Posterior petrous face meningiomas presenting with Ménière's-like syndrome: a case series and review of the literature

OBJECTIVE

Ménière's disease is an inner ear disorder classically characterized by fluctuating hearing loss, tinnitus, and aural fullness accompanied by episodic vertigo. While the pathogenesis of Ménière's remains under debate, histopathological analyses implicate endolymphatic sac dysfunction with inner ear fluid homeostatic dysregulation. Little is known about whether external impingement of the endolymphatic sac by tumors may present with Ménière's-like symptoms. The authors present a case series of 7 patients with posterior fossa meningiomas that involved the endolymphatic sac and new onset of Ménière's-like symptoms and review the literature on this rare clinical entity.

METHODS

A retrospective review of patients undergoing resection of a posterior petrous meningioma was performed at the authors' institution. Inclusion criteria were age older than 18 years; patients presenting with Ménière's-like symptoms, including episodic vertigo, aural fullness, tinnitus, and/or hearing loss; and tumor location overlying the endolymphatic sac.

RESULTS

There were 7 cases of posterior petrous face meningiomas involving the vestibular aperture presenting with Ménière's-like symptoms. Imaging and intraoperative examination confirmed no cranial nerve VIII compression or labyrinthine artery involvement accounting for audiovestibular symptoms. Of the 7 patients in the series, 6 experienced significant improvement or resolution of their vertigo, and all 7 had improvement or resolution of their tinnitus after resection. Of the 5 patients who had preoperative hearing loss, 2 experienced improvement or resolution of their ipsilateral preoperative hearing deficit, whereas the other 3 had unchanged hearing loss compared to preoperative evaluation.

CONCLUSIONS

Petrous face meningiomas overlying the endolymphatic sac can present with a Ménière's syndrome. Early recognition and microsurgical excision of these tumors is critical for resolution of most symptoms and stabilization of hearing loss.

Rare Disorders of the Vestibular Labyrinth: of Zebras, Chameleons and Wolves in Sheep's Clothing

The differential diagnosis of vertigo syndromes is a challenging issue, as many - and in particular - rare disorders of the vestibular labyrinth can hide behind the very common symptoms of "vertigo" and "dizziness". The following article presents an overview of those rare disorders of the balance organ that are of special interest for the otorhinolaryngologist dealing with vertigo disorders. For a better orientation, these disorders are categorized as acute (AVS), episodic (EVS) and chronic vestibular syndromes (CVS) according to their clinical presentation. The main focus lies on EVS sorted by their duration and the presence/absence of triggering factors (seconds, no triggers: vestibular paroxysmia, Tumarkin attacks; seconds, sound and pressure induced: "third window" syndromes; seconds to minutes, positional: rare variants and differential diagnoses of benign paroxysmal positional vertigo; hours to days, spontaneous: intralabyrinthine schwannomas, endolymphatic sac tumors, autoimmune disorders of the inner ear). Furthermore, rare causes of AVS (inferior vestibular neuritis, otolith organ specific dysfunction, vascular labyrinthine disorders, acute bilateral vestibulopathy) and CVS (chronic bilateral vestibulopathy) are covered. In each case, special emphasis is laid on the decisive diagnostic test for the identification of the rare disease and "red flags" for potentially dangerous disorders (e. g. labyrinthine infarction/hemorrhage). Thus, this chapter may serve as a clinical companion for the otorhinolaryngologist aiding in the efficient diagnosis and treatment of rare disorders of the vestibular labyrinth.

A posterior petrous meningioma with recurrent vertigo

Meningioma's account for around 15% of all primary brain tumors with some 10% of meningiomas arising in the posterior fossa. In rare cases, a meningioma can form around the endolymphatic sac. When formed in the posterior fossa, meningioma tumors can produce vague, non-specific vertiginous symptoms. Research has observed that a subset of these lesions could produce symptoms indistinguishable from those of Meniere's disease. Therefore, we described the clinical features of a case of posterior petrous meningioma with recurrent vertigo as well as the substantial resolution of symptoms after tumor removal via transmastoid approach.

The intravestibular source of the vestibular aqueduct: Its structure and pathology in Ménière's disease

CONCLUSION

We describe a thin, highly vascular layer of mineralized cartilage, which surrounds most of the endolymphatic duct. In the normal ear this may act in helping to control the chemical composition of endolymph. In Ménière's disease (MD) there is a marked apoptotic change among the mineralized cartilage cells of this layer, which seems to be associated also with the deposition of a pathological substance in the walls of many blood vessels. This may lead to serious chemical change in the nearby endolymph and so provoke the symptoms of MD.

