Natural history vs. surgery for Menière's disease

Changes in symptom pattern in Meniere's disease by duration: the need for comprehensive management

Purpose

This retrospective study aimed to analyze the symptom profile of Meniere's disease (MD) patients, particularly focusing on the cessation of episodic vertigo and the disease's longitudinal course and the impact of major symptoms on quality of life (QoL).

Methods

The study employed a cross-sectional design and was conducted on 365 out of 560 individuals with definite MD from the Finnish Vestibular and Meniere Federation, utilizing an internet-based questionnaire. Participants were surveyed on vertigo attacks, vestibular drop attacks (VDA), balance issues, selective cognitive complaints, hearing loss, and their effects on overall quality of life (QoL). The study population comprised 79.5% females and 20.5% males, with a mean age of 63 years and an average disease duration of 15.2 years.

Results

The onset of MD was characterized by simultaneous hearing loss, vertigo, and tinnitus in 38% of participants. There was a significant delay in diagnosis for many, with 20% experiencing a delay of over 5 years. The frequency and duration of vertigo attacks generally decreased over time, with attacks becoming shorter and less severe as the disease progressed. Spontaneous remission from episodic vertigo occurred in 34% of participants variably throughout the course of MD. Of the participants 65.5% reported balance issues, and 34% experienced mild VDAs, with severe falls occurring in 10%. VDAs were more common with longer disease duration. Bilateral hearing loss developed in 34.5% of participants over the long term, with a higher risk associated with younger onset age, migraines, and family history of MD. Fatigue, anxiety, and depression were prevalent, particularly among younger participants. Cognitive impairments were linked to the severity of these symptoms and the presence of constant dizziness. QoL was significantly lower among participants with constant dizziness, with factors like fatigue, depression, VDA, and hearing loss contributing to this reduction.

Conclusions

The study highlights the complexity of MD. While vertigo may spontaneously remit, other symptoms such as VDAs, balance issues, cognitive complaints, and hearing loss often persist and worsen over time. Assessing MD solely on primary symptoms like vertigo and hearing loss is insufficient; a comprehensive evaluation is necessary for effective management.

The evolution of intractable Ménière's disease: attacks resolve over time

Introduction

Knowledge of the natural and temporal course of a disease is important when deciding if an intervention is appropriate. In the case of Ménière's disease (MD), there is some evidence that attacks diminish over time, but the topic remains controversial. A conservative approach to surgery is usually followed in northern Europe, and leads to strict patient selection before considering surgery. Here, we describe the evolution of vertigo attacks among a group of intractable MD patients in whom surgery was considered.

Methods

Retrospective cohort study in a Ménière's disease expert center. Patients with definite unilateral Ménière's disease and persisting vertigo attacks despite treatment with intratympanic steroid injections were included. All patients had been waitlisted for participation in a planned trial assessing non-ablative surgery. They were waitlisted between June 2016 and June 2021 without undergoing the surgical intervention. In September 2022, data were collected from patient's files and follow-up telephone interviews were conducted to assess the evolution of their vertigo attacks.

Results

Thirty-five patients (54% male, mean age of onset 52 years, 51% right sided) were included in the analysis. Twenty-five patients (71%) eventually declined surgery. Of the 33 patients with complete information on vertigo attacks, 21 (64%) were free of vertigo attacks upon data collection, after a median disease duration of 5.3 years. Patients who did undergo surgery, had longer duration of disease than patients who did not.

Discussion

Even in a population with intractable MD, most patients will experience relief of symptoms over time. On one hand, active treatment may accelerate relief of symptoms, but on the other hand, non-ablative therapies are of debatable effect and ablative intervention carries a risk of life long side effects. Therefore, any active intervention should be carefully considered.

Popularizing Surgical Cures: Walter Dandy and the Vestibular Neurectomy for Menière's Disease at the Johns Hopkins Hospital

OBJECTIVES

To uncover the context that allowed for the vestibular neurectomy to grow in favor and practice at the Johns Hopkins Hospital in the early 20th century, and the reasons for its broad abandonment since.

METHODS

The Walter E. Dandy (1905-1946) and Samuel J. Crowe collections (1905-1920) at the Alan Mason Chesney Medical Archives were reviewed, as well as the Samuel J. Crowe and Stacy Guild Temporal Bone Collection.

RESULTS

Speculation on the etiology of Menière's disease (MD) has been countless, as have the medical and surgical interventions aimed at treating it. At the Johns Hopkins Hospital, Walter Dandy popularized the neurectomy for MD and performed 692 procedures from 1924 to 1946, believing it to be a curative therapy for vertigo. When he later modified the procedure from a total cranial nerve section to a partial vestibular neurectomy preserving auditory function, surgical candidacy expanded to include nearly any patient with vestibular symptoms. After his passing, trainees' attention shifted to traumatic injuries, likely influenced by WWII. This left the procedure scarcely used until third parties rekindled interest decades later.

CONCLUSIONS

Neurectomy as the preferential treatment for MD at the Johns Hopkins Hospital was not driven by pure scientific reasoning but was rather contingent on historical context and sponsorship by a prominent figure like Walter Dandy. Appreciation of MD's natural history has since curtailed the favorability of destructive procedures in preference for conservative management.

Historical Therapies for Suspected Autonomic Dysregulation in Meniere's Disease

OBJECTIVE

This narrative review examines how speculative belief that the autonomic nervous system causes Meniere's Disease (MD) led otolaryngologists to adopt invasive surgical procedures and medical treatments still offered today.

DATA SOURCES

Google Scholar, PubMed.

REVIEW METHODS

A comprehensive literature review (1860-2022) was performed using the terms "Meniere AND (sympathetic OR sympathectomy OR vasomotor OR cervical ganglion)," returning 5360 items. All abstracts were briefly reviewed, relevant publications selected for further study, and key articles discussed by all authors. As it became clear that betahistine was related to the historical narrative, an additional search was performed using "Betahistine AND Meniere AND (vasomotor OR sympathetic OR sympathectomy OR cervical ganglion OR autonomic)," which yielded 336 results.

RESULTS

In the 19th and 20th centuries, growing knowledge of human anatomy led the scientific community to speculate that autonomic dysregulation caused many medical conditions. Excessive sympathetic mediated vasomotor changes were thought to cause hypertension, ischemia, and tissue damage. Clinicians applied the hypothesis to MD, assigning the sympathetic nervous system responsible for vertigo secondary to paroxysmal vasospasm and for hearing loss to poor cochlear nutrition. Despite limited animal experiments and isolated clinical observations, otolaryngologists performed sympathectomies, and, in the 1970s, replaced the procedure with betahistine as an alternative medical treatment.

CONCLUSION

Premature excitement about a plausible hypothesis led to unnecessary and unwarranted operations. Despite absent evidence of sympathetic overactivation in MD, surgeons eagerly adopted sympathectomies, and later betahistine. Rigorous evaluation of the validity of these treatment practices is needed.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:535-542, 2024.

Pathogenesis and Etiology of Ménière Disease: A Scoping Review of a Century of Evidence

IMPORTANCE

Ménière disease is a rare chronic benign disorder of the inner ear with a natural history of multiple clinical phenotypes of variable severity and a tendency to burnout with time. Although multiple treatment modalities have been shown to improve the disease process-some adversely affecting cochleovestibular function-it remains uncertain whether one, several separate, or a combination of pathophysiologic mechanisms affect the disease process. A scoping review of the evidence underlying proposed pathophysiologic mechanisms of Ménière disease is needed to determine which processes are most likely to be etiopathogenic factors.

OBSERVATIONS

Of the 4602 relevant articles found through Embase, Ovid, and PubMed, 444 met inclusion criteria. The most common reported causes of Ménière disease were autoimmune or immune-mediated, genetic, or structural dysfunction of the inner ear. During the study period from inception to March 2021, etiologic theories shifted from structural dysfunction to autoimmune and genetic causes of Ménière disease.

CONCLUSIONS AND RELEVANCE

This scoping review found that Ménière disease is a multifactorial disease with lifelong comorbidities and loss of quality-associated life-years whose most commonly reported causes were structural dysfunction, immunologic damage, and genetic susceptibility. Recent studies have examined how autoinflammatory processes and vestibular migraine may be associated with Ménière disease. Large heterogeneity among studies may be explained by historical differences in the clinical understanding of the disease, as well as evolving intervention methodologies and practitioner expertise. Ménière disease is a multifactorial disease with lifelong comorbidities and loss of quality-associated life-years; therefore, future studies of reliable biomarkers of endolymphatic hydrops and real-time imaging are warranted to improve understanding and treatment.

