL did not increase asymmetry in the responses of individual type I or II neurons to ipsilateral vs. contralateral rotation, nor does it change the power law relationship between neuronal firing and level of stimulation. Increased sensitivities of contralesional type I neurons to the remaining vestibular nerve input and increased efficacy of inhibitory vestibular commissures projecting to the ipsilesional vestibular nucleus appear to be responsible for recovery of dynamic function of central vestibular neurons in compensated animals. The portion of type I neurons on the ipsilesional side is reduced in compensated animals, which likely accounts for the asymmetries in vestibular reflexes and perception that characterize vestibular function after UL.

Vestibular labyrinth contributions to human whole-body motion discrimination

To assess the contributions of the vestibular system to whole-body motion discrimination in the dark, we measured direction recognition thresholds as a function of frequency for yaw rotation, superior-inferior translation ("z-translation"), interaural translation ("y-translation"), and roll tilt for 14 normal subjects and for 3 patients following total bilateral vestibular ablation. The patients had significantly higher average threshold measurements than normal (p < 0.01) for yaw rotation (depending upon frequency, 5.4× to 15.7× greater), z-translation (8.3× to 56.8× greater), y-translation (1.7× to 4.5× greater), and roll tilt (1.3× to 3.0× greater)--establishing the predominant contributions of the vestibular system for these motions in the dark.

Surgical management of common peripheral vestibular diseases

PURPOSE OF REVIEW

To review the latest developments in the surgical management of common peripheral vestibular disorders.

RECENT FINDINGS

Although surgery is indicated mainly for patients with Meniere's disease, other less common disorders such as benign paroxysmal positional vertigo, semicircular canal dehiscence, perilymphatic fistulae, fistulae of semicircular canals, VIII nerve vascular compression, chronic vestibular neuronitis, and dizziness following sudden sensorineural hearing loss may require surgical intervention when conservative management has failed.

SUMMARY

Surgery for vestibular disorders is less often indicated at present. Office-administered intratympanic gentamicin and steroid treatment have been found to be effective for control of vertigo in Meniere's disease. Side-effects of this treatment are overall acceptable. Surgery may be considered for Meniere's disease patients with good hearing who have failed intratympanic steroid treatment. Surgery is indicated for patients with debilitating dizziness associated with benign paroxysmal positional vertigo, semicircular canal dehiscence, vascular loop compression, and perilymphatic fistulae.

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.

Transmastoid labyrinthectomy versus translabyrinthine vestibular nerve section: does cutting the vestibular nerve make a difference in outcome?

OBJECTIVE

Analyze differences in outcomes between labyrinthectomy with and without vestibular nerve section, including characteristics of symptoms and time course for improvement.

STUDY DESIGN

Patient survey.

SETTING

Tertiary referral neurotologic private practice.

PATIENTS/INTERVENTION

Twenty-five patients who underwent transmastoid labyrinthectomies and 17 who underwent translabyrinthine vestibular nerve section (TLVNS). Patients with a diagnosis of Meniere's disease comprised 64.0 and 64.7% of the two groups, respectively.

MAIN OUTCOME MEASURES

A mail questionnaire assessed frequency, severity, interference, and disability for both vertigo ("spinning dizziness") and dysequilibrium ("imbalance/unsteadiness") before and after surgery as well as the time course of improvements.

RESULTS

Approximately 24% of each group still has vertigo (spinning dizziness). On average, both groups indicated resolution of vertigo at 2 to 3 weeks on average (longer for imbalance). There were no significant differences between groups in vertigo characteristics, but TLVNS did show advantages in imbalance outcomes. American Academy of Otolaryngology-Head and Neck Surgery functional disability showed improvement in 73 and 52% of the TLVNS and labyrinthectomy groups, respectively. The TLVNS group was more likely to have improved imbalance (81.3 versus 45.8%, p <or= 0.047) and tended more frequently to rate it as currently not severe/none (76.5 versus 45.8%, p <or= 0.06). The labyrinthectomy group did not show significant improvement in any imbalance characteristics, whereas the TLVNS group improved in all characteristics. When limited to patients with Meniere's disease, results are similar, but differences between groups are smaller, and improvement in imbalance did also occur for the labyrinthectomy group.

