Low-Dose Intratympanic Gentamicin and the Treatment of Meniere's Disease: Preliminary Results

The most disabling symptom for most patients with unilateral Meniere's disease is vertigo. Eradication of the diseased end organ is effective in eliminating the vertigo. Labyrinthectomy remains the “gold standard”; unfortunately, residual hearing is sacrificed to obtain this end. The purpose of this study is to evaluate low-dose intratympanic gentamicin for the control of vertigo and for the preservation of hearing. A single dose of gentamicin(10-80 mg) was injected into the middle ear space of 23 patients with unilateral Meniere's disease as an office procedure. Eighty-four percent of the patients had no episodes of vertigo during the last 6 months of follow-up. Pure tone average and word discrimination scores were unchanged as a group. Ninety-five percent of patients had a hearing loss at 6 and 8 kHz that averaged 7.5 dB. Caloric function was reduced in 93%. Low-dose intratympanic gentamicin is a safe, simple, office procedure that is effective in controlling the definitive vertiginous episodes in most patients with unilateral Meniere's disease. Control of vertigo can be obtained with preservation of hearing.     

Low-dose intratympanic gentamicin treatment of Meniere's disease

To control attacks of vertigo while preserving both hearing and labyrinthine function, low doses of gentamicin were instilled intratympanically in nine patients with intractable unilateral Meniere's disease. Each patient received six instillations of antibiotic of 4 mg each (total dose, 24 mg). Patients were then followed for 2–4 years. Long-term results of treatment are reported according to the American Academy of Otolaryngology-Head and Neck Surgery 1985 criteria. Of the nine cases, three experienced complete control of vertiginous attacks, while six received substantial control. Post-treatment hearing acuity was unaffected, although disability following treatment became worse in one patient, a 66-year-old man. Caloric responses after therapy were absent or severely reduced in three ears, moderately reduced in two ears and unchanged in four ears. In three patients, labyrinthine function was found damaged 4–8 days after administration of the last dose of drug. Overall, intratympanic instillations of low doses of gentamicin in patients with intractable Meniere's disease were found to control vertiginous attacks with less damage to the inner ear function than that reported in the literature.     

Overpressure in treatment of meniere's disease

Influence of ambient pressure changes on the hearing levels in Meniere's disease was previously demonstrated, using a pressure chamber. The present report concerns a new method for management of Meniere's disease by local application of overpressure. The experimental background and methodologic considerations in therapy are summarized. Five illustrative cases of verified Meniere's disease are presented. The patients had advanced, nonfluctuating hearing loss and incapacitating vestibular symptoms. Long periods of remission were obtained in all cases. Improvement of hearing was a major clinical consideration in the treatment. Use of local overpressure seems to offer possibilities of improving hearing even in advanced stages of Meniere's disease. Despite the disabling pretreatment hearing loss, hearing in these 5 patients was restored to normal or serviceable levels. The follow-up period was about 2 years from start of treatment.     

Maximum Compliance and Ménière's Disease

In this study an electroacoustic impedance bridge and an X–Y recorder were used to measure maximum compliance (Cm) in 53 patients symptomatic of Meniere's disease in only one ear. Various parameters of Meniere's disease were investigated by comparing Cm values between ears. The parameters which were investigated included: (1) Meniere's disease; (2) the symptom of fullness; (3) the length of disease; and (4) the degree of hearing loss. The data were interpreted as demonstrating that there were differences in Cm which were indicative and consistent with what would be expected for mechanical changes in the inner ear associated with Meniere's disease.     

Neurovascular compression syndrome with Meniere's disease—a report of the treatment of a patient with microvascular decompression

Neurovascular compression syndrome(NVCS) is currently regarded as one of the causes of disabling positional vertigo (DPV). A 59-year-old man visited our hospital on December 15, 1993. The neuro-otological examination suggested that the patient had Meniere's disease and he was treated with conservative medication. However, the patient continued to suffer definite vertigo attacks, as well as a fluctuation in his hearing. A consultation and discussion lead us to believe the patient was also suffering from NVCS. We planned the microvascular decompression surgery. After surgery, the patient stopped suffering from vertigo attacks but his audiogram showed severe fluctuation in sensorineural hearing levels. It was concluded that the present patient had been suffering from NVCS combined with Meniere’s disease.     

