Outcomes of Endolymphatic Shunt Surgery for Ménière's Disease: Comparison With Intratympanic Gentamicin on Vertigo Control and Hearing Loss

Functional outcomes and caloric response changes after endolymphatic sac decompression

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Vestibular and audiometric results after endolymphatic mastoid shunt surgery in patients with Menière's disease

PURPOSE

Treatment of Menière's Disease (MD) comprises an array of both non-destructive and destructive treatment options. In patients who are therapy-refractory to non-destructive medical treatment, endolymphatic mastoid shunt surgery (EMSS) is both recommended and debated controversially. The aim of this study was to investigate safety in terms of hearing, vestibular function, complication rate, and efficacy with regards to vertigo control of EMSS in patients with MD according to the current diagnostic criteria of 2015.

METHODS

Retrospective analysis of 47 consecutive patients with definite or probable MD with description of demographic parameters, pre- and postoperative MD treatment, pre- and postoperative audiometric (pure tone audiometry) and vestibular (caloric testing) results. The parameters were compared between patients with and without postoperative vertigo control.

RESULTS

31/47 patients (66.0%) had improved vertigo control postoperatively. Postoperative hearing and vestibular preservation were predominantly stable. No significant differences between patients with improved vertigo control and patients with no change or worse vertigo episodes were found. In the treatment refractory group, 4 patients required a revision EMSS and 6 a destructive MD treatment (5 gentamicin intratympanically, 1 labyrinthectomy). No peri- or postsurgical complications were reported.

CONCLUSIONS

EMSS was found to be beneficial in two thirds of the patients with definite or probable Morbus Menière and a safe procedure regarding hearing and vestibular preservation with no postoperative complications. Therefore, EMSS should be considered before inducing destructive treatment options, such as intratympanic gentamicin application or labyrinthectomy.

Outcomes of Endolymphatic Sac Surgery for Meniere's Disease with and without Comorbid Migraine

Purpose

To explore outcomes of endolymphatic sac surgery for patients with Meniere's disease with and without the comorbid condition of migraine.

Materials and Methods

A retrospective chart review of adult patients undergoing endolymphatic sac surgery at a single tertiary care center from 1987 to 2019 was performed. All adult patients who failed medical therapy and underwent primary endolymphatic sac surgery were included. The main outcome measures were vertigo control and functional level scale (FLS) score. Patient characteristics, comorbidities, and audiometric outcomes were tracked as well.

Results

Patients with Meniere's disease and migraine had a stronger association with psychiatric comorbidities (64.29% vs. 25.80%, p=0.01), shorter duration of vertigo episodes (143 vs. 393 min, p=0.02), and younger age (36.6 vs. 50.8 yr, p=0.005) at the time of endolymphatic sac surgery. Postoperative pure tone averages and word recognition scores were nearly identical to preoperative baselines. Class A vertigo control (47.92%) was most common, followed by class B vertigo control (31.25%). The FLS score improved from 4.2 to 2.8 (p < 0.001). Both patients with and without migraine had classes A-B vertigo control (66.67% vs. 80.95%) without any statistically significant difference (p=0.59). Of the patients who required secondary treatment (10.42%), none had migraine.

Conclusions

Endolymphatic sac surgery is an effective surgical intervention for Meniere's disease with and without migraine. Patients with comorbid migraine tend to be younger and present with psychiatric comorbidities.

New marsupialization technique in endolymphatic sac surgery

OBJECTIVES

The aim of the present study was to describe and evaluate the results of a new technique in endolymphatic sac decompression surgery.

METHODS

Forty-three patients with intractable unilateral Meniere's disease were selected. Endolymphatic sac was identified after simple mastoidectomy, and its lateral layer was incised, using a sickle knife. Outer layer of the sac was turned around and placed under the anterior bony border.

RESULTS

Mean duration of the follow-up was 24 months. Mean tinnitus handicap index, pure tone average (PTA) on thresholds at 500, 1000, 2000, and 4000 Hz, mean speech reception threshold, mean speech discrimination score, hearing stage, and mean vertigo score before and after surgery were evaluated.

CONCLUSION

The new marsupialization technique with anterior bony border is a safe and effective way to improve tinnitus, vertigo, and ear fullness among these patients. According to PTA and hearing stage, this surgery can control progressive hearing loss.

LEVEL OF EVIDENCE

3.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2455-2460, 2020.

Menière's disease treated by grommet insertion

INTRODUCTION

Menière's disease (MD) is an uncommon cause of sudden profound vertigo. A variety of medical and surgical treatments have been used to manage this condition. This study reviewed the outcomes of patients treated with grommet insertion and transtympanic steroid injection.

METHODS

Patients diagnosed with MD between 2007 and 2017 were identified, and case notes and audiological data were retrieved for those managed by grommet (ventilation tube) insertion with and without transtympanic steroid injection.

