Bilateral Ménière's disease

Brazilian Society of Otology task force - cochlear implant ‒ recommendations based on strength of evidence

OBJECTIVE

To make evidence-based recommendations for the indications and complications of Cochlear Implant (CI) surgery in adults and children.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on cochlear implantation were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: (1) Evaluation of candidate patients and indications for CI surgery; (2) CI surgery - techniques and complications.

CONCLUSIONS

CI is a safe device for auditory rehabilitation of patients with severe-to-profound hearing loss. In recent years, indications for unilateral hearing loss and vestibular schwannoma have been expanded, with encouraging results. However, for a successful surgery, commitment of family members and patients in the hearing rehabilitation process is essential.

Does labyrinthectomy have an impact on hearing in the contralateral ear during long-term follow-up?

OBJECTIVE

To quantify contralateral hearing outcomes after labyrinthectomy for unilateral Ménière's disease (MD).

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary neurotology referral center.

PATIENTS

Labyrinth removal for the management of MD or translabyrinthine (TLAB) acoustic neuroma resection between 2008 and 2012.

MAIN OUTCOME MEASURE

Long-term hearing changes via pure tone averages (PTA).

RESULTS

Upon comparison of low-frequency PTA (250, 500, 1000 Hz), MD patients experienced a greater degree of hearing loss during the follow-up period when compared to the TLAB lab group (7.54 ± 2.11 dB vs 2.39 ± 1.10 dB, p = 0.035). This difference as attributable to 12 (28.6 %) MD patients experiencing a ≥30 dB increase in low-frequency PTA, whereas none (0.0 %) of the TLAB surpassed this threshold.

CONCLUSIONS

At 10 years post-labyrinthectomy there is a heightened risk for MD patients to develop low-frequency sensorineural hearing loss. Clinicians should monitor for audiometric changes through regular testing in the decade following labyrinth removal.

Characteristics of clinical details and endolymphatic hydrops in unilateral and bilateral Ménière's disease in a single Asian group

Objectives

To elucidate the characteristics of the clinical details and endolymphatic hydrops (EH) in bilateral Ménière's disease (BMD).

Methods

A total of 545 patients with definite MD were enrolled. Demographic variables; the age of onset; disease course; inner ear function; the coexistence of related disorders such as migraine, delayed MD, drop attacks, and autoimmune diseases; familial history; and characteristics of EH were analyzed.

Results

In the study population, the prevalence of BMD was 15.4%. The disease duration of BMD (84.0 ± 89.6 months) was significantly longer than that of unilateral MD (UMD, 60.1 ± 94.0 months) (P = 0.001). As evaluated by hearing thresholds and cervical and ocular vestibular evoked myogenic potentials, inner ear functions were more deteriorated in BMD (P < 0.05) than in UMD. The proportions of delayed MD and a family history of vertigo were significantly larger in BMD (P < 0.05). EH was observed in 100% of cases on the clinically affected side and 6.1% of cases on the unaffected side.

Conclusion

A low prevalence of BMD, longer disease duration, higher frequencies of delayed MD, and family history of vertigo in patients with BMD were significant findings observed in the present study. All affected ears presented with EH, and a low percentage of unaffected sides presented with EH.

Radiological Configuration of the Vestibular Aqueduct Predicts Bilateral Progression in Meniere's Disease

Objective: Meniere's disease (MD) progresses from unilateral to bilateral disease in up to 50% of patients, often chronically and severely impairing balance and hearing functions. According to previous studies, 91% of bilateral MD patients demonstrate bilateral hypoplasia of the endolymphatic sac (ES) upon histological and radiological examination of their inner ears. Here, we seek to validate a radiological marker for ES hypoplasia that predicts the risk for future progression to bilateral MD in individual patients.

Methods: Patients with unilateral MD and radiological evidence for ES hypoplasia in either the clinically affected inner ear (cohort MD_uni-hp_uni) or both inner ears (cohort MD_uni-hp_bi) were included. Given our hypothesis that ES hypoplasia critically predisposes the inner ear to MD, we expected progression to bilateral MD only in the MD_uni-hp_bi cohort. To investigate eventual progression to bilateral MD, clinical, audiometric, and imaging data were retrospectively collected over follow-up periods of up to 31 years.

