Regulation of Fn14 Receptor and NF-κB Underlies Inflammation in Meniere's Disease

Molecular differences between neonatal and adult stria vascularis from organotypic explants and transcriptomics

Summary

The stria vascularis (SV), part of the blood-labyrinth barrier, is an essential component of the inner ear that regulates the ionic environment required for hearing. SV degeneration disrupts cochlear homeostasis, leading to irreversible hearing loss, yet a comprehensive understanding of the SV, and consequently therapeutic availability for SV degeneration, is lacking. We developed a whole-tissue explant model from neonatal and adult mice to create a robust platform for SV research. We validated our model by demonstrating that the proliferative behaviour of the SV in vitro mimics SV in vivo, providing a representative model and advancing high-throughput SV research. We also provided evidence for pharmacological intervention in our system by investigating the role of Wnt/β-catenin signaling in SV proliferation. Finally, we performed single-cell RNA sequencing from in vivo neonatal and adult mouse SV and revealed key genes and pathways that may play a role in SV proliferation and maintenance. Together, our results contribute new insights into investigating biological solutions for SV-associated hearing loss.

Significance

Hearing loss impairs our ability to communicate with people and interact with our environment. This can lead to social isolation, depression, cognitive deficits, and dementia. Inner ear degeneration is a primary cause of hearing loss, and our study provides an in depth look at one of the major sites of inner ear degeneration: the stria vascularis. The stria vascularis and associated blood-labyrinth barrier maintain the functional integrity of the auditory system, yet it is relatively understudied. By developing a new in vitro model for the young and adult stria vascularis and using single cell RNA sequencing, our study provides a novel approach to studying this tissue, contributing new insights and widespread implications for auditory neuroscience and regenerative medicine.

Highlights

- We established an organotypic explant system of the neonatal and adult stria vascularis with an intact blood-labyrinth barrier. - Proliferation of the stria vascularis decreases with age in vitro , modelling its proliferative behaviour in vivo . - Pharmacological studies using our in vitro SV model open possibilities for testing injury paradigms and therapeutic interventions. - Inhibition of Wnt signalling decreases proliferation in neonatal stria vascularis.- We identified key genes and transcription factors unique to developing and mature SV cell types using single cell RNA sequencing.

Immune-Related Disorders Associated With Ménière's Disease: A Systematic Review and Meta-analysis

OBJECTIVE

To analyze evidence supporting an association between immune-related diseases and Ménière's disease (MD) since it has long been thought to be related to autoimmune disorders and allergies.

DATA SOURCES

We retrieved records from Pubmed, Web of Science, Scopus, and Cochrane Library to identify studies published between January 2002 and October 2022.

REVIEW METHODS

Articles were independently assessed by 2 reviewers and verified by a third reviewer. Published cross-sectional studies, cohort/longitudinal studies, case series, and noncomparative cohort studies were considered eligible for inclusion. We conducted a systematic review and meta-analysis according to a registered protocol on the International Prospective Register of Systematic Reviews and Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Selected studies were classified into 2 groups: epidemiological and genetic association studies. Relative frequencies and odds ratios (ORs) for each autoinflammatory/autoimmune disease or genetic marker reported to be associated with MD.

RESULTS

Fifteen studies from 6 countries met our inclusion criteria. Nine are epidemiological studies and 6 are genetic association studies. The epidemiological studies were used to perform 3 different meta-analyses. Airway allergic disease and autoimmune thyroid disease showed a significant association with MD (OR = 2.27 [2.08-2.48] and OR = 1.35 [1.25-1.46]); while rheumatoid arthritis did not (OR = 0.63 [0.28-1.41]). Other comorbidities also showed a significant association with MD like chronic obstructive pulmonary disease, vitiligo, fibromyalgia, arthritis, and psoriasis.

CONCLUSION

Epidemiological evidence supports an association between MD and immune-related disorders in European and Asian populations, with population-specific effects. The evaluation of thyroid diseases, airway allergic diseases, and other inflammatory diseases should be implemented in the clinical management of MD patients.

Single-cell immune profiling of Meniere Disease patients

BACKGROUND

Meniere Disease (MD) is an inner ear syndrome, characterized by episodes of vertigo, tinnitus and fluctuating sensorineural hearing loss. The pathological mechanism leading to sporadic MD is still poorly understood, however an allergic inflammatory response seems to be involved in some patients with MD.

OBJECTIVE

Decipher an immune signature associated with the syndrome.

METHODS

We performed mass cytometry immune profiling on peripheral blood from MD patients and controls. We analyzed differences in state and differences in abundance of the different cellular subsets. IgE levels were quantified through ELISA on supernatant of cultured whole blood.

RESULTS

We have identified two clusters of individuals according to the single cell cytokine profile. These clusters presented differences in IgE levels, immune cell population abundance, including a reduction of CD56^dim NK-cells, and changes in cytokine expression with a different response to bacterial and fungal antigens.

CONCLUSION

Our results support a systemic inflammatory response in some MD patients that show a type 2 response with allergic phenotype, which could benefit from personalized IL-4 blockers.

Serum/glucocorticoid-inducible kinase 1 deficiency induces NLRP3 inflammasome activation and autoinflammation of macrophages in a murine endolymphatic hydrops model

Ménière's disease, a multifactorial disorder of the inner ear, is characterized by severe vertigo episodes and hearing loss. Although the role of immune responses in Ménière's disease has been proposed, the precise mechanisms remain undefined. Here, we show that downregulation of serum/glucocorticoid-inducible kinase 1 is associated with activation of NLRP3 inflammasome in vestibular-resident macrophage-like cells from Ménière's disease patients. Serum/glucocorticoid-inducible kinase 1 depletion markedly enhances IL-1β production which leads to the damage of inner ear hair cells and vestibular nerve. Mechanistically, serum/glucocorticoid-inducible kinase 1 binds to the PYD domain of NLRP3 and phosphorylates it at Serine 5, thereby interfering inflammasome assembly. Sgk^-/- mice show aggravated audiovestibular symptoms and enhanced inflammasome activation in lipopolysaccharide-induced endolymphatic hydrops model, which is ameliorated by blocking NLRP3. Pharmacological inhibition of serum/glucocorticoid-inducible kinase 1 increases the disease severity in vivo. Our studies demonstrate that serum/glucocorticoid-inducible kinase 1 functions as a physiologic inhibitor of NLRP3 inflammasome activation and maintains inner ear immune homeostasis, reciprocally participating in models of Ménière's disease pathogenesis.

