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Varghese JJ, Shew MA, Walia A, Lefler SM, Durakovic N, Wick CC, Ortmann AJ, Herzog JA, Buchman CA. Validating an Evoked Potential Platform for Electrocochleography During Cochlear Implantation. Laryngoscope 2024. [PMID: 39189299 DOI: 10.1002/lary.31724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 07/28/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024]
Abstract
OBJECTIVE To validate electrocochleography (ECochG) between an auditory evoked potential (AEP) machine and an established cochlear implant (CI) manufacturer ECochG system. METHODS Intraoperative validation study at a tertiary referral center. Patients included adults and children undergoing cochlear implantation. Intraoperative ECochG was measured with both the Intelligent Hearing Systems (IHS) Duet AEP machine and Cochlear Corporation (CC) ECochG platform. Recording electrodes captured extracochlear measurements through a standard facial recess. Tone-bursts were presented from 250 Hz to 2 kHz (~110 dB SPL). A fast Fourier transform (FFT) of ECochG waveforms at key frequencies was summed into a total response (ECochG-TR). Pearson's correlation was utilized to evaluate the relationship between IHS-ECochG-TR and CC-ECochG-TR after confirming normality. RESULTS Thirty patients were enrolled with an average age of 67 years (SD 18.8). In the ear that was implanted, mean preoperative pure-tone average (PTA; 0.5, 1, 2, and 4 kHz) was 87.4 dB HL (SD 19.3) and mean preoperative word-recognition scores (WRS) was 17.0% correct (SD 19.1). There was strong correlation (r = 0.905, 95% confidence interval: 0.809 to 0.954) between IHS-ECochG-TR (median 2.30 μV, range 0.1-148.26) and CC-ECochG-TR (median 3.00 μV, range 0.1-239.63). Four patients underwent transtympanic ECochG with the IHS system for feasibility evaluation and achieved similar responses. CONCLUSION Extracochlear ECochG has been predictive of CI speech perception performance. The IHS duet system is a valid measure of extracochlear ECochG for the CI population. Future work will utilize this system for measuring transtympanic ECochG to improve preoperative estimation of CI performance. LEVEL OF EVIDENCE 3 Laryngoscope, 2024.
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Affiliation(s)
- Jordan J Varghese
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Matthew A Shew
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Amit Walia
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Shannon M Lefler
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Nedim Durakovic
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Cameron C Wick
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Amanda J Ortmann
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jacques A Herzog
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Craig A Buchman
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
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Bonaventurová M, Balatková Z, Červený K, Černý R, Bandúrová V, Koucký V, Peterková L, Fík Z, Komarc M, Mrázková E, Plzák J, Čada Z. The comparison between intratympanic gentamicin prehabilitation and postoperative virtual reality exposure to standard vestibular training in patients with vestibular schwannoma. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08891-8. [PMID: 39127800 DOI: 10.1007/s00405-024-08891-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE Resection of the vestibular schwannoma causes acute peripheral vestibular loss. The process of central compensation starts immediately afterward. The rehabilitation goal is to support this process and restore the quality of life. MATERIALS AND METHODS In this prospective single-center study, 67 consecutive patients underwent vestibular schwannoma resection (40 females, mean age 52 ± 12 years). The patients were divided into three groups: the prehabilitation with intratympanic gentamicin group, the virtual reality group (optokinetic stimulation via virtual reality goggles in the first ten days after the surgery), and the control group. All patients were examined with objective methods and completed questionnaires before the prehabilitation, before the surgery, at the hospital discharge, and after three months. RESULTS Intratympanic gentamicin prehabilitation leads ipsilaterally to a significant aVOR reduction in all semicircular canals (p < 0.050), the increase of the unilateral weakness in air calorics (p = 0.026), and loss of cVEMPs responses (p = 0.017). Prehabilitation and postoperative exposure to virtual reality scenes improved the patient's perception of vertigo problems according to Dizziness Handicap Inventory (p = 0.039 and p = 0.076, respectively). These findings conform with the optokinetic testing results, which showed higher slow phase velocities at higher speeds (40 deg/s) in both targeted groups compared to the control group. CONCLUSION Preoperative intratympanic gentamicin positively affects peripheral vestibular function, influencing balance perception after VS resection. In long-term follow-up, prehabilitation and postoperative exposure to virtual reality improve patients' quality of life in the field of vertigo problems.
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Affiliation(s)
- Markéta Bonaventurová
- Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague, 150 06, Czech Republic
| | - Zuzana Balatková
- Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague, 150 06, Czech Republic.
| | - Květoslav Červený
- Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague, 150 06, Czech Republic
| | - Rudolf Černý
- Department of Neurology, 2nd Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Veronika Bandúrová
- Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague, 150 06, Czech Republic
| | - Vladimír Koucký
- Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague, 150 06, Czech Republic
| | - Lenka Peterková
- Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague, 150 06, Czech Republic
| | - Zdeněk Fík
- Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague, 150 06, Czech Republic
| | - Martin Komarc
- Department of Anthropomotorics and Methodology, Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic
| | - Eva Mrázková
- Department of Otorhinolaryngology and Head and Neck Surgery, Havířov Hospital, Havířov, Czech Republic
| | - Jan Plzák
- Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague, 150 06, Czech Republic
| | - Zdeněk Čada
- Department of Otorhinolaryngology, The Second Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czech Republic
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Scarpa A, Avallone E, Carucci M, Salzano G, Chiarella G, Cassandro C, Viola P, Ricciardiello F, Ralli M, De Luca P, Salzano FA. Efficacy and preservation of hearing with low-dose gentamicin in unilateral meniere's disease: A clinical symptomatology-based study. Am J Otolaryngol 2024; 45:104116. [PMID: 37984050 DOI: 10.1016/j.amjoto.2023.104116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/12/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE Meniere's disease (MD), a disorder of the inner ear, presents numerous therapeutic challenges, and intratympanic (IT) gentamicin has been proposed for intractable cases. However, controversy regarding dosage and method persists. The purpose of this study was to assess the efficacy and safety of low-dose IT gentamicin on vertigo attacks in MD using a clinical symptomatology-based method, wherein administration was repeated only if vertigo attacks recurred, with a 2-week interval between injections. MATERIALS AND METHODS This study included 88 patients with unilateral intractable MD. All patients received one to five IT injections with 0.5 ml of 10 mg of gentamicin (80 mg/2 ml) with an interval of 2 weeks between injections. Vertigo attacks were evaluated before and after therapy and categorized into classes A-F according to the 2015 Equilibrium Committee criteria. Audiovestibular assessments, including Pure Tone Audiometry and Vestibulo-Ocular Reflex evaluations, were performed. RESULTS Before treatment, patients had an average of 4.4 vertigo attacks/month; after treatment, this average decreased to 0.52. The majority of patients (57 %) reached Class A or B vertigo control with five or fewer gentamicin injections. VOR gain was slightly affected on the healthy side and significantly reduced on the affected side. No hearing deterioration was found in any of the treated patients. CONCLUSIONS Low-dose IT gentamicin administration based on clinical symptomatology can produce a satisfactory control of vertigo attacks after treatment. This protocol primarily affected the vestibular function, as demonstrated by the significant reduction in VOR gain on the affected side, while avoiding cochlear damage. The lack of adverse events and preservation of hearing underscore the safety and efficacy of this method. These findings have significant clinical implications, suggesting that a low-dose, clinical symptomatology-based gentamicin treatment regimen could be an effective and safe strategy for managing unilateral Meniere's disease in a larger population.
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Affiliation(s)
- Alfonso Scarpa
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy.
| | - Emilio Avallone
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Medizinische Hochschule Hannover, Germany
| | - Mario Carucci
- Department of Otolaryngology, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Giovanni Salzano
- Maxillofacial Surgery Unit, University Hospital of Naples "Federico II", Naples, Italy
| | - Giuseppe Chiarella
- Unit of Audiology, Regional Centre for Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | | | - Pasquale Viola
- Unit of Audiology, Regional Centre for Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | | | - Massimo Ralli
- Department of Sense Organs, Sapienza University Rome, Rome, Italy
| | - Pietro De Luca
- Otolaryngology Department, San Giovanni-Addolorata Hospital, Rome, Italy
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Webster KE, Galbraith K, Lee A, Harrington-Benton NA, Judd O, Kaski D, Maarsingh OR, MacKeith S, Ray J, Van Vugt VA, Burton MJ. Intratympanic gentamicin for Ménière's disease. Cochrane Database Syst Rev 2023; 2:CD015246. [PMID: 36847592 PMCID: PMC9969977 DOI: 10.1002/14651858.cd015246.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Ménière's disease is a condition that causes recurrent episodes of vertigo, associated with hearing loss and tinnitus. Aminoglycosides are sometimes administered directly into the middle ear to treat this condition. The aim of this treatment is to partially or completely destroy the balance function of the affected ear. The efficacy of this intervention in preventing vertigo attacks, and their associated symptoms, is currently unclear. OBJECTIVES To evaluate the benefits and harms of intratympanic aminoglycosides versus placebo or no treatment in people with Ménière's disease. SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 September 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs in adults with a diagnosis of Ménière's disease comparing intratympanic aminoglycosides with either placebo or no treatment. We excluded studies with follow-up of less than three months, or with a cross-over design (unless data from the first phase of the study could be identified). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) change in hearing, 6) change in tinnitus and 7) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We included five RCTs with a total of 137 participants. All studies compared the use of gentamicin to either placebo or no treatment. Due to the very small numbers of participants in these trials, and concerns over the conduct and reporting of some studies, we considered all the evidence in this review to be very low-certainty. Improvement in vertigo This outcome was assessed by only two studies, and they used different time periods for reporting. Improvement in vertigo was reported by more participants who received gentamicin at both 6 to ≤ 12 months (16/16 participants who received gentamicin, compared to 0/16 participants with no intervention; risk ratio (RR) 33.00, 95% confidence interval (CI) 2.15 to 507; 1 study; 32 participants; very low-certainty evidence) and at > 12 months follow-up (12/12 participants receiving gentamicin, compared to 6/10 participants receiving placebo; RR 1.63, 95% CI 0.98 to 2.69; 1 study; 22 participants; very low-certainty evidence). However, we were unable to conduct any meta-analysis for this outcome, the certainty of the evidence was very low and we cannot draw any meaningful conclusions from the results. Change in vertigo Again, two studies assessed this outcome, but used different methods of measuring vertigo and assessed the outcome at different time points. We were therefore unable to carry out any meta-analysis or draw any meaningful conclusions from the results. Global scores of vertigo were lower for those who received gentamicin at both 6 to ≤ 12 months (mean difference (MD) -1 point, 95% CI -1.68 to -0.32; 1 study; 26 participants; very low-certainty evidence; four-point scale; minimally clinically important difference presumed to be one point) and at > 12 months (MD -1.8 points, 95% CI -2.49 to -1.11; 1 study; 26 participants; very low-certainty evidence). Vertigo frequency was also lower at > 12 months for those who received gentamicin (0 attacks per year in participants receiving gentamicin compared to 11 attacks per year for those receiving placebo; 1 study; 22 participants; very low-certainty evidence). Serious adverse events None of the included studies provided information on the total number of participants who experienced a serious adverse event. It is unclear whether this is because no adverse events occurred, or because they were not assessed or reported. AUTHORS' CONCLUSIONS: The evidence for the use of intratympanic gentamicin in the treatment of Ménière's disease is very uncertain. This is primarily due to the fact that there are few published RCTs in this area, and all the studies we identified enrolled a very small number of participants. As the studies assessed different outcomes, using different methods, and reported at different time points, we were not able to pool the results to obtain more reliable estimates of the efficacy of this treatment. More people may report an improvement in vertigo following gentamicin treatment, and scores of vertigo symptoms may also improve. However, the limitations of the evidence mean that we cannot be sure of these effects. Although there is the potential for intratympanic gentamicin to cause harm (for example, hearing loss) we did not find any information about the risks of treatment in this review. Consensus on the appropriate outcomes to measure in studies of Ménière's disease is needed (i.e. a core outcome set) in order to guide future studies in this area and enable meta-analysis of the results. This must include appropriate consideration of the potential harms of treatment, as well as the benefits.
