Endolymphatic Sac Surgery Research Articles

Do Middle Ear Muscles Trigger Attacks of Ménière's Disease?

Objective – Current surgical methods for treating Ménière's disease (MD), e.g. endolymphatic sac surgery, mastoidectomy or insertion of middle ear ventilation tubes, only improve vertigo and fail to influence the hearing threshold. In this retrospective study we examined the long-term effects of tenotomy on the symptoms of MD.Material and Methods – A total of 45 patients suffering from definite MD underwent middle ear muscle tenotomy, a treatment that is very rarely considered nowadays. Of these 45 patients, 20 were observed postoperatively for a period of >2 years. The disease was scored pre- and postoperatively and the results were evaluated according to the American Academy of Otolaryngology–Head and Neck Surgery Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy for MD.Results – Sectioning of the tensor tympani and stapedius muscle tendons significantly reduced the frequency and intensity of vertigo and improved both the functional profile and tinnitus. Pure-tone audiometry at frequencies between 500 and 3000 Hz substantiated the improvement in hearing threshold, as did the pure-tone average. The therapeutical outcome was stable in cases where both tendons remained persistently disconnected. Intratympanal inflammatory reactions were observed in most patients during surgery.Conclusion – Our results prove that tenotomy is a successful and enduring therapeutic approach for treating the auditory and vestibular symptoms of MD and strongly suggest that it should be reconsidered as a promising surgical treatment for the symptoms of MD.

Topical Mitomycin C and Cephalosporin in Endolymphatic Sac Surgery

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. 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. 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. 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.

Intratympanic gentamicin therapy for persistent vertigo after endolymphatic sac surgery

Objectives: To evaluate the role of intratympanic gentamycin therapy (ITGM) in controlling vertigo in patients with refractory Meniere's who have recurrent or persistent vertigo after endolymphatic sac surgery. Study Design and Setting: A retrospective review of 491 patients seen in a university balance clinic between July 1999 and July 2000. Of these, 68 patients had Meniere's disease; 4 patients had recurrent vertigo after endolymphatic sac surgery and were followed for at least 1 year. These 4 patients received a series of ITGM injections. Outcome measures included control of vertigo and audiometric results. Results: Three of 4 (75%) patients had control of their vertigo with ITGM therapy. The 1 patient who failed ITGM therapy underwent a successful vestibular neurectomy with ultimate control of his vertigo. No patients had progression of their sensorineural hearing loss. Conclusion: ITGM therapy can be used to control vertigo in selected patients with Meniere's disease who have persistent vertigo after unsuccessful endolymphatic sac surgery. Significance: ITGM therapy may reduce the need for vestibular neurectomy in patients with refractory Meniere's disease after endolymphatic sac surgery. (Otolaryngol Head Neck Surg 2002;126: 31-3.)

Intratympanic steroid injections for intractable Ménière's disease.

To examine whether intratympanic injection of dexamethasone is effective in controlling vertigo in patients with Ménière's disease who have persistent vertigo despite standard medical treatment, including a low-salt/no-caffeine diet and diuretics. A prospective study. From August 1999 to November 2000, 21 patients with intractable Ménière's disease underwent intratympanic injections of 4 mg/mL dexamethasone over a period of 4 weeks as an office procedure. American Academy of Otolaryngology-Head and Neck Surgery guidelines for the definition and reporting of results in Ménière's disease were used. Complete relief of vertigo was maintained in 11 of the 21 patients (52%) at 3 months and in 9 of 21 patients (43%) at 6 months. Repeat injections in 5 patients who had initial control of vertigo, but later failed, yielded control in 3 (60%) patients. The complication rate was low: one patient had a 35-decibel pure tone average decrease in hearing during treatment and one patient had a persistent tympanic membrane perforation. Intratympanic injections of dexamethasone are a reasonable initial surgical treatment for persistent vertigo in Ménière's disease. The principal benefits are avoidance of systemic administration of steroids, lower cost than endolymphatic sac surgery, and ease of administration as an office procedure. The disadvantages are the need for repeated office visits for injections and the decreasing effectiveness over time.