In Silico Localization of Perilymph Proteins Enriched in Meńier̀e Disease Using Mammalian Cochlear Single-cell Transcriptomics

Hypothesis

Proteins enriched in the perilymph proteome of Meńier̀e disease (MD) patients may identify affected cell types. Utilizing single-cell transcriptome datasets from the mammalian cochlea, we hypothesize that these enriched perilymph proteins can be localized to specific cochlear cell types.

Background

The limited understanding of human inner ear pathologies and their associated biomolecular variations hinder efforts to develop disease-specific diagnostics and therapeutics. Perilymph sampling and analysis is now enabling further characterization of the cochlear microenvironment. Recently, enriched inner ear protein expression has been demonstrated in patients with MD compared to patients with other inner ear diseases. Localizing expression of these proteins to cochlear cell types can further our knowledge of potential disease pathways and subsequent development of targeted therapeutics.

Methods

We compiled previously published data regarding differential perilymph proteome profiles amongst patients with MD, otosclerosis, enlarged vestibular aqueduct, sudden hearing loss, and hearing loss of undefined etiology (controls). Enriched proteins in MD were cross-referenced against published single-cell/single-nucleus RNA-sequencing datasets to localize gene expression to specific cochlear cell types.

Results

In silico analysis of single-cell transcriptomic datasets demonstrates enrichment of a unique group of perilymph proteins associated with MD in a variety of intracochlear cells, and some exogeneous hematologic and immune effector cells. This suggests that these cell types may play an important role in the pathology associated with late MD, suggesting potential future areas of investigation for MD pathophysiology and treatment.

Conclusions

Perilymph proteins enriched in MD are expressed by specific cochlear cell types based on in silico localization, potentially facilitating development of disease-specific diagnostic markers and therapeutics.

Genetic advances in Meniere Disease

Meniere Disease (MD) is an idiopathic inner ear disease with complex etiology and pathogenesis, which is still unclear. With the development in gene analysis technology, the genetic research of MD has attracted extensive attention, resulting in a large number of studies on the research of the relationship between human genes and MD. This paper aims to review the studies on this topic in recent years. The studies mainly focused on the genetics of familial MD and the correlation between MD and potentially related functional genes. The results of these studies have demonstrated the complexity and diversity of the pathogenesis of MD with both genetic and epigenetic alterations, suggesting that MD might be related to inflammation, immunity, aqua and ion balance in the lymphatic fluid, virus infection, metabolism, and abnormal function of nerve conduction. The finding of rare mutations in TECTA, MYO7A and OTOG genes and other genes such as CDH23, PCDH15 and ADGRV1 in the same families suggest that the integrity of the stereocilia and their interaction with the tectorial and otolithic membranes could be involved in the pathophysiology of familial MD.

Systemic pharmacological interventions for Ménière's disease

BACKGROUND

Ménière's disease is a condition that causes recurrent episodes of vertigo, associated with hearing loss and tinnitus. A number of pharmacological interventions have been used in the management of this condition, including betahistine, diuretics, antiviral medications and corticosteroids. The underlying cause of Ménière's disease is unknown, as is the way in which these treatments may work. The efficacy of these different interventions at preventing vertigo attacks, and their associated symptoms, is currently unclear.

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable Ménière's disease comparing betahistine, diuretics, antihistamines, antivirals or systemic corticosteroids with either placebo or no treatment. We excluded studies with follow-up of less than three months, or with a cross-over design (unless data from the first phase of the study could be identified).  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) change in hearing, 6) change in tinnitus and 7) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We used GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: We included 10 studies with a total of 848 participants. The studies evaluated the following interventions: betahistine, diuretics, antivirals and corticosteroids. We did not identify any evidence on antihistamines.  Betahistine Seven RCTs (548 participants) addressed this comparison. However, we were unable to conduct any meta-analyses for our primary outcomes as not all outcomes were considered by every study, and studies that did report the same outcome used different time points for follow-up, or assessed the outcome using different methods. Therefore, we were unable to draw meaningful conclusions from the numerical results. Some data were available for each of our primary outcomes, but the evidence was low- or very low-certainty throughout. One study reported on the outcome 'improvement in vertigo' at 6 to ≤ 12 months, and another study reported this outcome at > 12 months. Four studies reported on the change in vertigo, but again all used different methods of assessment (vertigo frequency, or a global score of vertigo severity) or different time points. A single study reported on serious adverse events.  Diuretics Two RCTs addressed this comparison. One considered the use of isosorbide (220 participants), and the other used a combination of amiloride hydrochloride and hydrochlorothiazide (80 participants). Again, we were unable to conduct any meta-analyses for our primary outcomes, as only one study reported on the outcome 'improvement in vertigo' (at 6 to ≤ 12 months), one study reported on change in vertigo (at 3 to < 6 months) and neither study assessed serious adverse events. Therefore, we were unable to draw meaningful conclusions from the numerical results. The evidence was all very low-certainty.  Other pharmacological interventions We also identified one study that assessed antivirals (24 participants), and one study that assessed corticosteroids (16 participants). The evidence for these interventions was all very low-certainty. Again, serious adverse events were not considered by either study.

AUTHORS' CONCLUSIONS

The evidence for systemic pharmacological interventions for Ménière's disease is very uncertain. There are few RCTs that compare these interventions to placebo or no treatment, and the evidence that is currently available from these studies is of low or very low certainty. This means that we have very low confidence that the effects reported are accurate estimates of the true effect of these interventions. Consensus on the appropriate outcomes to measure in studies of Ménière's disease is needed (i.e. a core outcome set) in order to guide future studies in this area and enable meta-analyses of the results. This must include appropriate consideration of the potential harms of treatment, as well as the benefits.

Association Between Meniere Disease and Migraine

Importance

A connection between Meniere disease (MD) and migraine has been proposed, but the temporal association remains unknown.

Objective

To examine the bidirectional association of MD with migraine.