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Affiliation(s)
- Katie E Webster
- Cochrane ENT, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Kevin Galbraith
- Cochrane ENT, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Ambrose Lee
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Canada
| | | | - Owen Judd
- ENT Department, University Hospitals Of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Diego Kaski
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Otto R Maarsingh
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Samuel MacKeith
- ENT Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Vincent A Van Vugt
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
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Thomas L, Lepcha A, Reka K, Augustine AM, Alex A, Philip A, Mammen MD. Comparing Intratympanic Gentamicin with Methylprednisolone in Meniere's Disease with Non-Serviceable Hearing. Indian J Otolaryngol Head Neck Surg 2022; 74:3738-3745. [PMID: 36742746 PMCID: PMC9895489 DOI: 10.1007/s12070-021-02528-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/22/2021] [Indexed: 02/07/2023] Open
Abstract
Abstract To compare the effectiveness of high dose fixed alternate day intratympanic gentamicin with methylprednisolone in the treatment of patients with unilateral, intractable Meniere's disease with poor hearing. Randomized single blind prospective parallel group trial in a tertiary referral centre. Twenty-two patients with definite unilateral Meniere's disease with average pure tone thresholds worse than 50 dB in the affected ear were enrolled. Eleven patients were treated with intratympanic buffered gentamicin and the other eleven were administered intratympanic methylprednisolone (both 4 injections, 40 mg/ml, on alternate days). Patients were assessed pre-intervention, 3 months post intervention and subsequently followed up for 2-4 years. Both groups of patients had significant control of vertigo, DHI scores and THI scores after treatment while the functional scores in the methylprednisolone group was not better than the pre- treatment scores in the long-term follow-up. 9 of 11(82%) patients in gentamicin group and 3 of 11(27%) patients in the methylprednisolone group achieved Class A vertigo control. The gentamicin group had better post intervention DHI scores (p = 0.016, 3 months and p = 0.046, long term) and Functional score (p = 0.014, 3 months and p = 0.05, long term). The hearing in both groups and THI scores, post intervention was similar between both groups. In patients with unilateral intractable MD with non-serviceable hearing, high fixed doses of both intratympanic gentamicin and methylprednisolone are effective in alleviating disease symptoms in long term follow-up. However, intratympanic gentamicin resulted in better control of vertigo, total DHI score and functional level scores than intratympanic methylprednisolone with no significant difference in hearing levels. Trail Registration Number Clinical Trials Registry of India (CTRI- REF/2016/10/012363).
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Affiliation(s)
- Leah Thomas
- Christian Medical College Vellore, Chittoor Campus, Chittoor, Andhra Pradesh India
| | - Anjali Lepcha
- Department of ENT, Christian Medical College, Vellore, Tamil Nadu 632004 India
| | - K. Reka
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu 632 002 India
| | - Ann Mary Augustine
- Department of ENT, Christian Medical College, Vellore, Tamil Nadu 632004 India
| | - Anu Alex
- Department of ENT, Christian Medical College, Vellore, Tamil Nadu 632004 India
| | - Ajay Philip
- Department of ENT, Christian Medical College, Vellore, Tamil Nadu 632004 India
| | - Manju Deena Mammen
- Department of ENT, Christian Medical College, Vellore, Tamil Nadu 632004 India
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Madhani A, Lewis RF, Karmali F. How Peripheral Vestibular Damage Affects Velocity Storage: a Causative Explanation. J Assoc Res Otolaryngol 2022; 23:551-566. [PMID: 35768706 PMCID: PMC9437187 DOI: 10.1007/s10162-022-00853-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 05/30/2022] [Indexed: 10/17/2022] Open
Abstract
Velocity storage is a centrally-mediated mechanism that processes peripheral vestibular inputs. One prominent aspect of velocity storage is its effect on dynamic responses to yaw rotation. Specifically, when normal human subjects are accelerated to constant angular yaw velocity, horizontal eye movements and perceived angular velocity decay exponentially with a time constant circa 15-30 s, even though the input from the vestibular periphery decays much faster (~ 6 s). Peripheral vestibular damage causes a time constant reduction, which is useful for clinical diagnoses, but a mechanistic explanation for the relationship between vestibular damage and changes in these behavioral dynamics is lacking. It has been hypothesized that Bayesian optimization determines ideal velocity storage dynamics based on statistics of vestibular noise and experienced motion. Specifically, while a longer time constant would make the central estimate of angular head velocity closer to actual head motion, it may also result in the accumulation of neural noise which simultaneously degrades precision. Thus, the brain may balance these two effects by determining the time constant that optimizes behavior. We applied a Bayesian optimal Kalman filter to determine the ideal velocity storage time constant for unilateral damage. Predicted time constants were substantially lower than normal and similar to patients. Building on our past work showing that Bayesian optimization explains age-related changes in velocity storage, we also modeled interactions between age-related hair cell loss and peripheral damage. These results provide a plausible mechanistic explanation for changes in velocity storage after peripheral damage. Results also suggested that even after peripheral damage, noise originating in the periphery or early central processing may remain relevant in neurocomputations. Overall, our findings support the hypothesis that the brain optimizes velocity storage based on the vestibular signal-to-noise ratio.
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Affiliation(s)
- Amsal Madhani
- Jenks Vestibular Physiology Lab, Massachusetts Eye and Ear Infirmary, Boston, MA USA
| | - Richard F. Lewis
- Jenks Vestibular Physiology Lab, Massachusetts Eye and Ear Infirmary, Boston, MA USA
- Department of Otolaryngology, Harvard Medical School, Boston, MA USA
- Department of Neurology, Harvard Medical School, Boston, MA USA
| | - Faisal Karmali
- Jenks Vestibular Physiology Lab, Massachusetts Eye and Ear Infirmary, Boston, MA USA
- Department of Otolaryngology, Harvard Medical School, Boston, MA USA
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Wegmann-Vicuña R, Manrique-Huarte R, Calavia-Gil D, Martín-Sanz E, Marques P, Perez-Fernandez N. Low-Dose Intratympanic Gentamicin for Unilateral Ménière‘s Disease: Accuracy of Early Vestibulo-Ocular Reflex Gain Reduction in Predicting Long-Term Clinical Outcome. Front Neurol 2022; 13:808570. [PMID: 35370892 PMCID: PMC8973913 DOI: 10.3389/fneur.2022.808570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe number of intratympanic gentamicin (ITG) injections needed to achieve vertigo control in patients with intractable Ménière's disease (MD) may vary from a single dose to several instillations. Changes in different vestibular test results have been used to define an endpoint of treatment, including the decrease of the vestibulo-ocular reflex (VOR) gain elicited by the head-impulse test.ObjectiveTo assess the accuracy of the VOR gain reduction after horizontal canal stimulation, as measured with the video head-impulse test (vHIT) 1 month after the first intratympanic injection, in predicting the need for one or more instillations to control vertigo spells in the long term.MethodsThe VOR gain reduction was calculated in 47 patients submitted to (ITG) therapy 1 month after the first instillation.ResultsSingle intratympanic treatment with gentamicin has a 59.6% efficacy in vertigo control in the long term. Hearing change in the immediate period after treatment (1 month) is not significant to pre-treatment result and is similar for patients who needed multiple doses due to recurrence. Chronic disequilibrium and the need for vestibular rehabilitation were less frequent in patients with a good control of vertigo with just one single injection of gentamicin. A fair accuracy was obtained for the VOR gain reduction of the horizontal canal (area under the curve = 0.729 in the Receiver Operating Characteristic analysis) in predicting the need for one or more ITG.ConclusionsSingle intratympanic treatment with gentamicin is an effective treatment for patients with MD. That modality of treatment has very limited damaging effect in hearing. The degree of vestibular deficit induced by the treatment is significant as measured by the reduction in the gain of the VOR but not useful for prognostic purposes.
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Affiliation(s)
- Ricardo Wegmann-Vicuña
- Department of Otorhinolaryngology, Clínica Universidad de Navarra, Pamplona, Spain
- Department of Otorhinolaryngology, Hospital Quirónsalud, Barcelona, Spain
| | | | - Diego Calavia-Gil
- Department of Otorhinolaryngology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Eduardo Martín-Sanz
- Department of Otolaryngology, University Hospital of Getafe, Madrid, Spain
- Department of Medicine, School of Biomedical Sciences and Health, Universidad Europea de Madrid, Madrid, Spain
| | - Pedro Marques
- Department of Otorhinolaryngology, S. João Hospital Centre, Porto, Portugal
| | - Nicolas Perez-Fernandez
- Department of Otorhinolaryngology, Clínica Universidad de Navarra, Pamplona, Spain
- Department of Otorhinolaryngology, Clínica Universidad de Navarra, Madrid, Spain
- *Correspondence: Nicolas Perez-Fernandez
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Effects of intratympanic gentamicin and intratympanic glucocorticoids in Ménière's disease: a network meta-analysis. J Neurol 2022; 269:72-86. [PMID: 33387016 DOI: 10.1007/s00415-020-10320-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/08/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Intratympanic therapies, usually including glucocorticoid and gentamicin, are becoming worldwide used in clinical practice of Ménière's disease today. However, clinical efficacy and safety of these two therapies are still in controversial. DATA SOURCES Electronic searches in PubMed, CENTRAL, Web of Science, EMBASE, CINAHL, ClinicalTrials.gov and the European Union Clinical Trials Register were conducted from inception until September 2020. REVIEW METHODS The pre-specified protocol of this systematic review and meta-analysis has been registered and published in November 2018 (PROSPERO Identifier: CRD42018114389). All randomized controlled trials of intratympanic gentamicin or glucocorticoids for Ménière's disease, compared with each other or placebo, were considered for this review. RESULTS Ten studies with 455 patients met the inclusion criteria. Pooled results indicated significant advantage of intratympanic gentamicin and glucocorticoids over placebo treatments in vertigo control (gentamicin vs placebo: risk rate, RR, 2.56; 95% CI 1.18-5.54; glucocorticoids vs placebo: RR, 3.02; 95% CI 1.36-6.73). There was no significant difference between gentamicin and glucocorticoids in vertigo control (gentamicin vs placebo: RR, 1.18; 95% CI 0.97-1.45). Intratympanic glucocorticoids showed better hearing protective results than gentamicin (change of pure tone audiometric, PTA, mean difference, MD, - 6.48 dB; 95% CI - 11.84 to - 1.13 dB; change of speech discrimination scale, SDS, MD 7.69%; 95% CI 0.83-14.55%). CONCLUSIONS Intratympanic gentamicin and glucocorticoids are two effective approaches to control vertigo symptoms for Ménière's disease. Glucocorticoids showed a potentially better hearing protective role over gentamicin.
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Endoscopic Transcanal Labyrinthectomy for Intractable Meniere's Disease: An Alternative to Transmastoid Labyrinthectomy? Otol Neurotol 2022; 43:113-119. [PMID: 34889845 DOI: 10.1097/mao.0000000000003355] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe a novel approach for intractable Ménière's disease exclusively through a transcanal endoscopic ear surgery (TEES) approach. PATIENT A 56-year-old male with intractable Ménière's disease despite conservative treatment and chemical labyrinthectomy. INTERVENTIONS Transcanal endoscopic labyrinthectomy. MAIN OUTCOME MEASURE Subjective vertigo control, surgical morbidity. RESULTS The TEES approach provided a wide exposure of the oval window. This facilitated removal of stapes crura and footplate. After widening of the oval window, the perilymph was suctioned, and gentamicin was injected through the oval window. The oval window was obliterated using the perichondrium of the tragal cartilage and fibrin glue. After 2 years of follow-up, there was no recurrence of vertigo. CONCLUSIONS As a compelling alternative to the transmastoid approach, we propose endoscopic labyrinthectomy as an option for patients with intractable MD without functional hearing who have failed chemical labyrinthectomy. Additional studies are needed to determine the risk-benefit profile of this technique.