Intratympanic dexamethasone, intratympanic gentamicin, and endolymphatic sac surgery for intractable vertigo in Meniere's disease

Intratympanic dexamethasone, intratympanic gentamicin, and endolymphatic sac surgery for intractable vertigo in Meniere's disease

Intratympanic dexamethasone, intratympanic gentamicin, and endolymphatic sac surgery for intractable vertigo in Meniere's disease

Objective: To compare the efficacy of intratympanic dexamethasone (ID), intratympanic gentamicin (IG), and decompression of the endolymphatic sac (ESD) for intractable vertigo in Meniere's disease. Study Design and Setting: This prospective study was conducted at Hacettepe University Medical Faculty, a tertiary care center. Dexamethasone was applied through a ventilation tube in 24 patients, intratympanic gentamicin (also through a ventilation tube) to 16 patients, and 25 patients underwent ESD. Results: Satisfactory control of vertigo was 72%, 75%, and 52%, respectively for the ID, IG, and ESD. Two patients in the gentamicine group had total hearing loss. In the dexamethasone group, hearing level remained the same in 46% of the patients with 16% increase and 38% decrease (30% 10dB and 8% 20 dB). Conclusion: If the vertiginous symptoms still persist after 6 months of medical treatment, ID can be started. If there is no further improvement after 3 months with ID, patients with profound sensorineural hearing loss undergo treatment with IG, ESD is reserved for patients with good hearing. If ESD also fails, patients with good hearing may undergo vestibular nerve section; patients with nonservicable hearing become candidates for labyrinthectomy. (Otolaryngol Head Neck Surg 2001;125:537-43.)

Endolymphatic mastoid shunt surgery

Menière's disease is characterized by fluctuating hearing loss, vertigo, tinnitus, and aural fullness in the involved ear. The diagnosis is based on patient history, and the pathophysiology has been associated with endolymophatic hydrops. Medical therapy (low-sodium diet and diuretic therapy) is the first line of treatment and effectively controls symptoms in the majority of patients. Medical failures whose lives are severely affected by disabling vertigo are offered either a destructive or nondestructive procedure. Destructive procedures (cochleosacculotomy, labyrinthectomy, chemical labyrinthectomy, and vestibular nerve section) are those that destroy either the inner ear neuroepithelium and/or deafferent the affected peripheral vestibular system. Destructive procedures either risk preoperative hearing or abolish it entirely. Endolymphatic sac procedures are nondestructive techniques that do not destroy the neuroepithelium and are intended to preserve hearing. A recent review of endolymphatic sac surgery found that it controlled or substantially improved vertigo in up to 84% of 1,880 patients. Furthermore, reevaluation of the Danish Sham Study ( 2. Thomsen J Tos M Johnsen NJ Placebo effect for surgery in Meniere's disease. Arch Otolaryngol Head Neck Surg. 1981; 107: 271-277 Crossref Scopus (186) Google Scholar ) with current statistical measures does support the use of endolymphatic mastoid shunt in refractory Menière's disease. Currently, we offer endolymphatic mastoid shunt to Menière's patients with useful preoperative hearing and intractable vertigo and reserve destructive procedures for those patients with poor hearing and/or endolymphatic mastoid shunt failure. Menière's disease is characterized by fluctuating hearing loss, vertigo, tinnitus, and aural fullness in the involved ear. The diagnosis is based on patient history, and the pathophysiology has been associated with endolymophatic hydrops. Medical therapy (low-sodium diet and diuretic therapy) is the first line of treatment and effectively controls symptoms in the majority of patients. Medical failures whose lives are severely affected by disabling vertigo are offered either a destructive or nondestructive procedure. Destructive procedures (cochleosacculotomy, labyrinthectomy, chemical labyrinthectomy, and vestibular nerve section) are those that destroy either the inner ear neuroepithelium and/or deafferent the affected peripheral vestibular system. Destructive procedures either risk preoperative hearing or abolish it entirely. Endolymphatic sac procedures are nondestructive techniques that do not destroy the neuroepithelium and are intended to preserve hearing. A recent review of endolymphatic sac surgery found that it controlled or substantially improved vertigo in up to 84% of 1,880 patients. Furthermore, reevaluation of the Danish Sham Study ( 2. Thomsen J Tos M Johnsen NJ Placebo effect for surgery in Meniere's disease. Arch Otolaryngol Head Neck Surg. 1981; 107: 271-277 Crossref Scopus (186) Google Scholar ) with current statistical measures does support the use of endolymphatic mastoid shunt in refractory Menière's disease. Currently, we offer endolymphatic mastoid shunt to Menière's patients with useful preoperative hearing and intractable vertigo and reserve destructive procedures for those patients with poor hearing and/or endolymphatic mastoid shunt failure.

