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

Cupping Therapy as a Potential Complimentary Treatment for Meniere's Disease: A Case Report

Meniere's disease is defined by the presence of three essential symptoms: episodic vertigo, tinnitus, and sensorineural hearing loss. The mainstay of its management constitutes lifestyle modification and medical and surgical therapies. Cupping therapy is an ancient treatment that is still widely used especially in the Middle East, Africa, and the United Kingdom. This study portraits the case of a 54-year-old patient suffering from long-standing Meniere's disease. The patient was treated with the routine treatment that was to no avail. It was decided that the patient undergoes cupping therapy. Over two years of monthly cupping therapy sessions, the patient reported a decrease in intensity and frequency of symptoms until its disappearance. Cupping therapy has shown a positive outcome on the patient. According to our search, there is a previous case report published in 2020 that shares multiple similarities with our case. Further studies on cupping therapy and its efficacy, mechanism of action, and complications on a larger scale are advised.

Role of prior intratympanic gentamicin and corticosteroids therapy on speech understanding in patients with Menière's disease after cochlear implantation

AIM

Intratympanic injection of corticosteroids (ITC) and gentamicin therapy (ITG) are widely used treatments for vertigo in Meniere's disease (MD). Even though studies show good results after cochlea implantation (CI) in MD patients when compared to non-MD groups, there is no indication on the effect of ITC and ITG prior to CI on hearing after CI. This study compares the post-operative hearing of CI patients with and without MD and patients who have received ITG or ITC prior to CI.

METHODS

In a retrospective case control study, adult patients with MD who received CI from 2002 till 2021 were compared to a matched control group of CI patients without MD. Patients with prior ITC/ITG were extracted from MD group. Pre-operative audiological results were measured and trends across post-operative monosyllabic word recognition score at 65 decibels (WRS65CI) at switch-on, 3-6 months, 1 year and last yearly value were analyzed across all groups.

RESULTS

28 MD ears were compared with 33 control ears. From MD ears 9 had received ITG and 6 ITC prior to CI. WRS65CI increased significantly with time within MD and control groups, but no difference in WRS65CI was found between these 2 groups. ITG ears showed fluctuating WRS65CI after CI with no change across time, while ITC ears showed significant increase in trend of WRS65CI values across time.

CONCLUSION

MD and non-MD patients showed comparable hearing results after CI. Prior ITC might positively influence hearing preservation after CI in MD patients whereas ITG group showed fluctuating hearing.

Hearing Outcomes Following Endolymphatic Duct Blockage Surgery and Factors Associated with Improved Audition at Two Years Follow-Up

Objective: To evaluate hearing outcomes at 2 years post endolymphatic duct blockage (EDB) surgery, with an analysis of factors that may predict hearing improvement. Study Design: Retrospective comparative study. Setting: Tertiary care center. Subjects: Definite Ménière's Disease (MD) patients undergoing EDB for refractory disease. Methods: Chart review was conducted to assign cases to one of the three hearing outcome groups (deteriorated, stable, and improved). All cases that met our inclusion criteria were selected. Preoperative data collected were audiograms, bithermal caloric tests, preoperative vertigo episodes, history of previous ear surgery for Ménière, intratympanic steroid injections (ITS) and intraoperative endolymphatic sac (ELS) tear or opening. Postoperative data collected at 24 months were audiograms, vertigo episodes and bithermal caloric testing. Results: Preoperative vertigo episodes, caloric paresis and history of surgery, ITS injections or ELS integrity, as well as postoperative vertigo class distribution and caloric paresis changes were not different between our groups. Preoperative word recognition score (WRS) was lowest in the improved hearing group (p = 0.032). The persistence of tinnitus at 2 years postoperatively was associated with deteriorated hearing (p = 0.033). Conclusions: There are no strong predictors of hearing improvement on presentation pre-EDB, but low preoperative WRS may be the best estimator available. Therefore, ablative interventions should be considered very carefully in patients presenting with low WRS, as they may benefit more from EDB; there is a fair chance of a good hearing outcome with EDB surgery. Persistence of tinnitus can reflect deteriorating audition. Vertigo control and hearing preservation are independent outcomes of EDB surgery, making it desirable as an early intervention for refractory MD cases.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical interventions for Ménière's disease

BACKGROUND

Ménière's disease is a condition that causes recurrent episodes of vertigo, associated with hearing loss and tinnitus. First-line treatments often involve dietary or lifestyle changes, medication or local (intratympanic) treatments. However, surgery may also be considered for people with persistent or severe symptoms. The efficacy of different surgical interventions at preventing vertigo attacks, and their associated symptoms, is currently unclear.