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Weckel A, Gallois Y. Clinical management of Menière's disease: Clinician perspective in 2020. J Vestib Res 2021; 31:323-325. [PMID: 33325419 DOI: 10.3233/ves-200794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Menière's disease (MD) still presents both diagnostic and therapeutic difficulties. Today, this pathology is diagnosed only on clinical criteria. The development of high resolution magnetic resonance imaging of the inner is very promising to improve diagnostic criteria in MD. MD treatment depending on the practitioner and the clinical center, is mainly based on conservative therapies, and if this fails, non-ablative or ablative therapies. MD therefore always exposes clinicians to diagnostic uncertainties, but also to therapeutic difficulties which still lead to destructive treatments, in the absence of targeted, curative treatments, acting on the cause and not on the consequence of the pathology.
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Affiliation(s)
- A Weckel
- Department of otology and neurotology, Purpan University Hospital, Pierre Paul Riquet Building, Toulouse, France
| | - Y Gallois
- Department of otology and neurotology, Purpan University Hospital, Pierre Paul Riquet Building, Toulouse, France
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Wittmeyer Cedervall L, Magnusson M, Karlberg M, Fransson PA, Nyström A, Tjernström F. vHIT Testing of Vertical Semicircular Canals With Goggles Yield Different Results Depending on Which Canal Plane Being Tested. Front Neurol 2021; 12:692196. [PMID: 34385970 PMCID: PMC8353365 DOI: 10.3389/fneur.2021.692196] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The use of goggles to assess vertical semicircular canal function has become a standard method in vestibular testing, both in clinic and in research, but there are different methods and apparatus in use. The aim of this study was to determine what the cause of the systematic differences is between gain values in testing of the vertical semicircular canals with two different video head impulse test (vHIT) equipment in subjects with normal vestibular function. Study Design: Retrospective analysis of gain values on patients with clinically deemed normal vestibular function (absence of a corrective eye saccade), tested with either Interacoustics or Otometrics system. Prospective testing of subjects with normal vestibular function with the camera records the eye movements of both eyes. Finally, 3D sensors were placed on different positions on the goggles measuring the actual vertical movement in the different semicircular planes. Results: In the clinical cohorts, the gain depended on which side and semicircular canal was tested (p < 0.001). In the prospective design, the combination between the stimulated side, semicircular canal, and position of the recording device (right/left eye) highly influenced the derived gain (p < 0.001). The different parts of the goggles also moved differently in a vertical direction during vertical semicircular canal testing. Conclusion: The gain values when testing the function of the vertical semicircular canals seem to depend upon which eye is recorded and which semicircular plane is tested and suggests caution when interpreting and comparing results when different systems are used both clinically as well as in research. The results also imply that further research and development are needed to obtain accurate vertical semicircular canal testing, in regard to both methodology and equipment design.
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Affiliation(s)
- Louise Wittmeyer Cedervall
- Department of Otorhinolaryngology, Head and Neck Surgery, Clinical Sciences, Lund Skåne University Hospital Lund, Lund, Sweden
| | - Måns Magnusson
- Department of Otorhinolaryngology, Head and Neck Surgery, Clinical Sciences, Lund Skåne University Hospital Lund, Lund, Sweden
| | - Mikael Karlberg
- Department of Otorhinolaryngology, Head and Neck Surgery, Clinical Sciences, Lund Skåne University Hospital Lund, Lund, Sweden
| | - Per-Anders Fransson
- Department of Otorhinolaryngology, Head and Neck Surgery, Clinical Sciences, Lund Skåne University Hospital Lund, Lund, Sweden
| | - Anastasia Nyström
- Department of Otorhinolaryngology, Head and Neck Surgery, Clinical Sciences, Lund Skåne University Hospital Lund, Lund, Sweden
| | - Fredrik Tjernström
- Department of Otorhinolaryngology, Head and Neck Surgery, Clinical Sciences, Lund Skåne University Hospital Lund, Lund, Sweden
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Wu Y, Zhou Y, Yu J, Song Z, Dai C, Wang J. Intratympanic gentamicin injection for refractory ménière's disease (MD) has potential effect in preventing contralateral MD occurrence. Acta Otolaryngol 2021; 141:657-662. [PMID: 33950779 DOI: 10.1080/00016489.2021.1915499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Ménière's disease (MD), characterized by episodic vertigo attacks and fluctuating progressive hearing loss, is treated by low-dose intratympanic gentamicin (ITG) injections. Whether ITG causes hearing loss is controversial, and knowledge about its effects on the contralateral hearing and vestibular function is lacking. AIMS/OBJECTIVES We aimed to evaluate the effect of ITG on bilateral auditory and otolith organ function in patients with unilateral refractory MD. MATERIAL AND METHODS The data of 30 patients was collected, including history, and pure tone audiometry and vestibular-evoked myogenic potentials (VEMPs) results before and one month after ITG treatment. Changes in vertigo were assessed at a two-year follow-up. RESULTS One month after ITG injection, auditory thresholds between 125 Hz and 8 kHz on the injection side remained unchanged but have improved on the contralateral side at 125 Hz, 250 Hz, 1 kHz. The cervical and ocular VEMP solicitation rates on the injection side were lower than before the injection. Two years after treatment, vertigo was improved in 88.5% and complete controlled in 76.7% patients respectively. CONCLUSIONS AND SIGNIFICANCE The intractable vertigo of MD can be effectively controlled by ITG injection. This can improve the low and medium frequency hearing level in the contralateral ear, suggesting that it might help prevent contralateral MD occurrence.
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Affiliation(s)
- Yongzhen Wu
- ENT institute and Department of Otorhinolaryngology, Eye & ENT Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine (Fudan University), Shanghai, China
| | - Yujuan Zhou
- ENT institute and Department of Otorhinolaryngology, Eye & ENT Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine (Fudan University), Shanghai, China
| | - Jing Yu
- ENT institute and Department of Otorhinolaryngology, Eye & ENT Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine (Fudan University), Shanghai, China
| | - Zijun Song
- ENT institute and Department of Otorhinolaryngology, Eye & ENT Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine (Fudan University), Shanghai, China
| | - Chunfu Dai
- ENT institute and Department of Otorhinolaryngology, Eye & ENT Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine (Fudan University), Shanghai, China
| | - Jing Wang
- ENT institute and Department of Otorhinolaryngology, Eye & ENT Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine (Fudan University), Shanghai, China
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Abstract
OBJECTIVE Menière's disease can be a debilitating condition but in most cases the symptoms are controlled by lifestyle changes and medical management. However, some patients remain symptomatic despite medical treatment and have the option of more invasive surgical treatments. Surgical intervention for Menière's includes a range of interventions from grommet insertion, intratympanic steroids/Gentamicin, endolymphatic sac decompression, labyrinthectomy, and vestibular neurectomy. A recently described technique involves the occlusion of all three semi-circular canals as an alternative in intractable Menière's disease. STUDY DESIGN This is a case series of three patients who underwent triple canal occlusion for the treatment of intractable Menière's disease. SETTING Patients were selected from those who were referred to Queen Elizabeth Hospital in Birmingham, a tertiary referral center. PATIENTS Patients who were severely symptomatic despite medical treatment who were considering ablative therapy were offered the option of triple canal occlusion as an alternative. INTERVENTION We report a series of Menière's patients treated by triple canal occlusion, describe the rationale behind this intervention, the surgical technique, and preliminary results. MAIN OUTCOME MEASURE Each patient was followed up for a minimum of 2 years following the procedure. The main outcomes measures were the class of vertigo control and hearing threshold levels according to the American Academy of Otolaryngology-Head and Neck Surgery guidelines. RESULTS Of the three patients, two were men and one was woman, the age range was 45 years to 61 years old. Two patients with unilateral disease achieved class A control whereas one patient with bilateral disease achieved class B control. Two patients who underwent the procedure had little or no effect to their hearing on the treated side however one patient suffered a 30 dB hearing loss on the operative side. CONCLUSIONS Based on our limited experience and the early reports in the literature we consider that there are potential patient benefits for triple canal occlusion for intractable Menière's disease as an alternative to vestibular neurectomy due to the reduced morbidity and long-term efficacy.
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Lee SY, Kim J, Oh S, Jung G, Jeong KJ, Tan Tran V, Hwang D, Kim S, Song JJ, Suh MW, Lee J, Koo JW. Contralateral spreading of substances following intratympanic nanoparticle-conjugated gentamicin injection in a rat model. Sci Rep 2020; 10:18636. [PMID: 33122804 PMCID: PMC7596480 DOI: 10.1038/s41598-020-75725-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 08/02/2020] [Indexed: 11/23/2022] Open
Abstract
This study was performed to investigate the Eustachian tube as a potential route for contralateral spreading following intratympanic nanoparticle (NP)-conjugated gentamicin injection in a rat model. Sprague–Dawley rats were divided into three groups and substances were injected in the right ear: group 1 (fluorescent magnetic nanoparticles [F-MNPs], n = 4), group 2 (F-MNP-conjugated gentamicin [F-MNP@GM], n = 2), and control group (no injections, n = 2). T2-weighted sequences corresponding to the regions of interest at 1, 2, and 3 h after intratympanic injection were evaluated, along with immunostaining fluorescence of both side cochlea. The heterogeneous signal intensity of F-MNPs and F-MNP@GM on T2-weighted images, observed in the ipsilateral tympanum, was also detected in the contralateral tympanum in 4 out of 6 rats, recapitulating fluorescent nanoparticles in the contralateral cochlear hair cells. Computational simulations demonstrate the contralateral spreading of particles by gravity force following intratympanic injection in a rat model. The diffusion rate of the contralateral spreading relies on the sizes and surface charges of particles. Collectively, the Eustachian tube could be a route for contralateral spreading following intratympanic injection. Caution should be taken when using the contralateral ear as a control study investigating inner-ear drug delivery through the transtympanic approach.
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Affiliation(s)
- Sang-Yeon Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea.,Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeonghyo Kim
- Department of Chemistry and Department of Chemical Enginnering and Applied Chemistry, Chungnam National University, Daejon, 34134, Republic of Korea
| | - Sangjin Oh
- Department of Chemistry and Department of Chemical Enginnering and Applied Chemistry, Chungnam National University, Daejon, 34134, Republic of Korea
| | - Gaon Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea
| | - Ki-Jae Jeong
- Department of Cogno-Mechatronics Engineering, Busan National University, Busan, 46241, Republic of Korea
| | - Van Tan Tran
- Department of Chemistry and Department of Chemical Enginnering and Applied Chemistry, Chungnam National University, Daejon, 34134, Republic of Korea.,Faculty of Biotechnology, Chemistry and Environmental Engineering, Phenikaa University, Hanoi, 10000, Vietnam
| | - Dajeong Hwang
- Department of Chemistry and Department of Chemical Enginnering and Applied Chemistry, Chungnam National University, Daejon, 34134, Republic of Korea
| | - SungIl Kim
- AMO LIFE SCIENCE Co., Ltd., Seoul, 06527, Republic of Korea
| | - Jae-Jin Song
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea
| | - Myung-Whan Suh
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jaebeom Lee
- Department of Chemistry and Department of Chemical Enginnering and Applied Chemistry, Chungnam National University, Daejon, 34134, Republic of Korea.
| | - Ja-Won Koo
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea.
