LETTER TO THE EDITOR: "IS MENIÈRE'S DISEASE A CONTRAINDICATION TO STAPEDECTOMY?"

Abstract

To the Editor: We read with interest the article that was recently published by Sioshansi et al. entitled “Is Menière's Disease a Contraindication to Stapedectomy?” (1) Issue of Otol Neurotol. The authors aimed to “Review surgical outcomes of stapedectomy for otosclerosis in patients with Menière's disease.” We congratulate the authors for their valuable work, but we would like to comment some issues. Vestibular symptoms have been reported in up to 40% of patients with otosclerosis. It is important to tease out the specifics of vestibular complaint while obtaining the history, as misdiagnosis can have significant implications on treatment outcomes. In the setting of Menière's disease (MD), saccular distention due to endolymphatic hydrops can put the saccular membrane in contact with the underside of the stapes footplate. In these patients, the stapedotomy can lead to injury of the membrane and profound sensorineural hearing loss (SNHL) (2). The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) has defined the diagnostic criteria that are based on the presence/absence and duration of the different symptoms allowing the classification of patients in different MD categories—probable and definite MD (3). However, the diagnosis of MD remains difficult probably due to the lack of a gold standard test. In the “MATERIAL AND METHODS” the authors affirms that “Data collected included demographics, symptomatology, vestibular testing, imaging findings, surgical findings, operative techniques, postoperative outcomes, and pre- and postoperative” (1), but we did not find what the vestibular testing was performed. It would be a valuable information to know about the vestibular symptoms of these patients before and after the surgery. It had been found that in MD patients, the reduced caloric response, rather than Video Head Impulse Test (vHIT) response, is correlated with the severity of endolymphatic hydrops. Because of the fluctuating nature of MD, the vestibular hair cell population driving the response could vary depending on the condition of the disease and the type of hair cell involved. It has been suggested the combination use of caloric test and horizontal vHIT in MD patients, as these tests allow for an integrated and comprehensive evaluation of the horizontal vestibulo-ocular reflex (VOR) function (4). Sobhy et al. (5) suggested that with the advancement in the stage of MD, the prevalence of abnormal cervical vestibular-evoked myogenic potential (cVEMP), ocular vestibular-evoked myogenic potential (oVEMP), caloric test, and vHIT responses was in agreement with the histopathological evidence of progression of the disease from the saccule up to the semicircular canals. Authors concluded “….. Menière's disease may not be an absolute contraindication to stapes surgery” (1). The audiological results presented are interesting. However, as the sample was small, the indication of stapedectomy in patients with MD may still be done with careful, once stapedotomy is an elective procedure. For the patients with otosclerosis and define MD, we recommend that a vestibular evaluation should be carried out in order to avoid severe complications. The authors disclose no conflicts of interest.