CONCLUSION

Both transmastoid labyrinthectomy and TLVNS provide good control of vertigo (>85% Class A or B). However, patients undergoing TLVNS were more likely to show improvement in imbalance and functional disability. This difference was less pronounced in patients with Meniere's disease.

Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal vertigo

CONCLUSION

Video-oculography demonstrates a higher occurrence of atypical positional nystagmus in patients with benign paroxysmal positional vertigo (BPPV). This includes anterior and horizontal canal variants and multiple positional nystagmus, suggesting combined lesions affecting several canals.

OBJECTIVE

To analyse the video-oculographic findings of positional tests in patients with BPPV.

MATERIAL AND METHODS

Seventy individuals with symptoms of BPPV and positional nystagmus were included in this study. The diagnosis was based on a history of brief episodes of vertigo and the presence of positional nystagmus as confirmed by video-oculographic examination during the Dix-Hallpike test, the McClure test or the head-hanging manoeuvre. Patients were treated by means of different particle repositioning manoeuvres according to the affected canal (Epley's manoeuvre for the posterior or anterior canals and Lempert's manoeuvre for the lateral canal) and the effectiveness was evaluated at 7 and 30 days.

RESULTS

Twenty-nine individuals (41.43%) presented an affected unilateral posterior canal. Fifteen patients (21.43%) presented a pure horizontal direction-changing positional nystagmus consistent with a diagnosis of horizontal canal BPPV. Twelve individuals (17.14%) presented a unilateral down-beating nystagmus, suggesting possible anterior canal BPPV. In addition, 14 patients (20%) showed multiple positional nystagmus during the examination corresponding to simultaneous multi-canal BPPV, 5 had bilateral posterior canal BPPV and 2 presented a positional down-beating nystagmus in both left and right Dix-Hallpike manoeuvres and the head-hanging manoeuvre, which is highly suggestive of anterior canal BPPV. However, seven individuals showed positional horizontal and vertical side-changing nystagmus that could not be explained by single-canal BPPV. These patients with multiple positional nystagmus showed changing patterns of positional nystagmus at follow-up.

Surgical Treatment of Peripheral Vertigo and Vertiginous Diseases

Although our understanding of the mechanisms of vertigo and pathophysiology of vertiginous disorders has increased, diagnosis and treatment of various vertiginous diseases is challenging. The objective for the treatment of a vertiginous disease is to eliminate the underlying pathology either with maneuvers or drugs. In vertiginous diseases, surgery is performed either to eliminate the underlying pathologic event or to create stability in the incoming vestibular signals. It is not always possible to treat the underlying disease. Therefore, surgery is usually performed for the relief of vertigo. There are various surgical approaches used to treat a variety of vertiginous diseases. Selection of the approach depends on the type of vertiginous disease. This review mainly focuses on the current status and outcome of the surgeries used in the treatment of a variety of vertiginous diseases.

Hearing outcome after concurrent endolymphatic shunt and vestibular nerve section

OBJECTIVE

To determine if endolymphatic shunt surgery concurrent with vestibular nerve section improves hearing outcome compared with vestibular nerve section alone.

STUDY DESIGN

Retrospective observational study with cross-sectional survey.

SETTING

Tertiary otologic private practice.

PATIENTS

Thirty-five patients who underwent vestibular nerve section and endolymphatic shunt surgery and 17 patients who had vestibular nerve section alone between 1985 and 2000.

METHODS

Chart review and correspondence for audiogram results and survey.

MAIN OUTCOME MEASURES

Hearing at last follow-up. Hearing Handicap Inventory, Dizziness Handicap Inventory, Tinnitus Handicap Inventory, and SF-36.