Design, Setting, and Participants

This case-control study included participants 40 years or older from the Korean National Health Insurance Service Health Screening Cohort from 2002 to 2015.

Main Outcomes and Measures

A total of 6919 patients with MD were matched with 27 676 control participants without MD for age, sex, income, region of residence, and index date. The incidence of migraine was analyzed in the MD and matched groups using a stratified Cox proportional hazard regression model. In addition, 35 889 patients with migraine were matched with 71 778 control participants without migraine. The incidence of MD was analyzed using a stratified Cox proportional hazard regression model.

Results

Of 142 262 total participants, 94 611 (66.5%) were women. Migraine occurred in 695 of 6919 patients with MD (10.0%) and 970 of 27 676 matched control participants (3.5%). The MD group demonstrated a 2.22-fold higher risk of migraine than the matched control group (95% CI, 1.99-2.49). Meniere disease was present in 1098 of 35 889 patients with migraine (3.1%) and 781 of 71 778 matched control participants (1.1%). The migraine group had a 1.95-fold higher risk of MD than the matched control group (95% CI, 1.77-2.15).

Conclusions and Relevance

The results of this case-control study suggest that patients with MD had a greater risk of migraine occurrence. Furthermore, patients with migraine had a higher risk of MD. Based on the bidirectional association, therapeutics for migraine could potentially be applied to MD and vice versa.

Role of Inner Ear Macrophages and Autoimmune/Autoinflammatory Mechanisms in the Pathophysiology of Inner Ear Disease

Macrophages play important roles in tissue homeostasis and inflammation. Recent studies have revealed that macrophages are dispersed in the inner ear and may play essential roles in eliciting an immune response. Autoinflammatory diseases comprise a family of immune-mediated diseases, some of which involve sensorineural hearing loss, indicating that similar mechanisms may underlie the pathogenesis of immune-mediated hearing loss. Autoimmune inner ear disease (AIED) is an idiopathic disorder characterized by unexpected hearing loss. Tissue macrophages in the inner ear represent a potential target for modulation of the local immune response in patients with AIED/autoinflammatory diseases. In this review, we describe the relationship between cochlear macrophages and the pathophysiology of AIED/autoinflammatory disease.

Up-Regulated Expression of Interferon-Gamma, Interleukin-6 and Tumor Necrosis Factor-Alpha in the Endolymphatic Sac of Meniere's Disease Suggesting the Local Inflammatory Response Underlies the Mechanism of This Disease

Background

Immune mediated inflammatory changes affecting the endolymphatic sac (ES) may underlie the pathology of Meniere's disease (MD). The aim of the present study was to explore the differentially expressed cytokines in ES luminal fluid (ELF) of patients with MD, and the correlation between the expression of cytokines in the ELF with that in the serum was determined by quantitatively analyzing the cytokines in human ELF and serum.

Methods

Human ELF, serum and ES tissues were collected from patients with unilateral MD and patients with acoustic neuroma (AN) during surgery. The Simoa Cytokine 6-Plex Panel kit was used to analyze the levels of cytokines in the ELF and blood samples of the patients. Immunohistochemistry and immunofluorescence were subsequently used to validate the relative expression levels of the cytokines in MD.

Results

Significant differences were identified in the expression levels of interferon-γ (IFN-γ) (P < 0.001), interleukin (IL)-6 (P = 0.008) and tumor necrosis factor-α (TNF-α) (P = 0.036) in the luminal fluid of the ES comparing between the MD and AN groups. By contrast, the levels of IFN-γ, IL-10, IL-12p70, IL-17A, IL-6 and TNF-α in the serum of the MD group were not significantly different from those of either the AN group or healthy control subjects. In addition, no significant correlations in the expression levels of cytokines compared between the ELF and serum were found for the patients in either the MD or the AN group. Finally, the detection of positive expression of TNF-α, IL-6 and IFN-γ in the epithelial cells of the majority of ES specimens from patients with MD confirmed the up-regulated expression of these cytokines in the ES of patients with MD.

Conclusions

The identification of up-regulated expression levels of TNF-α, IL-6 and IFN-γ in the ELF in the present study has provided direct evidence for an increased immunologic activity in the microenvironment of the ES in patients with unilateral MD, may suggest the local inflammatory response underlies the mechanism of this disease.

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.

Cytokines and Inflammation in Meniere Disease

Meniere disease (MD) is a rare set of conditions associated with the accumulation of endolymph in the cochlear duct and the vestibular labyrinth with a decrease of endocochlear potential. It is considered a chronic inflammatory disorder of the inner ear with a multifactorial origin. The clinical syndrome includes several groups of patients with a core phenotype: sensorineural hearing loss, episodes of vertigo, and tinnitus with a non-predictable course. Genetic factors and the innate immune response seem to play a central role in the pathophysiology of the condition. Autoimmune MD should be diagnosed if a patient fulfills the diagnostic criteria for MD and one of the following autoimmune disorders: autoimmune thyroid disease, psoriasis, autoimmune arthritis, ankylosing spondylitis, or systemic lupus erythematosus. We summarize the evidence to support autoimmune MD as an endophenotype in bilateral MD associated with the allelic variant rs4947296 and nuclear factor-kappa B (NF-κB)-mediated inflammation, the role of cytokines (particularly interleukin-1β and tumor necrosis factor-α) in defining a subset of patients with autoinflammation, and the potential role of cytokines as biomarkers to distinguish between patients with MD and vestibular migraine. Finally, we also introduce a list of potential drugs that could regulate the immune response in MD with potential for repurposing in clinical trials.

Potential inflammatory biomarkers for tinnitus in platelets and leukocytes: a critical scoping review and meta-analysis

OBJECTIVE

To explore the association between platelets or leukocytes and tinnitus.

DESIGN

A meta-analysis and scoping review examining the association between tinnitus and platelets and leukocytes. All 11 studies included were critically appraised using the Joanna Briggs Institute (JBI) checklist (2017a). A random effects model was used to pool the results of the studies examining mean platelet volume (MPV) and tinnitus.

STUDY SAMPLE

1935 studies were identified in the initial search, 11 of which were included in the scoping review. 6 of the 11 studies had their MPV values pooled in the meta-analysis.