Patients' subjective evaluations of quality of life related to disease-specific symptoms, sense of coherence, and treatment in Ménière's disease.

To evaluate the self-rated quality of life associated with vertigo, hearing loss, and tinnitus in Ménière's patients, and to identify potential relationships between these findings, treatment regimens, and sense of coherence in comparison to the classification of the American Academy of Otolaryngology-Head and Neck Surgery (AAO/HNS). Cross-sectional. Tertiary referral hospital centers. 112 patients with Méniére's disease, who had undergone endolymphatic sac surgery or intratympanic gentamicin injections, or were surgically untreated. Questionnaires concerning quality of life aspects and symptom-specific instruments: the Vertigo Symptom Scale (VSS), the Hearing Disability Handicap scale (HDHS), the Tinnitus Severity Questionnaire (TSQ), the AAO/HNS criteria for reporting results of treatment of Ménière's disease, and the Sense of Coherence Scale. A majority of the patients reported their quality of life in general as very good or good. There was no difference in general quality of life, present hearing loss, or tinnitus between the three treatment groups, but the gentamicin-treated patients had less vertigo than did the other groups. Sense of coherence showed a strong correlation to reported quality of life in all measurements. Even though the gentamicin-treated patients had less vertigo, no difference in overall quality of life was found between the surgically treated and untreated patients. The sense of coherence seems to be an important factor in the patient's experience of quality of life. Quality of life instruments can measure both specific symptoms and related aspects on quality of life and may give complementary information to the AAO/HNS classification in evaluating the treatment of patients with Ménière's disease.

Prognostic value of electrocochleography in patients with unilateral Meniere's disease undergoing saccus surgery*

Although a controversial operation, saccus surgery has continued to be used in patients with severe Menière's disease in whom hearing preservation is the objective. The aim of this study was to determine if electrocochleography (ECoG) could predict the patients who would be free of vertigo, 2 and 5 years after surgery. Seventy patients with severe Menière's syndrome underwent ECoG prior to endolymphatic sac surgery. Eighty-four per cent of the patients had an abnormal electrocochleogram. The patients were interviewed 2 and 5 years after surgery. At 2 years, 4/10 (40%) patients with normal ECoG were relieved of dizziness compared to 38/51 (75%) with abnormal ECoG (P < 0.05). At 5 years, 5/8 (63%) patients with normal ECoG were relieved of dizziness compared to 30/30 (100%) with abnormal ECoG (P < 0.001). The patients with a normal ECoG do have less severe measurable hearing impairment (P < 0.05) although they are more likely (P < 0.05) to complain of constant tinnitus. Their history of dizziness is longer and their dizziness more disabling before surgery. In conclusion, patients with a normal ECoG will be less likely to benefit from saccus surgery in the first 5 years. These patients may represent a different nosological entity.