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15
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Weckel A, Fraysse MJE, Marx M, Fraysse B, Gallois Y, Chabbert C. Vestibular disorders: clinician ENT perspective on the need for research and innovation. J Neurol 2020; 267:36-44. [PMID: 33048218 DOI: 10.1007/s00415-020-10242-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Vertigo and dizziness are a frequent reason for medical consultation. However, diagnostic and therapeutic management is sometimes limited, and clinicians are faced with many unmet needs. The purpose of this study was to identify and prioritize these needs. METHODS A questionnaire methodology was used to determine the need for innovation in vestibular disorder management. The questionnaire was sent to 19 teams in French-speaking ENT centers. We measured the concordance of the panel of experts on 56 questions related to the different vestibular pathologies encountered and the desired modalities of innovations. RESULTS Thirteen questions were identified as priorities. The needs expressed by the experts had better knowledge of the pathophysiological mechanisms of the main diseases encountered and the development of new treatment modalities. Particular attention was paid to inner ear imaging techniques and the development of specific electrophysiology techniques. DISCUSSION Some of the anticipated innovations are already under development, such as new inner ear fluid imaging techniques (hydrops visualization using MRI) or in situ treatments (transtympanic dexamethasone or gentamicin injections). Others, such as new electrophysiological techniques, are still not fully developed CONCLUSION: This study provides a snapshot of the needs of the medical profession in vestibular disorder management. It highlights a real concern of the attending personnel, as well as a critical need to optimize the means of diagnosing and treating patients with vestibular disorders.
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Affiliation(s)
- A Weckel
- ENT and Neurootology Department, Purpan University Hospital, Pierre Paul Riquet Building, Toulouse, France
| | - M J Esteve Fraysse
- ENT and Neurootology Department, Purpan University Hospital, Pierre Paul Riquet Building, Toulouse, France
| | - M Marx
- ENT and Neurootology Department, Purpan University Hospital, Pierre Paul Riquet Building, Toulouse, France
| | - B Fraysse
- ENT and Neurootology Department, Purpan University Hospital, Pierre Paul Riquet Building, Toulouse, France
| | - Y Gallois
- ENT and Neurootology Department, Purpan University Hospital, Pierre Paul Riquet Building, Toulouse, France
| | - C Chabbert
- Pathophysiology and Therapy of Vestibular Disorders, UMR7260 Sensory and Cognitive Neuroscience, Marseille, France.
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Basura GJ, Adams ME, Monfared A, Schwartz SR, Antonelli PJ, Burkard R, Bush ML, Bykowski J, Colandrea M, Derebery J, Kelly EA, Kerber KA, Koopman CF, Kuch AA, Marcolini E, McKinnon BJ, Ruckenstein MJ, Valenzuela CV, Vosooney A, Walsh SA, Nnacheta LC, Dhepyasuwan N, Buchanan EM. Clinical Practice Guideline: Ménière's Disease. Otolaryngol Head Neck Surg 2020; 162:S1-S55. [PMID: 32267799 DOI: 10.1177/0194599820909438] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Matthew L Bush
- University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Julie Bykowski
- University of California San Diego, San Diego, California, USA
| | - Maria Colandrea
- Duke University School of Nursing and Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | | | | | - Kevin A Kerber
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | | | | | - Evie Marcolini
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Brian J McKinnon
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | | | - Sandra A Walsh
- Consumers United for Evidence-Based Healthcare, Baltimore, Maryland, USA
| | - Lorraine C Nnacheta
- American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA
| | - Erin M Buchanan
- American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA
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Poly-Lactic Acid-Based Biopolymer Formulations Are Safe for Sustained Intratympanic Dexamethasone Delivery. Otol Neurotol 2020; 40:e739-e746. [PMID: 31295207 DOI: 10.1097/mao.0000000000002305] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HYPOTHESIS AND BACKGROUND The clinical treatment of sudden sensorineural hearing loss currently relies on the administration of steroids, either systemically or via intratympanic injections. Intratympanic injections bypass the hemato-cochlear barrier, reducing its systemic side effects. The efficacy of the injections is limited through rapid drug clearance via the Eustachian tube, and through nonoptimal properties of slow-release drug carriers. A new slow-release drug delivery vehicle based on hexyl-substituted-poly-lactic-acid (HexPLA), with the highest possible safety profile and complete bio-degradability, has been evaluated for safety and efficacy in a standardized guinea pig model of intratympanic injection. METHODS A total of 83 animals received through retrobullar injection either empty Nile-red-colored HexPLA vehicle, 5%-dexamethasone-HexPLA, 5%-dexamethasone suspension, or a sham operation. Long-term residence time of vehicle, biocompatibility, click- and pure-tone hearing thresholds, and dexamethasone levels in the perilymph were prospectively assessed. RESULTS At 1 week after injection, HexPLA vehicle was morphologically present in the middle ear and perilymph levels in the 5%-dexamethasone-HexPLA were on average 2 to 3 μg/ml and one order of magnitude higher compared with those of the 5%-dexamethasone suspension group. No significant postoperative morphological or functional changes were observed up to 3 months postdelivery. CONCLUSIONS HexPLA is safe, fully biocompatible, and efficient for sustained high-dose, intratympanic delivery of dexamethasone at least for 1 week and therefore of high interest for the treatment of sudden sensorineural hearing loss and other acute inner ear diseases. Due to the favorable chemical properties, a wide range of other drugs can be loaded into the vehicle further increasing its potential value for otological applications.
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On-Demand and Low Dose Intratympanic Gentamicin for Meniere's Disease: A Customized Approach. Otol Neurotol 2020; 41:504-510. [PMID: 32176139 DOI: 10.1097/mao.0000000000002563] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the efficacy of on demand and low dose intratympanic gentamicin (ITG) in patients with intractable Meniere's disease (MD). STUDY DESIGN Clinical chart review. SETTING Secondary care center. PATIENTS Subjects with MD who failed conventional treatment and underwent on demand ITG infiltration from June 2013 to December 2018. INTERVENTION 0.4 to 0.5 ml of buffered gentamicin were administered through an intratympanic route. A total of 5 mg in case of low dose and 20 mg as a standard dose. MAIN OUTCOME MEASURES Vertigo control, Meniere's Disease Functional Level Scale (MDFLS), Dizziness Handicap Inventory (DHI), and pure tone audiometry pre and posttreatment. RESULTS Thirty-one patients, 16 women and 15 men with a mean age of 52.81 (22-79) years were included. The number of ITG injections ranged from 1 to 7, with a mean of 2.52 applications per patient. Mean interval between doses was 212.15 (21-1442) days. Average follow-up was 24.03 months. An improvement on MDFLS was seen on 77.4% (n = 24) patients. DHI score improved after gentamicin treatment (mean 55.23 versus 24.06, p ≤ 0.001). Thirty patients (96.8%) reached complete or substantial vertigo control. Only one patient did not achieve control. Hearing was preserved in 43.5% (n = 10) of analyzed audiograms, whereas 17.4% (n = 4) developed hearing loss greater than 20 dB, which was not statistically significant (p = 0.099). CONCLUSIONS In our study, on demand and low dose ITG was effective for vertigo control in patients with intractable MD. Individualized therapy is recommended in all patients to minimize vestibular and cochlear toxicity.
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Gibson AW, Moon IJ, Golub JS, Rubinstein JT. A comparison of endolymphatic shunt surgery and intratympanic gentamicin for meniere's disease. Laryngoscope 2019; 130:2455-2460. [PMID: 31808957 DOI: 10.1002/lary.28445] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/05/2019] [Accepted: 11/11/2019] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Alec W Gibson
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, USA
| | - Il Joon Moon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Justin S Golub
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, USA
| | - Jay T Rubinstein
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, USA
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Scarpa A, Ralli M, Cassandro C, Gioacchini FM, Alicandri-Ciufelli M, Viola P, Chiarella G, de Vincentiis M, Cassandro E. Low-dose intratympanic gentamicin administration for unilateral Meniere's disease using a method based on clinical symptomatology: Preliminary results. Am J Otolaryngol 2019; 40:102289. [PMID: 31537428 DOI: 10.1016/j.amjoto.2019.102289] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 09/09/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE There are many therapeutic options for Meniere's disease (MD); intratympanic (IT) gentamicin has been proposed for intractable cases although controversy about dosage and method exists. The purpose of this study was to assess the efficacy and safety of low-dose IT gentamicin on vertigo attacks in MD using a clinical symptomatology-based method in which administration was repeated only if vertigo attacks recurred, with a 2-week interval between injections. MATERIALS AND METHODS Forty-eight patients with unilateral intractable MD were included in the study. All patients received one to five IT injections with 0.5 ml of 10 mg of gentamicin (80 mg/2 ml) with an interval of 2 weeks between injections. Vertigo attacks were evaluated before and after therapy and categorized into classes A-F according to the 2015 Equilibrium Committee criteria. Audiovestibular assessment with pure tone audiometry, vestibular bed-side examination and video head impulse test was performed. RESULTS Before treatment patients had an average of 4.4 vertigo attacks/month; after treatment the average number decreased to 0.52. The majority of patients (77%) reached Class A vertigo control with 5 or less gentamicin injections. VOR gain was unaffected in the healthy side and significantly reduced in the affected side. No hearing deterioration was found in all treated patients. CONCLUSIONS Low-dose IT gentamicin administration based on clinical symptomatology can produce a satisfactory control of vertigo attacks after treatment; such protocol had an effect mainly on the vestibular function as demonstrated by the significant reduction in VOR gain in the affected side avoiding a cochlear damage.
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Affiliation(s)
- Alfonso Scarpa
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Massimo Ralli
- Department of Sense Organs, Sapienza University Rome, Rome, Italy; Center for Hearing and Deafness, University at Buffalo, Buffalo, NY 14214, USA.
| | | | - Federico Maria Gioacchini
- ENT Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | | | - Pasquale Viola
- Unit of Audiology, Regional Centre for Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Chiarella
- Unit of Audiology, Regional Centre for Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | | | - Ettore Cassandro
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
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Rutka J. Editorial. Rear Admiral (Astronaut) Alan Shepard: De mortuis nil nisi bonum (say nothing bad of the departed). J Neurosurg 2019; 131:301-303. [PMID: 30771767 DOI: 10.3171/2018.11.jns182794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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The Clinical Outcomes After Intratympanic Gentamicin Injection to Treat Menière's Disease: A Meta-analysis. Otol Neurotol 2019; 40:419-429. [DOI: 10.1097/mao.0000000000002159] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Eliezer M, Poillon G, Horion J, Lelion P, Gerardin E, Magne N, Gillibert A, Attyé A. MRI diagnosis of saccular hydrops: Comparison of heavily-T2 FIESTA-C and 3D-FLAIR sequences with delayed acquisition. J Neuroradiol 2019; 48:446-452. [DOI: 10.1016/j.neurad.2019.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/19/2019] [Accepted: 04/12/2019] [Indexed: 10/26/2022]
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Long-term Vertigo Control and Vestibular Function After Low-dose On-demand Transtympanic Gentamicin for Refractory Menière's Disease. Otol Neurotol 2019; 40:218-225. [PMID: 30624404 DOI: 10.1097/mao.0000000000002101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the long-term clinical vertigo control along with measured lateral canal vestibular function in patients with unilateral refractory Menière's disease (MD) treated with gentamicin transtympanic injections (TTI). STUDY DESIGN Retrospective analytic study. SETTING Tertiary referral center. PATIENTS Thirty-eight patients treated by TTI for medically refractory unilateral MD, defined by the 1995 AAO-HNS criteria, between May 2006 and December 2012. INTERVENTION(S) One-year course of treatment with gentamicin TTI following a low dose on-demand protocol. TTI were repeated in new courses of treatment when MD recurrence occurred. MAIN OUTCOME MEASURE(S) AAO-HNS class of control, caloric tests (CalT), recurrence rate. RESULTS After an average clinical follow-up of 71 months, all patients entered a class of control A (78%) or B (22%), with an average of 2.3 TTI received. The mean maximal obtained deficit was 88.5%, and the mean long-term deficit was 85.5%. Ten (26%) patients had disease recurrence requiring a new course of treatment. A value of the first CalT in the 3 months following the first TTI strictly higher than 78% was significantly associated with disease control and the absence of symptom recurrence (p≤0.01). In the "recurrence" group, four patients had a significantly lower mean value of all CalT performed after the first TTI when compared with other patients (p≤0.001), indicating gentamicin resistance CONCLUSION:: Achieving a sustainable vestibular deficit on caloric testing is key for MD symptom control after gentamicin TTI. Gentamicin resistance must be diagnosed early to adapt therapeutic strategies.