Effects of intratympanic gentamicin and intratympanic glucocorticoids in Ménière's disease: a network meta-analysis

OBJECTIVE

Intratympanic therapies, usually including glucocorticoid and gentamicin, are becoming worldwide used in clinical practice of Ménière's disease today. However, clinical efficacy and safety of these two therapies are still in controversial.

DATA SOURCES

Electronic searches in PubMed, CENTRAL, Web of Science, EMBASE, CINAHL, ClinicalTrials.gov and the European Union Clinical Trials Register were conducted from inception until September 2020.

REVIEW METHODS

The pre-specified protocol of this systematic review and meta-analysis has been registered and published in November 2018 (PROSPERO Identifier: CRD42018114389). All randomized controlled trials of intratympanic gentamicin or glucocorticoids for Ménière's disease, compared with each other or placebo, were considered for this review.

RESULTS

Ten studies with 455 patients met the inclusion criteria. Pooled results indicated significant advantage of intratympanic gentamicin and glucocorticoids over placebo treatments in vertigo control (gentamicin vs placebo: risk rate, RR, 2.56; 95% CI 1.18-5.54; glucocorticoids vs placebo: RR, 3.02; 95% CI 1.36-6.73). There was no significant difference between gentamicin and glucocorticoids in vertigo control (gentamicin vs placebo: RR, 1.18; 95% CI 0.97-1.45). Intratympanic glucocorticoids showed better hearing protective results than gentamicin (change of pure tone audiometric, PTA, mean difference, MD, - 6.48 dB; 95% CI - 11.84 to - 1.13 dB; change of speech discrimination scale, SDS, MD 7.69%; 95% CI 0.83-14.55%).

CONCLUSIONS

Intratympanic gentamicin and glucocorticoids are two effective approaches to control vertigo symptoms for Ménière's disease. Glucocorticoids showed a potentially better hearing protective role over gentamicin.

A Historical Perspective on Surgical Manipulation of the Membranous Labyrinth for Treatment of Meniere's Disease

Meniere's disease is an inner ear disorder without a known cause. Endolymphatic hydrops is a swelling of the endolymph spaces that has been observed consistently on post-mortem histology in patients with a history of Meniere's disease but can occur in asymptomatic individuals and in association with other diseases. Since its discovery, Meniere's disease has been a disorder managed primarily by otolaryngologists. Surgical treatments, therefore, have accompanied attempts at medical management. Inspired by patients' sensations of ear fullness and later by the histologic findings of hydrops, surgeons began manipulating the membranous labyrinth to relieve episodes of vertigo while attempting to preserve hearing. This review highlights this history of manipulation of the membranous labyrinth. These procedures indicate a rich history of innovation that parallels developments in otologic surgery. The studies involving patients are uniformly retrospective, with some procedures performed first in animal models of endolymphatic hydrops. Many approaches were endorsed by eminent otologic surgeons. Surgeries on the endolymphatic sac are performed by some surgeons today; however, procedures on the membranous labyrinth resulted in similar symptomatic relief through a minimally invasive technique, in many cases performed using only local anesthetic. Episodic vertigo in patients with Meniere's disease is a distressing symptom, yet spontaneous remissions are common. The reports of procedures on the membranous labyrinth reviewed here consistently indicated fewer vertigo episodes. Variable degrees of hearing loss were common following these procedures, and many were abandoned. Additional innovative surgeries are inevitable, but we must understand better the relationships among endolymphatic hydrops, Meniere's disease pathophysiology, and patient symptoms.

Effectiveness of endolymphatic duct blockage versus endolymphatic sac decompression in patients with intractable Ménière's disease: study protocol for a double-blinded, randomised controlled trial

INTRODUCTION

Outcomes of surgery for Ménière's disease (MD) remain discordant. Recently, a new surgical procedure in which the endolymphatic duct is clipped was proposed. To date, only one prospective trial assessing this technique was published, yielding promising results. This protocol describes a prospective, double-blinded, randomised controlled trial that will be carried out to assess the effectiveness of this surgical intervention.

METHODS

Eighty-four patients with intractable MD will be recruited from 13 hospitals in the Netherlands. Intraoperatively, randomisation will determine whether endolymphatic duct blockage (EDB) or endolymphatic sac decompression (ESD) will be performed. Randomisation will be 1:1 stratified for gender and duration of MD (recent-onset versus mature MD). All participants receive vestibular rehabilitation after surgery. Patients are followed up during 1 year after surgery. Follow-up visits will take place at 1 week, 3 months, 6 months and 12 months after surgery. The main study endpoint is proportion of patients who are free of vertigo spells at 12 months postoperatively. Secondary parameters include cumulative number of vertigo bouts, co-intervention, tinnitus, hearing, quality of life, cost effectiveness and a budget impact analysis. Total duration of the study is 4 years.

ANALYSIS

The primary analysis will follow the intention-to-treat principle. For the primary outcome, a χ² test will be performed. Secondary outcomes will be analysed using a linear mixed model (EDB versus decompression group) at the different time measurement point.

ETHICS AND DISSEMINATION

This study was reviewed and approved by a board of specialists before funding was obtained, as well as by the Medical Research Ethics Committee Leiden-The Hague-Delft and the boards of all participating centres. Results of this study will be published in international peer-reviewed scientific journals and will be presented on (inter)national scientific conferences and meetings.

TRIAL REGISTRATION NUMBERS

NL9095 and ISRCTN12074571; Pre-Results.

Betahistine in Ménière's Disease or Syndrome: A Systematic Review

BACKGROUND

Ménière's disease is characterized by recurrent episodes of vertigo, hearing loss, and tinnitus, often with a feeling of fullness in the ear. Although betahistine is thought to be specifically effective for Ménière's disease, no evidence for a benefit from the use of betahistine exists, despite its widespread use. Reassessment of the effect of betahistine for Ménière's disease is now warranted.

SEARCH METHODS

We searched for randomized controlled trials (RCTs) in the Central Register of Controlled Trials (CENTRAL), Ovid Medline, Ovid Embase, CINAHL, Web of Science, Clinicaltrials.gov, ICTRP, and additional sources for published and unpublished trials, in which betahistine was compared to placebo.

DATA COLLECTION AND ANALYSIS

Our outcomes involved vertigo, significant adverse effect (upper gastrointestinal discomfort), hearing loss, tinnitus, aural fullness, other adverse effects, and disease-specific health-related quality of life. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 10 studies: 5 studies used a crossover design and the remaining 5 were parallel-group RCTs. One study with a low risk of bias found no significant difference between the betahistine groups and placebo with respect to vertigo after a long-term follow-up period. No significant difference in the incidence of upper gastrointestinal discomfort was found in 2 studies (low-certainty evidence). No differences in hearing loss, tinnitus, or well-being and disease-specific health-related quality of life were found (low- to very low-certainty of evidence). Data on aural fullness could not be extracted. No significant difference between the betahistine and the placebo groups (low-certainty evidence) could be demonstrated in the other adverse effect outcome with respect to dull headache. The pooled risk ratio for other adverse effect in the long term demonstrated a lower risk in favor of placebo over betahistine.

CONCLUSIONS

High-quality studies evaluating the effect of betahistine on patients with Ménière's disease are lacking. However, one study with low risk of bias found no evidence of a difference in the effect of betahistine on the primary outcome, vertigo, in patients with Ménière's disease when compared to placebo. The main focus of future research should be on the use of comparable outcome measures by means of patient-reported outcome measures.

Endolymphatic Sac Surgery And Posterior Semicircular Canal Fenestration For Meniere's Disease

Objective: To evaluate the efficiency and safety of the simultaneous endolymphatic sac drainage (ELSD) and posterior semicircular canal fenestration (PSCF) primary on the vestibular function as an new therapeutic strategy in the patients with medically refractory Meniere's disease (MD).Study Design: retrospective follow-up study.Setting: University Clinic of Otolaryngology.Methods: Twenty-six patients with MD with severe vertigo and disability who underwent ELSD and PSCF in the same time in the period of 1988 and 2007 were reviewed. The main outcome measures were frequency of vertigo, functional disability according the guidelines for diagnosis and evaluation of therapy in MD. The canal paresis was evaluated by caloric test. The degree of reduced vestibular response rates as an indicators of the vestibular function were compared before and after surgery.Results: The preoperative audition was already altered in all cases except in 8 patients who had no significant changes in hearing threshold. The mean value of vertigo attacks before operation was 8.6. After 3 years of surgery only one patient (3.8%) had one vertigo attack. Functional level was highly ameliorated except in two patients who presented functional level 2 or B in the late postoperative period. The mean caloric testing duration after 3 years postoperatively showed that the 50% of the patients approaching the normal results.Conclusion: Based on the results of simultaneous endolymphatic sac surgery and posterior canal fenestration, they are effective methods for treatment of the refractory Meniere's disease. Endolymphatic sac surgery enables drainage of endolymphatic fluid and the fenestration of the posterior semicircular canal enables the distension or dilatation of the membranous canal in the decompressed perilymphatic space across the perilymphatic leak at the level of the new fenestra, and, so, appearing of certain decrease of the endolymphatic pressure. Both techniques at the same time decrease the pressure in the case of the endolymphatic hydrops.