Cochlear implantation in patients with Meniere's disease

Abstract

Objectives

Few studies have addressed the benefits of cochlear implantation for the small group of patients with bilateral, end-stage Meniere's disease, or unilateral disease with contralateral hearing loss from another cause. Our retrospective study evaluates the effectiveness and post-operative performance in these Meniere's disease patients and discusses these findings relative to other post-lingually deafened adults.

Methods

Among 456 adults who received cochlear implants, we identified eight (1.7%) patients with Meniere's disease who met clinical indications for implantation and a control group of seven non-Meniere's patients of comparable age and deafness. Data gathered included demographics, auditory and vestibular symptoms pre-implantation, and clinical course after implantation, including audiometric scores (consonant-nucleus-consonant (CNC), hearing-in-noise testing (HINT), and AzBio score) and audiologic evaluations.

Results

Comparing the Meniere's and non-Meniere's patients, pre- to post-implant scores averaged 15 and 16%–57 and 76% for CNC; and 4.5 and 40.5%–78 and 81% for AzBio and/or HINT tests, respectively; scores between groups did not statistically differ. Of note, five of eight patients had 0% word recognition scores pre-operatively. Fluctuations in CI performance were seen in five patients with Meniere's disease but not for those without the disease.

Conclusions

Audiologic testing found a strong likelihood that CIs did benefit our subset of Meniere's patients with severe to profound sensorineural hearing loss. Fluctuations in hearing sensitivity (perhaps owing to physical changes relative to the implant array with the spiral ganglion neurons during an acute attack or changes in spiral ganglion neurons because of the hydropic state) can often be resolved by subsequent reprogramming.     

An holistic approach to Meniere's disease. Medical and surgical management

A review of the medical and surgical management of 195 patients with Meniere's disease is presented. In order to avoid a piecemeal approach to the problem of Meniere's disease, the “whole” patient must be treated. Psychological counseling, medical management, and when indicated selective surgical management is advocated. The diagnosis of Meniere's must be confirmed through careful history, physical, neurotological evaluation and selective testing. The majority of patients can be controlled medically; however, in this study 52 (26%) patients underwent surgical therapy. Twenty-eight patients underwent some type of saccus surgery for Meniere's disease with overall relief of 71%; however, better relief of vertigo was seen with labyrinthectomy and nerve section. The most common indication for surgery was disabling vertigo. However, fluctuating progressive sensorineural loss, may be an important reason to advise surgery. Surgical techniques for Meniere's disease continue to evolve. A graduated approach is preferred, starting with endolymphatic-mastoid shunt, proceeding to middle fossa vestibular nerve section when medical status and hearing are adequate. When hearing is socially inadequate, labyrinthectomy with or without yestibular nerve section is preferred. A good working relationship with a neurosurgeon is advised for otolaryngologists performing middle fossa surgery.     

Cochleosacculotomy for the treatment of meniere's disease in the elderly patient

Cochleosacculotomy is a surgical option for the treatment of incapacitating vertigo in elderly patients with Meniere's disease. This procedure was performed in nine patients (mean age: 73 years) for control of vertigo and/or drop attacks. The average follow-up period was 29 months. Vertigo was controlled in eight of nine patients, hut hearing worsened in all but one patient. No patient developed a transient increase in vertigo in the postoperative period. Cochleosacculotomy should be considered in elderly patients with recurrent vertigo and severe non-fluctuating sensorineural hearing loss who would otherwise be candidates for labyrinthectomy.     