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Marques P, Duan M, Perez-Fernandez N, Spratley J. Gentamicin delivery to the inner ear: Does endolymphatic hydrops matter? PLoS One 2018; 13:e0207467. [PMID: 30440019 PMCID: PMC6237362 DOI: 10.1371/journal.pone.0207467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 10/31/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction Middle ear application of gentamicin is a common medical treatment for uncontrolled Ménière’s disease. The objective of the study was to evaluate the impact of endolymphatic hydrops on inner ear delivery. Methods Perilymph gentamicin concentrations and correlation with endolymphatic hydrops in an animal model were assessed. A group of 24 guinea pigs was submitted to surgical obstruction of the endolymphatic sac and duct of the right ear. Gentamicin was applied either to the right ear’s round window niche or through a transtympanic injection. Perilymph specimens were collected at different times. Histologic morphometry was used to evaluate both turn-specific and overall hydrops degree. Results In animals with endolymphatic hydrops, lower concentrations of gentamicin were observed after 20 or 120 minutes of exposure and in both types of administration, when compared to controls. This difference reached statistical significance in the round window niche application group (Mann-Whitney, p = 0,007). A negative correlation between perilymphatic gentamicin concentration and hydrops degree could be observed in both groups, after 120 minutes of exposure (Spearman correlation, round window niche p<0,001; TT p = 0,005). Conclusions The study indicates that the endolymphatic hydrops degree has a negative interference on the delivery of gentamicin into the inner ear following middle ear application.
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Affiliation(s)
- Pedro Marques
- Department of Otorhinolaryngology, S.João Hospital Centre, Porto, Portugal
- Unit of Otorhinolaryngology, Department of Surgery and Physiology, University of Porto Medical School, Porto, Portugal
- * E-mail:
| | - Maoli Duan
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Otolaryngology, Head and Neck Surgery, Karolinska Universisty Hospital, Karolinska Institutet, Stockholm, Sweden
| | | | - Jorge Spratley
- Department of Otorhinolaryngology, S.João Hospital Centre, Porto, Portugal
- Unit of Otorhinolaryngology, Department of Surgery and Physiology, University of Porto Medical School, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), University of Porto Medical School, Porto, Portugal
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Naples JG, Henry L, Brant JA, Eliades SJ, Ruckenstein MJ. Intratympanic Therapies in Ménière Disease: Evaluation of Outcomes and Early Vertigo Control. Laryngoscope 2018; 129:216-221. [PMID: 30284276 DOI: 10.1002/lary.27392] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate outcomes of intratympanic (IT) dexamethasone and gentamicin in Ménière Disease (MD). METHODS Charts of adult patients with unilateral definite MD receiving IT gentamicin or dexamethasone from 2005 to 2017 were retrospectively reviewed. All patients had at least 6 months follow-up. Failure in each group was defined as the need for more aggressive therapy. Prior to 2011, all patient received IT gentamicin, administered as primary therapy after failure of conservative treatment measures. Gentamicin was administered every 2 weeks, up to three injections, until vertigo control was achieved. Beginning in 2011, the treatment protocol shifted to IT dexamethasone as initial treatment, with gentamicin used for dexamethasone failures. Dexamethasone was administered weekly for up to three injections. Treatments could be repeated if symptoms recurred. RESULTS Thirty-three patients received IT dexamethasone, and 70 patients received IT gentamicin. Dexamethasone patients received a mean of 3.3 injections compared to 2.7 in the gentamicin group (P = 0.011). There were 12 (38%) failures in the dexamethasone group and only seven (10%) gentamicin failures (P = 0.025). No patients failed both treatments. The mean time to failure in the dexamethasone group was 5 months, whereas in the gentamicin group it was 27 months. Change in pure tone audiometry from baseline was not different between treatment groups (P = 0.30). CONCLUSION Subjects receiving IT gentamicin required fewer injections and had a significantly longer time to failure than IT dexamethasone. Audiometric outcomes were similar between the groups. The use of IT gentamicin as initial therapy for early and long-term control of MD is safe and effective. LEVEL OF EVIDENCE 3 Laryngoscope, 129:216-221, 2019.
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Affiliation(s)
- James G Naples
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, U.S.A
| | - Laura Henry
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Jason A Brant
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, U.S.A
| | - Steven J Eliades
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, U.S.A
| | - Michael J Ruckenstein
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, U.S.A
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Marques PS, Dias CC, Perez-Fernandez N, Spratley J. Instrumental head impulse test changes after intratympanic gentamicin for unilateral definite Ménière's disease: A systematic review and meta-analysis. Auris Nasus Larynx 2018; 45:943-951. [PMID: 29402608 DOI: 10.1016/j.anl.2018.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 12/18/2017] [Accepted: 01/10/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To estimate how much could intratympanic gentamicin (ITG) interfere with the vestibular-ocular reflex (VOR) parameters on instrumental head impulse test (HIT), either with scleral search coil or video head impulse test and, eventually, foresee the control of vertigo crisis in unilateral intractable Ménière's disease (MD). METHODS A literature search was conducted in PubMed, Scopus, Web of Science and Cochrane search engines. The search terms used were "vestibular ocular reflex", "head impulse test", "gentamicin," and "Meniere's disease". Limitations included text availability to be full text, species to be humans and language to be English. All study types were included. 89 articles were screened identifying four eligible studies were identified. Studies were included after consensus of the authors. Meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data was analysed using Review Manager software. RESULTS Instrumental HIT, after ITG for MD, demonstrated, in the treated ear, a decreased gain in the horizontal, posterior and superior semicircular canals (SCC), of 0.36 (0.26; 0.47; 95% CI), 0.35 (0.22; 0.48; 95% CI) and 0.28 (0.21; 0.35; 95% CI), respectively. Gain asymmetry increases between the treated and non-treated ear of 23.78 (7.22; 40.35; 95% CI), 32.01 (12.27; 51.76; 95% CI) and 17.49 (9.99; 24.99; 95% CI), were similarly detected in the horizontal, posterior and superior SCC, respectively. Significantly smaller gain values after the first treatment were observed for a single injection group versus multiple injection group in the horizontal (p=0.002) and superior SCCs (p=0.016). CONCLUSIONS Instrumental HIT is effective in evaluating the SCC function after ITG for intractable unilateral MD. VOR gain changes in the direction of the treated ear in the three SCC have been clearly registered. An increased reduction of the VOR gain in the horizontal and anterior SCC also seemed to foresee the control of vertigo crisis. Still, after meta-analysis, the small number of patients' data available did not allow to define a treatment end-point value. This review also indicated that further and better-designed studies are warranted.
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Affiliation(s)
- Pedro Santos Marques
- Department of Otorhinolaryngology, S. João Hospital Centre, Alameda Prof. Hernâni Monteiro, Porto, Portugal; Department of Surgery and Physiology/Otorhinolaryngology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal.
| | - Claudia Camila Dias
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Nicolas Perez-Fernandez
- Department of Otorhinolaryngology, Clinica Universidad Navarra, University of Navarra, Pamplona, Spain
| | - Jorge Spratley
- Department of Otorhinolaryngology, S. João Hospital Centre, Alameda Prof. Hernâni Monteiro, Porto, Portugal; Department of Surgery and Physiology/Otorhinolaryngology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal
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Ghavami Y, Haidar YM, Moshtaghi O, Lin HW, Djalilian HR. Evaluating Quality of Life in Patients With Meniere’s Disease Treated as Migraine. Ann Otol Rhinol Laryngol 2018; 127:877-887. [DOI: 10.1177/0003489418799107] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To evaluate the change in quality of life (QOL) of patients with Meniere’s disease (MD) after treatment with migraine prophylaxis therapy. Methods: Patients with definite MD were given the Meniere’s Disease Outcomes Questionnaire–Retrospective (MDOQ-R) after migraine prophylactic therapy to assess QOL. Changes in physical, emotional, and social parameters affected by MD were calculated, along with a global pre- and posttreatment QOL scores. Results: The MDOQ-R was given to 27 consecutive patients with definite MD. Patients who had at least an 18-month follow-up were included, resulting in 25 questionnaires. The mean change in QOL score was 25 ± 16 (range, –3 to 55), P = .02. Quality of life was improved in 23 (92%) of the respondents in every metric measured, unchanged in 1 (4%), and poorer in 1 (4%) of patients after migraine prophylaxis treatment. Conclusions: Majority of MD patients who had all failed diuretic therapy responded positively to medications used for migraine prophylaxis, as indicated by a significant improvement in QOL. This study may further suggest a correlation between the pathophysiologic basis of disease in MD and vestibular migraine. Patients with MD may be successfully managed with medications intended to treat migraine.
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Affiliation(s)
- Yaser Ghavami
- Division of Otology, Neurotology, and Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Irvine, CA, USA
| | - Yarah M. Haidar
- Division of Otology, Neurotology, and Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Irvine, CA, USA
| | - Omid Moshtaghi
- Division of Otology, Neurotology, and Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Irvine, CA, USA
| | - Harrison W. Lin
- Division of Otology, Neurotology, and Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Irvine, CA, USA
| | - Hamid R. Djalilian
- Division of Otology, Neurotology, and Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Irvine, CA, USA
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
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Low Concentration Intra-Tympanic Gentamicin Treatment for Menière's Disease: A Long-Term Follow Up. Otol Neurotol 2018; 39:903-907. [PMID: 29995010 DOI: 10.1097/mao.0000000000001882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intra-tympanic injections of gentamicin (ITG), a known ototoxic agent, have been proven to be effective in controlling Menière's disease (MD) symptoms, in patients who did not respond to conservative therapy, although its safety was questionable. OBJECTIVES To study whether low-concentration ITG, in refractory MD, had an effect on the ipsilateral hearing, in comparison to the contralateral ear, and to study the effectiveness of such treatment. METHODS A comparative, retrospective cohort study was conducted between 2003 and 2015, and compared the change in the hearing level between the injected ear and the contralateral, untreated ear. OUTCOMES In 20 of 27 patients (74.1%), one course of ITG treatment was considered as successful. In the short-term, there was improvement of hearing level at 1000 Hz (p = 0.014), and deterioration of hearing level at 8000 Hz (p = 0.039), both in comparison to the control ear. In the long-term and after confounders adjustment, we found there were no differences in the hearing levels between the treated ear and the untreated contralateral ear. CONCLUSIONS A high success rates of treating vertigo attacks with low concentration ITG in refractory unilateral MD patients is herein reported, while a significant difference was not observed in the hearing threshold compared with the healthy contralateral ear.
