梅尼埃病的手术疗效分析

目的比较前庭神经切断及内淋巴囊手术治疗梅尼埃病效果。方法将所有梅尼埃病患者根据听力及生活质量情况进行分期;根据分期情况予以非手术治疗以及内淋巴囊减压或引流术、前庭神经切断术。分析手术治疗梅尼埃病患者病史特点、手术情况;对于手术满24个月以上的梅尼埃病患者进行术前术后的眩晕、听力及生活质量等疗效评价。结果手术治疗梅尼埃病共77例患者79次手术(1例双侧梅尼埃病患者接受左右各1次内淋巴囊减压术;另1例双侧梅尼埃病患者接受了左侧前庭神经切断术及1次右侧内淋巴囊减压术),其中内淋巴囊手术34次,前庭神经切断术45次。术后24个月的眩晕控制率为:内淋巴囊手术73%,前庭神经切断术100%。结论内淋巴囊减压或引流术可以减轻患者眩晕、改善患者的生活质量;前庭神法。     

Assessment of surgical procedures for ménière's disease

There are numerous surgical procedures for the treatment of Meniere's disease, and the current status of their efficacy is controversial. A review of the literature is presented as a basis for the evaluation of the relative merit of these procedures. Emphasis is placed on endolymphatic sac procedures, sacculotomy, vestibular neurectomy and labyrinthectomy. Vestibular neurectomy and surgical labyrinthectomy provide high rates of improvement in vertigo. The hearing is frequently made worse by vestibular neurectomy. Endolymphatic sac procedures result in improvement in vertigo less frequently. They are most likely to improve hearing. Although sacculotomies are associated with improvement in vertigo in approximately 80% of patients, they are associated with high rates of hearing loss.     

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.     

梅尼埃病手术治疗的探讨

目的：探讨不同手术治疗梅尼埃病的临床疗效。方法：对21例梅尼埃病患者行内淋巴囊减压术．9例行乙状窦后前庭神经切断术，并进行随访观察。结果：术后经3～6年随访，内淋巴囊减压组眩晕完全控制11例，基本控制4例，部分控制4例，未控制2例。前庭神经切断组眩晕均得到完全控制。结论：内淋巴囊减压术仍然是手术治疗梅尼埃病的首选方法，但对内淋巴囊手术治疗无效或严重眩晕失去工作能力者．应考虑采用前庭神经切断术。     

感音神经性聋并迟发性眩晕（附13例报告）

报告感音神经性聋并迟发性眩晕（ＳＨＬ－ＤＶ）１４耳，其中由中耳炎及其有关手术所致者８耳，突聋和原因不明各３耳，１４耳由耳聋至眩晕发作相隔期平均２２．６年，眩晕病程平均６．２年，２耳行内淋巴囊减压术；３耳由中耳炎所致进严重耳聋，行迷路切除术，３耳行庆大霉素鼓室灌注术，６耳行链霉素外规管灌注术，１４耳平均随访２．３年，迷路切除术者眩晕消除，听力丧失，氨基糖甙类药物灌注者眩晕控制，听力有不同程度保存，提     

Results of endolymphatic sac surgery for Ménière's disease

From 1976 to 1982, 72 patients with Ménière's disease had endolymphatic sac surgery. Sixty of the 72 were reviewed after a mean period of 33 months from operation; in these, sac surgery (regardless of type) provided abolition or improvement of vertigo in 75%, and 70% of these had hearing improvement or stabilization. Twelve had failure of vertigo control and required either labyrinthectomy or vestibular neurectomy, usually within one year of the first operation. In a smaller subgroup followed for a mean period of 51 months, vertigo control was achieved in 60% and hearing maintenance in 40%. Our data indicate that sac surgery provides good control of vertigo and maintenance of hearing for a period up to about three years, with a significant decline in benefit at about four or five years after operation.     