On the Relationship Between Menière's Disease and Endolymphatic Hydrops

: The relationship between Menière's disease and endolymphatic hydrops is ambiguous. On the one hand, the existence of cases of endolymphatic hydrops lacking the classic symptoms of Menière's disease has prompted the assertion that endolymphatic hydrops alone is insufficient to cause symptoms and drives the hypothesis that endolymphatic hydrops is a mere epiphenomenon. Yet, on the other hand, there is considerable evidence suggesting a relationship between the mechanical pressure effects of endolymphatic hydrops and resultant disordered auditory physiology and symptomatology. A critical appraisal of this topic is undertaken, including a review of key histopathologic data chiefly responsible for the epiphenomenon hypothesis. Overall, a case is made that A) the preponderance of available evidence suggests endolymphatic hydrops is likely responsible for some of the auditory symptoms of Menière's disease, particularly those that can be modulated by mechanical manipulation of the basilar membrane and cochlear microphonic; B) Menière's disease can be reasonably considered part of a larger spectrum of hydropic inner ear disease that also includes some cases that lack vertigo. C) The relationship with endolymphatic hydrops sufficiently robust to consider its presence a hallmark defining feature of Menière's disease and a sensible target for diagnostic detection.

The Physiologic Role of Corticosteroids in Menière's Disease: An Update on Glucocorticoid-mediated Pathophysiology and Corticosteroid Inner Ear Distribution

: There are multiple treatment options for Ménière's disease (MD), including dietary modifications, aminoglycoside therapy, and surgery. All have limitations, ranging from limited effectiveness to permanent hearing loss. Corticosteroids have long been used to manage MD due to their relative efficacy and tolerability, but the exact mechanism for disease alleviation is uncertain. Until recently, the precise distribution and role that glucocorticoid receptors play in inner ear diseases have remained largely uninvestigated. Several studies propose they influence mechanisms of fluid regulation through ion and water homeostasis. This review will provide an update on the basic science literature describing the activity of endogenous glucocorticoids and exogenous corticosteroids in the inner ear and the relevance to MD, as well as early clinical trial data pertaining to the application of novel technologies for more effective administration of corticosteroids for the treatment of MD.

Vertiginous Episodes in Menière Disease following Transmyringeal Ventilation Tube Insertion: A Systematic Review on the Current State of Evidence

Introduction  Menière disease (MD) is a disorder characterized by episodes of vertigo, sensorineural hearing loss, tinnitus and aural fullness. Objectives  To assess the effect of ventilation tube insertion (VTI) on vertiginous episodes in patients (≥ 18 years old) with MD. Data Synthesis  A systematic literature search on randomized clinical trials (RCTs), nonrandomized trials and other systematic reviews was performed. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to assess the overall certainty of evidence. Two RCTs and four nonrandomized studies were identified. Data extraction was only possible for one RCT. Results showed that the number of patients with no vertigo attacks significantly increased following active treatment (relative risk 1.52; [95% confidence interval: 1.19-1.94]). The quality of evidence was rated as low. None of the nonrandomized trials included a proper control group, which hindered data extraction and quality assessment. Conclusion  There are currently no RCTs that specifically assess the efficacy of VTI in patients with MD. Current limited data suggest a considerable positive effect on the number of vertiginous episodes in patients with MD. However, due to poor evidence, a fluctuating course and a substantial placebo-effect associated with MD-treatment, no solid conclusion(s) regarding the efficacy of VTI can be made. There is a need for high-quality RCTs.

Intratympanic Treatment in Menière's Disease, Efficacy of Aminoglycosides Versus Corticosteroids in Comparison Studies: A Systematic Review

OBJECTIVE

To compare the functional outcomes and complications of intratympanic gentamicin (ITG) versus intratympanic corticosteroids (ITC) in Menière's disease.

DATA SOURCES

An electronic search was conducted in the Cochrane Library, PubMed, and Embase databases on February 3, 2019. Articles written in English, Dutch, German, French, or Turkish language were included.

STUDY SELECTION

Study inclusion criteria were: 1) patients diagnosed with definite Menière's disease according to the criteria of the American Academy of Otolaryngology-Head and Neck Surgery, 2) treated with ITG or ITC in a comparison study, and 3) reported subjective and objective outcomes concerning Menière's disease.

DATA EXTRACTION

The quality of eligible studies was assessed according to an adjusted version of the Cochrane Risk of Bias tool. The extracted data were study characteristics (study design, publication year, and number of relevant patients), patient's characteristics (sex and age), disease characteristics (uni or bilateral and duration of Menière's disease), treatment protocol, and different therapeutic outcomes (vertigo, tinnitus, aural fullness, and hearing loss).

DATA SYNTHESIS

A total of eight articles were included for data extraction and analysis. For subjective outcomes, ITG was slightly favored compared to intratympanic corticosteroids. This was significant only in three studies (p < 0.05). For objective outcomes and complications, no significant differences were seen.

CONCLUSIONS

The result of this systematic review shows some benefit of ITG over ITC for subjective outcomes and no difference regarding objective outcomes or complication rate. However, this superiority of ITG is rather weak. Both interventions can be effectively and safely used in controlling Menière's disease in acute situations.

Clinical Practice Guideline: Ménière's Disease Executive Summary

OBJECTIVE

Ménière's disease (MD) is a clinical condition defined by spontaneous vertigo attacks (each lasting 20 minutes to 12 hours) with documented low- to midfrequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo. It also presents with fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear. The underlying etiology of MD is not completely clear, yet it has been associated with inner ear fluid volume increases, culminating in episodic ear symptoms (vertigo, fluctuating hearing loss, tinnitus, and aural fullness). Physical examination findings are often unremarkable, and audiometric testing may or may not show low- to midfrequency sensorineural hearing loss. Imaging, if performed, is also typically normal. The goals of MD treatment are to prevent or reduce vertigo severity and frequency; relieve or prevent hearing loss, tinnitus, and aural fullness; and improve quality of life. Treatment approaches to MD are many, and approaches typically include modifications of lifestyle factors (eg, diet) and medical, surgical, or a combination of therapies.

PURPOSE

The primary purpose of this clinical practice guideline is to improve the quality of the diagnostic workup and treatment outcomes of MD. To achieve this purpose, the goals of this guideline are to use the best available published scientific and/or clinical evidence to enhance diagnostic accuracy and appropriate therapeutic interventions (medical and surgical) while reducing unindicated diagnostic testing and/or imaging.

Clinical Practice Guideline: Ménière's Disease

OBJECTIVE

Ménière's disease (MD) is a clinical condition defined by spontaneous vertigo attacks (each lasting 20 minutes to 12 hours) with documented low- to midfrequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo. It also presents with fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear. The underlying etiology of MD is not completely clear, yet it has been associated with inner ear fluid (endolymph) volume increases, culminating in episodic ear symptoms (vertigo, fluctuating hearing loss, tinnitus, and aural fullness). Physical examination findings are often unremarkable, and audiometric testing may or may not show low- to midfrequency sensorineural hearing loss. Conventional imaging, if performed, is also typically normal. The goals of MD treatment are to prevent or reduce vertigo severity and frequency; relieve or prevent hearing loss, tinnitus, and aural fullness; and improve quality of life. Treatment approaches to MD are many and typically include modifications of lifestyle factors (eg, diet) and medical, surgical, or a combination of therapies.

PURPOSE

The primary purpose of this clinical practice guideline is to improve the quality of the diagnostic workup and treatment outcomes of MD. To achieve this purpose, the goals of this guideline are to use the best available published scientific and/or clinical evidence to enhance diagnostic accuracy and appropriate therapeutic interventions (medical and surgical) while reducing unindicated diagnostic testing and/or imaging.

Long-Term Follow-Up of Intratympanic Methylprednisolone Versus Gentamicin in Patients With Unilateral Menière's Disease

OBJECTIVES

To determine whether long term (>48 months) symptomatic vertigo control is sustained in patients with Menière's disease from a previous comparative trial of intratympanic methylprednisolone versus gentamicin, and if the two treatments remain nonsignificantly different at long-term follow-up.

STUDY DESIGN

Mail survey recording vertigo frequency in the previous one and six months, further intratympanic treatment received, and validated symptom questionnaires.

