Meniere's disease: a reappraisal supported by a variable latency of symptoms and the MRI visualisation of endolymphatic hydrops

Labor market effects of rehabilitation for patients diagnosed with dizziness - a Danish nationwide register-based cohort study

PURPOSE

Both vestibular neuronitis (VN) and Meniere's disease (MD) have great impact on quality of life and are associated with a significant number of sick leave days absent from work. The aim was to assess labor market participation rate one year after hospital diagnosis of VN and MD and the use of rehabilitation measures.

STUDY DESIGN

Nationwide register-based cohort study including patients with VN (n = 1,341) and MD (n = 843) and control persons matched in 1:5 with a VN cohort control (n = 6,683) and MD cohort control (n = 4,209).

RESULTS

Compared to control persons, VN patients were more likely to be single, have higher income, and a higher Charlson comorbidity index score. MD patients had a higher level of education and a higher Charlson index compared to control persons. One year after patients were diagnosed with VN, no significant difference in labor market participation was observed (p = 0.88). However, MD patients had a 10.4% reduced probability of possessing a full-time job one year after diagnosis compared to matched control persons (58.1 ± 0.5% vs. 68.5 ± 0.5%, p < 0.001). Both VN and MD patients consulted otorhinolaryngologists, general practitioners, and physiotherapists more than control persons both before and after the initial diagnosis (p < 0.01). In addition, MD patients also consulted psychologists more frequently before and after diagnosis of the disease (p < 0.01).

CONCLUSION

Intrahospital diagnosed MD increases the risk of leaving the labor market in opposition to VN. Both MD and VN are associated with significant expenses to the Danish health care system from the use of public rehabilitation measures and medical consultations.

Predictive nomograms and an algorithm for managing patients with probable Meniere's disease

PURPOSE

To explore the efficacy of diagnostic tests in accurately reclassifying patients initially diagnosed with probable Meniere's disease (MD) into either definite or non-MD categories.

MATERIALS AND METHODS

A retrospective cohort study was conducted at a neurotology clinic between 1/2016 and 5/2022. Patients underwent a battery of tests, from which sensitivity, specificity, positive and negative predictive values, as well as positive and negative likelihood ratios, were calculated. Additionally, prediction nomograms were developed.

RESULTS

Of the 69 patients, 25 (36.2 %) were initially classified as definite MD, 21 (30.4 %), probable MD, and 23 (33.4 %) non-MD. The mean follow-up was 3.5 years. The sensitivity of electrocochleography (ECochG) was the highest (92 %), with a negative likelihood ratio of 15 %. Magnetic resonance imaging (MRI) with MD-protocol had the highest specificity (100 %), with a positive likelihood ratio of 100 %. Videonystagmography, video head impulse test, and cervical vestibular-evoked myogenic potentials, had lower sensitivity and specificity. We were able to reclassify 18 (86 %) patients with probable MD: 12 (57 %) were diagnosed with definite MD, and 6 (29 %) were diagnosed with non-MD, consistent with their clinical course.

CONCLUSIONS

The combination of ECochG and MRI with MD-protocol provides the most reliable approach to reclassify patients with Probable MD, ensuring a precise and accurate diagnosis. Vestibular tests express the functional status of the labyrinth and may not be reliable. Our findings provide valuable insights into clinical decision-making for patients with Probable MD and raise the consideration of additional diagnostic tests as supplementary to the existing clinical-only diagnosis criteria.

Spatial position changes in the semicircular canals may be the anatomical basis of Meniere's disease: a preliminary study based on ultra-high-resolution computed tomography (CT) and intelligent segmentation

Background

Meniere's disease (MD) is an ear-related vestibular disorder accompanied by vertigo, hearing loss, and tinnitus. The anatomical structure and spatial position of the semicircular canals are important for understanding vestibular function and disease; however, research on MD and the effect of anatomical changes in the semicircular canals is limited. This study explored the relationship between the spatial location of the semicircular canals and MD using ultra-high-resolution computed tomography (U-HRCT) and intelligent segmentation.

Methods

Isotropic U-HRCT images obtained from patients with MD and healthy controls (HCs) were retrospectively analyzed. We extracted the semicircular canal structures and extracted their skeleton. The plane of the skeleton of each semicircular canal was fitted separately. The mutual angles between the semicircular canals, and the angles between each semicircular canal and each plane of the coordinate system were measured.

Results

Among 45 MD-affected ears (MDAEs), 33 MD-healthy ears (MDHEs), and 45 HC ears, the angle between the superior and lateral semicircular canals (LSCs) and the angle between the superior and posterior semicircular canals (PSCs) were larger in the MDAE and MDHE groups than the HC group (P<0.01), while the angle between the posterior and LSCs was smaller in the MDAE group than the HC group (P<0.001). The angles between the superior and PSCs and coronal plane (CP) of the coordinate system were significantly smaller in the MDAE and MDHE groups than the HC group (P<0.01); however, the angles between the LSC and axial plane and CP were significantly larger in the MDAE and MDHE groups than the HC group (P<0.001).

Conclusions

Spatial position changes in the semicircular canals may be the anatomical basis of MD.

An Update on the Epidemiology and Clinicodemographic Features of Meniere's Disease

OBJECTIVE

To characterize the estimated prevalence and clinicodemographic features of Ménière's disease (MD) using current diagnostic criteria.

METHODS

A cross-sectional study was undertaken at our tertiary academic referral center. All patients seen in Otolaryngology clinic with ICD-10 diagnoses of MD, from January 1, 2013 to July 31, 2022 were identified. Chart review was undertaken to determine the estimated prevalence of MD meeting AAO-HNS diagnostic criteria. Clinicodemographic features were evaluated against a comparator group without MD seen in our health system.

RESULTS

Of 806 ICD-10 diagnoses of MD, we identified 480 MD cases meeting diagnostic criteria (168 definite). Mean age at presentation for MD cases was 49 years. Forty-seven percent of cases were male. A significantly higher proportion of MD cases than comparators were white (76% vs. 66%, p < 0.001). Mean time since MD symptom onset was 6.7 years, with a mean attack duration of 4.6 h; 7.5% of MD cases reported a positive family history, and 7% had bilateral disease. The odds of reporting migraine were significantly greater among MD patients than comparators (OR 1.74 [1.26-2.42]); the odds of having autoimmune conditions were lower (OR 0.45 [0.28-0.74]); and the odds of reporting allergies were no different (OR 0.96 [0.74-1.25]) versus comparator patients after controlling for demographic characteristics.

CONCLUSIONS

Among MD diagnoses, there is a low estimated prevalence of MD meeting diagnostic criteria, and an even lower prevalence of definite MD. Compared to a comparator group of patients seen for any disorder, patients with MD are more likely to be white, male, and have a history of migraine.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3310-3315, 2024.

Association of Head Injury, Neck Injury or Acoustic Trauma on Phenotype of Ménière's Disease

The aim of the present study was to investigate adverse effects of head injury, neck trauma, and chronic noise exposure on the complaint profile in people with Ménière's disease (MD). The study used a retrospective design. Register data of 912 patients with MD from the Finnish Ménière Federation database were studied. The data comprised case histories of traumatic brain injury (TBI), neck trauma and occupational noise exposure, MD specific complaints, impact related questions, and the E-Qol health-related quality of life instrument. TBI was classified based on mild, moderate, and severe categories of transient loss of consciousness (TLoC). The mean age of the participants was 60.2 years, the mean duration of the disease was 12.6 years, and 78.7% were females. Logistic regression analysis, linear correlation, and pairwise comparisons were used in evaluating the associations. 19.2% of the participants with MD had a history of TBI. The phenotype of participants with TBI was associated with frequent vestibular drop attacks (VDA), presyncope, headache-associated vertigo, and a reduction in the E-QoL. Logistic regression analysis explained the variability of mild TBI in 6.8%. A history of neck trauma was present in 10.8% of the participants. Neck trauma associated with vertigo (NTwV) was seen in 47 and not associated with vertigo in 52 participants. The phenotype of NTwV was associated with balance problems, VDA, physical strain-induced vertigo, and hyperacusia. Logistic regression analysis explained 8.7% of the variability of the complaint profile. Occupational noise exposure was recorded in 25.4% of the participants and correlated with the greater impact of tinnitus, hyperacusis, and hearing loss. Neither the frequency, duration, or severity of vertigo or nausea were significantly different between the baseline group and the TBI, NTwV, or noise-exposure groups. The results indicate that TBI and NTwV are common among MD patients and may cause a confounder effect.

