Endolymphatic sac decompression as a treatment for Meniere's disease

OBJECTIVES/HYPOTHESIS

Endolymphatic sac decompression is a surgical treatment option for patients with medically intractable Meniere's disease. However, effectiveness is debated because published data show great variability. Outcome-based research studies are useful in incorporating the patient's perspective on the success of treatment. To further assess effectiveness of endolymphatic sac decompression, we performed a prospective study to examine both symptom-specific and general health outcomes.

STUDY DESIGN

Prospective, observational outcome study.

METHODS

Nineteen patients with endolymphatic sac decompression responded to symptom-specific questionnaires and the Medical Outcomes Short-Form 36 Health Survey (SF-36) before and after surgery. Follow-up ranged from 6 to 58 months with a mean duration of 50 months.

RESULTS

Overall measures of physical health were significantly improved following endolymphatic sac decompression (P = .04), whereas overall measures of mental health were unchanged (P = .74). Role Physical and Social Functioning scores were significantly improved following endolymphatic sac decompression (P = .04 and P = .03, respectively). Study patients scored significantly lower (P < .05) than SF-36 normative data in 6 of 10 categories before endolymphatic sac decompression but patient scores were not significantly different from normal scores in all but one category (General Health) following endolymphatic sac decompression. The mean number of vertigo episodes was significantly reduced from an average of 8.3 times per month to an average of 2.6 times per month following endolymphatic sac decompression (P = .006). Ninety-five percent of patients (18 of 19 patients) reported improvement in symptoms (frequency, duration, or intensity) of vertigo and 37% (7 of 19 patients) reported complete resolution of vertigo.

CONCLUSION

Endolymphatic sac decompression significantly improved perception of physical health, as well as symptom-specific outcomes, in patients with medically intractable Meniere's disease.

[Changes in plasma inner ear hormones after endolymphatic sac drainage and steroid-instillation surgery (EDSS)]

We treated 33 cases of intractable Meniere's disease with endolymphatic sac drainage and steroid-instillation surgery (EDSS), attaining good long-term results in vertigo and hearing. To elucidate how EDSS affects the diseased inner ear, we examined changes in plasma inner ear hormones after EDSS. Among inner ear hormones, plasma vasopressin was significantly decreased after EDSS compared to after mastoidectomy. In cases with good long-term results in vertigo and hearing, postoperative plasma vasopressin remained lower over the long term than in cases with poor results. In cases with negative glycerol test results one year after surgery, postoperative plasma vasopressin also remained significantly lower over the long term than in cases with positive results. Previous studies reported that vestibular neurons projected into hypothalamic supraoptic and paraventricular nuclei and that changes in the inner ear pressure were related to plasma vasopressin. Taken together with present findings, this suggests that EDSS may reduce plasma vasopressin through modification of the diseased inner ear environment, resulting in improved inner ear function.

[Endolymphatic sac drainage and steroid-instillation surgery (EDSS) for intractable Meniere's disease]

Endolymphatic sac surgery is one of the most widely accepted techniques used to treat intractable Meniere's disease. To improve this surgery, we developed the following techniques: A simple mastoidectomy was used to expose the endolymphatic sac between the sigmoid sinus and inferior margin of the posterior semicircular canal. The sac was opened and filled with a mass of prednisolone. A bundle of absorbable gelatin films was then inserted into the sac lumen to expand it, followed by gelatin sponges dipped in a high concentration of dexamethasone. Long-term results (17-32 months) in 20 patients with intractable Meniere's disease treated with endolymphatic sac drainage and steroid-insertion surgery (EDSS) showed that definitive spells were completely controlled in 15 of 20 cases (75%); all reports of vertigo decreased; hearing improved in 12 of 20 cases (60%); and annoyance due to tinnitus decreased in 15 of 20 cases (75%). Steroids directly instilled into the endolymphatic cavity may thus be more effective with the diseased inner ear organs than those applied via any other route. Draining of endolymphatic fluid at the sac into the mastoid cavity also contributed to these satisfactory EDSS results.

Effects of exposing the opened endolymphatic sac to large doses of steroids to treat intractable Meniere's disease

To enhance the effect of treatment for intractable Meniere's disease, we exposed the opened endolymphatic sac to high concentrations of steroids. This technique--endolymphatic sac drainage and steroid instillation surgery--involves the application of a mass of prednisolone followed by absorbable gelatin sponges soaked in a high concentration of dexamethasone into a sac lumen opened and expanded with a bundle of absorbable gelatin film. These sponges are also placed around the sac and coated with biochemical adhesive so that the medicine is slowly delivered into the sac over a prolonged period of time by means of a natural sustained-release vehicle. The short-term results (6 to 14 months) in 12 patients with Meniere's disease, including those in stage IV, treated by the above techniques showed that definitive spells were completely controlled in all cases. Hearing was improved, and annoyance due to tinnitus was decreased in all cases except one.