Results: A total of 44 patients were included in the MD-hp_uni (n = 15) and MD_uni-hp_bi (n = 29) cohorts. In line with our radiology-based predictions, none (0/15) of the MD-hp_uni patients exhibited progression to bilateral MD, whereas 20/29 (69%) MD-hp_bi patients have already progressed to bilateral MD. Using the Kaplan–Meier estimator, bilateral disease progression would be observed in 100% of MD-hp_bi patients 31 years after the initial diagnosis with an estimated median time to bilateral progression of 12 years. The nine MD-hp_bi patients who, so far, remained with unilateral disease demonstrated a median time since initial (unilateral) MD diagnosis of only 6 years and are thus still expected to progress to bilateral disease.

Conclusion: Progression to bilateral MD adheres to predictions based on the radiological presence or absence of ES hypoplasia. This prognostic tool, if validated by prospective long-term studies, will provide clinically relevant information about a patient's future disease burden and will help to select more personalized treatment regimens.

[Diagnostic criteria for Menière's disease according to the Classification Committee of the Bárány Society]

This paper presents diagnostic criteria for Menière's disease jointly formulated by the Classification Committee of the Bárány Society, The Japan Society for Equilibrium Research, the European Academy of Otology and Neurotology (EAONO), the Equilibrium Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the Korean Balance Society. The classification includes two categories: definite Menière's disease and probable Menière's disease. The diagnosis of definite Menière's disease 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, tinnitus and/or fullness) in the affected ear. Duration of vertigo episodes is limited to a period between 20 min and 12 h. Probable Menière's disease is a broader concept defined by episodic vestibular symptoms (vertigo or dizziness) associated with fluctuating aural symptoms occurring in a period from 20 min to 24 h.

Clinical Characteristics of Bilateral Meniere's Disease in a Single Asian Ethnic Group

OBJECTIVES/HYPOTHESIS

To identify the clinical characteristics of patients with bilateral Meniere's disease (MD) in an Asian population.

STUDY DESIGN

Cross-sectional retrospective study.

METHODS

We compared the clinical features of bilateral MD (BMD) and unilateral MD (UMD) in 320 Asian patients with single ethnicity. Demographic variables; age of onset; inner ear function; the coexistence of related disorders such as vestibular migraine, delayed MD, systemic autoimmune diseases, and familial MD; and prognoses were analyzed and compared.

RESULTS

The overall prevalence of BMD was 5.6%. The mean age of disease onset was 40.3 ± 14.8 and 47.0 ± 14.1 years for patients with BMD and UMD, respectively (P = .07). Demographic variables were not significantly different between patients with BMD and UMD (P > .05). Inner ear function, evaluated by hearing thresholds, caloric tests, and cervical vestibular evoked myogenic potentials, was significantly more deteriorated in the first involved ear of patients with BMD than in the second involved ear or the affected side of patients with UMD (P < .05). Among the comorbid conditions, only the prevalence of delayed MD was significantly higher in patients with BMD than in patients with UMD. Systemic autoimmune disease was found in only three patients with UMD. There was no significant prognostic difference between patients with UMD and BMD (P > .05).

CONCLUSIONS

A low prevalence of BMD, a higher frequency of delayed MD in BMD patients, and a low frequency of systemic autoimmune diseases in both UMD and BMD patients are significant findings in an Asian population.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1191-1196, 2019.

Bilateral Vestibular Weakness

Bilateral vestibular weakness (BVW) is a rare cause of imbalance. Patients with BVW complain of oscillopsia. In approximately half of the patients with BVW, the cause remains undetermined; in the remainder, the most common etiology by far is gentamicin ototoxicity, followed by much rarer entities such as autoimmune inner ear disease, meningitis, bilateral Ménière’s disease, bilateral vestibular neuritis, and bilateral vestibular schwannomas. While a number of bedside tests may raise the suspicion of BVW, the diagnosis should be confirmed by rotatory chair testing. Treatment of BVW is largely supportive. Medications with the unintended effect of vestibular suppression should be avoided.