Surgical treatment of vertigo with retrolabyrinthine vestibular neurectomy

Results for control of vertigo and preservation of hearing in patients who have had a retrolabyrinthine vestibular neurectomy (RVN) by our group were analyzed retrospectively. This procedure consists of selective section of the vestibular nerve in the posterior cranial fossa. Vertigo was completely controlled in all but two of 31 patients, one of whom required revision surgery to control attacks. Analysis of these two cases suggests that the cause of persistent vertigo is incomplete neurectomy. With our current surgical technique in patients with Meniere's disease, hearing results were not statistically different from our results with surgery of the endolymphatic sac. Control of vertigo was much more successful with the RVN than endolymphatic sac surgery.     

梅尼埃病的个体化治疗及疗效评估

目的:探讨梅尼埃病的个性化临床治疗方法,评估梅尼埃病的非手术及手术疗效.方法:将所有梅尼埃病患者根据听力及生活质量情况进行分期;根据分期情况予以非手术治疗(改变生活方式、口服药物以及鼓室内注射地塞米松)、内淋巴囊减压或引流术、前庭神经切断术或迷路切除术.分析手术治疗梅尼埃病患者病史特点和手术情况;对于手术满1年以上的梅...     

Comparison of Labyrinthectomy and Vestibular Neurectomy in the Control of Vertigo

One hundred twenty-six patients who were treated with labyrinthectomy (81 patients) or vestibular neurectomy (45) between the years 1979 and 1994 were reviewed. The cause for vertigo in 124 of the 126 patients was Meniere's disease (89 patients), labyrinthitis (15), delayed endolymphatic hydrops (8), vestibular neuritis (7), and failed labyrinthectomy (5). In the remaining 2 patients, a normal labyrinth was sacrificed to fistulize a petrous apex cyst. Both procedures were equally effective in relieving vertigo (labyrinthectomy 98.8%; neurectomy 97.8%), but the length of hospitalization, length of disability before return to work, and cost were twice as great with vestibular neurectomy than with labyrinthectomy. More patients exhibited prolonged ataxia following neurectomy (5 patients) than after labyrinthectomy (2). Vestibular neurectomy was associated with several serious complications: reversible facial paresis (15 patients), meningitis (1), cerebrospinal fluid leak (1), and epidural hematoma (1). Labyrinthectomy was complicated by postoperative hyponatremia in 1 patient. Selective vestibular neurectomy preserved hearing in 32 (82%) of 39 patients. Criteria for recommending either ablation procedure are discussed. The incidence of sequential involvement of the contralateral ear was 1.5%.     

梅尼埃病手术方法的选择

为总结选择不同的手术方法治疗梅尼埃病的经验，分析１１９例（１１９耳）采用手术方法治疗的梅尼埃病患者。诊断和疗效评定按１９９６年上海全国会计制定的梅尼埃病诊断依据和疗效分级，在病的分期和劳动能力方面，参照ＡＡＯ－ＨＮＳ９９５年的梅尼埃病的诊断和疗效评价标准分期，第二期４８例均行内淋巴囊分流术，第三期４４例，行Ｓｃａｒｐａ神经节切除术３２例，迷路入路前庭耳蜗神经切断术１２例；第四期２７例，行Ｓｃａｒｐ     