SETTING

Outpatient hospital clinic setting.

PATIENTS

Adult patients with definite unilateral refractory Menière's disease, who previously received intratympanic treatment in a comparative trial.

INTERVENTION

A survey of trial participants who received intratympanic gentamicin (40 mg/mL) or methylprednisolone (62.5 mg/mL).

OUTCOME MEASURES

Primary: number of vertigo attacks in the 6 months prior to receiving this survey compared with the 6 months before the first trial injection. Secondary number of vertigo attacks over the previous 1 month; validated symptom questionnaire scores of tinnitus, dizziness, vertigo, aural fullness, and functional disability.

RESULTS

Forty six of the 60 original trial patients (77%) completed the survey, 24 from the gentamicin and 22 from the methylprednisolone group. Average follow-up was 70.8 months (standard deviation 17.0) from the first treatment injection. Vertigo attacks in the 6 months prior to receiving the current survey reduced by 95% compared to baseline in both drug groups (intention-to-treat analysis, both p < 0.001). No significant difference between drugs was found for the primary and secondary outcomes. Eight participants (methylprednisolone = 5 and gentamicin = 3) required further injections for relapse after completing the original trial.

CONCLUSION

Intratympanic methylprednisolone treatment provides effective long-lasting relief of vertigo, without the known inner-ear toxicity associated with gentamicin. There are no significant differences between the two treatments at long term follow-up.

Patient Perceptions of Effectiveness in Treatments for Menière's Disease: a National Survey in Italy

OBJECTIVES

The aim of the present study was to investigate current treatment practices and self-reported effectiveness in Ménière's disease.

MATERIALS AND METHODS

Members of two Italian Ménière's disease support (n=170) with ≥6-month history of Ménière's disease were administered an online survey about recent treatments. Vertigo episode count, work absenteeism, and limitations in family life, social life, work, or travel as included in the Social Life and Work Impact of Dizziness Questionnaire before and after recent treatments were queried.

RESULTS

Twenty-four different treatments were reported for Ménière's disease, with dietary modifications (55%), diuretics (47%), and betahistine (41%) being the most common. The majority (71%) received multiple simultaneous treatments. Prior to the most recent treatments, 78%-89% of respondents indicated limitations in family or social life, work, or traveling. After their most recent treatment, respondents reported improvements in mean vertigo episode counts (5.7±7.6 vs. 2.6±4.6, p<0.001), days off work per month (10.1±9.2 vs. 4.2±6.7, p<0.001), and proportions indicating limitations in any functional measure assessed (p<0.05). These findings were consistent regardless of treatment approach (p<0.05 for all). Intratympanic gentamicin provided the greatest reductions in vertigo count, functional limitations, and work absenteeism (p<0.01 for all), as well as the fewest respondents reporting post-treatment functional limitations (16%-37%).

CONCLUSION

Despite many treatment approaches targeting different proposed pathophysiology for Ménière's disease in this cross-sectional survey, all treatments are reported as effective by patients. These findings support a prominent placebo effect in Ménière's disease and highlight challenges in studying treatment outcomes; there is a critical need to better understand Ménière's disease.

Prediction of Unilateral Meniere's Disease Attack Using Inner Ear Test Battery

OBJECTIVES

In the clinical setting, a variety of inner ear test results are obtained from patients with unilateral Meniere's disease (MD). In this study, the authors use inner ear test results as parameters to illustrate the relationship between inner ear function and vertigo attack frequency.

DESIGN

We retrospectively enrolled 50 unilateral MD patients. In addition to clinical symptoms, the results of pure-tone audiometry and caloric, acoustic cervical vestibular-evoked myogenic potential (cVEMP), galvanic cVEMP, vibratory ocular VEMP (oVEMP), and galvanic oVEMP tests were collected via chart review. The multiple linear regression method was used to examine which independent variables have a statistically significant influence on vertigo attacks.

RESULTS

In affected ears, the abnormal rate of the caloric, acoustic cVEMP, galvanic cVEMP, vibratory oVEMP, and galvanic oVEMP tests was 74%, 76%, 48%, 34%, and 30%, respectively. According to the regression model, the abnormal galvanic cVEMP response and abnormal galvanic oVEMP response had significantly negative correlations with the frequency of vertigo attacks after logarithmic transformation. A predictive model for disease attack frequency using significant parameters and their regression coefficients was proposed: (Equation is included in full-text article.) CONCLUSIONS:: Using the proposed model with galvanic VEMP, clinicians could develop better strategies to manage vertigo attacks in patients with MD.

Restriction of salt, caffeine and alcohol intake for the treatment of Ménière's disease or syndrome

BACKGROUND

Ménière's disease or syndrome is a chronic inner ear disorder that results in sporadic attacks of vertigo, sensorineural hearing loss, aural fullness and tinnitus.There is no definitive treatment for Ménière's disease and treatment options range from dietary modification through medication to surgery.Modification of diet, including restriction of salt, caffeine and alcohol intake, is a management option that is widely recommended to patients with Ménière's as a first-line treatment. There has not previously been a systematic review of this intervention.

OBJECTIVES

To assess the effects of dietary restriction of salt, caffeine and alcohol intake in patients with Ménière's disease or syndrome.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 28 March 2018.

SELECTION CRITERIA

Randomised controlled trials of dietary modification, specifically salt, caffeine and alcohol restriction or substitution (or both), compared to no modification of these agents or a placebo intervention, in adult patients with Ménière's disease or syndrome.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were control of vertigo or decrease in vertigo attacks, and adverse effects. Secondary outcomes included hearing (change in hearing loss or its progression), tinnitus (severity), perception of aural fullness, well-being and quality of life (overall changes), and other adverse effects. We planned to use GRADE to assess the quality of the evidence for each outcome.

MAIN RESULTS

We did not identify any studies that met the inclusion criteria for the review.

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials to support or refute the restriction of salt, caffeine or alcohol intake in patients with Ménière's disease or syndrome.High-quality research in this field is warranted. The best evidence may come from a randomised controlled trial comparing dietary interventions (e.g. low salt versus general healthy diet advice), using rigorous methodology for patient selection, randomisation and blinding, and strictly adhering to the Bárány Society diagnostic criteria. However, this research question might be more pragmatically addressed by using information from carefully constructed patient registries that include information on dietary intake of substances of interest such as salt, caffeine and alcohol. It will be important to address the question of any possible harms or unwanted effects of dietary modification.

Intratympanic Therapies in Ménière Disease: Evaluation of Outcomes and Early Vertigo Control

OBJECTIVE

To evaluate outcomes of intratympanic (IT) dexamethasone and gentamicin in Ménière Disease (MD).

METHODS

Charts of adult patients with unilateral definite MD receiving IT gentamicin or dexamethasone from 2005 to 2017 were retrospectively reviewed. All patients had at least 6 months follow-up. Failure in each group was defined as the need for more aggressive therapy. Prior to 2011, all patient received IT gentamicin, administered as primary therapy after failure of conservative treatment measures. Gentamicin was administered every 2 weeks, up to three injections, until vertigo control was achieved. Beginning in 2011, the treatment protocol shifted to IT dexamethasone as initial treatment, with gentamicin used for dexamethasone failures. Dexamethasone was administered weekly for up to three injections. Treatments could be repeated if symptoms recurred.

RESULTS

Thirty-three patients received IT dexamethasone, and 70 patients received IT gentamicin. Dexamethasone patients received a mean of 3.3 injections compared to 2.7 in the gentamicin group (P = 0.011). There were 12 (38%) failures in the dexamethasone group and only seven (10%) gentamicin failures (P = 0.025). No patients failed both treatments. The mean time to failure in the dexamethasone group was 5 months, whereas in the gentamicin group it was 27 months. Change in pure tone audiometry from baseline was not different between treatment groups (P = 0.30).

CONCLUSION

Subjects receiving IT gentamicin required fewer injections and had a significantly longer time to failure than IT dexamethasone. Audiometric outcomes were similar between the groups. The use of IT gentamicin as initial therapy for early and long-term control of MD is safe and effective.

LEVEL OF EVIDENCE

3 Laryngoscope, 129:216-221, 2019.

Endolymphatic Sac Decompression With Intra-Sac Dexamethasone Injection in Menière's Disease

OBJECTIVE

Endolymphatic sac decompression surgery (ELSD) may be used to treat patients who have Menière's 's disease refractory to medical therapy. In this study, we investigated whether or not the injection of steroid into the endolymphatic sac at the time of ELSD provides additional benefit to patient outcomes.

STUDY DESIGN

Randomized prospective single-blinded placebo-controlled study.