Clinical significance of posterior expansion of the utricular endolymphatic space

BACKGROUND

Posterior expansion of the utricular endolymphatic space (ES) is a finding occasionally observed, and often occurs in bilateral ears. The clinical significance of posterior expansion of the utricular ES is not clear.

OBJECTIVES

To investigate the clinical significance of posterior expansion of the utricular ES detected on magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Among 957 patients who underwent contrast-enhanced MRI to investigate the presence of endolymphatic hydrops (EH), clinical findings in cases with posterior expansion of the utricular ES were evaluated and the significance of their existence is considered.

RESULTS

Posterior expansion of the utricular ES was detected in 30 ears from 20 cases (7 males, 13 females; mean age 48.7 years). The ears with posterior expansion had a significantly lower incidence of vestibular EH than those without, and this tendency was more prominent in cases in bilateral ears. Some cases with posterior expansion had vestibular symptoms and were diagnosed with Ménière's disease, although EH was not detected in their vestibules.

CONCLUSION AND SIGNIFICANCE

Posterior expansion of the utricular ES was associated with Ménière's disease without vestibular EH. Posterior expansion of the utricular ES might not be associated with the formation of EH but may occur independently.

A 3-hour time interval may not be sufficient for delayed enhancement magnetic resonance imaging with intravenous gadoteridol injection based on 3d-real IR sequence of the inner ear in Meniere's disease patient

BACKGROUND

Magnetic resonance imaging (MRI) can be applied to visualize endolymphatic hydrops (EH).

AIMS/OBJECTIVES

To explore whether a 3-h time interval was feasible for clinical practice.

MATERIALS AND METHODS

We prospectively enrolled 15 patients with unilateral Meniere's disease, each of whom underwent delayed enhancement MRI scan of the inner ear after intravenous gadoteridol injection at a 3-h interval. The ears of these patients were divided into two groups (group A: the affected ears; group B: the unaffected ears). Among the two groups, the signal intensity in perilymphatic area of the basal turn of cochlea, the results of visual evaluations in the vestibule, cochlea and semicircular canal and the detection results of EH were compared.

RESULTS

Regarding the signal intensity, a difference was found between group A and group B (p = .016). Besides, no difference was found between the visual evaluations in the vestibule, cochlea and semicircular canal of the two groups. Regarding the detection results of EH, group A (6 vestibules were undiagnosable; 8 cochleae were undiagnosable); group B (9 vestibules were undiagnosable; 10 cochleae were undiagnosable).

CONCLUSIONS AND SIGNIFICANCE

In the clinical application of gadoteridol for the inner ear, 3-h delayed MR imaging may not be sufficient.

Meniere's disease: Pathogenesis, treatments, and emerging approaches for an idiopathic bioenvironmental disorder

Meniere's disease (MD) is a severe inner ear condition known by debilitating symptoms, including spontaneous vertigo, fluctuating and progressive hearing loss, tinnitus, and aural fullness or pressure within the affected ear. Prosper Meniere first described the origins of MD in the 1860s, but its underlying mechanisms remain largely elusive today. Nevertheless, researchers have identified a key histopathological feature called Endolymphatic Hydrops (ELH), which refers to the excessive buildup of endolymph fluid in the membranous labyrinth of the inner ear. The exact root of ELH is not fully understood. Still, it is believed to involve several biological and bioenvironmental etiological factors such as genetics, autoimmunity, infection, trauma, allergy, and new theories, such as saccular otoconia blocking the endolymphatic duct and sac. Regarding treatment, there are no reliable and definitive cures for MD. Most therapies focus on managing symptoms and improving the overall quality of patients' life. To make significant advancements in addressing MD, it is crucial to gain a fundamental understanding of the disease process, laying the groundwork for more effective therapeutic approaches. This paper provides a comprehensive review of the pathophysiology of MD with a focus on old and recent theories. Current treatment strategies and future translational approaches (with low-level evidence but promising results) related to MD are also discussed, including patents, drug delivery, and nanotechnology, that may provide future benefits to patients suffering from MD.

The Caloric Test Is More Consistent With the Presence of Endolymphatic Hydrops Than the Vestibular-Evoked Myogenic Potential Test in Meniere's Disease

Objective This study aimed to investigate the correlation between enhanced inner ear magnetic resonance imaging (MRI) findings and vestibular and cochlear function test results in patients with definite Meniere's disease and confirmed endolymphatic hydrops. Methods Among 70 consecutive patients diagnosed with definite Meniere's disease, 49 underwent contrast-enhanced 3-T inner ear MRI. The patients also underwent pure-tone audiometry, glycerol, caloric, and vestibular-evoked myogenic potential (VEMP) tests. Correlations between the pure-tone audiometry, glycerol test, caloric test, VEMP test, and MRI findings were evaluated using the chi-square test or Fisher's exact test, Student's t-test, one-way ANOVA, and Bonferroni's post-hoc test. Results Contrast-enhanced inner ear MRI revealed that 33 of 49 patients (67.3%) had endolymphatic hydrops. Among them, 19 patients had bilateral endolymphatic hydrops, and 14 had unilateral hydrops. The mean hearing threshold was higher in patients with endolymphatic hydrops than those without (p< 0.001). The proportion of patients with positive glycerol test results was higher among those with endolymphatic hydrops than in those without (p= 0.01). The rate of abnormal caloric response in patients with and without endolymphatic hydrops was not significantly different (p= 0.09). Furthermore, the rate of abnormal VEMP response in patients with and without endolymphatic hydrops was not significantly different (p= 0.70). On the affected side, in the caloric test, the ratio of the presence of vestibular and cochlear hydrops was similar (p= 1.00). On the affected side, in the VEMP test, the ratio of the presence of vestibular and cochlear hydrops was also similar (p= 0.80). The consistency of the caloric test in detecting cochlear hydrops was higher than that of the VEMP test (p= 0.04). The consistency of the caloric test in detecting vestibular hydrops tended to be higher (but not significantly) than that of the VEMP test (p= 0.11). Conclusion The cochlea and vestibule on the clinically affected side were more likely to have endolymphatic hydrops revealed by contrast-enhanced 3-T inner ear MRI than on the unaffected side. The sum of the three low frequencies (125, 250, and 500 Hz) of the pure-tone audiometry was higher in patients with endolymphatic hydrops than in those without endolymphatic hydrops. The caloric test was more consistent in detecting endolymphatic hydrops, especially cochlear hydrops, than the VEMP test in patients with definite Meniere's disease. The results of this study may contribute to the future diagnosis of Meniere's disease and improve the understanding of endolymphatic hydrops.

Episodic Vertigo: A Narrative Review Based on a Single-Center Clinical Experience

(1) Background: Usually, the majority of patients suffering from vertigo and dizziness can be identified in four major categories: acute spontaneous vertigo, episodic (recurrent) vertigo, recurrent positional vertigo, and chronic imbalance. Our purpose is to retrospectively evaluate the main causes of episodic vertigo and to find indications for a reliable clinical suspicion useful for a definitive diagnosis, comparing patients affected by different presenting symptomatology (acute vertigo, recurrent episodic vertigo, and imbalance). (2) Methods: we retrospectively evaluated the clinical records in a population of 249 consecutive patients observed for vertigo in our tertiary referral center in the period 1 January 2019-31 January 2020. On the basis of the reported clinical history, patients were divided into three groups: patients with their first ever attack of vertigo, patients with recurrent vertigo and dizziness, and patients with chronic imbalance. (3) Results: On the basis of the results of the instrumental examination, we arbitrarily divided (for each type of symptoms) the patients in a group with a normal vestibular instrumental examination and a group of patients in which the clinical-instrumental evaluation showed some pathological results; a highly significant difference (p: 0.157) was found between recurrent and acute vertigo and between recurrent vertigo and imbalance. (4) Conclusions: Patients with recurrent vertigo more frequently exhibit a negative otoneurological examination since they are often examined in the intercritical phase. A precise and in-depth research of the patient's clinical history is the key to suspect or make a diagnosis together with the search for some instrumental or clinical hallmark, especially in cases where the clinical picture does not fully meet the international diagnostic criteria.

[Validity of the German Menière's Disease Patient-Oriented Symptom Severity Index]

BACKGROUND

The MD POSI is a disease-specific questionnaire to determine the health-related quality of life (HRQoL) of patients with Menière's disease (MD).

OBJECTIVES

Validity and reliability of the German translation of the MD POSI.

