A further critical assessment of the efficacy of endolymphatic sac surgery

It is 2015: What are the best diagnostic and treatment options for Ménière’s disease?

Ménière’s disease (MD) is a common cause of recurrent vertigo. Its pathophysiology is still unclear and controversial. The most common histological finding in postmortem temporal bone studies of patients is endolymphatic hydrops (EH). However, not all cases of hydrops are associated with MD and it may represent the end point of various etiologies. The diagnostic criteria for MD have undergone changes during the past few decades. A recent collaboration among specialty societies in United States, Europe and Japan has given rise to a new set of guidelines for the diagnosis and classification of MD. The aim is to develop international consensus criteria for MD that would help improve the quality of data collected from patients. The diagnosis of MD can be difficult in some cases as there is no gold standard for testing. Previous use of audiometric data and electrocochleography are poorly sensitive as screening tools. Recently magnetic resonance imaging as a diagnostic tool for identifying EH has gained popularity in Asia and Europe. Vestibular evoked myogenic potentials are also used but lack specificity. Finally, the treatment for MD has improved with the introduction of intratympanic treatments with steroids and gentamicin as well as less invasive treatment with the Meniett device.

Hearing outcome after concurrent endolymphatic shunt and vestibular nerve section

OBJECTIVE

To determine if endolymphatic shunt surgery concurrent with vestibular nerve section improves hearing outcome compared with vestibular nerve section alone.

STUDY DESIGN

Retrospective observational study with cross-sectional survey.

SETTING

Tertiary otologic private practice.

PATIENTS

Thirty-five patients who underwent vestibular nerve section and endolymphatic shunt surgery and 17 patients who had vestibular nerve section alone between 1985 and 2000.

METHODS

Chart review and correspondence for audiogram results and survey.

MAIN OUTCOME MEASURES

Hearing at last follow-up. Hearing Handicap Inventory, Dizziness Handicap Inventory, Tinnitus Handicap Inventory, and SF-36.

RESULTS

Eight patients in the vestibular nerve section and 15 in the vestibular nerve section and endolymphatic shunt surgery group had an audiogram at more than 16 months after surgery available for review. In the vestibular nerve section group, three patients had same hearing whereas five were worse. In the vestibular nerve section and endolymphatic shunt surgery group, 2 patients showed improvement, 2 were the same, and 11 were worse. There was no significant difference in the change from preoperative pure tone average or Word Discrimination Score to postoperative levels between the surgical groups. Eighteen patients had serviceable hearing preoperatively. Five of 8 in the vestibular nerve section and 4 of 10 in the vestibular nerve section and endolymphatic shunt surgery groups maintained serviceable hearing postoperatively. Of the 52 patients, 33 responded to the survey (63%). There were no significant differences between the groups for Dizziness Handicap Inventory, Hearing Handicap Inventory, Tinnitus Handicap Inventory, or SF-36, suggesting that patient-oriented outcomes are the same in both groups.

CONCLUSIONS

Concurrent endolymphatic shunt surgery and vestibular nerve section does not improve hearing or tinnitus outcome over vestibular nerve section alone.

Endolymphatic sac surgery for Meniere's disease: experience with over 3000 cases

The foregoing discussion has attempted to substantiate and clarify the six propositions outlined at the outset in light of the author's personal experience. In sum, the following points are emphasized: Employment of ESS for treatment of intractable Meniere's disease in cases where the sac is definitively delineated, the real sac lumen entered, the sac's integrity preserved, and sac enlargement technique is employed has an approximate 90% chance of achieving complete or substantial control of vertigo in the short run (2-3 years). Although there seems to be little likelihood of pushing the short-term rate of vertigo control obtainable with ESS significantly beyond the 90% mark, there is still room for improvement of longer-term control of Meniere's disease symptoms, either through modification of surgical procedure or, as the author recommends, through treatment at an early stage of the disease. The efficacy of ESS almost certainly has a definite, although presently ill-understood, pathophysiologic basis and cannot be purely attributable to a placebo effect. Regardless of limitations and uncertainties surrounding Meniere's disease and treatment of it, ESS is indisputably both safe and highly effective and, in the author's opinion, continues to be the preferred treatment for medically refractory Meniere's symptom-complex.

Topical mitomycin C and cephalosporin in endolymphatic sac surgery

OBJECTIVE

To determine whether intraoperative topical application of the drug mitomycin C to the endolymphatic sac area in conjunction with endolymphatic sac ballooning surgery (ESBS) can safely achieve longer-lasting relief from incapacitating, medically intractable Meniere symptom-complex than ESBS alone.

STUDY DESIGN/METHOD

A retrospective study is presented of 142 cases of ESBS performed by the author between May 1998 and November 1999, in which a solution of mitomycin C diluted to 1 mg/mL of physiological saline was applied to the sac area for 5 minutes followed by irrigation with a cephalosporin antibiotic solution. The results of the 103 of 142 cases diagnosed as classic Meniere's disease or endolymphatic hydrops are given special attention, comparing them with the results of an earlier-reported series of 109 cases of ESBS sharing the same diagnostic and result evaluation criteria but not using mitomycin C.

RESULTS

In terms of vertigo control, the comparative short-term rates (<3 y) of complete/substantial control for the aforementioned 103-case series and earlier 109-case series are similar: respectively, 90.3% (after 1.5--3 years' follow-up) versus 91.7% (after 2.5-3 years' follow-up). In the 103-case series, to date, there has been no recurrence of incapacitating vertiginous symptoms necessitating revision surgery, whereas in the 109-case series, although there were likewise no cases necessitating revision surgery during the reported 2.5-to 3-year follow-up period, at least 8 patients in that series are known to have undergone revision surgery at later dates. Hearing results were significantly better (P =.004) in the 103-case series than the 109-case series: respectively, 30.0% versus 12.8% hearing improvement.

CONCLUSIONS

Preliminarily, the superior hearing results in the present series indicate that possible adverse effects of mitomycin C on the inner ear and endolymphatic system have been averted; and no recurrence of incapacitating symptoms to date offers hope that longer-term efficacy of endolymphatic sac surgery using mitomycin C can be maintained.