Combined vestibular neurectomy and endolymphatic sac shunt via the retrosigmoid approach in the treatment of Ménière's disease

The nature of surgical treatment for Ménière's disease has evolved from destructive to conservative in the interest of preserving hearing. We have performed a combined procedure that involves a vestibular neurectomy to control vertigo, which is followed by an endolymphatic sac shunt to control hydrops in 26 patients. Both procedures are performed via the retrosigmoid approach during the same surgical step. We believe this combination procedure is a worthwhile option to consider in order to achieve good control of vertigo and endolymphatic hydrops and to preserve hearing in patients with Ménière's disease.

Three new surgeries for treatment of intractable Meniere's disease

OBJECTIVE

This study aimed to describe the rationales for and preliminary results of three new types of surgery for the treatment of intractable Meniere's disease, all involving insertion of a capillary tube into the endolymphatic duct. This study also aimed to compare the contrasting surgical strategies of endolymphatic sac enhancement versus sac supplantation.

STUDY DESIGN AND SETTING

The study design was a retrospective review of 129 surgeries conducted by the author at Chang Gung Memorial Hospital since 1993: 51 cases of Huang/Gibson inner ear shunt implantation, 52 cases of intraductal capillary tube implantation (ICTI), and 26 cases of ICTIin combination with endolymphatic sac ballooning surgery (ESBS).

PATIENTS

This study is limited to patients with classic Meniere's disease whose vertiginous symptoms were disabling and refractory to dietetic and medical treatment.

MAIN OUTCOME MEASURES

Comparison of preoperative and postoperative conditions (e.g., vertigo control, hearing, disability) using American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 1985 criteria and chi-square statistical method was measured.

RESULTS

After 1 year of follow-up, use of the Huang/Gibson shunt resulted in a 94.1% vertigo control rate (complete or substantial) and fairly good hearing results, ICTI by itself resulted in an 88.5% rate of vertigo control and relatively unremarkable hearing results, and the ICTI in combination with ESBS (ICTI/ESBS) achieved a vertigo control rate of 96.1% in addition to good hearing results.

CONCLUSIONS

The 1-year follow-up results for Huang/Gibson shunt implantation and sac-preserving ICTI/ESBS have approximately duplicated the excellent performance of the Arenberg implant after the same follow-up period, perhaps attributable in part to enhancement of endolymph flow through the endolymphatic duct.

Summating potential and action potential ratio in Meniere's disease before and after treatment

OBJECTIVE

This study aimed to compare the summating potential and action potential ratio (SP:AP) in patients with Meniere's disease before and after various surgical and medical treatments as an indication of change in endolymphatic hydrops to study the progression of Meniere's disease.

STUDY DESIGN

The study design was a retrospective case review.

SETTING

The study was conducted at an otology-neurotology referral center.

PATIENTS

Eighty-eight ears of 84 patients with Meniere's disease received medical treatment in 18 ears and surgical treatments including endolymphatic shunt in 12 ears, streptomycin perfusion of the lateral semicircular canal in 9 ears, streptomycin perfusion of the middle ear in 33 ears, and dexamethasone perfusion of the middle ear in 16 ears.

INTERVENTION

Transtympanic electrocochleography (ECoG) was performed in all patients before treatment and 1-57 months after treatment (mean, 13.5 months) with a 2-year interval in 28 patients.

MAIN OUTCOME MEASURE

An enlarged SP:AP ratio (> or = 0.40) was used as the diagnostic criterion for endolymphatic hydrops.

RESULTS

Overall, an enlarged SP:AP ratio was found in 75% of ears before treatment and 78% after treatment. The SP:AP ratio, when enlarged, remained enlarged in 91% of ears. A nonenlarged SP:AP ratio before treatment became enlarged after treatment in 41% of ears. In American Academy of Otolaryngology-Head and Neck Surgery stage 1 Meniere's disease (pure-tone threshold average < or = 25 dB), an enlarged SP:AP was found in 58% of ears before treatment and 79% after. Twenty-five (89%) of 28 patients followed for 2 years were free of vestibular symptoms after treatment, and in 22 patients (79%), the SP:AP remained enlarged. The distribution of an enlarged SP:AP ratio was associated with the duration of disease (chi-square = 33.5552, p < 0.01).