MATERIAL AND METHODS

Prospective data analysis of a patient group with vertigo (n = 162), which was treated in the otorhinolaryngology of a University Hospital from 2005-2019. A clinical selection was made according to the new Bárány classification in a "definite" and "probable" Menière's disease. HRQoL was assessed using the German translation of the MD POSI, the Vertigo Symptom Score (VSS) and the Short Form (SF-36). Reliability was measured by Cronbach's α and test-retesting after 12 months and again 2 weeks later. Content and agreement validity were examined.

RESULTS

Cronbach α values greater than 0.9 indicated good internal consistency. There was no statistically significant difference from baseline to 12 months, except for the subscore "during the attack". There were significant positive correlations between the VSS overall/VER/AA and the overall index of the MD POSI and negative significant correlations with the SF-36 domains physical functioning, physical role functioning, social functioning, emotional role functioning, mental well-being. There were low SRM (standardized response mean) values below 0.5.

CONCLUSIONS

The German translation of the MD POSI is a valid and reliable instrument to evaluate the impact of MD on patients' disease-specific quality of life.

Delayed post gadolinium MRI descriptors for Meniere's disease: a systematic review and meta-analysis

OBJECTIVES

Delayed post-gadolinium magnetic resonance imaging (MRI) detects changes of endolymphatic hydrops (EH) within the inner ear in Meniere's disease (MD). A systematic review with meta-analysis was conducted to summarise the diagnostic performance of MRI descriptors across the range of MD clinical classifications.

MATERIALS AND METHODS

Case-controlled studies documenting the diagnostic performance of MRI descriptors in distinguishing MD ears from asymptomatic ears or ears with other audio-vestibular conditions were identified (MEDLINE, EMBASE, Web of Science, Scopus databases: updated 17/2/2022). Methodological quality was evaluated with Quality Assessment of Diagnostic Accuracy Studies version 2. Results were pooled using a bivariate random-effects model for evaluation of sensitivity, specificity and diagnostic odds ratio (DOR). Meta-regression evaluated sources of heterogeneity, and subgroup analysis for individual clinical classifications was performed.

RESULTS

The meta-analysis included 66 unique studies and 3073 ears with MD (mean age 40.2-67.2 years), evaluating 11 MRI descriptors. The combination of increased perilymphatic enhancement (PLE) and EH (3 studies, 122 MD ears) achieved the highest sensitivity (87% (95% CI: 79.92%)) whilst maintaining high specificity (91% (95% CI: 85.95%)). The diagnostic performance of "high grade cochlear EH" and "any EH" descriptors did not significantly differ between monosymptomatic cochlear MD and the latest reference standard for definite MD (p = 0.3; p = 0.09). Potential sources of bias were case-controlled design, unblinded observers and variable reference standard, whilst differing MRI techniques introduced heterogeneity.

CONCLUSIONS

The combination of increased PLE and EH optimised sensitivity and specificity for MD, whilst some MRI descriptors also performed well in diagnosing monosymptomatic cochlear MD.

KEY POINTS

• A meta-analysis of delayed post-gadolinium magnetic resonance imaging (MRI) for the diagnosis of Meniere's disease is reported for the first time and comprised 66 studies (3073 ears). • Increased enhancement of the perilymphatic space of the inner ear is shown to be a key MRI feature for the diagnosis of Meniere's disease. • MRI diagnosis of Meniere's disease can be usefully applied across a range of clinical classifications including patients with cochlear symptoms alone.

Improving diagnostic accuracy for probable and definite Ménière's disease using magnetic resonance imaging

PURPOSE

To determine whether magnetic resonance imaging (MRI) can improve diagnostic accuracy for definite and probable Ménière's disease (MD) based on perilymphatic enhancement (PE) and endolymphatic hydrops (EH).

METHODS

363 patients with unilateral MD (probable MD, n = 75 and definite MD, n = 288) were recruited. A three-dimensional zoomed imaging technique with parallel transmission SPACE real inversion recovery was performed 6 h after intravenous gadolinium injection to investigate the presence of PE and to evaluate the grading and location of EH. PE and EH characteristics were analyzed and compared between the probable and definite MD groups.

RESULTS

The cochlear and vestibular EH grading on the affected side was more severe in the definite MD group than that in the probable MD group (P < 0.001). The EH locations within the inner ear on the affected side also differed between the two groups (χ2 = 81.15, P < 0.001). The signal intensity ratio (SIR) on the affected side was significantly higher in the definite MD group than in the probable MD group (t = 2.18, P < 0.05). The assessment of the combination of PE and EH parameters within the inner ear revealed a higher area under the curve (AUC) in the definite MD group (0.82) compared with the AUCs of the parameters assessed alone.

CONCLUSION

The assessment of a combination of PE and EH parameters improved the diagnostic accuracy for probable and definite MD, suggesting that MRI findings may be clinically useful in the diagnosis of MD.

Visualization and clinical relevance of the endolymphatic duct and sac in Ménière's disease

Background

Ménière's disease (MD) is a chronic inner ear disorder with a multifactorial etiology. Decreased visualization of the endolymphatic duct (ED) and sac (ES) is thought to be associated with MD, although controversy exists about whether this finding is specific to MD. Recent literature has revealed that two distinct ES pathologies, developmental hypoplasia and epithelial degeneration, can be distinguished in MD using the angular trajectory of the vestibular aqueduct (ATVA) or ED-ES system as a radiographic surrogate marker. It has been suggested that these two subtypes are associated with distinct phenotypical features. However, the clinical differences between the ATVA subtypes require further validation.

Research objective

The objective of this study is to investigate whether (1) non-visualization of the ED-ES system is a discriminative radiological feature for MD in a cohort of vertigo-associated pathologies (VAPs) and whether (2) different angular trajectories of the ED-ES system in MD are associated with distinguishable clinical features.

Setting

The study was conducted in the Vertigo Referral Center (Haga Teaching Hospital, The Hague, the Netherlands).

Methods

We retrospectively assessed 301 patients (187 definite MD and 114 other VAPs) that underwent 4h-delayed 3D FLAIR MRI. We evaluated (1) the visibility of the ED-ES system between MD and other VAP patients and (2) measured the angular trajectory of the ED-ES system. MD patients were stratified based on the angular measurements into αexit ≤ 120° (MD-120), αexit 120°-140° (MD-intermediate), or αexit ≥ 140° (MD-140). Correlations between ATVA subgroups and clinical parameters were evaluated.

Results

Non-visualization of the ED-ES system was more common in definite MD patients compared with other VAPs (P < 0.001). Among definite MD patients, the MD-140 subtype demonstrated a longer history of vertigo (P = 0.006), a higher prevalence of bilateral clinical disease (P = 0.005), and a trend toward a male preponderance (p = 0.053). No significant differences were found between ATVA subgroups regarding the presence or severity of auditory symptoms, or the frequency of vertigo attacks.

Conclusion

Non-visualization of the ED-ES system is significantly associated with MD. Among MD patients with a visible ED-ES system, we demonstrated that the MD-140 subtype is associated with a longer disease duration, a higher prevalence of bilateral MD, and a trend toward a male preponderance.

The value of postcontrast delayed 3D fluid-attenuated inversion recovery MRI in the diagnosis of unilateral peripheral vestibular dysfunction

Background

Clinically, unilateral peripheral vestibular dysfunction (UPVD) with dizziness or vertigo as the chief complaint is quite common. This study aimed to investigate the correlations between 3-dimensional fluid-attenuated inversion recovery magnetic resonance imaging (3D-FLAIR MRI) findings and cochleovestibular function test results in patients with UPVD and to explore the possible etiologies of UPVD.

Methods

This retrospective study enrolled 76 patients with UPVD. Endolymphatic hydrops (EH) and perilymphatic enhancement (PE) in the vestibule and cochlea on 3D-FLAIR images, their correlations with the parameters of the cochleovestibular function test and vascular risk factors, and the immunological findings of patients with EH and PE were assessed.

Results

Of the included patients, 48.7% showed positive MRI findings (the presence of EH and PE on 1 side). The pure-tone average (PTA) was higher in patients with cochlear PE than in those with vestibular (P=0.014) and cochlear EH (P=0.02). The canal paresis (CP) value was also higher in patients with vestibular PE than in those with vestibular (P=0.002) and cochlear EH (P=0.003). Video head impulse test (vHIT) gains were lower in patients with vestibular and cochlear PE than in those with vestibular and cochlear EH (P<0.001). A positive correlation was observed between the degree of vestibular and cochlear EH and PTA (both P values <0.001). PTA and CP with a cutoff value of 32 dB and 46.5%, respectively, yielded high sensitivity and specificity in determining positive MRI findings (P<0.001 and P=0.029, respectively). The prevalence of vascular risk factors was significantly higher in patients with PE than in those with EH (P=0.033).

