Tenotomy of the stapedius and tensor tympani muscles reduces subjective dizziness handicap in definite Meniere's disease

A Comparison of Falls and Dizziness Handicap by Vestibular Diagnosis

PURPOSE

There is a paucity of data that directly compares the falls rate and dizziness handicap of different vestibular diagnoses. The purpose of this study is to compare the falls rate and dizziness handicap of common vestibular diagnoses encountered among a cohort of vestibular patients at a single institution.

METHOD

We conducted a retrospective cross-sectional study of patients evaluated for dizziness at a tertiary care center vestibular clinic between August 1, 2017, and March 19, 2019. Vestibular diagnosis, demographic variables, comorbidities, falls status, and Dizziness Handicap Inventory (DHI) were extracted from the medical record for analysis. Associations between vestibular diagnosis and falls history or DHI were evaluated using multivariate logistic and linear regression, respectively.

RESULTS

A total of 283 patients met our inclusion criteria with the following diagnoses: benign paroxysmal positional vertigo (BPPV; n = 55), acoustic neuroma (n = 30), Ménière's disease (n = 28), multiple vestibular diagnoses (n = 15), vestibular migraine (n = 135), or vestibular neuritis (n = 20). After adjusting for age, sex, race, medications, and comorbidities, the odds of falling was 2.47 times greater (95% CI [1.08, 6.06], p = .039) and the DHI score was 11.66 points higher (95% CI [4.99, 18.33], p < .001) in those with vestibular migraine compared to those with BPPV. Other diagnoses were comparable to BPPV with respect to odds of falling and dizziness handicap.

CONCLUSIONS

Patients with vestibular migraine may suffer an increased risk of falls and dizziness handicap compared to patients with BPPV. Our findings highlight the need for timely evaluation and treatment of all patients with vestibular disease.

Menière's disease treated by grommet insertion

INTRODUCTION

Menière's disease (MD) is an uncommon cause of sudden profound vertigo. A variety of medical and surgical treatments have been used to manage this condition. This study reviewed the outcomes of patients treated with grommet insertion and transtympanic steroid injection.

METHODS

Patients diagnosed with MD between 2007 and 2017 were identified, and case notes and audiological data were retrieved for those managed by grommet (ventilation tube) insertion with and without transtympanic steroid injection.

RESULTS

Thirty-three patients were identified as being diagnosed with MD. Grommet insertion resulted in cessation or improvement of attacks in 91% of cases. The mean follow-up duration was 33.8 months (median: 29 months). The mean hearing threshold across the low frequencies improved from 57.2dBHL to 49.4dBHL (p=0.031). Following the intervention, improved tinnitus was reported in 80% of cases. Twelve patients (36%) reported aural fullness prior to grommet insertion; all reported improved symptoms following the procedure.

CONCLUSIONS

Early grommet insertion with transtympanic steroid injection, combined with customised vestibular physiotherapy, may provide an alternative first-line strategy for MD, preventing further true MD attacks. In some patients, it may significantly improve hearing thresholds.

An Integrative Model Accounting for the Symptom Cluster Triggered After an Acoustic Shock

Acoustic shocks and traumas sometimes result in a cluster of debilitating symptoms, including tinnitus, hyperacusis, ear fullness and tension, dizziness, and pain in and outside the ear. The mechanisms underlying this large variety of symptoms remain elusive. In this article, we elaborate on the hypothesis that the tensor tympani muscle (TTM), the trigeminal nerve (TGN), and the trigeminal cervical complex (TCC) play a central role in generating these symptoms. We argue that TTM overuse (due to the acoustic shock), TTM overload (due to muscle tension), and ultimately, TTM injury (due to hypoxia and "energy crisis") lead to inflammation, thereby activating the TGN, TCC, and cortex. The TCC is a crossroad structure integrating sensory inputs coming from the head-neck complex (including the middle ear) and projecting back to it. The multimodal integration of the TCC may then account for referred pain outside the ear when the middle ear is inflamed and activates the TGN. We believe that our model proposes a synthetic and explanatory framework to explain the phenomena occurring postacoustic shock and potentially also after other nonauditory causes. Indeed, due to the bidirectional properties of the TCC, musculoskeletal disorders in the region of the head-neck complex, including neck injury due to whiplash or temporomandibular disorders, may impact the middle ear, thereby leading to otic symptoms. This previously unavailable model type is experimentally testable and must be taken as a starting point for identifying the mechanisms responsible for this particular subtype of tinnitus and its associated symptoms.

Tenotomy of the middle ear muscles : An unknown surgical approach in Meniere's disease

Tenotomy of the tendon of the stapedius and tensor tympani muscles is a relatively unknown therapeutic procedure in Menière's disease. Widespread approaches include medicinal treatment with betahistine or diuretics as well as interventional procedures, such as intratympanic gentamicin or glucocorticoid injection, vestibular neurectomy, labyrinthectomy or endolymphatic sac surgery. The exact pathomechanism of this approach is not fully known. It is assumed that by cutting the tendons of both middle ear muscles in cases of endolymphatic hydrops the stapes is not additionally actively pushed against the oval window but can deviate laterally and thereby does not augment the inner ear pressure even further. Studies have shown that this method does not only improve vestibular symptoms but also, in contrast to most other strategies, increases the hearing level. The formation of scar tissue and the resulting reduction of ossicular chain mobility, especially due to postoperative infections, may limit the success of tenotomy and should be considered as a possible factor in cases of limited postoperative vertigo control.