RESULTS

Pooled results of 818 subjects from 6 studies indicated that MPV was significantly higher in those with tinnitus compared to a comparison group without tinnitus. The overall mean difference was 0.43 fL with a 95% confidence interval (CI) from 0.31 to 0.55 and a p value of < 0.0001 which was statistically significant. MPV is the only haematological parameter which is reliably associated with tinnitus.

CONCLUSIONS

MPV could be a useful biomarker for tinnitus. Further studies should aim to standardise methodology with more rigorous exclusion criteria to reproduce and define this association. NLR, PLR, WBC count, RDW and PDW do not show a reliable association with tinnitus.

Association Between Asthma and Meniere's Disease: A Nested Case-Control Study

OBJECTIVES/HYPOTHESIS

This study aimed to investigate the association between Meniere's disease and prior history of asthma.

STUDY DESIGN

A nested case-control study.

METHODS

Among the patients aged ≥40 years from the Korean National Health Insurance Service-Health Screening Cohort 2002-2015, 7,734 diagnosed with Meniere's disease between 2004 and 2015 were enrolled in this study. From the 505,834 participants without a prior history of Meniere's disease, 30,936 control participants were selected based on age, sex, income, and region of residence. The presence of a prior history of asthma before the diagnosis of Meniere's disease was compared between the Meniere's disease group and control group using conditional logistic regression with odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Prior history of asthma was associated with 1.30 (1.21-1.39) times higher odds of Meniere's disease (E-value = 1.92 [1.71]). Both allergic asthma and nonallergic asthma patients demonstrated higher odds of Meniere's disease than the control group (adjusted OR = 1.21 [1.08-1.36] and E-value = 1.72 [1.37] for allergic asthma; adjusted OR = 1.26 [1.17-1.36] and E-value = 1.83 [1.60] for nonallergic asthma).

CONCLUSIONS

This study is the first to demonstrate a positive relationship between Meniere's disease and prior asthma history in adults. The association between prior asthma history and Meniere's disease was noted in both allergic and nonallergic asthma cases. The potential development of Meniere's disease should be considered when managing the asthma patients with dizziness or vertigo.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Effects of short- and long-term exposure to air pollution and meteorological factors on Meniere's disease

The association between air pollutants and Meniere’s disease has not been explored. The present study investigated the relationship between meteorological factors and air pollutants on Meniere’s disease. Participants, aged ≥ 40 years, of the Korean National Health Insurance Service-Health Screening Cohort were included in this study. The 7725 patients with Meniere’s disease were matched with 30,900 control participants. The moving average meteorological and air pollution data of the previous 7 days, 1 month, 3 months, and 6 months before the onset of Meniere’s disease were compared between the Meniere’s disease and control groups using conditional logistic regression analyses. Additional analyses were conducted according to age, sex, income, and residential area. Temperature range; ambient atmospheric pressure; sunshine duration; and levels of SO₂, NO₂, O₃, CO, and PM₁₀ for 1 month and 6 months were associated with Meniere’s disease. Adjusted ORs (odds ratios with 95% confidence interval [CI]) for 1 and 6 months of O₃ concentration were 1.29 (95% CI 1.23–1.35) and 1.31 (95% CI 1.22–1.42), respectively; that for the 1 and 6 months of CO concentration were 3.34 (95% CI 2.39–4.68) and 4.19 (95% CI 2.79–6.30), respectively. Subgroup analyses indicated a steady relationship of O₃ and CO concentrations with Meniere’s disease. Meteorological factors and air pollutants were associated with the rate of Meniere’s disease. In particular, CO and O₃ concentrations were positively related to the occurrence of Meniere’s disease.

MR Imaging of Cochlear Modiolus and Endolymphatic Hydrops in Patients With Menière's Disease

Background: Menière's disease (MD) is an inner ear disorder characterized by recurrent episodes of spontaneous vertigo, unilateral low-frequency sensorineural hearing loss, tinnitus, and aural fullness. Current diagnosis still often has to rely on subjective and audiometric criteria only, although endolymphatic hydrops is recognized as the pathophysiological substrate of the disease, having been demonstrated in anatomical pathological studies and by magnetic resonance (MRI). The modiolus has a close functional and anatomical relationship with the cochlear nerve and membranous labyrinth and can be evaluated with MRI but no data exist on the modiolar size in MD.

Purpose: Our purpose is to examine the following hypothesis. Is cochlear modiolus smaller in symptomatic ears in MD?

Methods: We used a retrospective 3 Tesla MR study (heavily T2-weighted 3D fast asymmetric spin-echo images and 0.5 mm slice thickness) comparing the mean modiolar area (MMA) in the index and best ears of eight patients with definite MD based on audiometric data. The obtained MMA values were compared against the audiometric data and the presence of vestibular endolymphatic hydrops.

Results: No differences were seen in MMA between best and worst ears. Ears with a pure tone average (PTA) ≥25 dB and more pronounced endolymphatic hydrops showed lower MMA (not statistically significant). Two patients with extreme endolymphatic hydrops showed a noteworthy ipsilateral decrease in the cochlear modiolus area.

Conclusion: No differences were seen in MMA between best and worst ears in definite MD. Worse hearing function (PTA ≥ 25dB) and more pronounced endolymphatic hydrops seem to be associated with lower MMA. This might be related to bone remodeling as a consequence of endolymphatic hydrops. Further research is needed to corroborate and explore these findings.

Distinct MicroRNA Profiles in the Perilymph and Serum of Patients With Menière's Disease

Hypothesis: Menière's disease microRNA (miRNA) profiles are unique and are reflected in the perilymph and serum of patients.

Background: Development of effective biomarkers for Menière's disease are needed. miRNAs are small RNA sequences that downregulate mRNA translation and play a significant role in a variety of disease states, ultimately making them a promising biomarker. miRNAs can be readily isolated from human inner ear perilymph and serum, and may exhibit disease-specific profiles.

Methods: Perilymph sampling was performed in 10 patients undergoing surgery; 5 patients with Meniere's disease and 5 patients with otosclerosis serving as controls. miRNAs were isolated from the serum of 5 patients with bilateral Menière's disease and compared to 5 healthy age-matched controls. For evaluation of miRNAs an Agilent miRNA gene chip was used. Analysis of miRNA expression was carried out using Qlucore and Ingenuitey Pathway Analysis software. Promising miRNAs biomarkers were validated using qPCR.