CONCLUSIONS

The development of endolymphatic hydrops, as indicated by an enlarged SP:AP, is part of the progression of Meniere's disease. The longer the duration of the disease, the more likely the SP:AP ratio will be enlarged. These findings indicate that endolymphatic hydrops as detected by ECoG was not reversed in this study by the treatments used. Despite the absence of definitive spells of vertigo in most patients, endolymphatic hydrops as evidenced by an enlarged SP:AP ratio persisted.

The role of endolymphatic mastoid shunt surgery in the managed care era

OBJECTIVE

Ongoing controversy regarding the surgical management of Meniere's disease has prompted us to review the effectiveness of the endolymphatic mastoid shunt procedure in the control of vertigo. In the current managed care environment in which outcome measures, cost effectiveness, and procedural efficacy must be demonstrated, the surgeon can no longer rely on anecdotal or empirical observations regarding the effectiveness of a treatment paradigm.

STUDY DESIGN

Retrooperative case review.

SETTING

A tertiary care center.

PATIENTS

The records of 327 patients with presumed Meniere's-related vertigo referred to the University of Cincinnati Medical Center were reviewed. One hundred nine patients underwent endolymphatic mastoid shunt. Our study population consists of 96 of these patients that were available for 5 years follow-up.

INTERVENTIONS

Endolymphatic mastoid shunt for the control of medically refractory vertigo.

MAIN OUTCOME MEASURE

Control of vertigo.

RESULTS

Using the Arenberg anatomic classification system, patients with a type I endolymphatic sac achieved 68% control of vertigo, those with a type II endolymphatic sac had a 92% control rate, and patients with a type III endolymphatic sac achieved 78% relief.

CONCLUSIONS

Based on an assessment of outcome variables, we conclude that there remains a definite role for endolymphatic shunt surgery in the contemporary approach to patients with Meniere's disease.

Long-term outcome of Ménière's disease: endolymphatic mastoid shunt versus natural history

This retrospective study evaluates the outcome of 38 patients with intractable Ménière's disease with a minimum of 7 years follow-up. Twenty underwent endolymphatic-mastoid shunt (EMS) and 18 were offered surgery but declined (natural history, NH, group). At the last control, 85% of the patients who were operated on (EMS group) and 74% of the NH patients had complete or substantial control of vertigo. The difference between the two groups was not significant. However, it was significant at 2 and 4 years follow-up. At 2 years, EMS patients had complete or substantial control of vertigo in 65% of the cases, at 4 and 6 years in 85% of the cases. Only 32 % of the NH patients had complete or substantial control of vertigo at 2 years. This percentage rose to 50% at 4 years and to 74% at 6 years. Hearing results in the two groups were not significantly different. Tinnitus disappeared or decreased in 56% of the EMS patients and in 18% of the NH patients. Sixty-seven percent of the EMS patients and 29% of the NH patients reported that their aural fullness was abolished. In conclusion, over the years, approximately 8 out of 10 of our patients with Ménière's disease achieved complete or substantial control of vertigo; however, this reduction was observed earlier in EMS patients than in those who declined surgery.

Endolymphatic mastoid shunt surgery in unilateral Menière's disease

One-hundred endolymphatic mastoid shunt operations in patients with classic unilateral Meniere's disease were analyzed. The patients were carefully preselected with a comprehensive protocol of audiovestibular and metabolic investigations. All patients had definitive electrophysiologic evidence of endolymphatic hydrops with an enhanced negative summating potential on transtympanic electrocochleography. The surgical results were analyzed both by the original American Academy of Ophthalmology and Otolaryngology Guidelines (AAOO, 1972), and the more recent modifications of the American Academy of Otolaryngology-Head and Neck Surgery (AA-HNS, 1985). Control of vertigo was achieved in 79% of the patients overall, with 42% sustaining complete control and 37% substantial control. A significant hearing improvement was obtained in 15% of cases, there was no change in 56% of patients, and hearing became worse in 29%. Tinnitus improved following surgery in 35% of patients, was the same in 56%, and worse in 9%. Postoperatively, there was no disability in 42% of the patients, some degree of disability in 50%, and severe disability and inability to sustain gainful employment in only 8%.

Austin endolymph dispersement shunt surgery for Menière's disease

This paper analyses the results of 53 Austin endolymph dispersement shunt procedures as compared to previously reported data on 87 Arenberg inner ear valve implants and 339 cases employing various other surgical techniques. Overall results are similar regardless of the surgical method involved, however findings indicate that capillary endolymph dispersement both affords more class A results, with isolated spectacular hearing gains, and creates a greater chance of completely eliminating dizziness in both definite and adjunctive spells. Furthermore, Austin's endolymph dispersement drain evidenced no adverse effects on inner ear function, unlike Arenberg's inner ear valve, and is herein documented as a safe and effective surgical option for the treatment of Meniere's disease.