Conclusions

(I) Nearly half of the patients UPVD exhibited abnormal MRI findings. Cutoff values for PTA and CP of 32 dB and 46.5%, respectively, indicated that patients were more likely to have abnormal imaging findings. (II) The severity of EH was positively correlated with hearing impairment. (III) Patients with PE showed severe hearing impairment and vestibular dysfunction, which was presumed to be associated with vascular damage.

Advanced Magnetic Resonance Imaging Sheds Light on the Distinct Pathophysiology of Various Types of Acute Sensorineural Hearing Loss

OBJECTIVE

To compare the findings of magnetic resonance imaging (MRI) with advanced protocols in patients with various types of acute sensorineural hearing loss (ASNHL).

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Two hundred eighty-seven patients with ASNHL.

INTERVENTIONS

All patients underwent MRI scanning, including heavily T2-weighted three-dimensional fluid-attenuated inversion recovery before and 4 hours after the intravenous administration of gadolinium contrast medium (delayed 3D-FLAIR). A hybrid of the reversed image of the positive endolymph signal and the native image of the perilymph signal image was constructed to visualize the endolymphatic space.

RESULTS

The detection rates of abnormal MRI findings vary significantly among different types of ASNHL. A hyperintense signal on delayed 3D-FLAIR was observed in all patients with intralabyrinthine schwannoma or vestibular schwannoma and 20.5% of patients with idiopathic sudden sensorineural hearing loss (ISSNHL) but was rarely observed in definite Ménière's disease (MD, 2.6%). In contrast, endolymphatic hydrops (EH) was frequently observed in patients with definite MD (79.5%) but was observed much less frequently in patients with ISSNHL (11.0%). In patients with cochlear MD and ALHL, detection rates of cochlear EH were similar to those with definite MD, whereas detection rates of vestibular EH were significantly lower than in patients with definite MD.

CONCLUSIONS

The significantly different detection rates of abnormal MRI findings among various types of ASNHL shed light on the distinct pathophysiology of each disorder. A diagnosis based on MRI findings with advanced protocols may help select treatment strategies and provide prognostic information for patients.

Systematic review of the diagnostic value of hydrops MRI in relation to audiovestibular function tests (electrocochleography, cervical vestibular evoked myogenic potential and caloric test)

The objective of this systematic review is to compare the diagnostic value of endolymphatic hydrops (EH) magnetic resonance imaging (MRI) with audiovestibular function tests, including electro cochleography (ECochG), cervical vestibular evoked myogenic potential (cVEMP) and caloric tests for the diagnosis of definite Meniere's disease (DMD). An electronic search was performed in the PubMed, Embase and Cochrane databases in August 2022. Original studies which reported the efficacy of gadolinium MRI for diagnosis of DMD were compared with ECochG, cVEMP and caloric tests from 2007 to 2022 published in English. Two reviewers extracted the methodology and results of MRI and functional tests, assessing them independently. A modified version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used for the assessment of the quality and the risk of bias of each study. The proportion of DMD cases diagnosed by MRI hydrops vs corresponding functional tests were calculated and the relationship between MRI and functional tests were evaluated using the Cohen's Kappa test. Concerning the MRI, the proportion diagnostic of DMD was 0.67 by cochlear EH and 0.80-0.82 by vestibular EH. Regarding the functional test, the propotiojn diagnostic of DMD was 0.48 by ECochG, 0.76 by cVEMP and 0.65 by caloric test. The findings of this systematic review were that the vestibular EH on imaging most effectively assisted in diagnosing DMD. Among the functional tests, cVEMP was the second most effective test. The agreement between imaging and cVEMP was moderate (0.44), indicating a gap between the patients identified by the imaging and functional tests based on the relatively small number of patients.

Presence of endolymphatic hydrops on listening difficulties in patients with normal hearing level

BACKGROUND

Listening difficulties (LiD) present difficulties in listening and paying attention to spoken information despite normal pure tone audiometry. Endolymphatic hydrops (EH) is a common inner ear condition associated with Ménière's disease but may also be present in the asymptomatic ear.

OBJECTIVES

Using magnetic resonance imaging, we investigated EH in patients with LiD and assessed whether the severity of EH was related to the results of auditory processing tests (APTs).

MATERIALS AND METHODS

111 patients with no abnormalities on pure tone audiometry, but displaying difficulties in listening, underwent evaluation through APTs and questionnaires. Upon obtaining informed consent, the inner ears of 20 consenting patients were evaluated utilizing a 3-Tesla magnetic resonance imaging.

RESULTS

A higher percentage of patients diagnosed with LiD by APTs had significant EH in the cochlea and vestibule than in previously reported control cases. The percentage of correct answers in the speech-in-noise test was significantly lower in patients with than in those without significant EH.

CONCLUSION AND SIGNIFICANCE

In this study, significant EH of the cochlea was associated with poor listening to noise. The presence of EH affects the functioning of the auditory processing system, even in ears that test normally on standard audiometric tests.

Impact of endolymphatic hydrops on DPOAE in subjects with normal to mild hearing loss

Objective

The increased endolymph volume affects a shift in the organ of Corti and basilar membrane in ears with endolymphatic hydrops (EH), which might affect distortion-product otoacoustic emissions (DPOAE) by altering the operating point of the outer hair cells. We investigated how changes in DPOAE are related to the distribution site of EH.

Study Design

Prospective study.

Methods

Among 403 patients with hearing or vestibular symptoms who underwent contrast-enhanced magnetic resonance imaging (MRI) for the diagnosis of EH and subsequent DPOAE testing, subjects whose hearing levels on pure tone audiometry were ≤35 dB at all frequencies were included in this study. In patients with EH on MRI, the presence and amplitude of DPOAE were evaluated between groups with hearing levels of ≤25 dB at all frequencies versus hearing levels of >25 dB at one or more frequencies.

Results

There were no differences in the distribution of EH between groups. The amplitude of DPOAE had no clear correlation with the presence of EH. However, in both groups, there was a significantly higher probability of the presence of a DPOAE response from 1001 to 6006 Hz in cases with EH in the cochlea.

Conclusion

Among patients whose hearing levels were ≤35 dB at all frequencies, better responses on DPOAE testing were found in subjects with EH in the cochlea. Alteration of DPOAEs in the early stages of hearing impairment could indicate morphological changes in the inner ear with altered basilar membrane compliance due to EH.

Level of Evidence

4.

Longitudinal variation of endolymphatic hydrops in patients with Ménière's disease

Background

The relationships of endolymphatic hydrops (EH) and perilymphatic enhancement (PE) with Ménière's disease (MD) remains unclear. This study aimed to describe the dynamic variation of EH and PE for MD patients over 2 hospitalizations by applying magnetic resonance imaging (MRI) to further clarify the relationships of EH and PE with MD.

Methods

A total of 77 MD patients who underwent inner ear MRI after intravenous administration of gadolinium and pure-tone average (PTA) testing during a first and second hospitalization were included. The degree of EH and PE were evaluated via MRI, and the duration and frequency of vertigo attacks and PTA were collected and recorded. The PTA, EH, and PE for the 2 hospitalizations were compared, and the relationships of EH and cochlear PE with the MD stage were investigated.

Results

There was no difference between the 2 hospitalizations for duration of vertigo attacks or frequency of vertigo attacks. However, there were significant differences in PTA (Z=-3.02, P=0.003). Additionally, the cochlear and vestibular EH in the asymptomatic ear at the second hospitalization was significantly worse than that of the first hospitalization (Z=-2.33 and -2.49, P=0.020 and 0.013, respectively), while there were no differences in EH and PE in the affected ear (all P>0.05). Moreover, the degree of cochlear and vestibular EH was correlated with MD stage (both P<0.01).

Conclusions

Although EH and PE in the affected ear were unchanged over 2 hospitalizations, an underlying EH in the asymptomatic ear and hearing loss in the affected ear for MD patients developed longitudinally with the duration of disease, and EH varied with the natural course of MD whereas PE did not. Therefore, EH instead of PE is necessary but insufficient to cause the clinical symptoms of MD.