Results: In the perilymph of patients with Menière's disease, we identified 16 differentially expressed miRNAs that are predicted to regulate over 220 different cochlear genes. Six miRNAs are postulated to regulate aquaporin expression and twelve miRNAs are postulated to regulate a variety of inflammatory and autoimmune pathways. When comparing perilymph with serum samples, miRNA-1299 and−1270 were differentially expressed in both the perilymph and serum of Ménière's patients compared to controls. Further analysis using qPCR confirmed miRNA-1299 is downregulated over 3-fold in Meniere's disease serum samples compared to controls.

Conclusions: Patients with Ménière's disease exhibit distinct miRNA expression profiles within both the perilymph and serum. The altered perilymph miRNAs identified can be linked to postulated Ménière's disease pathways and may serve as biomarkers. miRNA-1299 was validated to be downregulated in both the serum and perilymph of Menière's patients.

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

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

Association Between Serum Vitamin D Level and Ménière's Disease

OBJECTIVES

Ménière's disease (MD) is a well-known inner ear disease; however, the etiopathogenesis is unknown. Several factors may be involved. Meanwhile, vitamin D is reported to have an important role in inner ear physiology. The aim of this study is to evaluate the relation between vitamin D deficiency and MD.

STUDY DESIGN

This matched case-control study compared serum vitamin D levels between patients with definite MD and those without it.

SETTING

The study was done between August 2018 and December 2019 at Ghaem University Hospital in Mashhad, Iran.

METHODS

Twenty-eight patients with definite MD were matched with a group of 84 healthy individuals, regarding age, sex, body mass index, and occupation (indoor vs outdoor). The serum level of vitamin D (25-hydroxyvitamin D3) was measured in both groups.

RESULTS

The mean ± SD vitamin D level was 18.9 ± 9.7 ng/mL in the case group and 25.2 ± 13.7 ng/mL in the control group (P = .027). There was a significant difference between the case and control groups according to the results of the conditional logistic regression model (P = .03; adjusted odds ratio, 0.96). In the MD group, 17 (60.7%) patients were vitamin D deficient, 6 (21.4%) insufficient, and only 5 (17.9%) sufficient.

CONCLUSIONS

The results of this study show that serum vitamin D level in MD is significantly lower than that of the control group. However, the role of vitamin D supplementation in the management of MD needs further study.

LEVEL OF EVIDENCE

4.

The transcriptome characteristics of vestibular organs from delayed endolymphatic hydrops patients (Meniere's disease)

OBJECTIVES

To identify genes that are related to delayed endolymphatic hydrops (DEH) in patients by RNA-Seq analysis.

DESIGN

Observational study.

SETTING

Eye & ENT Hospital, Fudan University (Shanghai, China).

PARTICIPANTS

We collected the entire vestibular system from four patients with DEH who underwent labyrinthectomy. Three control samples were collected from patients with acoustic neuroma or facial neuroma treated via the translabyrinthine approach. High-throughput RNA-Seq analysis was performed to investigate gene expression in the pathological vestibular system.

MAIN OUTCOME MEASURES

Our bioinformatic analysis identified 17 genes that were upregulated and eight genes that were downregulated in patients with DEH compared with the controls.

RESULTS

The altered gene expression profile suggested that DEH is closely related to neuropathy and autoimmune disease. In addition, many of the differentially regulated genes were involved in cell adhesion, suggesting a role of cell adhesion in DEH. Immunofluorescence analysis confirmed the expression of PMP2 and CLDN19 in the cytoplasm of hair cells and scattered expression of MPZ at cell junctions. The protein expression levels were higher in specimens from patients with Ménière's disease and DEH compared with controls.

CONCLUSIONS

The protein expression profile of vestibular organs in patients with endolymphatic hydrops exhibited a degree of similarity to that of Ménière's disease. Endolymphatic hydrops is characterised by autoimmune abnormalities. DEH and Ménière's disease are likely to be different manifestations of the same disease, with disparate clinical symptoms. RNA-Seq is a useful analytical tool to characterise the vestibular pathology based on its transcriptome.

Could ionic regulation disorders explain the overlap between meniere's disease and migraine?

Ménière's disease (MD) is an inner ear disorder characterized by a burden of symptoms and comorbidities, including migraine. In both disorders, ionic dysregulation may play a role as a predisposing factor. In recent years. aquaporins have been widely investigated, but the results are far from conclusive. We recently studied the genetics of ionic transporters and the hormone endogenous ouabain as predisposing factors for development of MD. In particular, we found two genetic polymorphisms associated with MD: 1) rs3746951, a missense variant (Gly180Ser) in the salt-inducible kinase-1 (SIK1) gene encoding a Na+, K+ ATPase; 2) rs487119, an intronic variant of gene SLC8A1 coding for a Na+, Ca++ exchanger (NCX-1). Ionic concentration in the brain also plays a role in the pathophysiology of migraine. In this brief review we summarize what has been published on MD and migraine.

Identification of Potential Meniere's Disease Targets in the Adult Stria Vascularis

The stria vascularis generates the endocochlear potential and is involved in processes that underlie ionic homeostasis in the cochlear endolymph, both which play essential roles in hearing. The histological hallmark of Meniere's disease (MD) is endolymphatic hydrops, which refers to the bulging or expansion of the scala media, which is the endolymph-containing compartment of the cochlea. This histologic hallmark suggests that processes that disrupt ion homeostasis or potentially endocochlear potential may underlie MD. While treatments exist for vestibular symptoms related to MD, effective therapies for hearing fluctuation and hearing loss seen in MD remain elusive. Understanding the potential cell types involved in MD may inform the creation of disease mouse models and provide insight into underlying mechanisms and potential therapeutic targets. For these reasons, we compare published datasets related to MD in humans with our previously published adult mouse stria vascularis single-cell and single-nucleus RNA-Seq datasets to implicate potentially involved stria vascularis (SV) cell types in MD. Finally, we provide support for these implicated cell types by demonstrating co-expression of select candidate genes for MD within SV cell types.