The surgical procedures and evaluation of two modifications of endolymphatic sac surgery: the epidural shunt and vein graft drainage

A method of ELS surgery was originally described in 1926 by George Portmann. However, the risk of adhesive closure of an incision on the lateral wall of the ELS in his technique has been a matter of dispute ever since. A number of modifications have been advocated in order to improve the patency of the ELS, such as Yamakawa-Naito's subarachnoid shunt (1954), House's endolymphatic-subarachnoid shunt (1962), Shea's Teflon film drainage of the sac (1966), the T-tube shunt of Paparella & Hanson (1976), the valve implant by Arenberg (1979), the epidural drainage by an L-shaped incision in the lateral wall of the sac with insertion of gelatin film, developed by Kitahara & Futaki (1974), and vein graft drainage of the ELS by Futaki & Nomura (1988). During the period July 1980 to February 1986, 142 patients with endolymphatic hydrops were followed postoperatively according to the AAO-HNS (1985) guidelines. Of these 142 cases, 122 patients were operated on by Kitahara & Futaki's procedure and 20 by the vein graft drainage procedure. The incidence of vertigo was cured in over 90% of the cases and hearing impairment was improved in over 30%. In this paper, the surgical procedures are described in detail, using illustrations.

Effects of endolymphatic mastoid shunt operation for patients with Menière's disease

During the past 10 years, the endolymphatic mastoid shunt operation was carried out on 108 patients with Meniere's disease: 54 men and 54 women between 22 and 72 years old. According to criteria AAOO proposed in 1972, 86 cases (79.6%) belonged to class A, 19 cases (17.7%) to class B and 3 cases (2.7%) to class C. Forty patients took the body sway test before and after the operation. Four of the 40 patients were found to have Meniere's disease on the contralateral side within 12 months after the operation and one patient was found to have a complicating psychogenic disease. The abnormal body sway had recovered 2 to 9 months after the operation, but the medical treatment could not be stopped during this period. The average hearing gain after the operation was 21.3 +/- 14.4 dB; that for the patients with a short period of illness (within 23 months of the first onset to the operation) was 25.2 +/- 14.5 dB and that for the patients with a longer period of illness (over 24 months) was only 13.8 +/- 10.6 dB.

Endolymphatic mastoid shunt surgery using the Denver inner ear shunt

This study, merging data from two different clinics, was undertaken to evaluate the efficacy of endolymphatic mastoid shunt surgery using the Denver Inner Ear Shunt operation for Meniere's disease. This surgery was performed by the senior authors (C.G.J., J.R.E.D., and M.E.G.) between May 1984 and October 1986, after we attended the Colorado Otologic Research Center (CORC) instructional course. Sixty-six and thirty-four cases, respectively, were performed. Follow-up questionnaires were sent to this total of 100 patients. Fifty-six patients returned completed questionnaires, which formed the basis of this report. A retrospective chart study was also carried out. The results of surgery and questionnaires are reported as statistical data, and, where applicable, the 1985 AAO-HNS criteria for reporting vertigo and hearing results in the treatment of Meniere's disease are used. Preliminary analysis of these data is reported because of its profound effect upon our treatment protocol for patients with Meniere's disease. Results on use of the Denver valve do not appear to be significantly different than the results of other shunt surgery not using the valve.

The subarachnoid shunt for Menière's disease: sixteen years' experience

One hundred forty patients have been treated at the Baptist Memorial Hospital in Memphis, Tennessee for Menière's disease over a 16-year period, using an endolymphatic sac-subarachnoid shunt. Emphasis was placed on surgical methods, including compression of the sigmoid sinus with bone wax during surgery, facial nerve identification, and coverage of the sac with vein tissue. Satisfactory follow-up was accomplished in 66% of patients. Results were reported according to the criteria of the American Academy of Ophthalmology and Otolaryngology (1972). Control of attacks was accomplished in 83% of cases; median pure tone average (PTA) was 49 dB preoperatively and 54 dB postoperatively. Speech discrimination was 78% preoperatively and 69% postoperatively. Sixty-eight patients (51%) were graded as class A or B. Sixty-six (49%) were class C or D. Twenty-three patients (17%) were A+. Absence of nasal allergy and the presence of fluctuation of hearing appeared to indicate a more favorable outcome.