Functional and Molecular Markers for Hearing Loss and Vertigo Attacks in Meniere's Disease

Meniere's disease (MD) is one of the most complicated diseases in the otologic clinic. The complexity of MD is partially due to the multifactorial etiological mechanisms and the heterogenous symptoms, including episodic vertigo, hearing loss, aural fullness and tinnitus. As a result, the diagnosis of MD and differentiating MD from other diseases with similar symptoms, such as vestibular migraine (VM), is challenging. In addition, it is difficult to predict the progression of hearing loss and the frequency of vertigo attacks. Detailed studies have revealed that functional markers, such as pure tone audiometry (PTA), electrocochleography (ECochG), vestibular evoked myogenic potential (VEMP), caloric test, video head impulse test (vHIT) and magnetic resonance imaging (MRI) could help to evaluate MD with different hearing levels and frequency of vertigo attacks. Investigations of molecular markers such as autoimmunity, inflammation, protein signatures, vasopressin and circadian clock genes in MD are still underway. This review will summarize these functional and molecular markers, address how these markers are associated with hearing loss and vertigo attacks in MD, and analyze the results of the markers between MD and VM.

Confrontation of endolymphatic hydrops diagnosis on 3-Tesla MRI to clinical and audiovestibular findings in Meniere's disease

Objective

The aim of this study was to compare different MRI diagnostic criteria for endolymphatic hydrops (EH) and to investigate the relation between audiovestibular and MRI findings in Meniere's disease (MD).

Materials and methods

Prospective cross-sectional cohort study in 2 referral centers included 76 patients with unilateral (n = 62) or bilateral (n = 14) MD. All patients underwent inner ear 3T-MRI 4 h (n = 52) or >24H (n = 24) following audiovestibular tests. T2-CISS and 3D-FLAIR images 4H after gadolinium were obtained. EH diagnosis was based on saccular morphology on coronal views (T2 and 3D-FLAIR), semi quantitative estimation of endolymphatic space enlargement, and saccule utricle ratio inversion (SURI) on 3D-FLAIR axial views.

Results

SURI was the best criterion related to the disease side (43 SURI+ on symptomatic ears, n = 77, vs. 6 SURI+ on asymptomatic ears, n = 53, p < 0.0001, Chi-2). Same-day MRI revealed relation between EH, hearing loss and caloric weakness which could not be detected on delayed MRI: SURI was associated with a higher pure-tone average (43 ± 4.1 dB in SURI+ ears, n = 42 vs. 23 ± 2.6 SURI-, n = 62, p < 0.0001, unpaired t-test,), and a higher proportion of vestibular caloric weakness (23/46 SURI+ ears vs. 4/62 SURI-, p < 0.001, Chi-2). Among all criteria, SURI combined to caloric weakness was the best predictor of the affected side in a logistic regression model.

Conclusion

SURI had the strongest relation to the side the disease and audio vestibular findings for unilateral, probable and definite meniere disease. A short delay between MRI and audio vestibular tests improved the coherence between the findings.

Pathophysiological analysis of idiopathic sudden sensorineural hearing loss by magnetic resonance imaging: A mini scoping review

Objective

To summarize the pathophysiological analysis of idiopathic sudden sensorineural hearing loss (ISSNHL) by magnetic resonance imaging (MRI), focusing on the findings of high signal or endolymphatic hydrops (EH) in the inner ear.

Methods

We summarize the published studies of our research group regarding the pathophysiological analysis of ISSNHL on MRI and review related clinical articles that have reported significantly high signal or the existence of EH in ears with ISSNHL.

Results

Pre-contrast high signal on MRI may indicate minor hemorrhage or increased permeability of surrounding vessels to the perilymph, whereas post-contrast high signal indicates breakdown of the blood-labyrinth barrier, in which irreversible changes would lead to poor prognosis. In some cases of ISSNHL, primary EH could be pre-existing and may be a risk factor for the onset of ISSNHL.

Conclusion

Analysis of ISSNHL by cutting-edge MRI evaluation could provide useful information for elucidating its pathophysiology and for predicting prognosis in this disease.

Vestibular assessment in sudden sensorineural hearing loss: Role in the prediction of hearing outcome and in the early detection of vascular and hydropic pathomechanisms

Introduction

Predicting hearing outcome in sudden sensorineural hearing loss (SSNHL) is challenging, as well as detecting the underlying pathomechanisms. SSNHL could be associated with vestibular damage since cochleo-vestibular structures share the same vascularization, along with being in close anatomical proximity. Whereas viral inflammations and autoimmune/vascular disorders most likely represent the involved aetiologies, early-stage Menière's disease (MD) can also present with SSNHL. Since an early treatment could beneficially influence hearing outcome, understanding the possible etiology plays a pivotal role in orienting the most appropriate treatment. We aimed to evaluate the extent of vestibular damage in patients presenting with SSNHL with or without vertigo, investigate the prognostic role of vestibular dysfunctions on hearing recovery and detect specific lesion patterns related to the underlying pathomechanisms.

Methods

We prospectively evaluated 86 patients with SSNHL. Audio-vestibular investigation included pure-tone/speech/impedance audiometry, cervical/ocular-VEMPs, vHIT and video-Frenzel examination. White matter lesions (WML) were evaluated on brain-MRI. Patients were followed-up and divided into "SSNHL-no-vertigo," "SSNHL+vertigo" and "MD" subgroups.

Results

Hearing was more impaired in "SSNHL+vertigo" patients who exhibited either down-sloping or flat-type audiograms, and was less impaired in "MD" where low frequencies were mostly impaired (p < 0.001). Otolith receptors were more frequently involved than semicircular canals (SCs). Although the "SSNHL-no-vertigo" subgroup exhibited the lowest vestibular impairment (p < 0.001), 52% of patients developed otolith dysfunctions and 72% developed nystagmus. Only "MD" subjects showed anterior SC impairment and upbeating spontaneous/positional nystagmus. They more frequently exhibited cervical-VEMPs frequency tuning (p = 0.036) and ipsilesional spontaneous nystagmus (p < 0.001). "SSNHL+vertigo" subjects presented with more frequently impaired cervical-VEMPs and posterior SC and with higher number of impaired receptors (p < 0.001). They mainly exhibited contralesional spontaneous and vibration-induced nystagmus (p < 0.05) and only they showed the highest WML score and "vascular" lesion patterns (p < 0.001). Concerning the outcomes, hearing was better in "MD" and worse in "SSNHL+vertigo" (p < 0.001). Hearing recovery was mostly affected by cervical-VEMPs impairment and the number of involved receptors (p < 0.05). Patients with "vascular" lesion patterns presented with the highest HL degree and WML score (p ≤ 0.001), while none of them exhibited a complete hearing recovery (p = 0.026).

Conclusions

Our data suggest that vestibular evaluation in SSNHL can provide useful information on hearing recovery and underlying aetiologies.

Reliability of Endolymphatic Hydrops Qualitative Assessment in Magnetic Resonance Imaging

The study aimed to compare the consistency of MRI interpretation of endolymphatic hydrops qualitative assessment of inner ear structures performed by independent observers. MRI with a delayed post-contrast 3D-FLAIR sequence was performed to visualize EH in patients suspected of having or diagnosed with MD. The scans were analyzed independently by three observers. In total, 220 ears were evaluated and, of these, 75 had definite MD, five probable MD, 67 with other Menieriform symptoms, and 73 were asymptomatic. Significant differences in cochlear endolymphatic hydrops (CoEH) grading between all observers were observed. On the Barath scale of vestibular endolymphatic hydrops (VEH), differences were found between the radiologists and otorhinolaryngologist in grading. No differences were noted in VEH on the Bernaerts scale and increased perilymphatic enhancement. Our study showed that evaluation of vestibular endolymphatic hydrops is repeatable between observers and easy to learn. It proved that Bernaerts' modification increased the sensitivity of EH diagnosis. Both parameters, CoEH and VEH, may serve as a differentiation method of EH from normal ears. The distinction between normal and hydropic ears is much easier to perform than EH grading. Therefore, it may be used to diagnose MD rather than EH staging.

Is there progression of endolymphatic hydrops in Ménière’s disease? Longitudinal magnetic resonance study

BACKGROUND

Endolymphatic hydrops (EH) is universal in Ménière´s disease (MD). Given its chronic course, with variable interval before complete clinical picture is installed, it seems relevant to understand the progression of vestibular EH and hemato-perilymphatic barrier disruption in patients with MD and monosymptomatic presentations.