Psoriasis Increases the Risk of Sudden Sensorineural Hearing Loss: A Longitudinal Follow Up Study Using a National Sample Cohort

Psoriasis is a well-known immune-mediated disease. Its autoimmune pathophysiology is consistent with the immune-mediated systemic vascular hypothesis regarding the pathogenesis of sudden sensorineural hearing loss (SSNHL). The purpose of our study was to investigate whether psoriasis affects the prevalence of SSNHL in all age groups matched by age, sex, income, and region of residence. Korean Health Insurance Review and Assessment Service-National Patient Samples were collected from 2002 to 2013. A 1:4 matched psoriasis group (n = 12,864) and control group (n = 51,456) were selected. The crude (simple) and adjusted (Charlson comorbidity index) hazard ratios (HR) for psoriasis and SSNHL were analyzed using the stratified Cox proportional hazard model. The incidence of SSNHL was significantly higher in the psoriasis group than in the control group (0.5% vs. 0.4%, p = 0.004). Psoriasis increased the risk of SSNHL (adjusted HR = 1.44, 95% confidence interval (CI) = 1.09–1.90, p = 0.010). In the stratification analysis, the incidence of SSNHL was significantly higher in the 30–59-year-old group than other group SSNHL (adjusted HR = 1.50, 95% CI = 1.06–2.12, p = 0.023). In addition, SSNHL occurred significantly more frequently in men with psoriasis (adjusted HR = 1.70, 95% CI = 1.17–2.49, p = 0.006). Psoriasis increased the risk of SSNHL, and SSNHL was more prevalent in between the age of 30–59-year-olds and men with psoriasis.

Current status on researches of Meniere's disease: a review

Background: Meniere's disease (MD) is a complex and multifactorial inner ear disease. The etiology of MD is unclear. Significant progress had been made in diagnosis and treatment. Complete cure for this disease is still impossible.Objectives: This review covers the updated research results in MD in the past decades.Material and methods: Recent publications were critically reviewed.Results: The relationship between Endolymphatic hydrops and Meniere symptoms requires further study. Direct visualization of EH is achieved by special sequences of inner ear MRI. Appearance of EH could be observed in MD patients both in symptomatic and asymptomatic ears. Visualization of EH in vivo might make a great substantial improvement in diagnose of MD. The first goal of the management of MD is to reduce the attack frequency. Several safe and effective medical and surgical therapies are practiced to help patients to control vertigo and preserve hearing.Conclusions and significance: There has been no major breakthrough in the pathogenesis research of MD in recent years. Visualization of EH in vivo might make a great substantial improvement in diagnose of MD. Clinicians still have few effective ways to alleviate the progress of the disease.

Clinical and molecular genetics of Meniere disease

Meniere disease (MD) represents a heterogeneous group of relatively rare disorders of the inner ear that causes vertigo attacks, fluctuating sensorineural hearing loss (SNHL) involving low and medium frequencies, tinnitus, and aural fullness. MD has been attributed to an accumulation of endolymph in the cochlear duct. The diagnosis of MD is based on the phenomenological association of clinical symptoms including SNHL during the vertigo attacks. At least two mechanisms are involved in MD: (a) a pro-inflammatory immune response mediated by interleukin-1 beta (IL-1β), tumor necrosis factor alpha (TNFα), and IL-6, and (b) nuclear factor-kappa B (NF-κB)-mediated inflammation in the carriers of the single nucleotide variant rs4947296. The majority of MD cases are considered sporadic, although familial aggregation has been recognized in European and East Asian populations in multiplex families, supporting a genetic contribution to the disease. In sporadic MD cases, the main genetic findings involve multiplex rare variants in several SNHL genes, such as GJB2, USH1G, SLC26A4, ESRRB, and CLDN14, and axonal guidance signaling genes, such as NTN4 and NOX3. Familial aggregation has been reported in 6–8 % of MD cases, and most families show an autosomal dominant inheritance. Few rare missense heterozygous variants have been described in simplex families in six genes (COCH, FAM136A, DTNA, PRKCB, SEMA3D, and DPT). Of note, 33 % of familial MD individuals show singleton and multiplex rare missense variants in the OTOG gene, suggesting a multiallelic inheritance. Moreover, potentially pathogenic rare variants in the familial genes FAM136A, DTNA, and DPT have been reported in Korean singletons with sporadic MD. Rare variants may have a significant contribution to sporadic and familial MD. The interaction of common cis-regulatory variants located in non-coding regions and rare variants in coding regions in one or more genes will determine the variation on the phenotype in MD. Further studies on genotype–phenotype correlations are required to improve the yield of genetic diagnosis, and different types of variants seem to contribute to the genetic structure of MD.

The Price of Immune Responses and the Role of Vitamin D in the Inner Ear

OBJECTIVE

In this review the authors discuss evidence from the literature concerning vitamin D and temporal bone diseases (benign paroxysmal positional vertigo [BPPV], Menière's disease [MD], vestibular neuritis, idiopathic facial paralysis, idiopathic acute hearing loss). Common features shared by Menière's disease, glaucoma, and the possible influence by vitamin D are briefly discussed.

DATA SOURCES, STUDY SELECTION

Publications from 1970 until recent times have been reviewed according to a keyword search (see above) in PubMed.

CONCLUSIONS

MD, BPPV, vestibular neuritis, idiopathic facial paralysis, idiopathic acute hearing loss may all have several etiological factors, but a common feature of the current theories is that an initial viral infection and a subsequent autoimmune/autoinflammatory reaction might be involved. Additionally, in some of these entities varying degrees of demyelination have been documented. Given the immunomodulatory effect of vitamin D, we postulate that it may play a role in suppressing an eventual postviral autoimmune reaction. This beneficial effect may be enhanced by the antioxidative activity of vitamin D and its potential in stabilizing endothelial cells. The association of vitamin D deficiency with demyelination has already been established in other entities such as multiple sclerosis and experimental autoimmune encephalitis. Mice without vitamin D receptor show degenerative features in inner ear ganglia, hair cells, as well as otoconia. The authors suggest further studies concerning the role of vitamin D deficiency in diseases of the temporal bone. Additionally, the possible presence and degree of demyelination in these entities will have to be elucidated more systematically in the future.