Abnormal Cervical Vestibular-Evoked Myogenic Potentials Predict Evolution of Isolated Recurrent Vertigo into Meniere's Disease

Introduction

Vestibular-evoked myogenic potentials (VEMPs) can be abnormal in patients with idiopathic recurrent spontaneous vertigo. We aimed to determine whether abnormal cervical vestibular-evoked myogenic potentials (cVEMPs) can predict evolution of isolated recurrent vertigo into Meniere’s disease (MD).

Methods

We had followed up 146 patients with isolated recurrent vertigo and an evaluation of cVEMPs for 0–142 months [median = 6, interquartile range (IQR) = 0–29] at the Dizziness Clinic of Seoul National University Bundang Hospital from June 2003 to May 2014. We defined the variables associated with a progression into MD and calculated cumulative progression rates.

Results

Among the 94 patients with recurrent vertigo and abnormal cVEMPs, 18 (18/94, 19%) showed an evolution into MD while only 2 of the 50 (4%) patients with normal cVEMPs evolved into MD during the follow-up (p = 0.01). The interval between onset of vertigo and development of cochlear symptoms ranged from 1 month to 13.6 years (median = 3 years, IQR = 0.5–4.5 years). Overall, pure tone audiometry (PTA) threshold at 0.25 kHz [hazard ratio (HR) = 1.1, 95% confidence interval (CI) = 1.0–1.2] and abnormalities of cVEMPs (HR = 5.6, 95% CI = 1.3–25.5) were found to be significantly associated with a later conversion into MD. The cumulative progression rate was 12% (95% CI = 5–18) at 1 year, 18% (8–26) at 2 years, and 22% (11–32) at 3 years.

Conclusion

Abnormal cVEMPs may be an indicator for evolution of isolated recurrent vertigo into MD. Patients with isolated recurrent vertigo may be better managed conforming to MD when cVEMPs are abnormal.

Clinical Subgroups in Bilateral Meniere Disease

Meniere disease (MD) is a heterogeneous clinical condition characterized by sensorineural hearing loss, episodic vestibular symptoms, and tinnitus associated with several comorbidities, such as migraine or autoimmune disorders (AD). The frequency of bilateral involvement may range from 5 to 50%, and it depends on the duration of the disease. We have performed a two-step cluster analysis in 398 patients with bilateral MD (BMD) to identify the best predictors to define clinical subgroups with a potential different etiology to improve the phenotyping of BMD and to develop new treatments. We have defined five clinical variants in BMD. Group 1 is the most frequently found, includes 46% of patients, and is defined by metachronic hearing loss without migraine and without AD. Group 2 is found in 17% of patients, and it is defined by synchronic hearing loss without migraine or AD. Group 3, with 13% of patients, is characterized by familial MD, while group 4, that includes 12% of patients, is associated by the presence of migraine in all cases. Group 5 is found in 11% of patients and is defined by AD. This approach can be helpful in selecting patients for genetic and clinical research. However, further studies will be required to improve the phenotyping in these clinical variants for a better understanding of the diverse etiological factors contributing to BMD.

Dizziness and vertigo

Dizziness is a common and challenging condition seen in the primary care office. Because dizziness is a vague term that can include a wide array of medical disorders, it is important to use a stepwise approach to differentiate between causes. This article focuses on vertigo and its four most common causes: benign paroxysmal peripheral vertigo, vestibular neuritis, vestibular migraine, and Meniere's disease.

Outcomes after cochlear implantation for patients with single-sided deafness, including those with recalcitrant Ménière's disease

OBJECTIVE

Compare preoperative and postoperative performance in patients undergoing cochlear implantation (CI) for unilateral severe-to-profound sensorineural hearing loss (single-sided deafness, SSD).

STUDY DESIGN

IRB-approved, prospective

SETTING

Tertiary center

PATIENTS

Twenty-nine patients have undergone CI for SSD. SSD was due to Ménière's disease (MD) in 10 subjects; these also suffered from recalcitrant vertigo spells and in these 10 patients along with 2 others the CI was placed simultaneous with a labyrinthectomy.