Delayed Endolymphatic Hydrops: Study and Review of Clinical Implications and Surgical Treatment

Delayed endolymphatic hydrops (DEH) differs from Ménière's disease in that it occurs in pre-existing ear pathology in patients who have a profound unilateral or total deafness that was caused by infection, trauma, or unknown causes during childhood or adulthood. We performed a retrospective review of 160 patients with ipsilateral, contralateral, or bilateral DEH. Eighty-seven patients who did not respond to medical therapy underwent surgical treatment. Our findings indicate that the more conservative surgical procedures--endolymphatic sac surgery, cochleosacculotomy, and streptomycin perfusion--are all as effective as and less destructive than labyrinthectomy for controlling vertigo. The clinical results of this study would seem to support the observations of others that DEH and Ménière's disease are related disorders caused predominantly by cases of viral labyrinthitis with unknown etiology.

The enlarged vestibular aqueduct syndrome

The enlarged vestibular aqueduct syndrome is characterized by the early onset of sensorineural hearing loss and detection of an enlarged endolymphatic sac and duct on temporal bone imaging. Progressive loss and hearing fluctuations may occur, and minor head trauma has been associated with further auditory decline. Exciting new developments concerning the hereditary and genetic basis of enlarged vestibular aqueduct syndrome have occurred in the past year. Pedigree analysis has revealed that many familial cases occur in an autosomal recessive fashion. Furthermore, mutations in the Pendred gene (PDS) have been identified in patients with enlarged vestibular aqueduct syndrome. Treatment has focused on the detection of progressive hearing loss, amplification, and avoidance of head trauma. Recent evidence has revealed that endolymphatic sac surgery does not modify the progressive loss in these patients and may have a detrimental effect on hearing. Additionally, recent data have shown that cochlear implantation is a safe and effective option for patients with enlarged vestibular aqueduct syndrome who have bilateral profound losses.

Vestibular symptoms and ENG findings during periods of convalescence after endolymphatic sac drainage and steroid-instillation surgery (EDSS)

Understanding the appearance of vestibular symptoms during periods of convalescence after surgery for the treatment of Meniere's disease is important for determining when a patient can return to work as well as the long-term results of the operation. We have treated 20 cases of intractable Meniere's disease with endolymphatic sac drainage & steroid-instillation surgery (EDSS) [Kitahara T, et al., Ann Otol Rhlnol Laryngol in press, 2000] and observed the subjective symptoms and objective vestibular findings using electronystagmogram (ENG) during the subsequent period of convalescence. The average postoperative durations of subjective static and evoked vestibular symptoms were 1.7 and 6.7 days, respectively. Those of spontaneous, positional and positioning nystagmus observed using ENG were 1.2, 2.0 and 7.9 days, respectively. In cases with a long history of Meniere's disease, postoperative static vestibular sensation and positional nystagmus lasted significantly longer than in cases with short histories. In cases with poorly developed temporal bony pneumatization in the area behind the posterior semicircular canal, postoperative evoked vestibular sensations and positioning nystagmus lasted significantly longer than in cases with well developed temporal bony pneumatization. Vestibular symptoms resulting from direct invasion during EDSS were considered to be slighter than those resulting from vestibular neurectomy or gentamicin treatment and almost the same as those resulting from endolymphatic sac surgery.

The Endolymphatic Sac in Patients with Ménière's Disease: Correlation between the MRI and the Surgical Findings

The endolymphatic sac (ES) is thought to have close relations to pathogenesis of endolymphatic hydrops. Here is reported a retrospective study of 41 patients (42 ears) with Ménière's disease who underwent MRI prior to endolymphatic sac surgery. Based on proton-density weighted image (PDI) and T2-weighted image (T2), the ES including an endolymphatic duct (ED) were estimated whether it was detectable or not. Fourteen ESs were detected on both images (Group A), 14 ESs were detected only on PDI (Group B), and the remaining 14 ESs were not detected on either image (Group D). The actual shape of the sac, obtained from surgical findings, was classified into three (normoplastic, atrophic, invisible). Seventeen ears showed normoplastic ESs and 14 showed atrophic ESs. ES was not detected in 11 ears during surgery, and these findings were compared with image classification. From the study data, normoplastic ESs tend to be observed on both images whereas atrophic or invisible sacs were hardly observed on T2. This classification of ES on MRI was thought to correlate with surgical findings and this correlation was statistically significant (Spearman's rank correlation coefficient. rs=0.58, p<0.01).