Is Early Progression to Bilateral Involvement in Menière's Disease a Poor Prognostic Indicator?

OBJECTIVE

To investigate differences in the clinical features of bilateral Menière's disease (BMD) with early and late bilateral involvement.

STUDY DESIGN

A retrospective case-comparison study.

SETTING

Tertiary referral center.

PATIENTS

In total, 25 patients with definite BMD were enrolled. Patients with bilateral involvement with a transition interval shorter than 1 month were considered to have synchronous BMD, whereas the others had metachronous BMD.

INTERVENTIONS

We investigated differences in prognosis as defined by changes in the number of vertigo attacks after treatment, demographics, comorbidities, and inner ear function according to the transition interval from unilateral to bilateral involvement.

MAIN OUTCOME MEASURE

We investigated other appropriate cut-off values in the interval from first- to second-ear involvement to predict poor prognosis.

RESULTS

Receiver operating characteristic curve analysis revealed that a cut-off value of < 18-month interval exhibited maximum sensitivity and specificity for predicting poor prognosis. According to this value, we categorized patients into the early bilateral involvement group (EBIG, < 18 months' interval) and the late bilateral involvement group (LBIG, ≥ 18 months' interval). Patients with synchronous BMD and patients in the EBIG group exhibited poorer prognosis compared with patients with metachronous BMD and those in LBIG (p = 0.011 and p ≤ 0.001). Demographics, hearing threshold, vestibular deficit, and comorbidities were not significantly different between the two groups (p > 0.05). None of the patients exhibited systemic autoimmune disease.

CONCLUSION

BMD with early bilateral progression exhibited poorer prognosis compared with late bilateral progression.

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

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

Systematic review of magnetic resonance imaging for diagnosis of Meniere disease

The diagnostic criteria for Meniere Disease (MD) are clinical and include two categories: definite MD and probable MD, based on clinical examination and without the necessity of advanced vestibular or audiological testing. The condition is a heterogeneous disorder and it is associated with endolymphatic hydrops (EH), an accumulation of endolymph in the inner ear that causes damage to the ganglion cells. Patients with suspected EH can be examined by Magnetic Resonance Imaging (MRI), offering new insights into these inner ear disorders. Results of imaging studies using the hydrops protocols show conflicting results in MD patients. These discrepancies can be dependent either on the MRI sequence parameters or on the method of hydrops grading or the inclusion criteria to select patients. The visualization of EH can be classified based on a semi-quantitative ratio between endolymph and perilymph liquids, or on the distinction between the saccule and the utricle structures. In addition, MRI can also be used to evaluate whether cochleovestibular nerves can present with imaging signs of axonal loss.In this systematic review, we have selected case-controlled studies to better characterize the potential added value in the diagnosis and management of patients with MD. Using different techniques, studies have identified the saccule as the most specifically involved structure in MD, and saccular hydrops seems to be associated with low to medium-tone sensorineural hearing loss degree. However, early symptoms still appear too subtle for identification using MRI and the reproducibility of the hydrops protocols with various MRI scan manufacturers is debatable, thus limiting expansion of these techniques into clinical practice for the diagnosis of MD at this time.Further research is needed. The future inclusion of semicircular canal hydrops location in the imaging signs and the application of MRI in patients with atypical presentations hold promise.

Autoinflammatory characteristics and short-term effects of delivering high-dose steroids to the surface of the intact endolymphatic sac and incus in refractory Ménière's disease

Objective

To investigate immune-related genetic background in intractable Meniere’s disease (MD) and the immediate results of a novel therapy by delivering steroids to the surface of the intact endolymphatic sac (ES) and incus in a sustainable manner.

Case report and methods

Candidate genes involved in immune regulation were sequenced using a next-generation sequencing method in a patient with intractable MD. Mutations were confirmed using the Sanger sequencing method. The ES was exposed, and gelatin sponge particles were immersed in high-dose methylprednisolone solution and placed onto the surface of ES. “L”-shaped gelatin sponge strips were immersed in dexamethasone solution and served as a guiding device for the steroids by touching the incus and gelatin sponge particles on the surface of the ES. Gelatin sponge particles immersed in dexamethasone solution were placed around the gelatin sponge strips and sealed using fibrin glue.

Results

Autoinflammation in the refractory MD case was indicated by genotype, including novel heterozygous mutations of PRF1, UNC13D, SLC29A3, ITCH, and JAK3, as well as phenotype. The vertigo was fully relieved immediately after operation. Tinnitus and aural fullness were resolved 3 weeks after operation, whereas hearing improved in 2 mon postoperation. No recurrence was noted during the 5-monfollow-up, and the final MRI supported the novel therapeutic hypothesis.

Conclusion

Autoinflammation was involved in a refractory MD. This novel therapy, which involves the delivery of steroids to the surface of the intact ES and incus, is effective in relieving vertigo and tinnitus and improves hearing function of refractory MD.

TRAIL, OPG, and TWEAK in kidney disease: biomarkers or therapeutic targets?

Ligands and receptors of the tumor necrosis factor (TNF) superfamily regulate immune responses and homeostatic functions with potential diagnostic and therapeutic implications. Kidney disease represents a global public health problem, whose prevalence is rising worldwide, due to the aging of the population and the increasing prevalence of diabetes, hypertension, obesity, and immune disorders. In addition, chronic kidney disease is an independent risk factor for the development of cardiovascular disease, which further increases kidney-related morbidity and mortality. Recently, it has been shown that some TNF superfamily members are actively implicated in renal pathophysiology. These members include TNF-related apoptosis-inducing ligand (TRAIL), its decoy receptor osteoprotegerin (OPG), and TNF-like weaker inducer of apoptosis (TWEAK). All of them have shown the ability to activate crucial pathways involved in kidney disease development and progression (e.g. canonical and non-canonical pathways of the transcription factor nuclear factor-kappa B), as well as the ability to regulate cell proliferation, differentiation, apoptosis, necrosis, inflammation, angiogenesis, and fibrosis with double-edged effects depending on the type and stage of kidney injury. Here we will review the actions of TRAIL, OPG, and TWEAK on diabetic and non-diabetic kidney disease, in order to provide insights into their full clinical potential as biomarkers and/or therapeutic options against kidney disease.