SETTING

Tertiary center.

PATIENTS

Patients with Menière's disease with poorly controlled vertigo despite medical therapy and serviceable hearing that were offered ELSD.

INTERVENTION(S)

Patients randomized into two groups, with control group (n = 17) undergone ELSD without steroid injection and experimental group undergone ELSD with steroid injection (n = 18) MAIN OUTCOME MEASURE(S):: Audiogram, dizziness handicap inventory, tinnitus handicap inventory, frequency of vertigo spells, functional level scale, and quality of life were obtained at multiple intervals from preoperatively to 24 months postoperatively.

RESULTS

ELSD resulted in a statistically significant improvement in vertigo control whether or not steroid was injected into the endolymphatic sac at the time of surgery. However, no additional benefit was observed with the addition of intra-sac steroid injection. No statistical difference in pure-tone average, tinnitus handicap inventory, dizziness handicap inventory, or quality of life was observed between the steroid and nonsteroid surgical groups up to 24 months postoperatively.

CONCLUSION

ELSD is an effective treatment for Menière's disease refractory to medical therapy; however, the addition of intra-sac steroid injection at the time of surgery does not seem to result in a further improvement in patient outcomes.

Newly Diagnosed Meniere's Disease: Clinical Course With Initiation of Noninvasive Treatment Including an Accounting of Vestibular Migraine

OBJECTIVE

To describe the course of Meniere's disease with noninvasive treatment during the first few years after initial diagnosis.

METHODS

A retrospective review of consecutive patients with newly diagnosed definite Meniere's disease between 2013 and 2016 and a minimum follow-up of 1 year. Patients received a written plan for low sodium, water therapy, and treatment with a diuretic and/or betahistine. Subjects were screened and treated for vestibular migraine as needed. Vertigo control and hearing status at most recent follow-up were assessed.

RESULTS

Forty-four subjects had an average follow up of 24.3 months. Thirty-four percent had Meniere's disease and vestibular migraine, and 84% had unilateral Meniere's disease. Seventy-five percent had vertigo well controlled at most recent follow-up, with only noninvasive treatments. Age, gender, body mass index, presence of vestibular migraine, bilateral disease, and duration of follow-up did not predict noninvasive treatment failure. Worse hearing threshold at 250 Hz and lower pure tone average (PTA) at the time of diagnosis did predict failure. Fifty-two percent of ears had improved PTA at most recent visit, 20% had no change, and 28% were worse Conclusions: Encountering excellent vertigo control and stable hearing after a new diagnosis of Meniere's disease is possible with noninvasive treatments. Worse hearing status at diagnosis predicted treatment failure.

Intratympanic Dexamethasone in the Treatment of Ménière's Disease: A Comparison of Two Techniques

OBJECTIVE

To assess the efficacy and safety of two different intratympanic dexamethasone (IT Dex) injection protocols for intractable unilateral Ménière's disease.

STUDY DESIGN

Prospective case series.

SETTING

Tertiary neurotology clinic.

PATIENTS

One hundred six consecutive adult patients with definite unilateral Ménière's disease who had failed medical management were studied for an average of 1,061 days. None had previous oral steroid, IT steroid, or ablative treatment.

INTERVENTIONS

Two different IT Dex regimes, either a single injection or a series of four injections, that were subsequently repeated as indicated.

MAIN OUTCOME MEASURE

Requirement for subsequent ablative therapy in the form of intratympanic gentamicin, vestibular nerve section, or labyrinthectomy. Hearing outcomes were measured using pure-tone average of 0.5, 1, 2, and 3 kHz on standard audiometry.

RESULTS

The number of intratympanic dexamethasone injections per patient ranged from 1 to 29 (median = 4). Using the Kaplan-Meier method, predicted survival (patients not requiring ablative therapy) at 2 and 4 years after initial treatment was 83.9 and 79.3%, respectively. The injection series protocol ultimately yielded 5% better survival than the single injection protocol, but this was not statistically significant. Injections did not protect against hearing loss, and the most recent pure-tone averages declined compared with pretreatment values by an average of 8.27 dB (p < 0.05). The treatments did not result in any acute hearing losses, permanent tympanic membrane perforations, or other significant adverse events.

CONCLUSION

Intratympanic dexamethasone injections were successful in controlling vertigo insofar as they were able to obviate ablative therapy in the majority of Ménière's disease patients in this study. The injection series protocol may have been more beneficial compared with the single injection, although the difference between the two protocols was nonsignificant. Hearing mildly declined over the treatment course, which likely represents natural disease progression. The lack of adverse events suggests that IT Dex may be a nonablative option for patients with bilateral disease or only hearing/vestibular ears.

Recent surgical options for vestibular vertigo

Vertigo is not a well-defined disease but a symptom that can occur in heterogeneous entities diagnosed and treated mainly by otolaryngologists, neurologists, internal medicine, and primary care physicians. Most vertigo syndromes have a good prognosis and management is predominantly conservative, whereas the need for surgical therapy is rare, but for a subset of patients often the only remaining option. In this paper, we describe and discuss different surgical therapy options for hydropic inner ear diseases, Menière's disease, dehiscence syndromes, perilymph fistulas, and benign paroxysmal positional vertigo. At the end, we shortly introduce the most recent developments in regard to vestibular implants. Surgical therapy is still indicated for vestibular disease in selected patients nowadays when conservative options did not reduce symptoms and patients are still suffering. Success depends on the correct diagnosis and choosing among different procedures the ones going along with an adequate patient selection. With regard to the invasiveness and the possible risks due to surgery, in depth individual counseling is absolutely necessary. Ablative and destructive surgical procedures usually achieve a successful vertigo control, but are associated with a high risk for hearing loss. Therefore, residual hearing has to be included in the decision making process for surgical therapy.

Intratympanic corticosteroids in Ménière's disease: A mini-review

This article reviews the effectiveness of intratympanic corticosteroids for vertigo control in Ménière's disease at 2-years follow-up according to the guidelines expressed by the American Academy of Otolaryngology-Head & Neck Surgery. Despite the increased use of intratympanic corticosteroids for vertigo control in Ménière's disease there is debate as to their effectiveness, particularly compared to gentamicin. Even so, after just a single course of injections, corticosteroids can reliably provide complete vertigo control (Class A) at 2-years in about 50% of cases as indicated in a recent double-blind randomized controlled clinical trial (Patel et al., 2016). But the effectiveness of intratympanic corticosteroids truly increases when treatment is provided 'as-needed', whereby complete vertigo control is established in up to 91% of cases. On the basis of available literature, there is good evidence to recommend the use of intratympanic steroid treatment for vertigo control in Ménière's disease, but patients must be monitored for non-response. The rationale for treating patients as-needed and the possible reasons for corticosteroid non-response are discussed.

Control of vertigo in Ménière's disease by intratympanic dexamethasone

OBJECTIVE

The main objective was to assess the efficacy of intratympanic dexamethasone injection in controlling vertigo in unilateral Ménière's disease refractory to medical treatment.

MATERIALS AND METHODS

A retrospective study included 25 patients with disabling unilateral Ménière's disease, defined according to the American Academy of Otorhinolaryngology-Head and Neck Surgery (AAO-HNS) criteria. Patients received intratympanic dexamethasone during the monitoring period. Control of vertigo was classified according to AAO-HNS vertigo control index, at 6 months, 1 year, and 2 years after treatment initiation. Complications and progression of hearing were also assessed.

RESULTS

Satisfactory control (class A or B) was obtained in 92% of patients (n=23/25) at 6 months, 68% (n=17/25) at 1 year, and 70% (n=16/23) at 2 years. There was no worsening of hearing in those patients who were well-controlled by this therapeutic strategy. No local or systemic complications were observed during follow-up.

CONCLUSION

Dexamethasone is part of the management strategy for patients with Ménière's disease refractory to conventional treatment, implemented before destructive treatment. It achieves control of vertigo in 70% of patients at 2 years.

Intratympanic (IT) Therapies for Menière's Disease: Some Consensus Among the Confusion

Purpose of Review

Aminoglycosides and corticosteroids are commonly used to treat Menière's disease. Intratympanic (IT) administration of these medications allows high inner ear concentrations without significant adverse systemic effects. As a direct result, IT therapy has grown in popularity. Recent studies have compared patient outcomes between IT aminoglycosides and corticosteroids. This review summarizes these findings.

Recent Findings

Trials comparing IT corticosteroids to IT placebo or oral therapy have had conflicting results. Most recently, Lambert et al. investigated the effect of IT dexamethasone in a sustained-release formulation compared to placebo. Their findings demonstrated improvement in some secondary measures of vertigo with the sustained-release formulation.IT gentamicin is known to be effective in controlling vertigo in Menière's disease. In a recent study from 2016, Patel et al compared IT gentamicin and IT methylprednisolone in a double-blind, randomized controlled trial and identified no significant differences between the two in vertigo control.