RESULTS

Thirty-three patients were identified as being diagnosed with MD. Grommet insertion resulted in cessation or improvement of attacks in 91% of cases. The mean follow-up duration was 33.8 months (median: 29 months). The mean hearing threshold across the low frequencies improved from 57.2dBHL to 49.4dBHL (p=0.031). Following the intervention, improved tinnitus was reported in 80% of cases. Twelve patients (36%) reported aural fullness prior to grommet insertion; all reported improved symptoms following the procedure.

CONCLUSIONS

Early grommet insertion with transtympanic steroid injection, combined with customised vestibular physiotherapy, may provide an alternative first-line strategy for MD, preventing further true MD attacks. In some patients, it may significantly improve hearing thresholds.

Volume-rendered computed tomography images of the surgical field for endolymphatic sac surgery

PURPOSE

Identification of the endolymphatic sac has failed occasionally. Postoperative complications have also rarely been reported. Given a safer and more reliable surgery, preoperative anatomical assessments are valuable, however, the vestibular aqueduct has seldom been seen with multi-planar reconstruction (MPR) computed tomography (CT) images yet. Our study aimed to determine the significance and utility of volume-rendered (VR) CT images of the surgical field for identifying the vestibular aqueduct, compared with MPR CT images.

SUBJECTS AND METHODS

14 patients with Meniere's disease who underwent endolymphatic sac surgery between 2008 and 2011. Location and size of the vestibular aqueduct were assessed using VR and MPR CT images, independently.

RESULTS

Accuracy of identifying the location differed significantly between VR and MPR CT images (rate of total correct evaluations: 100% by VR CT images vs 75% by MPR CT images, p = 0.02). Size was correctly identified in cases with a small endolymphatic sac using VR CT images (rate of total correct evaluations for size of the vestibular aqueduct: 100% by VR CT vs 57% by MPR CT, p = 0.046). VR CT images also demonstrated clearly the relationship between the endolymphatic sac and high jugular bulb. In two cases, the endolymphatic sac was identified by VR images, not by MPR images.

CONCLUSION

Accurate information about the location and size of vestibular aqueduct can allow sac surgeons to identify a tiny endolymphatic sac more easily and certainly, and also aids surgical trainees to learn sac surgery safely.

Surgery for vertigo: 10-year audit from a contemporary vertigo clinic

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.

Comparison the results of two different vestibular system surgery in patients with persistent Meniere's disease

Background:

Incidence rates of Meniere's disease vary considerably from 157/100,000 in the United Kingdom to 15/100,000 in the United States. Furthermore, in Iran prevalence of Meniere's disease is high, whereas we have not a reliable statistical study on it. A wide range of treatments are used for the treatment of the condition with no consensus on the most effective intervention. The aim of the present study, which involved 37 patients treated because of severe vertigo due to persistent Meniere's disease from 1996 to 2011, was to compare the effectiveness of two surgical methods cochleosacculotomy and endolymphatic sac decompression on vertigo and tinnitus.

Materials and Methods:

In a cross-sectional study, we compared two surgical approaches in patients with Meniere's disease who did not respond to usual medical treatment. Twenty-three patients underwent cochleosacculotomy surgery and 14 patients endolymphatic sac decompression surgery. We compared all the patients for resolving of vertigo, tinnitus.

Results:

After surgery, in patients of both group vertigo was improved significantly (P < 0.0001), tinnitus was improved, but it was not significant (P > 0.05) and hearing level was worse than before (especially in patients who had undergone cochleosacculotomy) (P < 0.0001).

Conclusion:

Based on the data of the current study, cochleosacculotomy and endolymphatic sac decompression improved vertigo in patients with persistent Meniere's disease.

Current evidence for endolymphatic sac surgery in the treatment of Meniere's disease: a systematic review

This paper aims to identify emerging evidence for endolymphatic sac surgery (ESS) in the treatment of Meniere's disease since the landmark study by Thomsen et al, published in 1998 (conducted from 1981 to 1989). Using the MEDLINE database (PubMed), a systematic review of the literature published from January 1990 to June 2014 was performed. We included all English-language, peer-reviewed randomised controlled trials (RCTs) and controlled studies. Single-arm cohort studies were included if the sample size was ≥ 90 with a response rate > 60%. Altogether, 11 studies fulfilled our inclusion criteria; one was an RCT, two were controlled trials and eight were single-arm cohort studies. There currently exists a low level of evidence for the use of ESS in the treatment of Meniere's disease. Further studies, in particular RCTs and/or controlled studies, are required to fully evaluate this modality. However, there are difficulties in designing a valid placebo and achieving adequate blinding of observers and investigators.

Endolymphatic sac surgery for Ménière's disease: a systematic review and meta-analysis

OBJECTIVE

To analyze current endolymphatic surgery techniques and quantify their efficacy in controlling vertigo and maintaining hearing in the short and long term.

DATA SOURCES

A comprehensive literature search using the PubMed-NCBI database from 1970 to 2013.

STUDY SELECTION

Articles on sac decompression and mastoid shunt (with and without silastic) were included. Included studies had to report data using the 1985 or 1995 American Academy of Otolaryngology-Head and Neck Foundation (AAO-HNS) guidelines, describe surgical technique in detail, include a minimum of 10 patients, and have minimum 12 months of follow-up.