Vincamine exerts protective effect on spiral ganglion neurons in endolymphatic hydrops guinea pig models

The aim of this study was to investigate the protective effects of vincamine in endolymphatic hydrops (ELH). After ELH guinea pigs treated by vincamine, the concentration of VAP in plasma, and the levels of cAMP, MDA, SOD, GSH-Px in right cochlea were measured using spectrophotometric method. The V2R, NMDAR1, p-NMDAR1, AQP2, p-AQP2, caspase3/9 and c-caspase3/9 expressions in right cochlea were detected using western blot analysis. The cochlear hydrops degree and SGNs density were evaluated by hemotoxylin and eosin staining (HE) test. Normal hearing and vestibular function were warranted by the tests of auditory brainstem response (ABR) and electronystagmography (ENG). After glutamate-injured SGNs treated with vincamine, the MDA, SOD GSH-Px, NGF, BDNF, NT3, NT4 and Trks levels were measured. Meanwhile, the Bcl2, Bax, NMDAR1, p-NMDAR1, PI3K, p-PI3K, Akt, p-Akt, caspase3/9 and cleaved-caspase3/9 expression levels were detected. Furthermore, the viability, apoptosis and necrosis of SGNs were tested by MTT and Hoechst/PI staining methods. The results indicated that vincamine could significantly inhibit the expression levels of cAMP, MDA, V2R, p-NMDAR1, p-AQP2 and c-caspase-3/-9 in cochlea, alleviate the cochlear hydrops degree, regulate the audiological and vestibular dysfunctions. The SGNs density, SOD and GSH-Px levels were also increased by vincamine. In vincamine-treating groups, the MDA, Bax, p-NMDAR1, and c-caspase3/9 levels were observably decreased, while SGNs survival, SOD, GSH, NGF, BDNF, NT3, NT4, Trks, Bcl2, p-PI3K, p-Akt expressions were improved. The present study indicated a novel use of vincamine in suppressing ELH formation by down-regulating the VAP/AQP2 signaling pathway. It also manifested that vincamine exerted protective effects on hearing via improving neurotrophin-dependent PI3K/Akt signaling pathway in SGNs.

Update on Vertigo in Autoimmune Disorders, from Diagnosis to Treatment

The prevalence of autoimmune diseases has been increasing over the last 20 years. The clinical presentation of this large and heterogeneous group of disorders depends on whether the involvement is organ-specific or non-organ-specific. Dizziness, vertigo, and disequilibrium are common symptoms reported by patients with vestibulocochlear involvement. The association of vertigo and autoimmune diseases has been largely documented, suggesting that autoimmune disorders could be overrepresented in patients with vertigo in comparison to the general population. The aim of this review is to present the recent literature findings in the field of autoimmune-mediated diseases with cochleovestibular involvement, focusing on the clinical presentation, diagnosis, and treatment of immune-mediated inner ear diseases including autoimmune inner ear disease (AIED), Meniere's disease, and bilateral vestibulopathy, as well as of systemic autoimmune diseases with audiovestibular disorders, namely, Behçet's disease, Cogan's syndrome, sarcoidosis, autoimmune thyroid disease, Vogt-Koyanagi-Harada syndrome, relapsing polychondritis, systemic lupus erythematosus, antiphospholipid syndrome, IgG4-related disease, and ANCA-associated vasculitides.

Towards personalized medicine in Ménière's disease

Ménière's disease (MD) represents a heterogeneous group of relatively rare disorders with three core symptoms: episodic vertigo, tinnitus, and sensorineural hearing loss involving 125 to 2,000 Hz frequencies. The majority of cases are considered sporadic, although familial aggregation has been recognized in European and Korean populations, and the search for familial MD genes has been elusive until the last few years. Detailed phenotyping and cluster analyses have found several clinical predictors for different subgroups of patients, which may indicate different mechanisms, including genetic and immune factors. The genes associated with familial MD are COCH, FAM136A, DTNA, PRKCB, SEMA3D, and DPT. At least two mechanisms have been involved in MD: (a) a pro-inflammatory immune response mediated by interleukin-1 beta (IL-1β), tumor necrosis factor alpha (TNFα), and IL-6, and (b) a nuclear factor-kappa B (NF-κB)-mediated inflammation in the carriers of the single-nucleotide variant rs4947296. It is conceivable that microbial antigens trigger inflammation with release of pro-inflammatory cytokines at different sites within the cochlea, such as the endolymphatic sac, the stria vascularis, or the spiral ligament, leading to fluid imbalance with an accumulation of endolymph. Computational integration of clinical and "omics" data eventually should transform the management of MD from "one pill fits all" to precise patient stratification and a personalized approach. This article lays out a proposal for an algorithm for the genetic diagnosis of MD. This approach will facilitate the identification of new molecular targets for individualized treatment, including immunosuppressant and gene therapy, in the near future.

Vitamin D supplementation may improve symptoms in Meniere's disease

In the last 4 years the authors observed a trend that correcting vitamin D deficiency in newly diagnosed cases of Meniere's disease decreased the necessity of the ablative therapy with intratympanic gentamicin. According to their hypothesis, vitamin D supplementation may indeed have a beneficial effect in Meniere's disease if the symptoms are caused by a local postviral autoimmune reaction. Vitamin D has a strong immunomodulatory role, one of which is the regulation of the expression of pro-inflammatory mediators. The authors suggest further epidemiological studies to decide if there is a connection between vitamin D deficiency and Meniere's disease.

Genetic contribution to vestibular diseases

Growing evidence supports the contribution of allelic variation to vestibular disorders. Heritability attributed to rare allelic variants is found in familial vestibular syndromes such as enlarged vestibular aqueduct syndrome or familial Meniere disease. However, the involvement of common allelic variants as key regulators of physiological processes in common and rare vestibular diseases is starting to be deciphered, including motion sickness or sporadic Meniere disease. The genetic contribution to most of the vestibular disorders is still largely unknown. This review will outline the role of common and rare variants in human genome to episodic vestibular syndromes, progressive vestibular syndrome, and hereditary sensorineural hearing loss associated with vestibular phenotype. Future genomic studies and network analyses of omic data will clarify the pathway towards a personalized stratification of treatments.