OBJECTIVES

Endolymphatic hydrops is found in all cases of MD, but is not specific for that condition. We sought a cellular change in the vicinity of the saccule that might be more specific than the lesion of endolymphatic hydrops and thus lead to a more successful management of the disease.

MATERIALS AND METHODS

We examined stained step sections of 33 autopsy temporal bones from 20 cases of MD, particularly in the region of the vestibule, and compared the changes with those found in a similar region of 65 temporal bones taken from randomly selected cases of non-Ménière conditions.

RESULTS

In all temporal bones there was a well-demarcated region of the posterior vestibule, which formed a skeletal arch around the opening of the tunnel of the vestibular aqueduct into which the endolymphatic duct entered from the vestibule. This 'vestibular arch' was composed mainly of blood vessels and mineralized chondrocytes. The inner skeletal layer surrounding the course of most of the endolymphatic duct in the tunnel of the vestibular aqueduct was composed of the same tissue and was in fact continuous with the vestibular arch. In the non-Ménière temporal bones the mineralized chondrocytes were congregated around normal thin-walled blood vessels and small numbers of them seemed to be undergoing apoptosis in this vicinity. In all of the MD temporal bones, except five in which the vestibular arch was either absent or atrophic, we found pronounced changes of apoptosis among the mineralized cartilage cells and these were associated with proliferative changes in blood vessels in which a bluish-staining translucent deposit, possibly mineralization of the vascular wall, was prominent.

POSTERIOR FOSSA MENINGIOMAS PRESENTING WITH MÉNIÈRE'S-LIKE SYMPTOMS

OBJECTIVE AND IMPORTANCE

In rare cases, posterior fossa meningiomas can involve the endolymphatic sac. Such involvement can result in endolymphatic hydrops and a constellation of symptoms suggestive of Ménière's disease. The diagnosis and management of patients with these tumors is discussed.

CLINICAL PRESENTATION

Three patients, each of whom presented with symptoms consistent with Ménière's disease, were found to have posterior fossa meningiomas limited to the dura overlying the endolymphatic sac.

INTERVENTION

All 3 patients were diagnosed by magnetic resonance imaging and underwent complete surgical resection. In all cases, the symptoms resolved after tumor removal.

CONCLUSION

Clinicians should have a degree of suspicion of posterior fossa meningioma when patients present with symptoms suggestive of Ménière's disease. Failure to do so may result in delayed diagnosis or worse outcomes for an otherwise treatable tumor.

Endolymphatic Duct Status During Middle Fossa Dissection of the Internal Auditory Canal: A Human Temporal Bone Radiographic Study

OBJECTIVE

Successful hearing preservation after acoustic neuroma resection is sometimes complicated by delayed hearing deterioration. The middle fossa approach appears to offer superior long-term hearing results when compared to the retrosigmoid surgical approach. The goal of this study is to investigate the hypothesis that internal auditory canal (IAC) drilling during middle fossa acoustic neuroma removal is associated with a lower incidence of endolymphatic duct (ELD) injury, a potential cause of delayed hearing loss (HL) known to accompany retrosigmoid hearing preservation dissection techniques.

STUDY DESIGN

A human temporal bone anatomic and radiographic study complemented with a literature review.

METHODS

Twenty human temporal bones were analyzed with high-resolution multislice computed tomography (HRMCT) and subjected to standard extended middle fossa IAC dissection with labyrinthine preservation and follow-up HRMCT for analyses of the ELD.

RESULTS

Zero of 20 (0%) temporal bones were found to have violation of the ELD with preservation of the labyrinthine structures and the endolymphatic sac. Reviews of human and animal studies indicate that injury to the ELD may create endolymphatic hydrops, a known cause of hearing deterioration.

CONCLUSION

The ELD is not vulnerable to injury during IAC dissection using the middle fossa approach. A previous radiographic study has shown that the ELD is violated in 24% of temporal bones during retrosigmoid dissection of the IAC. These findings support and may help explain other outcome studies that show that long-term hearing results are superior with the use of the middle fossa approach when compared to results following retrosigmoid dissection.