OBJECTIVES

To evaluate the benefits and harms of surgical interventions versus placebo or no treatment in people with Ménière's disease.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable Ménière's disease comparing ventilation tubes, endolymphatic sac surgery, semi-circular canal plugging/obliteration, vestibular nerve section or labyrinthectomy with either placebo (sham surgery) or no treatment. We excluded studies with follow-up of less than three months, or with a cross-over design (unless data from the first phase of the study could be identified).  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) change in hearing, 6) change in tinnitus and 7) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We used GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: We included two studies with a total of 178 participants. One evaluated ventilation tubes compared to no treatment, the other evaluated endolymphatic sac decompression compared to sham surgery.  Ventilation tubes We included a single RCT of 148 participants with definite Ménière's disease. It was conducted in a single centre in Japan from 2010 to 2013. Participants either received ventilation tubes with standard medical treatment, or standard medical treatment alone, and were followed up for two years. Some data were reported on the number of participants in whom vertigo resolved, and the effect of the intervention on hearing. Our other primary and secondary outcomes were not reported in this study. This is a single, small study and for all outcomes the certainty of evidence was low or very low. We are unable to draw meaningful conclusions from the numerical results. Endolymphatic sac decompression We also included one RCT of 30 participants that compared endolymphatic sac decompression with sham surgery. This was a single-centre study conducted in Denmark during the 1980s. Follow-up was predominantly conducted at one year, but additional follow-up continued for up to nine years in some participants. Some data were reported on hearing and vertigo (both improvement in vertigo and change in vertigo), but our other outcomes of interest were not reported. Again, this is a single, very small study and we rated the certainty of the evidence as very low for all outcomes. We are therefore unable to draw meaningful conclusions from the numerical results.  AUTHORS' CONCLUSIONS: We are unable to draw clear conclusions about the efficacy of these surgical interventions for Ménière's disease. We identified evidence for only two of our five proposed comparisons, and we assessed all the evidence as low- or very low-certainty. This means that we have very low confidence that the effects reported are accurate estimates of the true effect of these interventions. Many of the outcomes that we planned to assess were not reported by the studies, such as the impact on quality of life, and adverse effects of the interventions. Consensus on the appropriate outcomes to measure in studies of Ménière's disease is needed (i.e. a core outcome set) in order to guide future studies in this area and enable meta-analyses of the results. This must include appropriate consideration of the potential harms of treatment, as well as the benefits.

Endolymphatic duct and sac decompression: A new technique for Ménière’s disease treatment

Background:

The present article aims to introduce the endolymphatic duct and sac decompression technique (DASD) and to give a spotlight on its benefits in Ménière’s disease (MD) treatment.

Methods:

Eighty-two patients with intractable MD which met the inclusion criteria were recruited and underwent DASD. This technique allows a meningeal decompression of the duct and the sac from the posterior cranial fossa to the labyrinthine block. The authors considered as main outcomes, the change of the dizziness handicap inventory (DHI) results, with the evaluations of the three sub-scales (Functional scale, Physical scale, and Emotional scale); ear fullness and tinnitus change on the perceptions of the patient; and hearing stage with four-Pure Tone Average (500 hz-1000 hz-2000 hz-4000 hz). The differences between the preoperative and the postoperative score were evaluated. A comparison with the literature was conducted.

Results:

After a 14-month follow-up, patients that underwent DASD reported a remarkable improvement of the symptoms in all three functional scales, confirmed by the total DHI. The difference between preoperative and postoperative scores is statistically significant. The data describe an ear fullness and tinnitus improvement. The multi-frequency tonal average before and after the surgery does not suggest a worsening of the value for any of 82 patients.

Conclusion:

The modification of sac surgery includes the endolymphatic duct in the decompression area allowing inner ear functional improvement, vertigo control, ear fullness improvement with minimal risk of facial nerve paralysis, and hearing loss. DASD is an improved old surgical technique.