Pathology as it relates to ear surgery. IV. Surgery of Menière's disease

Conservative shunting procedures, i.e. ESS, ultrasonic irradiation and cryosurgery, are based on the assumption that there is increased volume and/or pressure of endolymph in Menière's disease. Since there is no reliable clinical test to detect endolymphatic hydrops, shunting procedures on cases without hydrops are doomed to failure. Surgery on the endolymphatic sac was not associated with fibrosis or obliteration of its lumen. Silastic shunt tubes were well tolerated by the body, and the shunt between the sac and the subarachnoid space seemed to remain open. The results of experimental surgery on the endolymphatic sac and its applicability to humans should be revised. Temporary improvement of Menière's symptom-complex may be expected from any surgical procedure on the membranous labyrinth, even in cases without endolymphatic hydrops. Post-operative serous labyrinthitis with associated biochemical changes is the cause of this improvement. The success of shunting procedures cannot be judged histologically by the position of Reissner's membrane. This membrane acts like varicose veins: once dilated, always dilated. Ultrasonic irradiation and cryosurgery of the labyrinth result in limited degenerative changes close to the site of probe application. Degenerated intact membranous walls may act as an internal otic-perotic shunt and may result in symptomatic improvement in Menière's disease. The idea of selective vestibular neurectomy and internal shunting procedures, i.e. without drainage of endolymph to the outside (mastoid) or to the inside (CSF), should be developed further. Recurrence of symptoms following shunting procedures may be due to failure of the shunt, or to the presence of endolymphatic hydrops in the non-operated ear. MF vestibular neurectomy results in complete denervation of the vestibular end-organs, without effect on the cochlea or facial nerve. Excision of Scarpa's ganglion causes retrograde degeneration in the proximal stump of the vestibular nerve, most probably to the level of the brain-stem. Recurrence of dizziness following TC labyrinthectomy is most commonly due to inadequate removal of the vestibular end-organs. The high regenerative capacity of the vestibular nerve is evidenced by the formation of traumatic neuromas in the vestibule following TC labyrinthectomy. Whether these neuromas produce symptoms is unknown. Persistent cochlear hydrops occurs following TC labyrinthectomy and TL vestibular neurectomy owing to obstruction in the hook region of the cochlea and in the ductus reuniens. This may result in persistent tinnitus and feeling of pressure in the ear.     

Vestibular neurectomy with simultaneous endolymphatic subarachnoid shunt

The purpose of this study was to assess the advantages of combined vestibular neurectomy (VN) and endolymphatic subarachnoid shunt (ELSS) surgeries in classic Menière's disease. We performed a retrospective analysis of the results of 116 patients with classic Menière's disease who were operated on via a posterior fossa approach. All patients underwent selective VN. In 86 of the patients, ELSS surgery was performed in conjunction with VN via the posterior fossa, which is called two-in-one surgery. Among the 86 patients who underwent two-in-one surgery, hearing preservation was achieved in 71 (82.5%), and the vertigo control rate was 96.5%. In patients who underwent VN without ELSS, hearing stabilization was achieved in 24 (80%), and the vertigo control rate was 96.7%. The hearing results and vertigo control rates were similar in the groups. Aural fullness subsided in 62 (72.1%) of the patients who underwent VN plus ELSS and in 14 (46.7%) who underwent VN alone. The recovery of fullness was significantly better with the combined VN and ELSS procedure ( P<0.05). In conclusion, although the two-in-one operation is a new procedure, its results for vertigo control and hearing stabilization are not different from that of VN alone. The only significant advantage of this technique was the achievement of a substantial improvement in the reduction of aural fullness.     

MANAGEMENT OF MENEERE＇S DISEASE--THE BEIJING TIANTAN HOSPITAL EXPERIENCE

Objective To report outcomes of nonsurgical and surgical management of Menire＇s disease at Beijing Tiantan Hospital. Methods Patients with Menire＇s disease were categorized into groups based on hearing and quality of life. Individualized management was provided, including life style modification, drug therapies, endolymphatic sac decompression and labyrin- thectomy. Treatment outcomes were evaluated during up to 24 months follow up. Results Eighty seven patients underwent life style modification and drug therapies. The vertigo control rate of Grade A and B was 76.9% and 83.8% respectively. Six patients received surgical management, including endolymphatic sac decompression （n = 5） and labyrinthecto- my （n = 1）. For these patients, the vertigo control rate of Grade A and B was 80% and 100%, respectively. Conclu- lsions Management of Meni6re＇s disease depends on several factors, i.e. severities of vertigo and hearing loss, quality of life, surgical contraindications and patient subjective desire. The treatment is drug therapies for the majority of patients, as well as life style modification. Surgical indications are rare and the least invasive procedures should be considered first. The results of surgery are generally satisfying.     

