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

Calvin J Kersbergen,Bryan K Ward

doi:10.3389/fneur.2021.794741

Abstract

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

Highlights

Meniere’s disease is a disorder of the inner ear consisting of intermittent, spontaneous episodes of vertigo in combination with other fluctuating ear symptoms including low-frequency sensorineural hearing loss, aural fullness, and tinnitus
New surgical approaches that manipulated the membranous labyrinth emerged following the adoption by otologic surgeons of the operating microscope and the increased popularity of Lempert’s single-stage lateral semicircular canal fenestration procedure for otosclerosis
He cauterized the tissue by running electrical current through the pick [22]. Lindsay repeated this approach without cauterization, and reported that patients no longer experienced episodes of vertigo, but uniformly developed hearing loss and sound-induced vertigo (i.e., Tullio phenomenon). He and Cawthorne described the Tullio phenomenon that developed in these cases as having been caused by the presence of a “third mobile window” in the inner ear, later associated with the pathophysiology of superior semicircular canal dehiscence syndrome [23, 24]

Summary

INTRODUCTION

New surgical approaches that manipulated the membranous labyrinth emerged following the adoption by otologic surgeons of the operating microscope and the increased popularity of Lempert’s single-stage lateral semicircular canal fenestration procedure for otosclerosis. Lindsay repeated this approach without cauterization, and reported that patients no longer experienced episodes of vertigo, but uniformly developed hearing loss and sound-induced vertigo (i.e., Tullio phenomenon) Femenic accessed and divided the membranous labyrinth through the fenestration, and routed the anterior end outside the labyrinth, leaving the posterior end free to communicate with the perilymph (Figure 1A) He reports all 4 cases having ‘satisfactory’ symptom control and preserved cochlear function (Table 1) [25]. In 1964 Fick proposed a transcanal approach to generate a conduit in the saccule to relieve excess endolymph [30] He inserted a fine needle through a fenestration made in the stapes footplate to puncture the dilated hydropic saccule (Figure 1B).

Findings

CONCLUSIONS AND FUTURE CONSIDERATIONS