Structural Analysis of Tensor Tympani Muscle, Tympanic Diaphragm, Epitympanum, and Protympanum in Menière's Disease: a Human Temporal Bone Study

HYPOTHESIS

We hypothesized that there would be significant anatomic differences of the tensor tympani muscle (TTM), tympanic diaphragm, epitympanum, and protympanum in patients with versus without Menière's disease.

BACKGROUND

The effects of tenotomy on Menière's disease suggested it relieves the pressure on the inner ear of the contraction of the TTM and of negative middle ear pressure.

METHODS

Using human temporal bones from patients with Menière's disease, two studies were conducted. We examined the presence of otitis media, cholesteatoma, and endolymphatic hydrops, the length, diameter, configuration, the volume of the TTM and tendon, and the area of the tympanic isthmus (Study 1). We examined the presence of otitis media, cholesteatoma and endolymphatic hydrops, and the area and volume of the protympanum (Study 2).

RESULTS

In study 1, we observed no significant differences between the two groups. In study 2, we did not observe a small and narrow protympanum in the Menière's disease group. None of the ears in the Menière's or control groups had otitis media or cholesteatoma in either study. We observed hydrops in all the temporal bones of the Menière's disease group and none in the control groups.

CONCLUSION

The position, configuration, and size of the tensor tympani muscle and tendon do not seem to play a role in the pathogenesis of Menière's disease. Because the tympanic isthmus and protympanum in Menière's disease are not smaller than controls and that none of the temporal bones had otitis media or cholesteatoma, it is unlikely that there was dysventilation in the middle ear.

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.

Audiometric findings with voluntary tensor tympani contraction

Background

Tensor tympani contraction may have a "signature" audiogram. This study demonstrates audiometric findings during voluntary tensor tympani contraction.

Methods

Five volunteers possessing the ability to voluntarily contract their tensor tympani muscles were identified and enrolled. Tensor tympani contraction was confirmed with characteristic tympanometry findings. Study subjects underwent conventional audiometry. Air conduction and bone conduction threshold testing was performed with and without voluntary tensor tympani contraction.

Main outcome measure

Changes in air conduction and bone conduction thresholds during voluntary tensor tympani contraction.

Results

Audiometric results demonstrate a low frequency mixed hearing loss resulting from tensor tympani contraction. Specifically, at 250 Hz, air conduction thresholds increased by 22 dB and bone conduction thresholds increased by 10 dB.

Conclusions

Previous research has demonstrated a low frequency conductive hearing loss in the setting of tensor tympanic contraction. This is the first study to demonstrate a low frequency mixed hearing loss associated with tensor tympani contraction. This finding may aid in the diagnosis of disorders resulting from abnormal tensor tympani function. Tensor tympani contraction should be included on the differential for low frequency mixed hearing loss.

Disability perception in Menière's disease: when, how much and why?

The purpose of the study was to evaluate self-perceived handicap in patients with definite Menière's disease (MD). A cross-sectional study was conducted. To examine the self-perception of disability, participants completed a DHI (Dizziness Handicap Inventory). Parameters compared with DHI scores: sex, age, unilateral/bilateral affectation, time elapsed since the onset of symptoms, pure-tone average (PTA), stages of MD, audiometric change (last 6 months), PTA in low frequencies (PTAl) and audiometric change in PTAl, subjective perception of fluctuating hearing threshold, tinnitus between attacks, number of vertiginous episodes (last 6 months), time elapsed since last attack, subjective perception of instability intercrises and Tumarkin attacks. 90 patients were included; they completed a total of 104 questionnaires. DHI scores ranged from 2 to 100 (average: 47.08, SD 24.45). In 29 cases (27.9 %) the disability perception was mild, in 43 (41.3 %) moderate, and in 32 (30.8 %) severe. Correlation between disability perception and some vestibular symptoms was found: number of typical attacks (last 6 months), time elapsed since last attack, instability intercrises and Tumarkin attacks. No relationship was found with the rest of variables. Disability perception in patients with MD depends primarily on vestibular symptoms (particularly, instability and frequency of attacks). So, we suggest to design a new staging system of MD taking into account both auditory criteria and also vestibular symptoms.

[The modern view of the clinical significance of tensor tympani muscle]

The objective of the present work was analyse the modern views of the role of tensor tympani muscle in the development of otic pathology. In this context, the authors discuss tenotomy of the middle ear muscles for the treatment of Meniere's disease, diagnostics and clinical aspects of middle ear myoclonus, and tonic tensor tympani syndrome.