Retrosigmoid Vestibular Neurectomy for Meniere's Disease: a technical note

BACKGROUND AND OBJECTIVE

Meniere's disease (MD) is an idiopathic peripheral pathology involving the acoustic apparatus. One of the most critical challenges in managing MD is intractable vertigo. In this context, the retrosigmoid vestibular neurectomy (RVN) has been described as a safe and effective technique to manage this symptom when resistant to first- and second-line treatments. In this article, the alternative treatment options, specific surgical anatomy, and relevant details to perform vestibular neurectomies for intractable MD are analyzed.

METHODS

Relevant neurovascular landmarks, critical surgical steps, adequate indications, and potential pitfalls of the RVN were analyzed based on an illustrative clinical case of intractable MD.

RESULTS

The illustrative case demonstrated how early recognition of the facial nerve and the vestibulo-cochlear plane is fundamental to performing RVN. This procedure is indicated in cases of resistant MD with pre-operative hearing integrity. Potential pitfalls of this technique are incomplete neurotomy, nerve regeneration, comorbidities in the contralateral ear, adverse anatomy, the possibility of non-otologic vertigo, and incomplete vestibular compensation.

CONCLUSIONS

Vestibular neurectomy represents a safe and effective technique in managing intractable MD resistant to medical treatment, allowing symptom control and hearing preservation. Nevertheless, detailed knowledge of surgical anatomy, as well as possible pitfalls, is of paramount importance to achieve a good outcome.

Evaluation of vestibular function following endolymphatic sac surgery

PURPOSE

To evaluate objective vestibular function after endolymphatic sac surgery (ELSS) for Menière's disease (MD), using comparative vestibular function tests: videonystagmography (VNG), vestibular evoked myogenic potentials (VEMP) and video head-impulse test (VHIT) METHODS: Patients with definite MD using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) of 1995 criteria modified in 2015 and treated with ELSS (sac decompression or sac opening) were included. The primary outcome was the preservation of vestibular function, comparing pre- and postoperative vestibular function tests: VNG, VEMP, VHIT. Secondary outcomes were control of episodes of vertigo, hearing outcome using AAO-HNS criteria, and QoL using the Menière's disease outcome questionnaire.

RESULTS

73 patients were included in the study. We found a significant preservation of vestibular function as measured by VNG and VHIT. There was no statistical difference in the presence or absence of cervical and ocular (P13/N23 and N1/P1) waves on VEMP pre- and postoperatively. 67% of patients had good control of episodes of vertigo post-operatively, with significantly better results in the sac opening group (75%). There was no significant change in hearing postoperatively, and QoL scores were significantly improved after surgery (p < 0.0001).

CONCLUSION

Endolymphatic sac surgery (ELSS) is a conservative surgical treatment, which does not negatively impact vestibular function. It was associated with improved control of episodes of vertigo, preservation of hearing, and a clear improvement in QoL scores. Despite its pathophysiology not being fully understood, it remains a first-line procedure preserving vestibular function, for MD refractory to medical management.

Vestibular Disorders

BACKGROUND

Recent research findings have improved the understanding of the diagnosis, pathophysiology, genetics, etiology, and treatment of peripheral, central, and functional vestibular vertigo syndromes.

METHOD

A literature search, with special attention to the current classification, treatment trials, Cochrane analyses, and other meta-analyses.

RESULTS

There are internationally accepted diagnostic criteria for benign positional paroxysmal vertigo, Menière's disease, bilateral vestibulopathy, vestibular paroxysmia, and functional dizziness. Whether an acute vestibular syndrome is central or peripheral can usually be determined rapidly on the basis of the history and the clinical examination. "Cere - bellar vertigo" is a clinically important entity. For bilateral vestibulopathy, balance training is an effective treatment. For Menière's disease, preventive treatment with betahistine (48 mg and 144 mg per day) is not superior to placebo. For vestibular paroxysmia, oxcarbazepine has been shown to be effective. Treatments that are probably effective for functional dizziness include vestibular rehabilitation, cognitive behavioral therapy, and serotonin reuptake inhibitors.

CONCLUSION

The diagnostic assessment of vestibular syndromes is much easier for clinicians now that it has been internationally standardized. There is still a lack of randomized, controlled trials on the treatment of, for example, Menière's disease, vestibular migraine, and "cerebellar vertigo."