Intratympanic therapy for Ménière's disease. High-concentration gentamicin with round-window protection.

Many therapeutic options exist for the management of patients with Ménière's disease. In the last few years, the use of intratympanic gentamicin has been investigated as an alternative treatment to vestibular nerve section or labyrinthectomy. In humans, the concentration of gentamicin used for intratympanic treatment of vertigo ranges from 10 mg/mL to 40 mg/mL, and the number of doses from 2 to 14, with a total administered amount between 6 and 2.400 mg. Here lower doses of gentamicin were used, usually had the lowest incidence of hearing loss, but more injections were needed to ablate vestibular function. The purpose of this study was to evaluate the acute and chronic ototoxic effects of intratympanic high-concentration gentamicin after having obliterated the round-window niche with connective tissue in 11 subjects' ears with Ménière's disease. Intratympanic gentamicin was administered according to a predetermined and fixed schedule consisting of two doses of 0.5 mL gentamicin solution, injected once a week with a drug concentration of 80 mg/mL. The total dose of gentamicin was < or = 80 mg. The charts of the patients were surveyed in accordance with the 1995 AAO-HNS guidelines. Three patients had recurrence of vertigo between 3 and 6 months after the second injection and went on to one additional dose of gentamicin. At 2 years follow-up, 10 patients (91%) had complete and 1 (9%) substantial control of vertigo; 3 subjects (27%) had hearing decreased. Tinnitus disappeared or decreased in 3 patients (27%); eight subjects (73%) reported their aural pressure abolished or decreased. The present study demonstrates that in patients with Ménière's disease, 0.5 mL gentamicin solution, with a concentration of 80 mg/mL (total dose < or = 80 mg), injected intratympanically once a week after having obliterated the round-window niche, permits complete or substantial control of vertigo in two-thirds of cases after two doses and in all subjects after three doses. This vertigo control rate is compared to that observed after vestibular nerve section. Hearing results are not different from those with natural control, with endolymphatic sac surgery, and with vestibular nerve section.

Book Review: Treatment Options for Ménière's Disease. Endolymphatic Sac Surgery: Do it or Don't Do it?

Book Review: Treatment Options for Ménière's Disease. Endolymphatic Sac Surgery: Do it or Don't Do it?

内リンパ嚢開放高濃度ステロイド挿入術 メニエール病に対する新しい治療の試み

Endolymphatic sac surgery is one of the most widely accepted techniques used to treat intractable Meniere's disease. In order to improve sac surgery, we have developed some new techniques. A simple mastoidectomy was performed, exposing the endolymphatic sac in the area between the sigmoid sinus and the 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 its volume, followed by gelatin sponges dipped in a high concentration dexamethasone. The short-term results (1-8 months) in 8 patients with intractable Meniere's disease treated with the above techniques, i. e. endolymphatic sac drainage and steroidinsertion surgery are as follows: vertigo was completely controlled, hearing was improved and annoyance due to tinnitus was decreased in all cases.

Innovar Treatment for Meniere's Disease

Patients with intractable vertigo due to clinical Meniere's disease were offered treatment with Innovar, a neurolept analgesic. The patients were from a single clinical practice, had failed conventional dietary and medical treatment and were eligible on clinical grounds for endolymphatic sac surgery. After a follow-up of 2-8 years, 58% of patients had long-lasting relief of vertigo. Hearing was not affected. Risk factors for a favorable response were male gender, fluctuating hearing, and early stage of the disorder. Innovar is a safe, cost-effective second-line therapy for patients with Meniere's disease who have failed conventional first-line medical therapy.