Triple semicircular canal occlusion for the treatment of Ménière's disease

CONCLUSION: Triple semicircular canal occlusion (TSCO) controls vertigo, is easy to perform, and could be used as an alternative procedure for the treatment of Meniere's disease in selected patients who complain mainly of intractable vertigo. OBJECTIVE: To seek an effective alternative surgical procedure for treating Ménière's disease in selected patients with intolerant rotational vertigo. PATIENTS AND METHODS: Three patients with Ménière's disease who underwent unsuccessful endolymphatic sac decompression or mastoid shunt, then underwent TSCO. Vertigo control and vestibular and auditory function were measured. RESULTS: The early vestibular symptoms caused by surgery resolved quickly and no hearing deterioration occurred after surgery. At the end of the follow-up period, based on the AAO-HNS criteria, two cases had complete control of vertigo (class A) and the other had substantial control of vertigo attacks (class B). Hearing was similar to the preoperative level at the end of the follow-up period.     

Stapes decompression

Footplate decompression, which has been described in Lyon in 1965, can be easily performed under local anesthesia. The surgical procedure consists of a 8/10 mm diameter stapedotomy followed by an obturation with spongel, gelfoam or a piece of thin fascia. The operation is not a labyrinthectomy or a sacculotomy but aims to decompress endolymphatic hydrops in Ménière's disease. It must be realised only in case of typical unilateral Ménière's disease with disabling vertigo and very poor residual hearing. More than two hundred cases have been operated on. Vertigo has been relieved in 90% of the operated cases, tinnitus less severe in 50% of cases and hearing sometimes worse but often unchanged. In patients suffering from a unilateral Ménière's disease with disabling vertigo and poor residual hearing, footplate decompression appears to be one of the most simple safe and effective surgical procedures.     

Endolymphatic sac surgery: methods of study and results

Surgery of the endolymphatic sac (ELS) in classical Meniere's disease has fallen under attack and has been abandoned by some surgeons. We studied our results for vertigo and hearing in 83 patients undergoing surgery of the ELS for intractable classical Meniere's disease. Half of the patients were completely free of definitive attacks at 2 years; another quarter experienced substantial control. Three fourths noted an improvement in their level of disability. Results for vertigo were sustained at longer follow-up intervals. Nineteen percent had revision surgery (usually retrolabyrinthine vestibular neurectomy) for intractable vertigo within 2 years of the sac operation. The 1985 reporting method of the American Academy of Otolaryngology--Head and Neck Surgery was found superior to previous methods because it specified a meaningful follow-up interval, used a graded scale accounting for partial success in treatment, and separated results for vertigo and hearing. Nevertheless, optimal use of the method in the future will require prospective reporting and a concerted effort to avoid confusion between definitive attacks of true vertigo and adjunctive vestibular symptoms. Even though the mechanism of the beneficial effect of sac surgery is unknown, we have found it useful in the control of disabling vertigo.     

联合应用内淋巴囊减压和局部激素治疗难治性梅尼埃病的短期与长期疗效分析

目的 探讨内淋巴囊减压联合经面隐窝鼓室内激素注射以及内淋巴囊表面覆盖激素明胶海绵治疗难治性梅尼埃病的短期与长期临床效果。 方法 回顾分析针对难治性梅尼埃病进行手术治疗的23例患者资料。手术方式在传统内淋巴囊减压的基础上,开放面隐窝,并在圆窗周围放置明胶海绵,鼓室内注射激素,同时在内淋巴囊表面放置明胶海绵并在乳突内注射激素。比较患者治疗前6个月与术后6~12个月(短期疗效),以及术后18~24个月(长期疗效)的眩晕发作次数以及平均听阈水平(500、1 000、2 000 Hz)。 结果 23例患者完成短期疗效评价,术后眩晕发作次数由(5.7±5.9)次(术前6个月)降至(0.4±1.0)次(术后6~12个月),眩晕控制率为87.0%。术后听力维持率为95.7%。13例患者完成长期疗效评价,术后眩晕发作次数由(4.2±2.6)次(术前6个月)降至(0.1±0.3)次(术后18~24个月),眩晕控制率为92.3%,术后听力维持率为100%。 结论 内淋巴囊减压联合局部激素治疗对于保守治疗无效的难治性梅尼埃病具有良好的眩晕控制率和听力维持率,值得推广。     

