Section 3: AdultMénière's Disease: A Challenging and Relentless Disorder
Section snippets
What is CH? What is its significance?
The term CH has been used to describe fluctuating hearing loss without associated vertigo, which may represent an earlier phase of a continuum, ranging from mild cochlear involvement to full cochleovestibular dysfunction as seen in MD.
House and colleagues8 studied the relationship between CH and MD. In their retrospective review of 950 hydropic ears, 71% were diagnosed with unilateral MD and 29% were labeled as unilateral CH. Bilateral MD at presentation was seen in 11%, with another 14% of
What is the pathophysiology of CH and Ménière's disease?
Although endolymphatic hydrops (ELH) is felt to be the underlying histopathologic correlate in MD, to date no histopathologic study has confirmed the presence of ELH in patients with CH. Despite the lack of direct evidence of this association, electrophysiologic studies showing increased SP/AP ratios suggest the presence of ELH.9
The pathophysiology of hydrops remains unknown. Several intrinsic (genetic, anatomic, autoimmune, or vascular)10, 11, 12, 13, 14 or extrinsic (allergic, viral, or
What is the role of adjunctive tests in the diagnosis of MD?
A national survey showed that, depending on the region (west, midwest, northeast, New England, and Atlantic coast), 26.9% to 46.7% of treating otolaryngologists relied on history, physical examination, and audiometry alone to establish the diagnosis of MD.21 Others obtained adjunctive tests to support their diagnosis.
What is the role of medical management?
The medical management of MD includes a low-salt diet, avoidance of caffeine derivatives and alcohol, diuretics, vasodilators, and steroids.
Diuretics and low-sodium diet are effective in controlling the symptoms of MD in 71% to 79% of patients.28, 29Although intratympanic gentamicin (IT-Gent) injection is a medical form of therapy, it is a destructive treatment that results in chemical labyrinthectomy.
A Cochrane database review of all prospective randomized controlled trials (RCT), between 1966
What is the role of vestibular rehabilitation in the acute phase?
The role of vestibular rehabilitation in the acute phase of the disease has been questioned. Because of the fluctuating and dynamic nature of the vestibular symptoms seen in MD, most physicians believe that vestibular rehabilitation has limited benefit. Although the acute vertiginous spells are usually self-limited, chronic unsteadiness between the episodes of vertigo is a common complaint in patients with MD. Gottshall and colleagues33 showed that vestibular rehabilitation, even outside the
What is the initial treatment if medical therapy fails?
In a survey by Kim and colleagues,21 50% of otologists proceed with ESS, whereas 39% perform an IT-Gent injection. A minority offer a Meniett Device (9%) or vestibular nerve section (2%).
What is the best next step in management if nondestructive procedures fail in controlling vertigo?
When conservative medical management and nondestructive procedures fail to control vertigo, the treating otologist needs to consider neural or labyrinthine destructive procedures to ablate all residual vestibular function in the hope of controlling the ongoing vestibulopathy. These procedures are grouped into chemical labyrinthectomy using IT-Gent injections, or surgical procedures, such as transcanal labyrinthectomy (TCL), TML, and selective vestibular nerve section (VNS).
What influences the surgeon’s decision in selecting the type of destructive surgical procedure?
A national survey of the preferred surgical approach showed that 77% performed RSVNS, 14% MFVNS, and 9% RLVNS.21
When contemplating a nerve section several factors should be considered in choosing the approach:
- (1)
Position of sigmoid sinus
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Far forward: RSVNS
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Posterior or lateral: RLVNS
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- (2)
Status of residual hearing
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Pure tone average (PTA)>80 dB, WDS<20%: TLVNS, TML, or TCL
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- (3)
Suspicion of cochleovestibular fibers
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MFVNS
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Retrosigmoid: internal auditory canal (IAC).