RESULTS

Eight patients in the vestibular nerve section and 15 in the vestibular nerve section and endolymphatic shunt surgery group had an audiogram at more than 16 months after surgery available for review. In the vestibular nerve section group, three patients had same hearing whereas five were worse. In the vestibular nerve section and endolymphatic shunt surgery group, 2 patients showed improvement, 2 were the same, and 11 were worse. There was no significant difference in the change from preoperative pure tone average or Word Discrimination Score to postoperative levels between the surgical groups. Eighteen patients had serviceable hearing preoperatively. Five of 8 in the vestibular nerve section and 4 of 10 in the vestibular nerve section and endolymphatic shunt surgery groups maintained serviceable hearing postoperatively. Of the 52 patients, 33 responded to the survey (63%). There were no significant differences between the groups for Dizziness Handicap Inventory, Hearing Handicap Inventory, Tinnitus Handicap Inventory, or SF-36, suggesting that patient-oriented outcomes are the same in both groups.

CONCLUSIONS

Concurrent endolymphatic shunt surgery and vestibular nerve section does not improve hearing or tinnitus outcome over vestibular nerve section alone.

Intratympanic gentamicin for intractable Meniere's disease

OBJECTIVE

The study aimed to analyze the results of the intratympanic injection of gentamicin as a treatment option for patients with unilateral Meniere's disease who were refractory to medical treatment.

STUDY DESIGN

Prospective study in the setting of a tertiary care medical center.

METHODS

Seventy-one patients with unilateral Meniere's disease according to 1995 American Academy of Otolaryngology-Head and Neck Surgery 1995 guidelines who had been unresponsive to medical therapy for at least 1 year were studied. Intratympanic injections of a prepared concentration of 27 mg/mL gentamicin were performed at weekly intervals until the development of symptoms and signs indicative of vestibular hypofunction in the treated ear. As the main outcome measure, the 1995 American Academy of Otolaryngology-Head and Neck Surgery criteria for reporting treatment outcome in Meniere's disease were used. The results of treatment were expressed in terms of control of vertigo, disability status (functional level and degree of overall impairment evaluated by the Dizziness Handicap Inventory and the University of California Los Angeles Dizziness Questionnaire), hearing level, and quantitative measurement of vestibular function.

RESULTS

Vertigo was controlled in 83.1% of the 71 patients. Recurrence of vertigo spells after initially complete control was noted in 17 patients. In 13 of these patients, this was cured by another course of intratympanic injections of gentamicin. Functional level and measures of self-reported handicap were significantly and promptly lowered after treatment in the patients who attained control of vertigo. Hearing level as pure-tone average was unchanged 2 years after treatment, but hearing loss as a result of gentamicin injections occurred in 23 patients at the end of treatment and in 9 and 11 patients at 3 months and 2 years after the treatment, respectively. Vestibular function was kept normal or reduced in 49.3% of the patients, whereas in the rest of the patients vestibular areflexia was observed. Control of vertigo did not depend on the amount of vestibular damage.

CONCLUSIONS

Ending weekly intratympanic injections when clinical signs of vestibular deafferentation appear can control vertigo in the majority of patients, and it is a useful alternative, together with other surgical options, for the treatment of patients with Meniere's disease who do not respond to medical treatment.

Dizziness: relating the severity of vertigo to the degree of handicap by measuring vestibular impairment

OBJECTIVE

We sought to correlate the severity of vertigo and handicap in patients with vestibular pathology according to measures of impairment.

STUDY DESIGN AND SETTING

We conducted a prospective assessment of patients with dizziness by means of caloric, rotatory test, and computerized dynamic posturography to estimate impairment. Handicap and severity of vertigo were determined with specific questionnaires (Dizziness Handicap Inventory and UCLA-DQ).

RESULTS

A fair relationship were found between severity of dizziness and vestibular handicap. When impairment was taken into consideration, values were still fair and only moderate for a group of patients with an abnormal caloric test as the only pathologic finding. The composite score from the sensory organization test portion of the computerized dynamic posturography is fairly correlated to severity of vertigo and handicap in the whole population of patients, but no correlation was found when they were assigned to groups of vestibular impairment.

CONCLUSION

To assess vestibular impairment, the results from several tests must be taken into account. However, vestibular handicap is not solely explained with measurements of impairment and/or severity.