Summary

IT injections of aminoglycosides and corticosteroids can improve vertigo control. Hearing and vestibular loss however may result with IT aminoglycosides. Corticosteroids demonstrate limited hearing loss but may not have the same efficacy in controlling vertigo. Further investigation in the etiology of Menière's disease is needed to tailor the proposed treatment to suit the disease mechanism.

Long-term outcomes of endolymphatic sac shunting with local steroids for Meniere's disease

OBJECTIVES

To evaluate the long-term efficacy of endolymphatic sac shunt techniques with and without local steroid administration.

STUDY DESIGN

Retrospective case series and patient survey.

SETTING

Tertiary university hospital.

PATIENTS

Meniere's disease (MD) patients that failed medical therapy and subsequently underwent an endolymphatic sac shunt procedure. All patients had definitive or probable MD and at least 18-months of follow-up.

INTERVENTIONS

Three variations on endolymphatic sac decompression with shunt placement were performed: Group A received no local steroids, Group B received intratympanic dexamethasone prior to incision, and Group C received dexamethasone via both intratympanic injection and direct endolymphatic sac instillation.

MAIN OUTCOME MEASURE(S)

Vertigo control, hearing results, and survey responses.

RESULTS

Between 2002 and 2013, 124 patients with MD underwent endolymphatic sac decompression with shunt placement. 53 patients met inclusion criteria. Groups A, B, and C had 6 patients, 20 patients, and 27 patients, respectively. Mean follow-up was 56months. Vertigo control improved in 66%, 83%, and 93% of Groups A, B, and C. Functional level improved for Group B (-2.0) and Group C (-2.2) but was unchanged in Group A. Pure-tone average and speech discrimination scores changed by +22dB and -30%, +6dB and -13%, and +6dB and -5% in Groups A, B, and C. The long-term hearing results were significantly better with steroids (Groups B and C) according to the AAO-HNS 1995 criteria but did not meet significance on non-parametric testing.

CONCLUSIONS

Endolymphatic sac shunt procedures may benefit from steroid instillation at the time of shunt placement.

Endolymphatic Sac Surgery for Ménière's Disease - Current Opinion and Literature Review

Introduction The endolymphatic sac is thought to maintain the hydrostatic pressure and endolymph homeostasis for the inner ear, and its dysfunction may contribute to the pathophysiology of Ménière's disease. Throughout the years, different surgical procedures for intractable vertigo secondary to Ménière's disease have been described, and though many authors consider these procedures as effective, there are some who question its long-term efficacy and even those who think that vertigo control is achieved more due to a placebo effect than because of the procedure itself. Objective To review the different surgical procedures performed in the endolymphatic sac for the treatment of Ménière's disease. Data Sources PubMed, MD consult and Ovid-SP databases. Data Synthesis We focus on describing the different surgical procedures performed in the endolymphatic sac, such as endolymphatic sac decompression, endolymphatic sac enhancement, endolymphatic sac shunting and endolymphatic duct blockage, their pitfalls and advantages, their results in vertigo control and the complication rates. The senior author also describes his experience after 30 years of performing endolymphatic sac surgery. Conclusions The endolymphatic sac surgery, with all its variants, is a good option for patients with incapacitating endolymphatic hydrops, providing a high percentage of vertigo control and hearing preservation.

Translabyrinthine vestibular neurectomy and simultaneous cochlear implant for Ménière's disease

BACKGROUND

Surgical management of Ménière's disease (MD) is recommended in case of medical and intratympanic treatment failures. Translabyrinthine vestibular nerve section has been considered the gold standard for denervation procedures in order to control vertigo attacks, although at the cost of sacrificing residual hearing. To the best of our knowledge, no work has been published with regard to a group of patients submitted to translabyrinthine vestibular neurectomy and simultaneous cochlear implant for MD. The aim of the present study was to assess the effectiveness of translabyrinthine vestibular nerve section and simultaneous cochlear implant in a prospective study.

METHODS

All adult patients (over 18 years of age) with a diagnosis of intractable unilateral definite MD and useless residual hearing function were enrolled after medical and intratympanic treatment failures. Pre- and postoperative otoneurological evaluation concerned: frequency of vertigo attacks, head impulse test and caloric testing, pure tone average and speech perception audiometry in quiet conditions, tinnitus handicap inventory test, functional level scale and rate of vertigo control, dizziness handicap inventory test, and MD patient-oriented severity index. At least 6 months of follow-up were needed to be enrolled in the study.

RESULTS

Four patients were included in the study. Translabyrinthine vestibular nerve section and simultaneous cochlear implant seemed to considerably improve the disabling effects of MD, achieving a good control of vestibular symptoms (mean pre/postoperative vertigo attacks per month: 16.5/0), resolving hearing loss (mean pre/postoperative pure tone average in the affected ear: 86.2/32.5 dB), improving the tinnitus (mean pre/postoperative tinnitus handicap inventory test: 77.2/6), and finally increasing the overall quality-of-life parameters.

CONCLUSIONS

In our preliminary report, translabyrinthine vestibular nerve section and simultaneous cochlear implant showed encouraging results in order to definitively control both vestibular and cochlear symptoms during the same therapeutic procedure.

Endolymphatic sac drainage for the treatment of Ménière's disease

OBJECTIVE

To describe the results obtained with endolymphatic sac drainage in patients with Ménière's disease.

METHOD

A retrospective case review study was conducted of 95 Ménière's disease patients who underwent endolymphatic sac drainage in a tertiary care referral centre, after failing a long course of medical management. The main outcome measures were vertigo control and hearing preservation.

RESULTS

In patients with unilateral disease, vertigo control was obtained in 94.3 per cent of patients. A significant improvement in cochlear function was seen in 14 per cent of patients, and hearing was preserved or improved in 88 per cent. For the bilateral group, vertigo control was obtained in 85.7 per cent of patients and cochlear function improved in 28 per cent. Hearing preservation was attained in 71 per cent of these patients.

CONCLUSION

Endolymphatic sac drainage is a good surgical option for patients with incapacitating endolymphatic hydrops, providing a high percentage of vertigo control and hearing preservation.

Intratympanic methylprednisolone versus gentamicin in patients with unilateral Ménière's disease: a randomised, double-blind, comparative effectiveness trial

BACKGROUND

Ménière's disease is characterised by severe vertigo attacks and hearing loss. Intratympanic gentamicin, the standard treatment for refractory Ménière's disease, reduces vertigo, but damages vestibular function and can worsen hearing. We aimed to assess whether intratympanic administration of the corticosteroid methylprednisolone reduces vertigo compared with gentamicin.

METHODS

In this double-blind comparative effectiveness trial, patients aged 18-70 years with refractory unilateral Ménière's disease were enrolled at Charing Cross Hospital (London, UK) and Leicester Royal Infirmary (Leicester, UK). Patients were randomly assigned (1:1) by a block design to two intratympanic methylprednisolone (62·5 mg/mL) or gentamicin (40 mg/mL) injections given 2 weeks apart, and were followed up for 2 years. All investigators and patients were masked to treatment allocation. The primary outcome was vertigo frequency over the final 6 months (18-24 months after injection) compared with the 6 months before the first injection. Analyses were done in the intention-to-treat population, and then per protocol. This trial is registered with ClinicalTrials.gov, number NCT00802529.

FINDINGS

Between June 19, 2009, and April 15, 2013, 256 patients with Ménière's disease were screened, 60 of whom were enrolled and randomly assigned: 30 to gentamicin and 30 to methylprednisolone. In the intention-to-treat analysis (ie, all 60 patients), the mean number of vertigo attacks in the final 6 months compared with the 6 months before the first injection (primary outcome) decreased from 19·9 (SD 16·7) to 2·5 (5·8) in the gentamicin group (87% reduction) and from 16·4 (12·5) to 1·6 (3·4) in the methylprednisolone group (90% reduction; mean difference -0·9, 95% CI -3·4 to 1·6). Patients whose vertigo did not improve after injection (ie, non-responders) after being assessed by an unmasked clinician were eligible for additional injections given by a masked clinician (eight patients in the gentamicin group vs 15 in the methylprednisolone group). Two non-responders switched from methylprednisolone to gentamicin. Both drugs were well tolerated with no safety concerns. Six patients reported one adverse event each: three in the gentamicin group and three in the methylprednisolone group. The most common adverse event was minor ear infections, which was experienced by one patient in the gentamicin group and two in the methylprednisolone group.