Diagnostic assessment of patients with Meniere's disease through caloric testing and the video-head-impulse test

IntroductionMeniere's disease is a labyrinth disease that usually presents with episodes of spontaneous vertigo associated with sensorineural hearing loss, tinnitus and ipsi- and unilateral aural fullness in most cases. Vestibular function tests, video-head-impulse test and the caloric test, are not specific for diagnosis of the disease, but may show alterations that help to evaluate the functional impairment.ObjectiveTo describe the results obtained at the caloric test and video-head-impulse test in patients with definite Meniere's disease and compare them between symptomatic, asymptomatic ears and those of the control group.MethodsCross-sectional and observational study including patients with definite Meniere's disease diagnosed according to the Bárány Society criteria (2015) and healthy individuals (control group) undergoing caloric test and video-head-impulse test. All subjects were assessed by neurotological anamnesis and audiological evaluation (pure-tone, vocal and immittance audiometry) to characterize the sample. The findings obtained at the caloric test and video-head-impulse test were described and compared between the symptomatic and asymptomatic ears of patients with Meniere's disease and those of the control group.ResultsThirty-two patients with definite Meniere's disease were evaluated, with a mean age of 45.7 years, mostly females (68.8%) and unilateral disease. The control group consisted of 20 healthy individuals, with a mean age of 44.7 years, mostly females (70.0%). The groups were homogeneous in relation to age and gender. The patients’ main complaint was vertigo (71.9%), and most patients had more than six episodes in the last six months (71.9%). Moderate sensorineural hearing loss was present in 38.5% of patients. The prevalence of hyporeflexia at the caloric test was higher in symptomatic (56.4%) and asymptomatic (36%) ears of patients with Meniere's disease compared to the ears of control subjects (7.5%), p < 0.001 and p = 0.004, respectively. Video-head-impulse test alterations in the lateral semicircular canals were more frequent in the symptomatic ears of patients with Meniere's disease than in the ears of control subjects (p = 0.026).ConclusionMost patients with definite Meniere's disease showed hyporeflexia at the caloric test and video-head-impulse test with normal function in the symptomatic ear. Vestibular hyporeflexia at the caloric test was more frequent in the symptomatic and asymptomatic ears of patients with Meniere's disease than in the control group. The video-head-impulse test showed more alterations in the lateral semicircular canals.     

Intratympanic gentamicin for unilateral Menière's disease: results of therapy

Intratympanic gentamicin for unilateral Menière's disease: results of therapy Patients with Menière's disease that remains refractory to conservative treatment have traditionally been subjected to ablative surgery. The purpose of this prospective study was to evaluate the use of intratympanic gentamicin in eliminating incapacitating vertigo, while preserving hearing. Over the past 8 years, 83 patients have received between 1 and 6 intratympanic injections of gentamicin in an out‐patient setting, with duration of therapy titrated to individual symptom response and effect on hearing. Using established AAO‐HNS guidelines, we present data on 50 patients who have a minimum of 2 years follow‐up. Control or significant improvement of definitive Menière's attacks was achieved in 92% of patients and hearing preserved or improved in 76%. Only one patient experienced profound sensorineural hearing loss. We feel this treatment option should be considered and offered to patients in whom medical treatment has failed.     

Significance of tomography in meniere's disease: Periaqueductal pneumatization

The revival of endolymphatic sac surgery has led to many investigations in Meniere's disease, including lateral tomography of the periaqueductal pneumatization. We radiologically assessed a series of Meniere's patients and a control group, and found hypocellularity to be more common in Meniere's disease as the literature has stated. However, we found this finding bilaterally in patients with unilateral disease. Our assessment of this information in regard to the etiology and treatment of Meniere's disease is presented.     

The current role of local intratympanic Gentamicin therapy in the management of unilateral Menière’s disease

Over the past 5 years 25 patients suffering from disabling unilateral Menière’s disease have been treated in our unit with local intratympanic Gentamicin therapy with the specific intent of creating a medical labyrinthectomy, together with preservation of hearing on the treated side. Results from the 16 patients who have completed a 2-year follow-up show that substantial control of vertigo was obtained in all subjects, while 87% experienced complete control of vertigo following treatment. In 66% this was achieved in association with a complete medical labyrinthectomy (no caloric response to an iced water stimulus). In 94% of patients the hearing on the treated side has remained unaffected, but tinnitus was largely unchanged. The simple treatment protocol uses a customized self-retaining intratympanic catheter system (courtesy of Exmoor Plastics Ltd). The findings suggest that local Gentamicin therapy is an effective treatment in patients with incapacitating unilateral Menière’s disease and is associated with low morbidity and good hearing preservation and thus provides a potentially superior alternative to the surgical treatment options currently available.     