METHODS

239 consecutive patients were referred to us with suspected hydropic ear disease. 50 individuals accepted to participate in this study-final longitudinal sample included 24 patients (7 D1, 7 D2, 10 D3). Control group included ten patients. At recruitment, a clinical and MRI re-evaluation was done (3T, intravenous technique) (MR2) and 2 years after MRI was repeated (MR3). Previous MRI (MRI1) were retrospectively evaluated. Patients were classified as definite (D1), possible (D2) and atypical (D3-monosymptomatic) MD. Control group included non-typical symptoms (C2/C3) and 6 asymptomatic (C1). Vestibular endolymphatic ratio (vER) and grading, presence/absence of cochlear EH, asymmetry of cochlear perilymphatic enhancement, and rate of progression of vER were assessed by two independent neuroradiologists and compared between patient and control groups (index ear).

RESULTS

EH was universal and pronounced in D1 and remained stable. vER progression was more variable and higher in some D3 patients (index ear worse) and in D2 (non-index), although this observation was not statistically significant.

CONCLUSIONS

Considering that many probable and monosymptomatic presentations progress years later into definite MD and given the bilateral tendency of the disease, these findings may indicate that there is an initial accelerated worsening of EH in initial stages of the disease. These data should be confirmed with controlled and larger sample studies.

Vestibular Migraine

PURPOSE OF REVIEW

To explore recent developments in vestibular migraine (VM).

RECENT FINDINGS

This review discusses the current diagnostic criteria for VM in the adult and pediatric populations, as proposed by the International Headache Society and Bárány Society. Recent VM studies confirm the prior findings and reveal new insights, including the wide range of vestibular symptoms, symptoms in the attack-free period, and triggers. Many patients experience persistent vestibular symptoms, even in the absence of acute attacks, which often significantly impact patients' quality of life. The syndrome of benign recurrent vertigo and its relationship to migraine, VM, and Meniere's disease is also discussed. There is a dearth of randomized controlled trials in VM treatment. Prospective and retrospective studies support the benefit of many migraine treatments are effective in VM, including neuromodulation, and calcitonin gene-related peptide monoclonal antibodies. VM affects almost 3% of the population, but remains under-diagnosed. Recent diagnostic criteria can help clinicians diagnose VM in adults and children.

A longitudinal study of unilateral Ménière's disease and clinical evolutionary models

OBJECTIVE

The heterogeneity of Ménière's disease is presently defined by a variety of subtypes. This study introduced three different subtypes of unilateral Ménière's disease based on the evolution of vertigo crises from their inception.

METHOD

A longitudinal descriptive study of 327 unilateral Ménière's disease patients was performed. In a subgroup of patients followed from the onset of the disease, 3 subtypes of unilateral Ménière's disease were defined according to the vertiginous crises suffered during the first 10 years of the disorder.

RESULTS

Data was available for 87 patients with unilateral Ménière's disease from the start of their disease (26.6 per cent of the original sample). These patients were grouped into three models according to their symptomatic evolution. Model 3 was associated with a worse hearing prognosis, a greater number of Tumarkin's otolithic crises and the need for surgery. Model 1 presented less hearing loss.

CONCLUSION

Unilateral Ménière's disease models based on the evolution of vertiginous crises present differences according to aspects such as hearing loss, vertiginous crisis, Tumarkin's otolithic crisis and the need for surgery.

Pathological significance and classification of endolymphatic hydrops in otological disorders

We summarize the presence of endolymphatic hydrops (EH) in otological disorders evaluated with magnetic resonance imaging (MRI) of temporal bones, and propose a classification of EH based on its pathological significance. A search of the literature published in English-language journals was performed using electronic databases, especially focusing on EH-related otological disorders. Clinical articles that contained the terms EH and contrast-MRI published from 2007 to the present, with relevant human temporal bone studies, were included. The following three main points are discussed based on the results in the relevant articles: i) otological disorders that present EH, ii) current grading for evaluation of EH on MRI, and iii) a proposed classification of EH based on its pathological significance. MRI evaluation revealed that EH exists extensively not only in ears with typical Meniere's disease (MD), but also in those with various other otological disorders. The etiological classification of EH helps to summarize ideas for determining the pathophysiology of otological disorders, while a therapeutic classification provides clues to their management. MRI evaluations of EH have led to breakthroughs in investigations of EH in otological disorders. Precise grading for evaluation and clarification of EH on MRI based on its pathological significance could provide keys to elucidating the pathophysiology of EH-related otological disorders.

Detailed insight into magnetic resonance assessment of Ménière's disease - description of methodology and imaging findings in a case series

Purpose

The study aimed to describe the methodology and detailed interpretation of magnetic resonance imaging (MRI) in patients with Ménière’s disease (MD).

Material and methods

MRIs were performed on a 3T scanner. The three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) sequence 4 hours after a double dose of intravenous contrast was added to the standard MRI protocol in patients with clinically diagnosed MD. MRI findings of 7 patients with unilateral MD were analysed using 2 qualitative grading systems by Barath and Bernaerts.

Results

In MRI, the following changes in the group of patients with MD were observed: lack of endolymphatic hydrops (cases #1 and #7), various grades of cochlear hydrops (cases #2 and #3), various grades of vestibular hydrops (cases #4, #5, and #6), endolymphatic hydrops herniation into the semi-circular canal (case #6), and more robust perilymphatic enhancement (case #7).

Conclusions

In patients with MD, endolymphatic hydrops can be studied on MRI using 3D-FLAIR delayed post-contrast images. The qualitative grading system may be easily used in endolymphatic hydrops assessment. Recently described new radiological signs of MD such as increased perilymphatic enhancement of the cochlea and an extra low-grade VH may increase MD diagnosis sensitivity. MRI not only supports the clinical diagnosis of MD but also may help to understand its pathophysiology.

Optimized 3D-FLAIR sequences to shorten the delay between intravenous administration of gadolinium and MRI acquisition in patients with Menière's disease

OBJECTIVES

The aim of this study was to shorten the 4-h delay between the intravenous administration of gadolinium and MRI acquisition for hydrops evaluation using an optimized 3D-FLAIR sequence in patients with Menière's disease.

METHODS

This was a single-center prospective study including 29 patients (58 ears), recruited between November 2020 and February 2021. All patients underwent a 3-T MRI with an optimized 3D-FLAIR sequence without contrast then at 1 h, 2 h, and 4 h after intravenous administration of gadobutrol. The signal intensity ratio was quantitatively assessed with the region of interest method. We also evaluated the volume of endolymphatic structures (saccule, utricle) then the presence of endolymphatic hydrops and blood-labyrinthine barrier impairment at each acquisition time.

RESULTS

For all ears, the signal intensity ratio was significantly non-inferior at 2 h compared to 4 h, with a mean geometric signal intensity ratio at 0.83 (95% CI: 0.76 to 0.90, one-sided p < .001 for non-inferiority at -30% margin). Mean volume equivalence of saccule and utricle between 2 and 4 h was proven at a ± 0.20 standardized deviation equivalence margin. Intra-rater agreements (Cohen's kappa) were all greater than 0.90 for all endolymphatic hydrops location and blood-labyrinthine-barrier impairment between the 2- and 4-h assessments.

CONCLUSIONS

We demonstrated that using an optimized 3D-FLAIR sequence we could shorten the acquisition from 4 to 2 h with a high reliability for the diagnosis of endolymphatic hydrops and blood-labyrinthine-barrier impairment.

CLINICAL TRIAL REGISTRATION

Clinical trial no: 38RC15.173 KEY POINTS: • Magnetic resonance imaging with delayed 3D-FLAIR sequences allows the diagnosis of endolymphatic hydrops in patients with definite Menière's disease. • An optimized 3D-FLAIR sequence with a long TR of 16000 ms and a constant flip angle allows for reducing the delay between intravenous injection of gadobutrol and MRI acquisition from 4 to 2 h to diagnose endolymphatic hydrops. • Reducing this delay between intravenous injection and MRI acquisition could have implications for clinical practice for both patients and imaging departments.

Correlation of semi-quantitative findings of endolymphatic hydrops in MRI with the audiometric findings in patients with Meniere’s disease

Purpose: To investigate the correlation between vestibular hydrops (VH), cochlearhydrops (CH), vestibular aqueduct non-visibility (VANV), and visually increased perilymphatic enhancement (VIPE) with the findings of pure-tone audiometry (PTA) in Meniere’s disease (MD) patients.