Analysis of Patients with Persistent Dizziness after Vestibular Nerve Section

Vestibular neurectomy can be an effective operation for the control of persistent dizziness refractory to medical treatment or even endolymphatic sac surgery. Past studies have reported favorable results, creating an almost deceptive impression of the procedure's success rate. However, not all patients will respond favorably. Some will continue to have significant postoperative disequilibrium and, worse yet, persistent vertigo. To analyze the reasons for continued problems, 142 patients undergoing various surgical approaches employed to divide the vestibular nerve (retrolabyrinthine, middle fossa, retrosigmoid and translabyrinthine) were retrospectively, reviewed. Twenty-nine patients (20%) continued to have significant dizziness despite vestibular neurectomy. The reasons for failure were incomplete vestibular nerve section, poor central nervous system compensation, new vestibular disease in the opposite ear, obstructive anatomy, the presence of other central nervous system diseases, and unknown causes. This paper will detail the advantages and disadvantages of various vestibular neurectomy approaches and will present recommendations for further treatment of this difficult-to-manage group of patients.

The Non-specific Effect of Endolymphatic Sac Surgery in Treatment of Meniere's Disease: A Prospective, Randomized Controlled Study Comparing "Classic" Endolymphatic Sac Surgery with the Insertion of a Ventilating Tube in the Tympanic Membrane

A prospective, randomized study was carried out comparing the effect of two surgical modalities in the treatment of patients with Meniere's disease: insertion of an endolymphatic sac shunt and insertion of a ventilating tube in the tympanic membrane. A total of 29 patients, 12 males and 17 females, age 27-71 years, were operated on in two ear, nose and throat (ENT) departments. Of these patients, 15 had an endolymphatic shunt inserted and 14 had a ventilating tube inserted in the tympanic membrane. Postoperative follow-up was carried out in the department in which the patients had not been operated. The severity of the disease was scored pre- and postoperatively, and the results evaluated under the guidelines of the Committee on Hearing and Equilibrium (1995) for the diagnosis and evaluation of therapy in Meniere's disease. The patients in both groups had a statistically significant reduction in dizzy spells, measured 6 and 12 months postoperatively, and there was no difference between the groups. The pathophysiological explanation for the reduction in dizzy spells in each of the treatment modalities is debatable and the effect is non-specific. The patients' hearing and tinnitus were statistically unaffected by the treatment in both groups, though 2 patients in the shunt group developed severe hearing loss (anacusis/70 dB).

Sac-vein decompression for intractable Meniere's disease: Two-year treatment results

Surgical intervention has been offered to patients with Meniere's disease who have failed medical treatment and have disabling symptoms. Surgical options have included labyrinthectomy (mechanical and chemical), vestibular neurectomy, and endolymphatic sac surgery with or without shunting. We present a modification of endolymphatic sac decompression surgery that includes wide decompression of the sigmoid sinus, posterior cranial fossa dura, and endolymphatic sac (sac-vein decompression). Thirty-five patients underwent 37 primary procedures with 2 years of follow-up. Patients were evaluated according to the 1985 American Academy of Otolaryngology–Head and Neck Surgery criteria for assessing Meniere's disease. Vestibular symptom severity was resolved or mild in 92% and disability severity was none or mild in 95% of patients at 2 years after surgery. Vertigo control was complete or substantial in 85% and 100% of patients at 1 and 2 years after surgery. Audiologic data showed stable or improved hearing in 86% and 85% of patients at 1 and 2 years after surgery. In summary, wide decompression of the sigmoid sinus, posterior cranial fossa dura, and endolymphatic sac offers improved control of vertigo and hearing stabilization for intractable Meniere's disease compared with simple endolymphatic sac decompression or shunt surgery. (Otolaryngol Head Neck Surg 1998;118:22-9.)