Endolymphatic subarachnoid shunt for ménière's disease in the only hearing ear

This report describes a series of 18 patients, deaf in one ear, upon whom an endolymphatic subarachnoid shunt procedure was performed on the reMayning hearing ear affected by Ménière's disease. As with other patients with Ménière's disease, those whose problem involves their only hearing ear can have differing priorities and etiologies requiring variations in diagnosis and management. The preservation of hearing is of major consideration as is the need for thorough study and careful diagnosis in the determination of when to operate. Special surgical techniques that help minimize the risks from surgery are employed resulting in no patient's hearing being made worse by the surgery. Study results lead to the conclusion that the use of the endolymphatic subarachnoid shunt procedure early in the course of Meniere's disease in an only hearing ear can significantly reduce the risk of permanent hearing loss and disability.     

Immunoperoxidase study of the endolymphatic sac in meniere's disease

A growing body of evidence suggests that some cases of Meniere's disease may be mediated by immune mechanisms. Because endolymphatic sac dysfunction is believed to be an underlying cause of Meniere's disease, this study used immunohistochemical techniques to demonstrate the presence of immune complex deposition in the sacs of patients with Meniere's disease. Positive immunoglobulin G (IgG) staining was noted in 10 of 23 sac biopsies from Meniere's patients, with 2 specimens showing perivascular deposition. Only 1 of 5 control specimens was only slightly positive for IgG. Clinical correlation showed a statistically significant increase in disease bilaterality (P<.05), larger summating potential/ action potential (SP/AP) ratios with electrocochleography (ECoG), and a tendency toward worse hearing and more progressive disease among the immunopositive Meniere's patients. The results provided histological evidence of immune injury in the endolymphatic sacs of patients with Meniere's disease.     

Eustachian tube function in patients with Meniere's disease

Objective

The aim of the present study was to clarify the relationship between Eustachian tube function and inner ear function, especially with respect to the hearing ability of patients with Meniere's disease.

Methods

Patients with Meniere's disease underwent nystagmic examinations and audiometric measurements, including hearing tests, tympanometry, and Eustachian tube function tests (sonotubometry). We compared the audiometric examination results of normal subjects to those of patients with Meniere's disease.

Results

Twenty-five percent of patients with Meniere's disease exhibited Eustachian tube dysfunction, but 92% displayed normal tympanometry findings. Their sonotubometry durations and amplitudes were not significantly different from those of normal subjects. However, the patients’ hearing level was significantly correlated to sonotubometry duration and amplitude. Our patients were classified according to the four stages of Meniere's disease: stage 1 (n = 9); stage 2 (n = 5); stage 3 (n = 8); and stage 4 (n = 2). The incidence of Eustachian tube dysfunction in these four groups of patients were 0% (0/9); 40% (2/5); 38% (3/8); and 50% (1/2), respectively.

Conclusion

Our study provides evidence demonstrating that treatment of Eustachian tube dysfunction may be useful in preventing the hearing of Meniere's patients from becoming worse.     

Clinical and radiological findings in subjects with unilateral Ménière's disorder

In order to contribute to the knowledge of the possible causes of Ménière's disorder, the authors have conducted systematic studies based on blood analysis and on petrous bone radiological examinations in patients suffering from unilateral Ménière's disorder and in two control groups, one of patients with unilateral sudden sensorineural deafness and the other one of normally hearing subjects suffering from neurological diseases. Blood tests have revealed systemic disorders (dyslipidosis, hypoglycaemia, hyperglicaemia, hypothyroidism, lues) in 49%, 48% and in 50% of the subjects respectively with Ménière's disorder, with sudden deafness, and with normal hearing. As to the radiological study, changes of the temporal bone (absence or small cells pneumatization and/or absence or narrowing of the vestibular aqueduct) were found in 78% of ears with Ménière's disorder, in 34% of ears with sudden deafness and in 46% of normal ears.     