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Sultemeier DR, Hoffman LF. Partial Aminoglycoside Lesions in Vestibular Epithelia Reveal Broad Sensory Dysfunction Associated with Modest Hair Cell Loss and Afferent Calyx Retraction. Front Cell Neurosci 2017; 11:331. [PMID: 29163044 PMCID: PMC5663721 DOI: 10.3389/fncel.2017.00331] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/09/2017] [Indexed: 11/13/2022] Open
Abstract
Although the effects of aminoglycoside antibiotics on hair cells have been investigated for decades, their influences on the dendrites of primary afferent neurons have not been widely studied. This is undoubtedly due to the difficulty in disassociating pathology to dendritic processes from that resulting from loss of the presynaptic hair cell. This was overcome in the present investigation through development of a preparation using Chinchilla laniger that enabled direct perilymphatic infusion. Through this strategy we unmasked gentamicin's potential effects on afferent calyces. The pathophysiology of the vestibular neuroepithelia after post-administration durations of 0.5 through 6 months was assessed using single-neuron electrophysiology, immunohistochemistry, and confocal microscopy. Hair cell densities within cristae central zones (0.5-, 1-, 2-, and 6-months) and utricle peri- and extrastriola (6-months) regions were determined, and damage to calretinin-immunoreactive calyces was quantified. Gentamicin-induced hair cell loss exhibited a profile that reflected elimination of a most-sensitive group by 0.5-months post-administration (18.2%), followed by loss of a second group (20.6%) over the subsequent 5.5 months. The total hair cell loss with this gentamicin dose (approximately 38.8%) was less than the estimated fraction of type I hair cells in the chinchilla's crista central zone (approximately 60%), indicating that viable type I hair cells remained. Extensive lesions to afferent calyces were observed at 0.5-months, though stimulus-evoked modulation was intact at this post-administration time. Widespread compromise to calyx morphology and severe attenuation of stimulus-evoked afferent discharge modulation was found at 1 month post-administration, a condition that persisted in preparations examined through the 6-month post-administration interval. Spontaneous discharge was robust at all post-administration intervals. All calretinin-positive calyces had retracted at 2 and 6 months post-administration. We found no evidence of morphologic or physiologic recovery. These results indicate that gentamicin-induced partial lesions to vestibular epithelia include hair cell loss (ostensibly reflecting an apoptotic effect) that is far less extensive than the compromise to stimulus-evoked afferent discharge modulation and retraction of afferent calyces (reflecting non-apoptotic effects). Additionally, calyx retraction cannot be completely accounted for by loss of type I hair cells, supporting the possibility for direct action of gentamicin on the afferent dendrite.
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Affiliation(s)
- David R. Sultemeier
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Larry F. Hoffman
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Brain Research Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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Evaluation of the possible protective role of naringenin on gentamicin-induced ototoxicity: A preliminary study. Int J Pediatr Otorhinolaryngol 2017; 100:247-253. [PMID: 28802382 DOI: 10.1016/j.ijporl.2017.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/16/2017] [Accepted: 07/07/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The purpose of this study is to evaluate the possible protective role of naringenin in gentamicin-induced ototoxicity through an audiological, biochemical and histopathological evaluation. METHODS This study was conducted on 32 adult male rats that were randomized into 4 groups(control, gentamicin, naringenin + gentamicin, and naringenin). Naringenin was given to the rats via oral gavage in a dose of 50 mg/kg/day during the 14 day study period. Gentamicin was given by the intraperitoneal route in a dose of 120 mg/kg/day. Audiological assessment was performed by the distortion product otoacoustic emission (DPOAE) and auditory brainstem response (ABR) measurements, applied to all rats at the beginning of the study, and also on day 14. Biochemical parameters were calculated on day 14 to evaluate the oxidative and antioxidative status. Their cochleae were removed and examined histopathologically, also on day 14. The cochlea of animals were evaluated with the terminal deoxynucleotidyl transferase-mediated dUTPbiotin nick end labeling (TUNEL) method for apoptosis. RESULTS On days 14, DPOAE values and ABR thresholds were preserved in group 3(naringenin + gentamicin) when compared with group 2(gentamicin)(p < 0.008). The total oxidant status values and oxidative stress index values were significantly higher in group 2(gentamicin) than in other groups (p < 0.008). The total antioxidant status value was significantly higher in group 3(naringenin + gentamicin) and group 4(naringenin) than in group 2(gentamicin)(p < 0.008). The number of TUNEL positive cells in both the organ of Corti and the stria vascularis were found to be statistically lower in group 3(naringenin + gentamicin) than in group 2(gentamicin)(p < 0.05). CONCLUSION Our study has demonstrated that the ototoxic effect generated by gentamicin could be ameliorated with the concurrent use of naringenin.
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Intratympanic (IT) Therapies for Menière's Disease: Some Consensus Among the Confusion. CURRENT OTORHINOLARYNGOLOGY REPORTS 2017; 5:132-141. [PMID: 29568697 DOI: 10.1007/s40136-017-0153-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Purpose of Review Aminoglycosides and corticosteroids are commonly used to treat Menière's disease. Intratympanic (IT) administration of these medications allows high inner ear concentrations without significant adverse systemic effects. As a direct result, IT therapy has grown in popularity. Recent studies have compared patient outcomes between IT aminoglycosides and corticosteroids. This review summarizes these findings. Recent Findings Trials comparing IT corticosteroids to IT placebo or oral therapy have had conflicting results. Most recently, Lambert et al. investigated the effect of IT dexamethasone in a sustained-release formulation compared to placebo. Their findings demonstrated improvement in some secondary measures of vertigo with the sustained-release formulation.IT gentamicin is known to be effective in controlling vertigo in Menière's disease. In a recent study from 2016, Patel et al compared IT gentamicin and IT methylprednisolone in a double-blind, randomized controlled trial and identified no significant differences between the two in vertigo control. Summary IT injections of aminoglycosides and corticosteroids can improve vertigo control. Hearing and vestibular loss however may result with IT aminoglycosides. Corticosteroids demonstrate limited hearing loss but may not have the same efficacy in controlling vertigo. Further investigation in the etiology of Menière's disease is needed to tailor the proposed treatment to suit the disease mechanism.
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Patel M, Agarwal K, Arshad Q, Hariri M, Rea P, Seemungal BM, Golding JF, Harcourt JP, Bronstein AM. Intratympanic methylprednisolone versus gentamicin in patients with unilateral Ménière's disease: a randomised, double-blind, comparative effectiveness trial. Lancet 2016; 388:2753-2762. [PMID: 27865535 DOI: 10.1016/s0140-6736(16)31461-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 08/12/2016] [Accepted: 08/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Ménière's disease is characterised by severe vertigo attacks and hearing loss. Intratympanic gentamicin, the standard treatment for refractory Ménière's disease, reduces vertigo, but damages vestibular function and can worsen hearing. We aimed to assess whether intratympanic administration of the corticosteroid methylprednisolone reduces vertigo compared with gentamicin. METHODS In this double-blind comparative effectiveness trial, patients aged 18-70 years with refractory unilateral Ménière's disease were enrolled at Charing Cross Hospital (London, UK) and Leicester Royal Infirmary (Leicester, UK). Patients were randomly assigned (1:1) by a block design to two intratympanic methylprednisolone (62·5 mg/mL) or gentamicin (40 mg/mL) injections given 2 weeks apart, and were followed up for 2 years. All investigators and patients were masked to treatment allocation. The primary outcome was vertigo frequency over the final 6 months (18-24 months after injection) compared with the 6 months before the first injection. Analyses were done in the intention-to-treat population, and then per protocol. This trial is registered with ClinicalTrials.gov, number NCT00802529. FINDINGS Between June 19, 2009, and April 15, 2013, 256 patients with Ménière's disease were screened, 60 of whom were enrolled and randomly assigned: 30 to gentamicin and 30 to methylprednisolone. In the intention-to-treat analysis (ie, all 60 patients), the mean number of vertigo attacks in the final 6 months compared with the 6 months before the first injection (primary outcome) decreased from 19·9 (SD 16·7) to 2·5 (5·8) in the gentamicin group (87% reduction) and from 16·4 (12·5) to 1·6 (3·4) in the methylprednisolone group (90% reduction; mean difference -0·9, 95% CI -3·4 to 1·6). Patients whose vertigo did not improve after injection (ie, non-responders) after being assessed by an unmasked clinician were eligible for additional injections given by a masked clinician (eight patients in the gentamicin group vs 15 in the methylprednisolone group). Two non-responders switched from methylprednisolone to gentamicin. Both drugs were well tolerated with no safety concerns. Six patients reported one adverse event each: three in the gentamicin group and three in the methylprednisolone group. The most common adverse event was minor ear infections, which was experienced by one patient in the gentamicin group and two in the methylprednisolone group. INTERPRETATION Methylprednisolone injections are a non-ablative, effective treatment for refractory Ménière's disease. The choice between methylprednisolone and gentamicin should be made based on clinical knowledge and patient circumstances. FUNDING Ménière's Society and National Institute for Health Research Imperial Biomedical Research Centre.
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Affiliation(s)
- Mitesh Patel
- Neuro-otology Unit, Division of Brain Sciences, Charing Cross Hospital Campus, Imperial College London, London, UK
| | - Kiran Agarwal
- Neuro-otology Unit, Division of Brain Sciences, Charing Cross Hospital Campus, Imperial College London, London, UK
| | - Qadeer Arshad
- Neuro-otology Unit, Division of Brain Sciences, Charing Cross Hospital Campus, Imperial College London, London, UK
| | - Mohamed Hariri
- Ear, Nose and Throat Department, Charing Cross Hospital, London, UK
| | - Peter Rea
- Ear, Nose and Throat Department, Leicester Royal Infirmary, Leicester University Hospitals, Leicester, UK
| | - Barry M Seemungal
- Neuro-otology Unit, Division of Brain Sciences, Charing Cross Hospital Campus, Imperial College London, London, UK
| | - John F Golding
- Neuro-otology Unit, Division of Brain Sciences, Charing Cross Hospital Campus, Imperial College London, London, UK; Department of Psychology, University of Westminster, London, UK
| | - Jonny P Harcourt
- Ear, Nose and Throat Department, Charing Cross Hospital, London, UK
| | - Adolfo M Bronstein
- Neuro-otology Unit, Division of Brain Sciences, Charing Cross Hospital Campus, Imperial College London, London, UK.
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Hearing and Vestibular Function After Preoperative Intratympanic Gentamicin Therapy for Vestibular Schwanomma as Part of Vestibular Prehab. Ear Hear 2016; 37:744-750. [DOI: 10.1097/aud.0000000000000340] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Is gentamycin delivery via sustained-release vehicles a safe and effective treatment for refractory Meniere’s disease? A critical analysis of published interventional studies. Eur Arch Otorhinolaryngol 2016; 274:1309-1315. [DOI: 10.1007/s00405-016-4294-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/02/2016] [Indexed: 10/21/2022]
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Prevention of gentamicin ototoxicity with N-acetylcysteine and vitamin A. The Journal of Laryngology & Otology 2016; 130:440-6. [PMID: 27095551 DOI: 10.1017/s0022215116000992] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To investigate the use of systemic N-acetylcysteine and vitamin A in the prevention of gentamicin ototoxicity in rats. METHODS Forty-two Wistar rats were divided into four groups according to treatment: intratympanic saline, intratympanic gentamicin, intraperitoneal vitamin A after intratympanic gentamicin, and intraperitoneal N-acetylcysteine after intratympanic gentamicin. Signal-to-noise ratio and distortion product otoacoustic emissions were evaluated in all groups. RESULTS N-acetylcysteine had a significant protective effect at 1.5, 2, 3, 4, 6 and 8 kHz, whilst vitamin A had a significant protective effect at 2, 3, 4 and 6 kHz, as determined by the distortion product otoacoustic emission measurements. According to the signal-to-noise measurements, N-acetylcysteine had a significant protective effect at 1.5, 2, 3, 4, 6 and 8 kHz, whilst vitamin A had a significant protective effect at 3, 6 and 8 kHz. CONCLUSION Gentamicin-induced hearing loss in rats may be prevented by the concomitant use of vitamin A and N-acetylcysteine. Specifically, N-acetylcysteine appeared to have a more protective effect than vitamin A for a greater range of noise frequencies.