INTERPRETATION

Methylprednisolone injections are a non-ablative, effective treatment for refractory Ménière's disease. The choice between methylprednisolone and gentamicin should be made based on clinical knowledge and patient circumstances.

FUNDING

Ménière's Society and National Institute for Health Research Imperial Biomedical Research Centre.

Assessment of Vestibulo-oculomotor Reflex in Ménière's Disease: Defining an Instrumental Profile

OBJECTIVES

To analyze and compare, in two groups of patients affected by definite Ménière's disease (MD) but treated differently, the Video Head Impulse Test findings especially by putting them in relationship with canal paresis, hearing loss, and duration of the disease.

STUDY DESIGN

Retrospective chart review.

PATIENTS

Seventy patients affected by unilateral definite MD (16 in Group 1 and 54 in Group 2) observed between March 2014 and May 2015 in a tertiary referral center were retrospectively studied and then divided into two groups: Group 1 was previously treated with intratympanic gentamicin, whereas Group 2 underwent only a conservative therapy. Instrumental tests included audiometry, caloric test, and Video Head Impulse Test. All the findings were statistically analyzed; significance was set at p = 0.005.

INTERVENTION

Diagnostic.

MAIN OUTCOMES MEASURES

If MD is treated conservatively the high-frequency vestibulo-oculomotor reflex gain determined with Video Head Impulse Test is normal; it is pathological if MD is treated with gentamicin.

RESULTS

High-frequency vestibulo-oculomotor reflex gain showed a statistically significant reduction in Group 1; at the same time, it showed no correlation in both groups with hearing loss, duration of disease or canal paresis.

CONCLUSION

High-frequency vestibulo-oculomotor reflex is naturally preserved even in late stage MD if the patient has been treated conservatively; the dissociation between Caloric Test and Video Head Impulse Test findings could be considered an instrumental hallmark of MD. Gentamicin significantly reduces high-frequency vestibulo-oculomotor reflex gain: this reduction can be taken into account when determining the effectiveness of an ablative treatment.

Endolymphatic Mastoid Shunt: A Reevaluation of Efficacy

OBJECTIVES: The main goal of this paper was to statistically reevaluate the efficacy of the endolymphatic shunt procedure for Meniere's disease.

METHODS: Thomsen et al (Arch Otolaryngol 1981; 107:271–7) reported on the placebo effect in surgery for Meniere's disease in a controlled doubleblind study. Thirty patients with typical Meniere's disease in whom medical treatment failed participated in the study. A placebo-controlled blinded surgical study has not since been replicated. We performed a retrospective statistical analysis using data extracted from the published report and reanalyzed it using both the original and new statistical measures and techniques.

RESULTS: The original conclusions drawn by Thomsen et al differed considerably from ours in 5 key areas, including postoperative vertigo, nausea and vomiting, tinnitus, and combined score.

CONCLUSIONS: This analysis strongly supports the effectiveness of the endolymphatic shunt in the management of Meniere's disease and refutes the placebo effect previously proposed.

A Two-Year Randomized Trial of Interventions to Decrease Stress Hormone Vasopressin Production in Patients with Meniere's Disease-A Pilot Study

Meniere's disease, a common inner ear condition, has an incidence of 15-50 per 100,000. Because mental/physical stress and subsequent increase in the stress hormone vasopressin supposedly trigger Meniere's disease, we set a pilot study to seek new therapeutic interventions, namely management of vasopressin secretion, to treat this disease. We enrolled 297 definite Meniere's patients from 2010 to 2012 in a randomized-controlled and open-label trial, assigning Group-I (control) traditional oral medication, Group-II abundant water intake, Group-III tympanic ventilation tubes and Group-IV sleeping in darkness. Two hundred sixty-three patients completed the planned 2-year-follow-up, which included assessment of vertigo, hearing, plasma vasopressin concentrations and changes in stress/psychological factors. At 2 years, vertigo was completely controlled in 54.3% of patients in Group-I, 81.4% in Group-II, 84.1% in Group-III, and 80.0% in Group-IV (statistically I < II = III = IV). Hearing was improved in 7.1% of patients in Group-I, 35.7% in Group-II, 34.9% in Group-III, and 31.7% in Group-IV (statistically I < II = III = IV). Plasma vasopressin concentrations decreased more in Groups-II, -III, and -IV than in Groups-I (statistically I < II = III = IV), although patients' stress/psychological factors had not changed. Physicians have focused on stress management for Meniere's disease. However, avoidance of stress is unrealistic for patients who live in demanding social environments. Our findings in this pilot study suggest that interventions to decrease vasopressin secretion by abundant water intake, tympanic ventilation tubes and sleeping in darkness is feasible in treating Meniere's disease, even though these therapies did not alter reported mental/physical stress levels.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01099046.

Prevalence of Menière's Disease in General Population of Southern Finland

OBJECTIVE: To study the prevalence of Menière's disease (MD) in the general population of Southern Finland.

STUDY DESIGN AND SETTING: Prospective study based on population register data. A questionnaire was sent to 5000 randomly selected persons aged 12 years or more living in the Helsinki University Hospital area. We enquired about whether recipients had experienced vertigo associated with a moving sensation, hearing loss, or tinnitus. For exclusion purposes, we also asked about general illnesses, ear infections, former head and ear traumas, noise exposure, medication, and use of tobacco and alcohol. To assess the validity of the population-based study, we randomly selected a sample of 100 people among those reporting vertigo. They were clinically examined at our vestibular unit. The clinical examination was supplemented by audiologic and otoneurologic tests.

RESULTS: The response rate was 63%. In the final study sample of 3116 people, 216 reported the triad of vertigo, hearing loss, and tinnitus. By using the most recent criteria of the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology–Head and Neck Surgery, we were able to identify 16 definite MD patients from the total sample, yielding a prevalence of 513 of 100,000 persons. Among the 16 MD subjects, 9 patients had already been diagnosed with MD and 1 patient was diagnosed during the clinical examination. A peak prevalence of 1709 of 100,000 was seen in the age group 61 to 70 years.

CONCLUSIONS: Our population-based estimate of MD prevalence is much higher than in previous reports.

Surgical management of Meniere's disease in the era of gentamicin

OBJECTIVE

For many years, surgery was the mainstay of therapy for medically refractory patients, but recently, transtympanic gentamicin perfusion has attracted increasing interest and is a method frequently used for treating Meniere's disease. Many otologists question the relevance of surgical treatments, and traditional options are rarely discussed or offered to patients. The purpose of this study is to describe results of labyrinthectomy, vestibular nerve section, and endolymphatic mastoid shunt surgery for patients with Meniere's disease and to compare them with published results for gentamicin perfusion.

STUDY DESIGN AND SETTING

Retrospective chart review. Two hundred twenty-nine patients underwent surgery for management of Meniere's disease between January 1, 1995 and December 31, 2001. One hundred eighty-nine patients' charts had sufficient data for review. Thirty-two patients had translabyrinthine labyrinthectomies, 83 underwent suboccipital vestibular nerve sections, and 74 elected for an endolymphatic mastoid shunt. Hearing results, dizziness classification, and functional level score were determined from patient charts and telephone conversations. All results were in accordance with the guidelines of the AAO-HNS Committee on Hearing and Equilibrium for evaluation of Meniere's disease therapy.

RESULTS

Audiologic results, functional level score, and dizziness classification are reported for the preoperative period and for the 18- to 24-month postoperative period for all surgical patients. These data are also reported individually for each of the 3 surgical procedures. Early postoperative data and most recent follow-up data are presented if available.

CONCLUSIONS

Surgical management of Meniere's disease is a safe and viable option for patients with medically refractory disease.

EBM RATING

C.

Meniere's disease

Meniere's disease (MD) is a disorder of the inner ear that causes vertigo attacks, fluctuating hearing loss, tinnitus and aural fullness. The aetiology of MD is multifactorial. A characteristic sign of MD is endolymphatic hydrops (EH), a disorder in which excessive endolymph accumulates in the inner ear and causes damage to the ganglion cells. In most patients, the clinical symptoms of MD present after considerable accumulation of endolymph has occurred. However, some patients develop symptoms in the early stages of EH. The reason for the variability in the symptomatology is unknown and the relationship between EH and the clinical symptoms of MD requires further study. The diagnosis of MD is based on clinical symptoms but can be complemented with functional inner ear tests, including audiometry, vestibular-evoked myogenic potential testing, caloric testing, electrocochleography or head impulse tests. MRI has been optimized to directly visualize EH in the cochlea, vestibule and semicircular canals, and its use is shifting from the research setting to the clinic. The management of MD is mainly aimed at the relief of acute attacks of vertigo and the prevention of recurrent attacks. Therapeutic options are based on empirical evidence and include the management of risk factors and a conservative approach as the first line of treatment. When medical treatment is unable to suppress vertigo attacks, intratympanic gentamicin therapy or endolymphatic sac decompression surgery is usually considered. This Primer covers the pathophysiology, symptomatology, diagnosis, management, quality of life and prevention of MD.