Methods: In this cross-sectional study, 53 ears belonging to 48 patients were divided into two groups and evaluated. In group “MD patients,” there were 24 ears of 19 patients diagnosed with the definite MD (14 patients with unilateral and 5 patients withbilateral involvements). The “control group” consisted of 29 non-symptomatic ears belonging to patients diagnosed with unilateral sudden sensory-neural hearing loss or unilateral schwannoma. All the patients underwent 2 sessions of temporal bone MRI using the same 3T system: an unenhanced axial T1, T2, and 3D-FLAIR MRI, an intravenous gadolinium-enhanced axial T1 fat-sat, and 4 h after the injection, an axial 3D-T2 cube and 3D-FLAIR session. VH, CH, VANV, and VIPE were assessed. Subsequently, the correlation between EH indices and PTA findings (in three frequency domains of low, middle, and high) were evaluated, and the predictive value of MRI was calculated.

Results: VH was significantly correlated with the hearing threshold in the low, middle, and high-frequency domains. CH was also correlated with the hearing threshold in the low and middle domains. Contrarily, VIPE was not associated with hearing thresholds, and VANV was only correlated with the hearing threshold in low frequencies.

Conclusion: The grade of VH, CH, and VANV were significantly correlated with the hearing thresholds in PTA.

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Endolymphatic hydrops (EH) is commonly found in Meniere's disease (MD).

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MRI-detected EH is associated with the diagnosis of definite MD.

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EH in MD includes vestibular and cochlear hydrops and invisible vestibular aqueduct.

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The EH grade is correlated with the degree of hearing loss in pure-tone audiometry.

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Low grades of EH were seen in normal ears of unilateral MD and non-MD patients.

Low-Dose Intratympanic Gentamicin for Unilateral Ménière‘s Disease: Accuracy of Early Vestibulo-Ocular Reflex Gain Reduction in Predicting Long-Term Clinical Outcome

Background

The 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.

Objective

To 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.

Methods

The VOR gain reduction was calculated in 47 patients submitted to (ITG) therapy 1 month after the first instillation.

Results

Single 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.

Conclusions

Single 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.

Clinical application of MIIRMR as a salvage method in gadolinium-enhanced MRI after intra-tympanic injection

BACKGROUND

Three-dimensional fluid-attenuated inversion-recovery (3 D-FLAIR) and real inversion-recovery (3 D-real IR) sequences are used to detect endolymphatic hydrops (EH), but medium inversion-time inversion-recovery imaging with magnitude reconstruction (MIIRMR) may be more sensitive.

AIMS

We investigated the inner-ear visualisation success rate and EH detection rates of 3 D-FLAIR and 3 D-real IR, and whether salvage MIIRMR could improve EH detection.

MATERIALS AND METHODS

Fifty-one patients (102 ears) with episodic or chronic vestibular syndrome were injected intra-tympanically with 8-fold diluted gadolinium, and 3 D-FLAIR and 3 D-real IR images obtained 24-h post-injection. If 3 D-FLAIR inner-ear visualisation failed, additional MIIRMR was performed. The success and EH detection rate increase by MIIRMR was calculated. The diagnostic performance of combined MIIRMR + 3D-FLAIR + 3D-real IR for Meniere's disease (MD) was evaluated.

RESULTS

The success rates of 3 D-FLAIR and 3 D-real IR were 88.90% and 72.55%, respectively. MIIRMR increased the success and EH detection rates by 11.10% and 6.86%, respectively. In MD, MIIRMR increased these rates by 10.53% and 10.53%, respectively. 3 D-FLAIR + 3D-real IR + MIIRMR had 92.11% sensitivity, 79.68% specificity, 72.92% positive-predictive value, and 94.44% negative-predictive value for MD diagnosis.

CONCLUSION AND SIGNIFICANCE

MIIRMR can improve success and EH detection rates when 3 D-FLAIR fails. Combined MIIRMR + 3D-FLAIR + 3D-real IR is more valuable for diagnosing MD than conventional sequences.

Imaging Analysis of Patients With Meniere's Disease Treated With Endolymphatic Sac-Mastoid Shunt Surgery

Objective: Endolymphatic sac surgery is effective in treating intractable Meniere's disease (MD), but the underlying mechanism is still unknown. Our study investigated the mechanism by which endolymphatic sac-mastoid shunt (EMS) surgery is effective in treating MD by means of imaging.

Methods: The experiment included 19 patients with intractable MD who underwent 3D-fluid-attenuated inversion recovery (FLAIR) MRI with a 3-Tesla unit 6 h after intravenous administration of gadolinium, before EMS, and 2 years after the surgery. The enhanced perilymphatic space in the bilateral cochlea, vestibule, and canals was visualized and compared with that in the endolymphatic space by quantitatively scoring the scala vestibuli of the cochlea and by measuring the developing area of the vestibules quantitatively.

Results: Gadolinium was present in the perilymph of the inner ear in the cochlea, vestibules, and canals of all patients. At the 2-year follow-up, 14 (73.68%) patients had vertigo control. Both before and 2 years after surgery, significant differences were observed in the scala vestibuli scores and the area of vestibular perilymph between the affected and healthy sides. The scala vestibuli scores and the area of vestibular perilymph, however, did not differ when comparing them before and after surgery.

Conclusions: According to our results, endolymphatic hydrops was not significantly reduced by surgery. The mechanism by which EMS controls vertigo might be unrelated to the improvement in hydrops.

Vestibular Aqueduct Size Correlates With the Degree of Cochlear Hydrops in Patients With and Without Menière's Disease

OBJECTIVE

To correlate the CT imaging findings of the visibility and size of the vestibular aqueduct (VA) with the degree of the cochlear hydrops determined in MRI late imaging of the hydrops. Study Design: Retrospective study. Setting: Tertiary referral center. Patients: A total of 127 patients (62 women, 65 men, average age 55.6 yrs): 86 of these were diagnosed with Menière's disease (American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS] criteria; 67 unilateral, 19 bilateral).

INTERVENTIONS

Temporal bone CT and hydrops MRI were performed in all patients.

MAIN OUTCOME MEASURES

Visibility/width of the VA in temporal bone CT and grade of cochlear hydrops evaluated by MRI.

RESULTS

The width of the VA is significantly smaller in patients diagnosed with Menière's disease (30% non-visible VA), compared with the patients who did not fulfill the diagnostic criteria of Menière's disease (12% non-visible VA) (double sided Spearman correlation, p < 0.001). In all ears of patients diagnosed with Menière's disease the width of the VA was significantly correlated with the degree of the cochlear hydrops (in cases of non-visible VA 65% [34/52] ears presented with hydrops grade 3 or 4; 13% [7/52] ears presented with hydrops grade 1 or 2 and 21% [11/52] ears showed no hydrops) (Spearman correlation p = 0.001/p < 0.01). This is also true for all ears that can be summarized as hydrophic ear disease (symptomatic ears that present with a hydrops in MRI).

CONCLUSIONS

The results of our study could confirm the importance of the VA in the pathogenesis of the endolymphatic hydrops in vivo.

A non-invasive, automated diagnosis of Menière's disease using radiomics and machine learning on conventional magnetic resonance imaging: A multicentric, case-controlled feasibility study

Purpose

This study investigated the feasibility of a new image analysis technique (radiomics) on conventional MRI for the computer-aided diagnosis of Menière’s disease.

Materials and methods

A retrospective, multicentric diagnostic case–control study was performed. This study included 120 patients with unilateral or bilateral Menière’s disease and 140 controls from four centers in the Netherlands and Belgium. Multiple radiomic features were extracted from conventional MRI scans and used to train a machine learning-based, multi-layer perceptron classification model to distinguish patients with Menière’s disease from controls. The primary outcomes were accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the classification model.

Results

The classification accuracy of the machine learning model on the test set was 82%, with a sensitivity of 83%, and a specificity of 82%. The positive and negative predictive values were 71%, and 90%, respectively.

Conclusion

The multi-layer perceptron classification model yielded a precise, high-diagnostic performance in identifying patients with Menière’s disease based on radiomic features extracted from conventional T2-weighted MRI scans. In the future, radiomics might serve as a fast and noninvasive decision support system, next to clinical evaluation in the diagnosis of Menière’s disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11547-021-01425-w.