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The most important factor in selecting the type of
VNS versus labyrinthectomy in controlling vertigo, chronic disequilibrium, and the resultant QOL
Teufert and colleagues47 reviewed their experience with 25 patients who underwent TML and 17 patients who had a TLVNS. In their series, 64% of patients having TML and 64.7% of those having TLVNS had MD, respectively. Class A and B vertigo control was achieved in 86% of the TML group and 88% of the TLVNS group. Despite comparable vertigo control, the resolution of the chronic imbalance and disequilibrium was seen in 82% of the TLVNS group and 52% of the TML group.
Diaz and colleagues,48 using a
VNS versus intratympanic perfusion of gentamicin
Colletti and colleagues49 reviewed their results in 209 patients who underwent RSVNS and 24 patients who received IT-Gent. Gentamicin (80 mg/mL) was mixed with 8.4% buffer (26 mg per injection) and injected up to once per week for 6 weeks. Class A and B vertigo control were obtained in 95.8% and 75% of patients in the RSVNS and IT-Gent groups, respectively. In the IT-Gent group, hearing was significantly worse than in the RSVNS group. In the IT-Gent group, mean PTA decreased from 50.1 dB to
What are the challenges in the diagnosis and treatment of bilateral MD?
In this case, the contralateral ear involvement was delayed in time and is consistent with bilateral MD. This diagnosis can be further supported by increased SP/AP ratio on ECoG.
Summary
The diagnosis and treatment of MD continues to challenge many physicians. Current treatment strategies, ranging from non-destructive, function-preserving interventions to destructive, function-ablative procedures, are effective in controlling vertigo attacks. To date, no therapy has been shown to prevent the progressive cochlear dysfunction seen in MD. Nevertheless, current hearing rehabilitative strategies using acoustic or electric auditory stimulation help restore hearing to affected
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The cardiovascular aspects of a Ménière's disease population – A pilot study
2019, Journal of OtologyCitation Excerpt :Ménière's disease (MD) is a multifactorial disorder affecting the inner ear characterized by episodic vestibular symptoms associated with sensorineural hearing loss, tinnitus, and aural pressure (Semaan and Megerian, 2011).
Long-term outcomes of endolymphatic sac shunting with local steroids for Meniere's disease
2017, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryTreatment of ear and bone disease in the Phex mouse mutant with dietary supplementation
2017, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryCitation Excerpt :Therapeutic options for patients with MD range from a conservative low-salt diet to complete ablation of labyrinthine function. Clinicians' inability to predict therapeutic response and the disease clinical course adds to both patient and clinician frustration with MD management [8]. Mouse models are commonly used to study human diseases.
Specialty Imaging: Temporomandibular Joint
2016, Specialty Imaging: Temporomandibular JointVasopressin induces endolymphatic hydrops in mouse inner ear, as evaluated with repeated 9.4 T MRI
2015, Hearing ResearchCitation Excerpt :Disturbance of this fluid balance may result in excess accumulation of endolymph in the inner ear, endolymphatic hydrops (EH) [Semaan et al., 2005, Salt and Plontke, 2010]. EH associated changes in the inner ear are believed to be of significance in relation to the symptoms associated with for example Ménière's disease such as fluctuating hearing loss, tinnitus, vertigo and aural fullness [Semaan and Megerian, 2011, Sajjadi and Paparella, 2008]. Although the pathogenesis of EH is unclear, the underlying problem is believed to be either overproduction or malabsorption of endolymph.
Early Diagnosis and Management of Acute Vertigo from Vestibular Migraine and Ménière's Disease
2015, Neurologic ClinicsCitation Excerpt :Although pathologic canal paresis is present in 42% to 73% of patients with MD,44 complete loss of function is rare, and therefore, only a minority of patients have an impaired head impulse test.44 Caloric testing may help in the assessment of contralateral function before an ablative procedure, evaluation of postablative residual function, and identification of patients with preserved ipsilesional canal function where nondestructive treatment options may be preferred.45 In an acute attack of MD, the treatment is symptomatic.