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Kudriavtseva AS, Amelin AV, Lilenko SV, Skoromets AA. [The differential diagnosis of recurrent episodes of vertigo]. Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:4-9. [PMID: 27240041 DOI: 10.17116/jnevro2016116414-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
UNLABELLED Recurrent episodes of vertigo are one of the most frequent reasons of referrals for medical help. In the Russian medicine, the development of vertigo is traditionally associated with a cerebral vascular pathology. It is suggested that correctly planned clinical neurovestibular study may identify the signs of a balance disorder of peripheral and central genesis. OBJECTIVE To increase the effectiveness of the differential diagnosis of peripheral and central vertigo in patients with recurrent episodes of balance disorders using the protocol of neurovestibular examination ALGORITM. MATERIAL AND METHODS The study included 120 outpatients with preliminary diagnoses of cerebral ischemia and autonomic vascular dystonia. RESULTS Signs of lesion of peripheral and central regions of the vestibular system were found in 43.5 and 17.5% patients, respectively. Benign positional vertigo was the most frequent cause of vertigo while chronic cerebral ischemia was identified in 16.5% of the patients. CONCLUSION Neurovestibularexamnation using the protocol ALGORITM is important for assessment of the level of vestibular system lesion. Iitis necessary to use it in complex examination of patients with complaints of vertigo.
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Affiliation(s)
- A S Kudriavtseva
- Pavlov First St. Petersburg State Medical University, St. Petersburg
| | - A V Amelin
- St. Petersburg Research Institute of Otolaryngology, St. Petersburg
| | - S V Lilenko
- Mechnikov North-Western State Medical University, St. Petersburg; Mechnikov North-Western State Medical University, St. Petersburg
| | - A A Skoromets
- St. Petersburg Research Institute of Otolaryngology, St. Petersburg
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Vestibular results after intratympanic gentamicin therapy in disabling Menière's disease. Eur Arch Otorhinolaryngol 2016; 273:3011-8. [PMID: 26780342 DOI: 10.1007/s00405-015-3889-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 12/29/2015] [Indexed: 10/22/2022]
Abstract
Intratympanic injection of gentamicin is increasingly used in the treatment of unilateral disabling Menière's disease (MD). Several objective functional and subjective tests have been developed to assess the control of vertigo after gentamicin treatment. The aim of this study was to show that subjective results require a vestibular deafferentation as profound as possible, evidenced with multifrequency vestibular assessment. Sixty four patients with intractable MD in situation of medical treatment failure longer than 6 months were included between 1998 and 2013 in this case control study. A 2-year follow-up was performed after the last intratympanic gentamicin performed with the titration technique. A vestibular assessment was applied before and after 2 years of treatment with a functional level score using the AAOHNS vertigo scale and multifrequency vestibular assessment: skull vibration-induced nystagmus test (SVINT), head-shaking test (HST) and caloric test (CaTe). The correlation between the results of the questionnaire and the level of the deafferentation as evaluated by the tests was analyzed with the Spearman test. Among the 64 included patients, 56 (87.5 %) described vertigo control. There was a correlation (=-0.33 [-0.53; -0.09], p = 0.008) between subjective improvement (AAO -HNS 1 or 2) and the degree of vestibular deafferentation as evidenced by a destructive nystagmus (beating toward the safe side) with the HST and the SVINT, as well as a caloric hypofunction >90 % with the CaTe. The present study demonstrates that a profound vestibular deafferentation confirmed with multifrequency test evaluation is needed to have a subjective improvement in the treatment of unilateral disabling MD with intratympanic gentamicin.
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Abstract
Menière's disease (MD) is a chronic multifactorial disorder of the inner ear characterized by episodic vestibular symptoms associated with sensorineural hearing loss, tinnitus, and aural pressure. Epidemiologic and genomic evidence supports a genetic susceptibility with multiple biochemical pathways involved, including the endocrine system, innate immune response, and autonomic nervous system. Allergens, infectious agents, vascular events, or genetic factors could modify inner-ear homeostasis and trigger MD. The diagnosis of MD is based on clinical criteria and requires the observation of an episodic vertigo syndrome associated with low- to medium-frequency sensorineural hearing loss and fluctuating aural symptoms (hearing loss, tinnitus, and/or fullness) in the affected ear. Headache is also found during the attacks and bilateral involvement is found in 25-40% of cases. Audiologic and vestibular assessment is recommended to monitor the clinical course. The treatment of MD is symptomatic to obtain relief of vestibular episodes and preventive to limit hearing loss progression. Treatment options include sodium restriction, betahistine, intratympanic gentamicin, or steroids and eventually surgery, such as cochlear implantation.
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Affiliation(s)
- J M Espinosa-Sanchez
- Otology and Neurotology Group, Department of Genomic Medicine, Centre for Genomics and Oncological Research (GENYO), Pfizer-University of Granada-Junta de Andalucia, Granada, Spain; Department of Otolaryngology, Hospital San Agustin, Linares, Jaen, Spain
| | - J A Lopez-Escamez
- Otology and Neurotology Group, Department of Genomic Medicine, Centre for Genomics and Oncological Research (GENYO), Pfizer-University of Granada-Junta de Andalucia, Granada, Spain; Department of Otolaryngology, Complejo Hospitalario Universitario de Granada, Granada, Spain.
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Abstract
Ideally, vestibular pharmacotherapy is intended, through specific and targeted molecular actions, to significantly alleviate vertigo symptoms, to protect or repair the vestibular sensory network under pathologic conditions, and to promote vestibular compensation, with the eventual aim of improving the patient's quality of life. In fact, in order to achieve this aim, considerable progress still needs to be made. The lack of information on the etiology of vestibular disorders and the pharmacologic targets to modulate, as well as the technical challenge of targeting a drug to its effective site are some of the main issues yet to be overcome. In this review, my intention is to provide an account of the therapeutic principles that have shaped current vestibular pharmacotherapy and to further explore crucial questions that must be taken into consideration in order to develop targeted and specific pharmacologic therapies for each type and stage of vestibular disorders.
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Affiliation(s)
- C Chabbert
- Integrative and Adaptative Neurosciences, University of Aix Marseille, Marseille, France.
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Surgery for vertigo: 10-year audit from a contemporary vertigo clinic. The Journal of Laryngology & Otology 2015; 129:1182-7. [PMID: 26654639 DOI: 10.1017/s0022215115002935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To present the profile of patients undergoing surgical treatment for vertigo at a contemporary institutional vertigo clinic. STUDY DESIGN A retrospective analysis of clinical charts. METHODS The charts of 1060 patients, referred to an institutional vertigo clinic from January 2003 to December 2012, were studied. The clinical profile and long-term outcomes of patients who underwent surgery were analysed. RESULTS Of 1060 patients, 12 (1.13 per cent) were managed surgically. Of these, disease-modifying surgical procedures included perilymphatic fistula repair (n = 7) and microvascular decompression of the vestibular nerve (n = 1). Labyrinth destructive procedures included transmastoid labyrinthectomy (n = 2) and labyrinthectomy with vestibular nerve section (n = 1). One patient with vestibular schwannoma underwent both a disease-modifying and destructive procedure (translabyrinthine excision). All patients achieved excellent vertigo control, classified as per the American Academy of Otolaryngology - Head and Neck Surgery 1995 criteria. CONCLUSION With the advent of intratympanic treatments, surgical treatments for vertigo have become further limited. However, surgery with directed intent, in select patients, can give excellent results.
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Nakayama M, Masuda A, Ando KB, Arima S, Kabaya K, Inagaki A, Nakamura Y, Suzuki M, Brodie H, Diaz RC, Murakami S. A Pilot Study on the Efficacy of Continuous Positive Airway Pressure on the Manifestations of Ménière's Disease in Patients with Concomitant Obstructive Sleep Apnea Syndrome. J Clin Sleep Med 2015; 11:1101-7. [PMID: 26094927 PMCID: PMC4582051 DOI: 10.5664/jcsm.5080] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 04/20/2015] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To evaluate the effect of continuous positive airway pressure (CPAP) therapy on Ménière's disease patients with concomitant obstructive sleep apnea syndrome (OSAS), since recent reports suggest OSAS may cause dysfunction of the vestibular system. STUDY DESIGN Prospective study using CPAP administered to patients diagnosed with "Definite Ménière's disease" according to the guidelines of the American Academy of Otolaryngology--Head and Neck Surgery and combined with OSAS. SETTING University hospital. METHODS Twenty consecutive patients, 14 male and 6 female with active, unilateral, cochleovestibular Ménière's disease refractory to medical management who also had concurrent OSAS as defined by International Classification of Sleep Disorders, Second Edition were selected to undergo solitary CPAP therapy. Audiometric testing, caloric testing, and DHI survey were conducted before and after CPAP therapy and compared to assess effectiveness of CPAP therapy as utilized for treatment of Ménière's disease. RESULTS Although caloric testing did not show significant difference, audiometric testing and results of dizziness handicap inventory were significantly improved (p < 0.05) after CPAP therapy only, without standard treatment for Ménière's disease. CONCLUSION Recent reports have suggested that OSAS may cause dysfunction of the vestibular system. We investigated whether standard therapy for OSAS would be of benefit in the management of vertigo and hearing loss in Ménière's disease patients. Our study cohort demonstrated significant improvement in both DHI and audiometric testing following solitary CPAP therapy for OSAS. Solitary CPAP therapy may become a new effective treatment strategy for Ménière's disease patients with OSAS, not just only for control of dizziness and vertigo but also for potential benefit of hearing.
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Affiliation(s)
- Meiho Nakayama
- Good Sleep Center, Nagoya City University Hospital, Nagoya, Japan
- Department of Otolaryngology, Nagoya City University, Nagoya, Japan
| | - Ayako Masuda
- Good Sleep Center, Nagoya City University Hospital, Nagoya, Japan
| | | | - Sachie Arima
- Good Sleep Center, Nagoya City University Hospital, Nagoya, Japan
| | - Kayoko Kabaya
- Department of Otolaryngology, Nagoya City University, Nagoya, Japan
| | - Akira Inagaki
- Department of Otolaryngology, Nagoya City University, Nagoya, Japan
| | | | - Motohiko Suzuki
- Department of Otolaryngology, Nagoya City University, Nagoya, Japan
| | - Hilary Brodie
- Department of Otolaryngology, University of California, Davis, CA
| | - Rodney C. Diaz
- Department of Otolaryngology, University of California, Davis, CA
| | - Shingo Murakami
- Department of Otolaryngology, Nagoya City University, Nagoya, Japan
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Is low-dose intratympanic gentamicin an effective treatment for Ménière's disease: the Birmingham experience. The Journal of Laryngology & Otology 2015; 129:970-3. [PMID: 26328875 DOI: 10.1017/s0022215115002200] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Since the development of intratympanic aminoglycoside in the 1950s, otologists have been able to chemically ablate the vestibule. We present the results of using low-dose intratympanic gentamicin to treat Ménière's disease. METHOD A retrospective review was performed of all patients who underwent low-dose intratympanic gentamicin therapy over seven years. Data on gender, age, number of procedures, pure tone audiometry and symptom control were analysed. RESULTS In all, 38 patients underwent low-dose intratympanic gentamicin therapy. These comprised 25 females and 13 males, with an average age of 58.4 years. Hearing was preserved in 87.5 per cent of patients, with no significant difference before and after treatment (p = 0.744). In all, 85.7 per cent of patients had complete or substantial symptom control (classes A and B, respectively). CONCLUSION Low-dose intratympanic gentamicin therapy was effective in controlling the symptoms of Ménière's disease patients, while preserving hearing.