DATA EXTRACTION

Endpoints were vertigo control and hearing preservation using AAO-HNS guidelines. Analysis included short-term (>12 mo) and long-term (>24 mo) follow-up.

DATA SYNTHESIS

Data analysis was performed using MedCalc 12.7.0. Each article was weighted according to the number of patients treated. Analysis of pooled proportion was performed, and Freeman-Tukey transformation was used to correct for probable variance. A t test (of proportions) was performed to compare differences between groups.

CONCLUSION

Endolymphatic sac surgery (sac decompression or mastoid shunt) is effective at controlling vertigo in the short term (>1 yr of follow-up) and long term (>24 mo) in at least 75% of patients with Ménière's disease who have failed medical therapy. Sac decompression and mastoid shunting techniques provide similar vertigo control rates. Mastoid shunting, with and without silastic, also provides similar vertigo control rates. Non-use of silastic, however, seems to maintain stable or improved hearing in more patients compared to silastic sheet placement. The data suggest that, once the sac is opened, placing silastic does not add benefit and may be deleterious.

Endolymphatic sac surgery versus tenotomy of the stapedius and tensor tympani muscles in the management of patients with unilateral definite Meniere's disease

This study aims to compare the outcomes of patients with Meniere's disease submitted to either endolymphatic mastoid shunt (ES) or tenotomy of the stapedius and tensor tympani muscles (TSTM). This is a retrospective chart review of patients treated with ES or TSTM between 2000 and 2010 and followed up for at least 12 months. The main outcomes were represented by: (1) vertigo class, hearing stage and functional level according to the American Academy of Otolaryngology-Head and Neck Surgery criteria; (2) adjustment of dizziness handicap inventory (DHI) and (3) complete and substantial vertigo control using the Kaplan-Meier survival method. Sixty-three patients met the inclusion criteria: 34 underwent ES and 29 TSTM. The baseline demographic characteristics, the hearing stage, the functional level, the DHI and hearing levels were not different between the two groups. No significant difference in vertigo class was demonstrated: 66 % of TSTM patients attained class A compared to 44 % in the ES group (p = 0.14). Kaplan-Meier survival curves specific to class A showed significant differences, favoring TSTM (log-rank test, p = 0.022). TSTM patients demonstrated significantly improved functional level (p = 0.0004) and improved DHI scores (p = 0.001). Eight ES patients (25 %) demanded a second surgical attempt compared to none in the TSTM. Aural fullness was significantly improved in TSTM group (p = 0.01), while the difference in tinnitus improvement was non-significant. Hearing preservation was significantly better in TSTM group (p = 0.001). TSTM is a safe surgical procedure, with significant vertigo control rates, and important hearing preservation rates. More patients and longer follow-up are needed to support our preliminary findings.

Intratympanic Therapies for Menière's disease

There are multiple treatment options to consider when managing patients with Menière's disease. When conservative measures fail to control symptoms of Menière's disease, escalation of interventions may be required. Targeted drug delivery to the round window with intratympanic injections allows for local application of high concentrations of medications, largely avoiding systemic side effects. Intratympanic steroids have been shown to be effective at controlling vertigo symptoms, with less robust control rates than those seen with the use of intratympanic gentamicin. Dosing strategies have been modified over time to limit the potential for intratympanic gentamicin-induced ototoxicity. The introduction of intratympanic steroids coupled to a polymer designed for sustained round window drug application, may potentially afford improved duration of symptom control. This review evaluates the recent literature over the last year involving intratympanic therapies for Meniere's disease.

Posterior semicircular canal dehiscence following endolymphatic sac surgery

Posterior semicircular canal dehiscence is a rare otologic entity that presents with third window signs and symptoms. Petrous apex cholesteatoma, fibrous dysplasia, high riding jugular bulb, and eosinophilic granuloma have been reported to be associated with posterior semicircular canal dehiscence. Here we report a case of development of posterior semicircular canal dehiscence following an endolymphatic sac surgery for the first time.

Round window perfusion dynamics: implications for intracochlear therapy

PURPOSE OF REVIEW

The treatments for inner ear diseases are evolving as the systemic administration of medication is replaced by novel intratympanic and intracochlear drug delivery. The current review explores the background and recent developments in this field.

RECENT FINDINGS

Although still in various stages of clinical development, novel drug delivery techniques such as the Silverstein MicroWick, the round window microcatheter, biodegradable hydrogels, biopolymers, nanoparticles, newly designed cochlear implant arrays, osmotic mini/micro pumps, and reciprocating perfusion systems hold significant promise. Animal data suggest that sustained delivery systems have more reliable inner ear pharmacokinetics than both systemic administration and intratympanic injections.

SUMMARY

As research scientists advance technologies for treating inner ear diseases, drug delivery techniques must keep pace. Viable treatment options for sensorineural hearing loss, tinnitus, and vestibular disorders are on the horizon and may usher in a new golden age for otology.