Effects of endolymphatic sac decompression combined with posterior tympanotomy with local steroids for intractable Meniere's disease

Background: Endolymphatic sac decompression surgery (ESDS) is commonly used for intractable Meniere's disease, but its effect remains controversial because of the low rate of vertigo control.Objectives: In the present study, we examined ESDS combined with posterior tympanotomy with local steroids as a new therapeutic strategy for intractable Meniere's disease.Materials and methods: This retrospective study enrolled 19 patients with Meniere's disease using ESDS combined with posterior tympanotomy with local steroids between 2015 and 2018. Postoperatively we recorded and evaluated changes in vertigo attack frequency and hearing level.Results: Vertigo episodes decreased from 3.6 ± 3.2 times preoperatively to 0.2 ± 0.5 times postoperatively, with 89.5% complete vertigo control rate. Mean PTA decreased from 40.5 ± 21.3 dB to 39.5 ± 17.5 dB postoperatively, with 21.1% improvement rate.Conclusions and significance: The present findings suggest that ESDS combined with posterior tympanotomy with local steroids could improve clinical results of hearing as well as vertigo control for intractable Meniere's disease.

Pharmacologic and surgical therapies for patients with Meniere's disease: a protocol for a systematic review and meta-analysis

BACKGROUND

Hearing loss is one of the leading causes of disability in Canada and worldwide, with more than one million Canadians enduring a hearing-related disability. Meniere's disease (MD) is a chronic condition of the inner ear, manifesting as a triad of disabling symptoms, including attacks of vertigo, fluctuating sensorineural hearing loss (SNHL), and tinnitus. Impacts on quality of life are severe, particularly with respect to restrictions in social participation and physical activity, fatigue, and reduced capacity to work. Anxiety and other psychological disorders may result from the restrictions imposed on life, the constant uncertainty of vertigo attacks, and fluctuating SNHL, with neuroses and depression affecting 40 to 60% of sufferers of intractable MD. There is a need to establish the benefits of previously studied interventions with greater certainty. The planned systematic review and meta-analyses/network meta-analyses (NMAs) will assess the relative effects of competing pharmacologic and surgical interventions for management of MD in adults.

METHODS

An experienced medical information specialist in consultation with the review team will develop the electronic search strategies. We will search various databases including MEDLINE, Embase, and the Cochrane Library with no date or language restrictions for published literature, and key clinical trial registries for in-progress and completed trials. Screening of the literature will be performed by two reviewers independently using pre-specified eligibility criteria, and quality of the included studies will be assessed using the Cochrane Risk of Bias tool. We will resolve disagreements through consensus or third-party adjudication. When applicable, meta-analyses and NMAs will be pursued to compare interventions in terms of their effects on outcomes, including frequency and severity of vertigo, occurrence and intensity of tinnitus, changes in hearing and speech recognition, quality of life, and harms. Separate analyses exploring the effects of pharmacologic and surgical approaches will be performed.

DISCUSSION

Our planned systematic review will provide informative evaluations of existing treatments for management of Meniere's disease. The findings will inform practitioners as to the relative benefits and harms of the existing competing interventions for MD, offer optimal clinical treatment strategies, identify evidence gaps, and determine promising therapies for evaluation in future trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019119129.

Current state of evidence for endolymphatic sac surgery in Menière's disease: a systematic review

Background: Endolymphatic sac surgery is an invasive procedure recommended to patients with Menière's disease. Aims/Objectives: To provide an overview and quality assessment of the existing evidence and to provide an updated assessment of the utility of endolymphatic sac surgery in Menière's disease. Material and Methods: We performed a systematic literature search for systematic reviews and randomized controlled trials (RCTs). The AMSTAR tool was used to assess the quality of systematic reviews and the Cochrane risk of bias tool for RCTs. The overall certainty of effects for the individual outcomes was evaluated using the GRADE approach. Results: One systematic review of high quality matched the inclusion criteria, and included three RCTs. An updated literature search from the last search date of the included review provided no further relevant RCTs. The identified RCTs individually reported a positive effect of both the placebo and active treatment groups following surgery, strongly indicative of a placebo effect. The overall certainty of the effect was very low. Conclusions and significance: There is still a lack of high-quality research suggesting that endolymphatic sac surgery provides a significant amount of symptomatic relief for Menière's patients.