INTERVENTION(S)

CI with or without labyrinthectomy.

MAIN OUTCOME MEASURE(S)

CNC word and AzBio sentences in quiet were administered to the implanted ear. A multiple-loudspeaker sound localization test was administered in the bilateral listening condition. All data were collected preoperatively and 3, 6, and 12 months postoperatively with postoperative data available for 19 subjects. Additionally, a tinnitus handicap questionnaire is administered pre- and 12-months post-operatively.

RESULTS

CNC word and AzBio sentence scores showed improvement in the implanted ear. Sound localization appeared to improve in an experience-dependent fashion in some patients. Most patients reported diminished tinnitus after cochlear implantation. All patients undergoing labyrinthectomy experienced resolution of vertigo attacks.

CONCLUSION

CI restores auditory function to the deafened ear. Additionally, the binaural input appears to improve sound localization for most patients. In patients with severe hearing loss and recalcitrant vertigo attacks because of MD, simultaneous labyrinthectomy and CI effectively relieves vertigo attacks and improves auditory function.

Characteristics of patients with unilateral and bilateral Ménière's disease

OBJECTIVE

To evaluate epidemiologic differences between patients with unilateral and bilateral Ménière's disease (MD). To evaluate these differences for insights into the possible causes of bilateral MD.

BACKGROUND

The diagnosis of MD is based on clinical criteria, and its cause is unknown. Differences in characteristics of patients with unilateral and bilateral MD have been noted, but these studies' diagnostic criteria have been variable. To delineate findings that might have implications as to the cause of MD, we have studied rigidly selected patient populations with unilateral and bilateral MD STUDY DESIGN: Prospective cohort.

MATERIALS AND METHODS

Patients with a potential diagnosis of MD underwent extensive evaluations (audiometric, radiologic, and immunologic), and only patients with idiopathic MD were included in this study. Bilaterality of disease was based on clinical and audiometric criteria. Variables identified as part of the evaluation were subjected to statistical analyses to determine if significant differences existed in the characteristics of patients in the unilateral and bilateral groups

RESULTS

Patients with bilateral disease presented at a significantly younger age and had a significantly higher incidence of a personal history of migraines and a family history of MD. None of the other identified variables were found to be significantly different.

CONCLUSION

Patients with bilateral MD have a higher incidence of migraines and of a family history of MD. Implications as to disease pathogenesis are discussed.

Functional variants of MIF, INFG and TFNA genes are not associated with disease susceptibility or hearing loss progression in patients with Ménière's disease

Variability in acute immune response genes could determine susceptibility or prognosis for Ménière's disease (MD). The cytokines tumor necrosis factor α (TNFα), macrophage migration inhibitory factor (MIF) and interferon γ (INFγ) are proinflammatory cytokines of the innate immune response. These cytokines mediate inflammation and have been previously associated with the inflammatory process in several autoimmune diseases. We investigated the association between functional allelic variants of MIF (rs35688089), IFNG (rs2234688) and TNFA (rs1800629) in patients with MD. In addition to testing these variants for an association with disease, we also tested for an association with clinical aspects of disease progression, such as persistence of vertigo and the sensorineural hearing loss. A total of 580 patients with diagnosis of definite MD, according to the diagnostic scale of the American Academy of Otolaryngology-Head and Neck Surgery, and 552 healthy controls were included. DNA samples from a set of 291 American patients were used to confirm the results obtained in the MIF gene in our Spanish cohort. Although we found a significant association with the allele containing five repeats of CATT within the MIF gene in patients with MD in the Spanish cohort [corrected p = 0.008, OR = 0.69 (95 % CI, 0.54-0.88)], this finding could not be replicated in the American set. Moreover, no genetic associations for variants in either the TNFA or IFNG genes and MD were found. These results support the conclusion that functional variants of MIF, INFG, and TFNA genes are not associated with disease susceptibility or hearing loss progression in patients with MD.