Combined vestibular neurectomy and endolymphatic sac shunt via the retrosigmoid approach in the treatment of Ménière's disease

The nature of surgical treatment for Ménière's disease has evolved from destructive to conservative in the interest of preserving hearing. We have performed a combined procedure that involves a vestibular neurectomy to control vertigo, which is followed by an endolymphatic sac shunt to control hydrops in 26 patients. Both procedures are performed via the retrosigmoid approach during the same surgical step. We believe this combination procedure is a worthwhile option to consider in order to achieve good control of vertigo and endolymphatic hydrops and to preserve hearing in patients with Ménière's disease.     

Persistent dizziness after surgical treatment of vertigo: an exploratory study of prognostic factors.

OBJECTIVE: Persistent vertigo and imbalance can occur after surgery for vertigo regardless of surgical approach. This study explored for factors affecting outcome of vertigo surgery. STUDY DESIGN: Patient survey and chart review. SETTING: Tertiary referral neurotologic private practice. PATIENTS/INTERVENTION: Of 111 patients (57.7% female; mean age, 52.3 yr), 59 underwent vestibular nerve section (middle fossa, retrolabyrinthine, and translabyrinthine), 25 underwent transmastoid labyrinthectomy, and 27 underwent endolymphatic sac shunt. Eighty-three percent had Ménière's disease. Mean follow-up was 4.3 years. MAIN OUTCOME MEASURES: Primary outcomes included American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) vertigo score and class, number of spells per month, current and change in AAO-HNS disability rating, vertigo and imbalance severity ratings, and frequency of imbalance. RESULTS: Three preoperative factors were consistently related to outcome: AAO-HNS disability rating, imbalance frequency rating, and duration of first symptom ([rho] = 0.19-0.51; all p's < 0.05). Greater disability and more frequent imbalance related to poorer outcome, but longer duration of disease related to better outcome. Presurgery vertigo characteristics were generally not related to outcome. Ménière's patients were more likely to have improvement in imbalance, as were those with no other significant disease and no allergy. The presence of tinnitus in the contralateral ear was associated with poorer outcomes, including a lower rate of results of Classes A and B (p = 0.023). Vertigo as a first symptom and the presence of eye disease also showed relationships to poorer outcome. CONCLUSION: Those rating themselves as more disabled before surgery are less likely to achieve the best outcomes, whereas frequency and severity of preoperative vertigo are not predictive. Several possible prognostic factors were identified that warrant future prospective study.     

梅尼埃病两种内淋巴囊手术方式的远期疗效观察

目的：评估与比较内淋巴囊乳突腔分流术（EMS）和内淋巴囊减压术（ESD）治疗梅尼埃病（MD）的远期疗效。方法：1994—06—2007—07采用内淋巴囊手术治疗原诊断为MD的患者59例,其中EMS34例,ESD25例,选择诊断符合MD诊断依据和疗效评估标准,术后2年以上、随访资料完整的23例24耳（分流术12例13耳,减压术11例11耳）进行回顾性总结。结果：EMS组12例13耳,随访3～14年,眩晕A级完全控制者9耳,B级基本控制4耳;ESD组11例11耳,随访2-14年,术后眩晕A级8耳,B级2耳,C级1耳。EMS组听力B级1耳（7．7％）,C级6耳,D级6耳;ESD组听力B级2耳（18．2％）,C级4耳,D级5耳。2组眩晕控制和听力改善差异无统计学意义。结论：EMS和ESD都是治疗MD的有效方法,对眩晕症状的控制效果满意,临床分期中晚期患者仍有疗效。