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Marques P, Manrique-Huarte R, Perez-Fernandez N. Single intratympanic gentamicin injection in Ménière's disease: VOR change and prognostic usefulness. Laryngoscope 2015; 125:1915-20. [PMID: 25641686 DOI: 10.1002/lary.25156] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 12/17/2014] [Accepted: 12/22/2014] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Assess angular vestibular-ocular reflex (VOR) changes after treatment with intratympanic gentamicin (ITG) for Ménière's disease (MD) and impact on short-term follow-up. DESIGN Prospective study. METHODS Patients submitted to ITG for unilateral MD. The gain VOR and the presence of compensatory saccades elicited by rapid head impulses were measured using the video head impulse test (vHIT). RESULTS The study included 31 subjects (mean age: 59 years). Functional Level Scale (FLS) distributions were 35,5% (FLS3); 32,2% (FLS4); and 32,2% (FLS5). Mean follow-up was 21 ± 7 months. Multiple injections were needed in nine patients. VOR gain in the treated ear was significantly reduced in all subjects and for all the semicircular canals (paired samples t test; P < 0,05). Gain averages after treatment were 0,61 (superior); 0,69 (horizontal); and 0,47 (posterior). A horizontal canal VOR gain superior to 0,80 after treatment was associated with the need for a second gentamicin injection (Chi-square; P = 0,003). Gain asymmetry between the symptomatic and asymptomatic ear (GASM) was increased after treatment. The rate of vestibular function reduction was 47,9%; 26,0%; and 35,8% for the superior, horizontal, and posterior canals, respectively. According to the receiving operator characteristic curve, the amount of change in GASM must be greater than 7 in order to predict the avoidance of a second procedure (area under the curve [AUC] horizontal canal = 0,861) and the amount of vestibular function reduction in the pathologic ear in patients with a controlled disease must be greater than 17,8% (AUC horizontal canal = 0,843). CONCLUSIONS When evaluated with the vHIT, intratympanic gentamicin changes in VOR seem to foresee short-term control of vertigo attacks. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Pedro Marques
- Department of Otorhinolarygology-Centro Hospitalar São João EPE, Porto, Portugal.,Department of Otorhinolaryngology-University of Oporto Medical School, Porto, Portugal
| | - Raquel Manrique-Huarte
- Department of Otorhinolaryngology-Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Nicolas Perez-Fernandez
- Department of Otorhinolaryngology-Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain
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Rah YC, Han JJ, Park J, Choi BY, Koo JW. Management of intractable Ménière's disease after intratympanic injection of Gentamicin. Laryngoscope 2014; 125:972-8. [DOI: 10.1002/lary.25009] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/22/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Yoon C. Rah
- Department of Otorhinolaryngology-Head and Neck Surgery; Seoul National University Bundang Hospital, Seoul National University College of Medicine; Seongnam Republic of Korea
| | - Jae J. Han
- Department of Otorhinolaryngology-Head and Neck Surgery; Seoul National University Bundang Hospital, Seoul National University College of Medicine; Seongnam Republic of Korea
| | - Jaehong Park
- Department of Otorhinolaryngology-Head and Neck Surgery; Seoul National University Bundang Hospital, Seoul National University College of Medicine; Seongnam Republic of Korea
| | - Byung Y. Choi
- Department of Otorhinolaryngology-Head and Neck Surgery; Seoul National University Bundang Hospital, Seoul National University College of Medicine; Seongnam Republic of Korea
| | - Ja-Won Koo
- Department of Otorhinolaryngology-Head and Neck Surgery; Seoul National University Bundang Hospital, Seoul National University College of Medicine; Seongnam Republic of Korea
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Bremer HG, van Rooy I, Pullens B, Colijn C, Stegeman I, van der Zaag-Loonen HJ, van Benthem PP, Klis SFL, Grolman W, Bruintjes TD. Intratympanic gentamicin treatment for Ménière's disease: a randomized, double-blind, placebo-controlled trial on dose efficacy - results of a prematurely ended study. Trials 2014; 15:328. [PMID: 25135244 PMCID: PMC4141100 DOI: 10.1186/1745-6215-15-328] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 07/02/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gentamicin is used as a therapeutic agent for Ménière's disease because of its vestibulotoxicity causing chemo-ablation of the vestibular sensory epithelia. Its use has increased in recent years. However, there is still no consensus about the dose regimen of gentamicin in the treatment of Ménière's disease. In this study two different dose regimen treatment protocols are compared in a placebo controlled study design. The primary objective is to quantify the treatment effect on dizziness, the secondary objective is hearing evaluation. METHODS We performed a randomized, double-blind, placebo-controlled study in adults with unilateral Ménière's disease according to the AAO-HNS guidelines resistant to conservative medication. Three groups received four injections, administered weekly (four intratympanic injections with 40 mg/mL gentamicin solution, two injections gentamicin solution and two injections of placebo in random order, or four injections with placebo). Outcome measures were the score on the Dizziness Handicap Inventory and pure tone audiometry (PTA). Intended follow-up was 2 years. RESULTS During follow-up one patient exceeded the accepted amount of hearing loss. Further, enrollment was very slow (until 12 months between two patients) and new insights showed an apparent benefit of intratympanic gentamicin treatment (ITG). Therefore we performed an unscheduled interim analysis which showed that PTA threshold shifts reached the stopping criteria in two more patients. Because of this, this study was ended. Of the three patients with the significant PTA threshold shift two were enrolled in the gentamicin group. CONCLUSION No conclusions can be drawn concerning doses regimens. Now that new publications have shown that ITG treatment can be an effective and safe treatment, a placebo-controlled randomized controlled trial may not pass the ethical committee because of these recent reports in literature. Still, a dose regimen study (without placebo) on ITG treatment needs to be performed. TRIAL REGISTRATION This trial was registered in The University Medical Center Utrecht/ Gelre hospital Apeldoorn. Protocol ID: 07/343, EudraCT number 2006-005913-37.
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Affiliation(s)
- Hendrik G Bremer
- />Department of Otorhinolaryngology, University Medical Center Utrecht, Heidelberglaan 100, Room G.02.531, Utrecht, 3584 CX The Netherlands
- />Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
| | - Ingrid van Rooy
- />Department of Otorhinolaryngology, University Medical Center Utrecht, Heidelberglaan 100, Room G.02.531, Utrecht, 3584 CX The Netherlands
| | - Bas Pullens
- />Department of Otorhinolaryngology, Erasmus Medical Center/ Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Carla Colijn
- />Department of Biometry, Gelre Ziekenhuizen Apeldoorn, Apeldoorn, The Netherlands
| | - Inge Stegeman
- />Department of Otorhinolaryngology, University Medical Center Utrecht, Heidelberglaan 100, Room G.02.531, Utrecht, 3584 CX The Netherlands
- />Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
| | | | - Peter Paul van Benthem
- />Department of Otorhinolaryngology, Gelre Ziekenhuizen Apeldoorn, Apeldoorn, The Netherlands
| | - Sjaak F L Klis
- />Department of Otorhinolaryngology, University Medical Center Utrecht, Heidelberglaan 100, Room G.02.531, Utrecht, 3584 CX The Netherlands
- />Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
| | - Wilko Grolman
- />Department of Otorhinolaryngology, University Medical Center Utrecht, Heidelberglaan 100, Room G.02.531, Utrecht, 3584 CX The Netherlands
- />Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
| | - Tjasse D Bruintjes
- />Department of Otorhinolaryngology, Gelre Ziekenhuizen Apeldoorn, Apeldoorn, The Netherlands
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Casani AP, Cerchiai N, Navari E, Dallan I, Piaggi P, Sellari-Franceschini S. Intratympanic gentamicin for Meniere's disease: short- and long-term follow-up of two regimens of treatment. Otolaryngol Head Neck Surg 2014; 150:847-52. [PMID: 24477826 DOI: 10.1177/0194599813520398] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES (1) To compare the results of the 2 regimens of treatment at 2-year follow-up and (2) to evaluate the need and the efficacy of retreatment after the recurrence of vertigo attacks in a longer period of follow-up (using the Kaplan-Meier method of analysis). STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. SUBJECTS AND METHODS We analyzed 77 patients treated with intratympanic gentamicin (ITG). Thirty-five patients were treated with high-dose (HD) ITG (in total 6 injections, twice a day, repeated every 3 days) and 42 with low-dose (LD) ITG (1-2 injections). The results of treatment were evaluated in terms of functional level scale, control of vertigo, and hearing impairment. RESULTS At 2-year follow-up, a similar percentage of vertigo control was obtained in the 2 groups; the incidence of hearing loss and posttreatment disequilibrium was significantly higher in patients treated with HD-ITG. The long-term follow-up showed a control of vertigo attacks with a single round of treatment in 71.4% of patients treated with HD-ITG and in 55% of those treated with LD-ITG. With repeated rounds, an effective control of vertigo could be achieved in 88.5% using a HD-ITG protocol and 97.7% using a LD-ITG protocol. CONCLUSIONS LD-ITG allows obtaining good results in term of vertigo attacks associated with a limited occurrence of side effects. The long-term follow-up showed that LD-ITG needed repeated rounds more frequently than the HD-protocol. HD-ITG ran less risk of needing repeated rounds, but retreatment was ineffective in 40% of the cases requiring surgical therapy.
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Affiliation(s)
- Augusto P Casani
- Department of Surgery and Medicine, Otorhinolaryngology Unit, Pisa University Hospital, Pisa, Italy
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Ciuman RR. Inner ear symptoms and disease: pathophysiological understanding and therapeutic options. Med Sci Monit 2013; 19:1195-210. [PMID: 24362017 PMCID: PMC3872449 DOI: 10.12659/msm.889815] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 10/11/2013] [Indexed: 12/13/2022] Open
Abstract
In recent years, huge advances have taken place in understanding of inner ear pathophysiology causing sensorineural hearing loss, tinnitus, and vertigo. Advances in understanding comprise biochemical and physiological research of stimulus perception and conduction, inner ear homeostasis, and hereditary diseases with underlying genetics. This review describes and tabulates the various causes of inner ear disease and defines inner ear and non-inner ear causes of hearing loss, tinnitus, and vertigo. The aim of this review was to comprehensively breakdown this field of otorhinolaryngology for specialists and non-specialists and to discuss current therapeutic options in distinct diseases and promising research for future therapies, especially pharmaceutic, genetic, or stem cell therapy.
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Control of Vertigo After Intratympanic Corticoid Therapy for Unilateral Ménière’s Disease. Otol Neurotol 2013; 34:1429-33. [DOI: 10.1097/mao.0b013e31828d655f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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50
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Zhai F, Zhang R, Zhang T, Steyger PS, Dai CF. Preclinical and clinical studies of unrelieved aural fullness following intratympanic gentamicin injection in patients with intractable Ménière's disease. Audiol Neurootol 2013; 18:297-306. [PMID: 24008307 DOI: 10.1159/000351805] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 04/30/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To clarify whether gentamicin affects vestibular dark cells in guinea pigs and relieves patients of aural fullness with intractable Ménière's disease following intratympanic administration. MATERIALS AND METHODS Purified gentamicin-Texas Red (GTTR) was injected intratympanically in guinea pigs that were sacrificed at 1, 3, 7, 14 and 28 days. GTTR uptake was examined in hair cells, and transitional cells and dark cells in vestibular end-organs were examined. Specific attention was paid to its distribution in dark cells under confocal microscopy, and the ultrastructure of dark cells using electron microscopy, following intratympanic injection. RESULTS Dark cells in the semicircular canals showed weak GTTR uptake at 1, 3, 7, 14 and 28 days after intratympanic injection, with no significant differences at various time points after injection. However, the adjacent transitional cells demonstrated intense GTTR uptake that was retained for at least 28 days. Ultrastructural studies demonstrated negligible characteristics associated with apoptosis or necrosis in these dark cells. The tight junctions between dark cells showed no signs of disruption at 7 or 28 days after injection. CONCLUSION Intratympanic gentamicin has little direct impact on vestibular dark cells. CLINICAL APPLICATION A modified low-dose titration intratympanic approach was used in 29 patients with intractable vertigo and the clinical outcomes were followed. Aural fullness following intratympanic gentamicin injection was not relieved based on our subjective scales, demonstrated by no statistically significant difference between preinjection (4.16 ± 3.08) and postinjection (3.58 ± 2.93; p > 0.05) aural fullness scores. Vertigo control was achieved in 88% of patients, with hearing deterioration identified in 16% of patients. Intratympanic gentamicin administration might not lead to relief of aural fullness in patients with intractable vertigo, although it can achieve a high vertigo control rate with some cochleotoxicity.
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Affiliation(s)
- Feng Zhai
- Department of Otology and Skull Base Surgery, Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai, China
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