Perspectives in vestibular diagnostics and therapy

Vestibular diagnostics and therapy ist the mirror of technological, scientific and socio-economics trends as are other fields of clinical medicine. These trends have led to a substantial diversification of the field of neurotology.The improvements in diagnostics have been characterized by the introduction of new receptor testing tools (e.g., VEMPs), progress in imaging (e.g., the endolymphatic hydrops) and in the description of central-vestibular neuroplasticity. The etiopathology of vestibular disorders has been updated by geneticists (e.g., the description of the COCH gene mutations), the detection of structural abnormalities (e.g., dehiscence syndromes) and related disorders (e.g. migraine-associated vertigo). The therapeutic options were extended by re-evaluation of techniques known a long time ago (e.g., saccus exposure), the development of new approaches (e.g., dehiscence repair) and the introduction of new drug therapy concepts (e.g., local drug delivery). Implantable, neuroprosthetic solutions have not yet reached experimental safety and validity and are still far away. However, externally worn neuroprosthetic solution were introduced in the rehab of vestibular disorders (e.g., VertiGuard system).These and related trends point into a medical future which is characterized by presbyvertigo as classical sign of the demographic changes ahead, by shortage of financial resources and a medico-legally over-regulated, even hostile environment for physicians in clinical medicine.

Cochlear function in Ménière's disease

OBJECTIVE

The authors assessed the effectiveness of therapy, common features of pure-tone audiograms, and results of non-invasive electrocochleography before and after mild inhibition of peripheral vestibular function by infrequent administration of single intratympanic gentamicin injections (ITPG) in patients with Ménière's disease (MD).

STUDY SAMPLE

Sixty-two patients with Ménière's disease.

DESIGN

Retrospective study.

RESULTS

Out of 62 patients 65% received one injection, 24% two, 6% three, 3% five, and 2% six injections. Between injections, class A vertigo control was obtained after two weeks in all cases. Before ITPG, out of 62 pure-tone threshold audiograms 37 were 'flat'. Average hearing threshold at 2 kHz was significantly better than that of 250, 500, and 0.75 kHz on the affected side.

CONCLUSIONS

Hearing threshold in advanced MD is often flat with a characteristic small peak in the high frequency range, most frequently around 2-3 kHz. Should the complaints be intolerable, single injection ITPG-therapy may be safe and effective.

Ocular and cervical vestibular-evoked myogenic potentials to bone conducted vibration in Ménière's disease during quiescence vs during acute attacks

OBJECTIVE

Two indicators of otolithic function were used to measure dynamic otolith function in the same patients both during an acute attack of Ménière's disease (MD) and in the quiescent period between attacks.

METHODS

The early negative component (n10) of the ocular vestibular-evoked myogenic potential (the oVEMP) to brief 500 Hz bone conducted vibration (BCV) stimulation of the forehead, in the midline at the hairline (Fz) was recorded by surface EMG electrodes just beneath both eyes while the patient looked up. It has been proposed that the n10 component of the oVEMP to 500 Hz Fz BCV indicates utricular function. It has been proposed that the early positive component (p13) of the cervical vestibular-evoked myogenic potential (the cVEMP) recorded by surface electrodes on both tensed SCM neck muscles to 500 Hz Fz BCV indicates saccular function.

RESULTS

Sixteen healthy control subjects tested on two occasions showed no detectable change in the symmetry of oVEMPs or cVEMPs to 500 Hz Fz BCV. In response to 500 Hz Fz BCV 15 early MD patients tested at both attack and quiescent phases showed a dissociation: there was a significant increase in contralesional of n10 of the oVEMP during the attack compared to quiescence but a significant decrease in the ipsilesional p13 of the cVEMP during the attack compared to quiescence.

CONCLUSIONS

During an MD attack, dynamic utricular function in the affected ear as measured by the n10 of the oVEMP to 500 Hz Fz BCV is enhanced, whereas dynamic saccular function in the affected ear as measured by the p13 of the cVEMP to 500 Hz Fz BCV is not similarly affected.

SIGNIFICANCE

The MD attack appears to affect different otolithic regions differentially.