Vestibular results after intratympanic gentamicin therapy in disabling Menière's disease

Intratympanic injection of gentamicin is increasingly used in the treatment of unilateral disabling Menière's disease (MD). Several objective functional and subjective tests have been developed to assess the control of vertigo after gentamicin treatment. The aim of this study was to show that subjective results require a vestibular deafferentation as profound as possible, evidenced with multifrequency vestibular assessment. Sixty four patients with intractable MD in situation of medical treatment failure longer than 6 months were included between 1998 and 2013 in this case control study. A 2-year follow-up was performed after the last intratympanic gentamicin performed with the titration technique. A vestibular assessment was applied before and after 2 years of treatment with a functional level score using the AAOHNS vertigo scale and multifrequency vestibular assessment: skull vibration-induced nystagmus test (SVINT), head-shaking test (HST) and caloric test (CaTe). The correlation between the results of the questionnaire and the level of the deafferentation as evaluated by the tests was analyzed with the Spearman test. Among the 64 included patients, 56 (87.5 %) described vertigo control. There was a correlation (=-0.33 [-0.53; -0.09], p = 0.008) between subjective improvement (AAO -HNS 1 or 2) and the degree of vestibular deafferentation as evidenced by a destructive nystagmus (beating toward the safe side) with the HST and the SVINT, as well as a caloric hypofunction >90 % with the CaTe. The present study demonstrates that a profound vestibular deafferentation confirmed with multifrequency test evaluation is needed to have a subjective improvement in the treatment of unilateral disabling MD with intratympanic gentamicin.

Endolymphatic duct blockage: quality of life assessment of a novel surgical technique for Ménière disease

The aim of this study is to evaluate the quality of life (QOL) of patients treated by endolymphatic duct blockage (EDB) for Ménière's disease with a dedicated questionnaire. This is a retrospective cross-sectional study which included 54 patients diagnosed with severe, refractory Ménière's disease according to the AAO-HNS criteria and treated with EDB between 2010 and 2013. Answers to the first 38 questions have assigned scores from 0 to 4 (0 corresponding to the poorest QOL). A preoperative score called S1 was calculated as follows: S1 = sum of preoperative question scores/maximum possible preoperative score ×100. The same formula was used to calculate the postoperative score S2. The change in QOL score, S3, was then calculated (S3 = S2-S1). All answers were analyzed anonymously. Statistical analysis was done using Student t test and Chi square test. A response rate of 89 % was obtained with the Ménière's disease outcome questionnaire. The preoperative (S1) score was 21.4 (±12.6) and the postoperative score (S2) was 64.6 (±21.6) with a change in QOL (S3) of 43.3 (p < 0.001). Postoperatively, 89.9 % reported no Ménière's attacks (p < 0.001). Seventy-nine percent (15/19) of the questions showed a significant improvement after surgery. These results show that EDB is associated with a significant improvement of the QOL of patients suffering from severe Ménière's disease.

Menière's disease

Menière's disease (MD) is a chronic multifactorial disorder of the inner ear characterized by episodic vestibular symptoms associated with sensorineural hearing loss, tinnitus, and aural pressure. Epidemiologic and genomic evidence supports a genetic susceptibility with multiple biochemical pathways involved, including the endocrine system, innate immune response, and autonomic nervous system. Allergens, infectious agents, vascular events, or genetic factors could modify inner-ear homeostasis and trigger MD. The diagnosis of MD is based on clinical criteria and requires the observation of an episodic vertigo syndrome associated with low- to medium-frequency sensorineural hearing loss and fluctuating aural symptoms (hearing loss, tinnitus, and/or fullness) in the affected ear. Headache is also found during the attacks and bilateral involvement is found in 25-40% of cases. Audiologic and vestibular assessment is recommended to monitor the clinical course. The treatment of MD is symptomatic to obtain relief of vestibular episodes and preventive to limit hearing loss progression. Treatment options include sodium restriction, betahistine, intratympanic gentamicin, or steroids and eventually surgery, such as cochlear implantation.

Diagnostic Value of Vestibular Evoked Myogenic Potentials in Endolymphatic Hydrops: A Meta-Analysis

In this study, we evaluated the clinical diagnostic value of vestibular evoked myogenic potentials (VEMPs) for endolymphatic hydrops (EH) by systematic review and Meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio and area under summary receiver operating characteristic curves (AUC) were calculated. Subgroup analysis and publication bias assessment were also conducted. The pooled sensitivity and the specificity were 49% (95% CI: 46% to 51%) and 95% (95% CI: 94% to 96%), respectively. The pooled positive likelihood ratio was 18.01 (95% CI: 9.45 to 34.29) and the pooled negative likelihood ratio was 0.54 (95% CI: 0.47 to 0.61). AUC was 0.78 and the pooled diagnostic odds ratio of VEMPs was 39.89 (95% CI: 20.13 to 79.03). In conclusion, our present meta-analysis has demonstrated that VEMPs test alone is not sufficient for Meniere’s disease or delayed endolymphatic hydrops diagnosis, but that it might be an important component of a test battery for diagnosing Meniere’s disease or delayed endolymphatic hydrops. Moreover, VEMPs, due to its high specificity and non-invasive nature, might be used as a screening tool for EH.

Intratympanic dexamethasone as a symptomatic treatment for Ménière's disease

OBJECTIVE

Determine whether intratympanic (IT) dexamethasone, when given on an as needed basis, can successfully control Ménière's disease (MD) symptoms in a large percentage of patients and allow them to avoid ablative therapies.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary medical center.

PATIENTS

One hundred fifty-nine patients met the American Academy of Otolaryngology-Head and Neck Surgery criteria for unilateral definitive MD. All patients failed dietary and medical therapy and received at least one IT dexamethasone treatment by one of 4 otologists in an academic center.

INTERVENTION(S)

IT dexamethasone.

MAIN OUTCOME MEASURE(S)

Patients were determined to be treatment failures if they did not achieve satisfactory control of their symptoms with IT dexamethasone and chose another treatment modality. Treatment success was defined as IT dexamethasone providing control of MD symptoms to the degree that they did not require any other further treatment modalities.

RESULTS

Successful avoidance of ablative surgery was achieved in 81.1% of patients with greater than 24 months of follow-up. No statistically significant associations were found related to age, sex, laterality, or duration of symptoms. For each IT dexamethasone perfusion sequence, there was a 20.0% increase in likelihood of successful treatment (OR, 1.20; 95% CI, 1.01-1.40; p = 0.01).

CONCLUSION

IT dexamethasone is a successful adjuvant treatment for Ménière's disease in patients on medial therapy and dietary restrictions.

Cochlear implantation in patients with advanced Ménière's disease

BACKGROUND/OBJECTIVES

Ménière's disease (MD) that results in bilateral severe to profound sensorineural hearing loss is a rare indication for cochlear implantation; only a few studies exist documenting performance in these patients. The primary objective was to compare the difference in preoperative to 12-month postoperative speech perception scores among subjects with MD and controls. Groupwise comparisons of secondary postoperative outcomes (Tinnitus Handicap Inventory [THI] scores, 36-Item Short Form [SF-36] scores, and postoperative dizziness) were also performed.

METHODS

A retrospective cohort study was conducted. Subjects with MD and controls matched by age, device manufacturer and model, preoperative sentence score, and sentence test used for preimplantation and postimplantation performance assessments were identified from 1,130 patients in the prospectively maintained cochlear implant database at our center. Speech perception, THI, and SF-36 scores and demographic variables were obtained from the database. Vestibular outcomes were obtained by retrospective chart review. Statistical comparisons were performed to compare preoperative to postoperative change between groups.

RESULTS

Twenty patients with MD were identified. At 1 year after CI, improvements in sentence and word understanding did not differ in magnitude from the controls. Tinnitus was reduced significantly in patients with MD, whereas there was a trend for improvement in the controls. Quality of life as measured by the SF-36 improved in both groups. Patients with MD had significant improvements in 1 domain compared with 5 domains for the controls. Subjects with MD had significantly more chronic dizziness in the postoperative period than did controls.

CONCLUSIONS

Patients with MD who have bilateral severe to profound sensorineural hearing loss benefit significantly from CI. Ongoing dizziness in some patients with MD may result in quality of life improvements that are slightly less than seen for the average adult patient with CI. Larger studies are needed to corroborate the results.