Hydropic Ear Disease: Correlation Between Audiovestibular Symptoms, Endolymphatic Hydrops and Blood-Labyrinth Barrier Impairment

Research Objective: To investigate the correlation between clinical features and MRI-confirmed endolymphatic hydrops (EH) and blood-labyrinth barrier (BLB) impairment. Study Design: Retrospective cross-sectional study. Setting: Vertigo referral center (Haga Teaching Hospital, The Hague, the Netherlands). Methods: We retrospectively analyzed all patients that underwent 4 h-delayed Gd-enhanced 3D FLAIR MRI at our institution from February 2017 to March 2019. Perilymphatic enhancement and the degree of cochlear and vestibular hydrops were assessed. The signal intensity ratio (SIR) was calculated by region of interest analysis. Correlations between MRI findings and clinical features were evaluated. Results: Two hundred and fifteen patients with MRI-proven endolymphatic hydrops (EH) were included (179 unilateral, 36 bilateral) with a mean age of 55.9 yrs and median disease duration of 4.3 yrs. Hydrops grade is significantly correlated with disease duration (P < 0.001), the severity of low- and high-frequency hearing loss (both P < 0.001), and the incidence of drop attacks (P = 0.001). Visually increased perilymphatic enhancement was present in 157 (87.7%) subjects with unilateral EH. SIR increases in correlation with hydrops grade (P < 0.001), but is not significantly correlated with the low or high Fletcher index (P = 0.344 and P = 0.178 respectively). No significant differences were found between the degree of EH or BLB impairment and vertigo, tinnitus or aural fullness. Conclusion: The degree of EH positively correlates with disease duration, hearing loss and the incidence of drop attacks. The BLB is impaired in association with EH grade, but without clear contribution to the severity of audiovestibular symptoms.

The Additional Value of Endolymphatic Hydrops Imaging With Intratympanic Contrast for Diagnostic Work-Up-Experience From a Neurotology Center in Austria

Objective: To illustrate the merit of hydrops imaging during clinical workup of dizziness and balance disorders. Background: Ever since the first description of in-vivo endolymphatic hydrops imaging in 2007, this diagnostic tool has been implemented in an increasing number of centers. The more experience in its clinical application is gathered, the more it is possible to critically assess its potential value for the diagnostic workup. This article intends to provide information about the experience of handling and utilization of endolymphatic hydrops imaging in one of the first centers in Austria. Methods: Retrospective analysis and review of clinical cases. Results: Based on our experience of endolymphatic hydrops imaging (EHI), which was established in cooperation between our departments of radiology and otorhinolaryngology in 2017, we have exclusively used intratympanic application of a contrast agent prior to magnetic resonance imaging, as this approach provides high quality imaging results. In 42.6% of cases, EHI could lead to the diagnosis of MD or HED. Since precise vestibular examination is still necessary, EHI is not a tool to replace the clinical examination but rather to add significantly to the interpretation of the results. Conclusion: Endolymphatic hydrops imaging represents a valuable, safe and well-applicable tool for evaluating cases with inconclusive clinical results. However, its potential additional diagnostic benefits rely on a correct indication based on prior thorough vestibular investigations.

Validation of inner ear MRI in patients with Ménière's disease by comparing endolymphatic hydrops from histopathologic specimens

Intravenous gadolinium-enhanced inner-ear magnetic resonance imaging (IV-Gd inner-ear MRI) has been used to visualize endolymphatic hydrops (EH) in clinical diagnosis of Ménière's disease (MD). However, lack of histological validation has led to several concerns regarding how best to interpret the resulting images. Here, we compared hydropic changes in temporal bone specimens with the results of IV-Gd inner-ear MRI in patients with MD. Histopathologic images of temporal bones from 37 patients with MD and 10 healthy controls were collected from the National Temporal Bone Bank of the Massachusetts Eye and Ear Infirmary in the United States. The EH ratios in the vestibule and cochlea were calculated from temporal bones using the methods used for IV-Gd inner-ear MRI, and the degree to which the saccular and utricular hydrops contributed to vestibular hydrops was measured. The presence of hydropic change in each semicircular canal was assessed using temporal bone images and compared with IV-Gd inner-ear MRI scans of 74 patients with MD. Based on human temporal bone imagery, the EH ratios in the cochlea and the vestibule on the affected side were 0.314 and 0.757, respectively. In the healthy control group, the ratio was 0.064 for the cochlea and 0.289 for the vestibule; these values were significantly different from those for the affected side of MD patients. The values for the affected ear were similar to the ratios from the IV-Gd inner-ear MRI scans in MD patients. In the vestibule, saccular hydrops were more common than utricular hydrops. The average EH ratios in the saccule and utricle were 0.513 and 0.242, respectively. No significant hydropic change from each of three semicircular canals was evident in temporal bone histopathology. However, herniation of otolithic organs (saccule or utricle) into the lateral semicircular canal was found in 44.4% of the patients, with saccular herniation (24.8%) more common than utricular herniation (16.7%). Although IV-Gd inner-ear MRI might not reflect fully the results of actual histopathology due to the limited resolution of MRI and image-processing techniques, the measured EH ratios from temporal bone specimens and IV-Gd inner-ear MRI scans were similar. Hydropic change in the three semicircular canals was not significant at either the ampullated or nonampullated end. Canal invasion of vestibular hydrops seen on MRI also appeared in temporal bone histopathology, and saccular invasion was dominant.

Auditory biophysics of endolymphatic hydrops

Audiological tests in patients with Menière's disease reveal abnormal patterns relevant for diagnostic purposes with some success. Electrocochleography, otoacoustic emissions and immittance measurements share a moderate sensitivity but a good specificity. Their potential for monitoring the patients suggests means to understand the characteristic time course of Menière's disease and the pathophysiology behind its attacks. Besides, magnetic resonance imaging now allows direct evaluation of endolymphatic hydrops. One issue is now to understand the links between volume inflation of endolymphatic spaces, which sometimes remains asymptomatic, and the functional signs, in the hope that a better understanding of what triggers the attacks may guide future treatments. This article provides a short review of the possible biophysical significance of audiological tests of Menière's disease, and of the attempts to make sense of functional and imaging data and of the patterns they form when combined.

Progressive and Degenerative Peripheral Vestibular Disorders

Initial diagnosis of peripheral vestibulopathy requires a detailed history, physical examination, and, in some cases, audiovestibular testing, radiographic imaging, or serology. Differentiation of a peripheral vestibulopathy as progressive or degenerative is often nuanced and influenced by a characterization of a patient's symptoms or natural history over time. A diverse group of vestibular pathology may fit into this category, including Ménière's disease, autoimmune conditions, congenital pathologies, ototoxic medications, radiation therapy, and perilymphatic fistula. Differentiation among these entities may be guided by initial or subsequent symptomatology, with various combinations of audiovestibular testing, serology, and imaging. Treatment options are disparate and disease-specific, ranging from observation to medical management or surgical intervention, underscoring the need for astute investigation and diagnosis.

MR Imaging of Cochlear Modiolus and Endolymphatic Hydrops in Patients With Menière's Disease

Background: Menière's disease (MD) is an inner ear disorder characterized by recurrent episodes of spontaneous vertigo, unilateral low-frequency sensorineural hearing loss, tinnitus, and aural fullness. Current diagnosis still often has to rely on subjective and audiometric criteria only, although endolymphatic hydrops is recognized as the pathophysiological substrate of the disease, having been demonstrated in anatomical pathological studies and by magnetic resonance (MRI). The modiolus has a close functional and anatomical relationship with the cochlear nerve and membranous labyrinth and can be evaluated with MRI but no data exist on the modiolar size in MD.

Purpose: Our purpose is to examine the following hypothesis. Is cochlear modiolus smaller in symptomatic ears in MD?

Methods: We used a retrospective 3 Tesla MR study (heavily T2-weighted 3D fast asymmetric spin-echo images and 0.5 mm slice thickness) comparing the mean modiolar area (MMA) in the index and best ears of eight patients with definite MD based on audiometric data. The obtained MMA values were compared against the audiometric data and the presence of vestibular endolymphatic hydrops.

Results: No differences were seen in MMA between best and worst ears. Ears with a pure tone average (PTA) ≥25 dB and more pronounced endolymphatic hydrops showed lower MMA (not statistically significant). Two patients with extreme endolymphatic hydrops showed a noteworthy ipsilateral decrease in the cochlear modiolus area.

Conclusion: No differences were seen in MMA between best and worst ears in definite MD. Worse hearing function (PTA ≥ 25dB) and more pronounced endolymphatic hydrops seem to be associated with lower MMA. This might be related to bone remodeling as a consequence of endolymphatic hydrops. Further research is needed to corroborate and explore these findings.