European Position Statement on Diagnosis, and Treatment of Meniere's Disease

Meniere Disease keeps challenges in its diagnosis and treatment since was defined by Prosper Meniere at the beginning of 19th Century. Several classifications and definition were made until now and speculations still exist on its etiology. As the etiology remains speculative the treatment models remain in discussion also. The European Academy of Otology and Neurotology Vertigo Guidelines Study Group intended to work on the diagnosis and treatment of Meniere's disease and created the European Positional Statement Document also by resuming the consensus studies on it. The new techniques on diagnosis are emphasized as well as the treatment models for each stage of the disease are clarified by disregarding the dilemmas on its treatment. The conservative, noninvasive and invasive therapeutic models are highlighted.

Endolymphatic duct blockage for refractory Ménière's disease: assessment of intraoperative CSF leak on short-term surgical outcomes

BACKGROUND

Endolymphatic sac decompression has shown limited success for the treatment of Ménière's disease (MD). We have published a novel technique with very promising results for the treatment of refractory MD: the Endolymphatic Duct Blockage (EDB) with two titanium clips. One of the challenges of this technique was an increased incidence of intraoperative Cerebrospinal Fluid (CSF) Leak.

OBJECTIVE

To assess the effect of intraoperative CSF Leak on short-term surgical outcomes.

METHODS

Retrospective comparative study in a tertiary care center (61 patients). MD patients who underwent EDB were included. Intraoperative CSF Leaks were documented. Surgical outcomes assessed were the presence of postoperative Benign Paroxysmal Positional Vertigo (BPPV), aural fullness, tinnitus, vertigo spells and pure tone average (PTA), speech discrimination scores (SDS) and bone conduction thresholds (BCT). Data were collected for these visits: preoperative, 1 week, 1 and 6 months postoperatively.

RESULTS

Outcomes for the CSF Leak group (CSF +) (n = 22) were compared to remaining patient (CSF-) (n = 39). There was no significant difference in the occurrence of postoperative BPPV, aural fullness, tinnitus and vertigo spells. There was no significant difference in PTA, BCT or SDS between our groups at any visit.

CONCLUSIONS

Intraoperative CSF Leak may cause a temporary non-significant worsening of hearing in the first-month postoperatively without any difference at 6 months.

International consensus (ICON) on treatment of Ménière's disease

OBJECTIVE

To present the international consensus for recommendations for Ménière's disease (MD) treatment.

METHODS

Based on a literature review and report of 4 experts from 4 continents, the recommendations have been presented during the 21st IFOS congress in Paris, in June 2017 and are presented in this work.

RESULTS

The recommendation is to change the lifestyle, to use the vestibular rehabilitation in the intercritic period and to propose psychotherapy. As a conservative medical treatment of first line, the authors recommend to use diuretics and Betahistine or local pressure therapy. When medical treatment fails, the recommendation is to use a second line treatment, which consists in the intratympanic injection of steroids. Then as a third line treatment, depending on the hearing function, could be either the endolymphatic sac surgery (when hearing is worth being preserved) or the intratympanic injection of gentamicin (with higher risks of hearing loss). The very last option is the destructive surgical treatment labyrinthectomy, associated or not to cochlear implantation or vestibular nerve section (when hearing is worth being preserved), which is the most frequent option.

Endolymph movement visualized with light sheet fluorescence microscopy in an acute hydrops model

There are a variety of techniques available to investigate endolymph dynamics, primarily seeking to understand the cause of endolymphatic hydrops. Here we have taken the novel approach of injecting, via a glass micropipette, fluorescein isothiocyanate-dextran (FITC-dex) and artificial endolymph into scala media of anaesthetized guinea pigs, with subsequent imaging of the inner ear using Light Sheet Fluorescence Microscopy (LSFM) as a means to obtain highly resolved 3D visualization of fluid movements. Our results demonstrate endolymph movement into the utricle, semicircular canals and endolymphatic duct and sac when more than 2.5 μl of fluid had been injected into scala media, with no apparent movement of fluid into the perilymphatic compartments. There was no movement of endolymph into these compartments when less than 2.5 μl was injected. The remarkable uptake of the FITC-dex into the endolymphatic duct, including an absorption into the periductal channels surrounding the endolymphatic duct, highlights the functional role this structure plays in endolymph volume regulation.