Polytomography in méaniègre's disease: An update

In a previous article the use of polytomography of the vestibular aqueduct in Ménière's disease was described. The value of this procedure in the prognosis of surgery was evaluated by contrast of results with a non-radiographically examined population. Since then five more years of experience has been gained through routine radiographic examination of all patients with Ménière's disease. Within the above epoch, several efforts have been made to effectively separate patients into categories based on therapeutic expectations and prognostic stratifications. In addition X-ray studies, glycerol tests, hearing levels, frequency of vertigo and other clinical features have been suggested as offering suitable data for prognostic stratification. This paper updates the radiologic data previously presented, and reviews the efforts to date to accomplish significant prognostic stratification. Several clinical aspects of patients with Meniere's disease which may affect its severity are outlined.     

Hearing preservation in vestibular neurectomy

The goal of vestibular neurectomy is to control disabling vertigo while preserving hearing in patients with nonhydropic intractable peripheral vertigo or in patients with Meniere's disease in which an endolymphatic sac procedure has failed. Labyrinthectomy continues to be used to treat patients with intractable vertigo and serviceable hearing. We feel that a labyrinthectomy is contraindicated when any useful hearing remains. Vestibular neurectomy affords the surgeon a means to eliminate the abnormal vestibular input without sacrificing hearing. Two approaches have been used to section the vestibular nerves: the middle fossa approach since 1961 and the retrolabyrinthine approach more recently. Both approaches are effective in relieving vertigo while preserving hearing. This paper presents a statistical analysis of these two approaches. Although differences did exist, both were found to be highly successful in alleviating incapacitating vertigo and preserving hearing in a large percentage of patients.     

Changes in endolymphatic hydrops in a patient with Meniere's disease observed using magnetic resonance imaging

We describe a case report of a patient with Meniere's disease whose changes in endolymphatic hydrops were observed using magnetic resonance imaging (MRI). Gadolinium was injected intratympanically through the tympanic membrane, and MRI scans performed with a 3-T MRI unit revealed endolymphatic hydrops inside the perilymphatic space filled with gadolinium. We evaluated the relationship between the image findings and hearing level. The correlation between the degree of endolymphatic hydrops observed by MRI and hearing level in patients with Meniere's disease offers a promising new method to study the progression of Meniere's disease.     

The association of antidiuretic hormone levels with an attack of Meniere's disease

Objectives: An elevation of the plasma antidiuretic hormone (ADH) levels has frequently been observed in Meniere's disease patients. However, little is known regarding the mechanism behind such an elevation of ADH level in Meniere's disease patients. Therefore, we measured the plasma ADH in Meniere's disease patients and other vertigo patients to elucidate the association between the ADH levels, stress levels and the development of Meniere's symptom. Design and setting: The plasma ADH levels and plasma osmotic pressure were determined in 23 definite Meniere's disease patients and 160 patients with other types of vertigo/dizziness. All participants were administered questionnaire regarding their psychological status including their stress levels. Results: The ADH levels of Meniere's disease patients in the acute phase (5.80 ± 1.37 pg/mL) were significantly higher in comparison with that of Meniere's disease patients in the remission phase (2.26 ± 0.41 pg/mL) (P < 0.05). In other peripheral vertigo patients, the ADH level in the acute phase (1.71 ± 0.23 pg/mL) was not significantly different from that in the remission phase (1.45 ± 0.15 pg/mL). Meniere's disease patients in the acute phase had a significantly higher stress score (114 ± 23) than Meniere's disease patients in the remission phase (56 ± 13) (P < 0.05). However, there was no significant correlation between their stress score and the ADH levels. Conclusions: These results suggest that the elevation of the plasma ADH levels in Meniere's disease patients in the acute phase is, therefore, associated with the pathogenesis of Meniere's disease attacks rather than with stress.