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。     

Is recurrent loss of low frequency tone perception--without vertigo--a precursor of Meniere disease?

PURPOSE: Recurrent low-frequency sensory hearing loss is one characteristic sign of Meniere's disease. It is therefore often assumed to be a prodromal sign of Meniere's disease. METHODS: We report on 81 patients with recurrent low-frequency sensory hearing loss who did not previously suffer from vertigo. All patients underwent a follow-up examination after at least 1 year up to more than 10 years after the onset of the disease [average: 64.65 months (SD 56.33)]. CONCLUSIONS: Only 3.7% of these patients developed the typical signs of Meniere's disease with labyrinthine vertigo, whereas 25.9% suffered from recurrent hearing loss and an unspecific vertigo, which could be diagnosed and treated as psychogenic vertigo; 3.7% showed a typical benign positional vertigo. We can thus conclude that although almost every patient with Meniere's disease suffers from recurrent hearing loss, only a few patients with recurrent hearing loss will develop Meniere's disease. However, many patients with low-frequency sensory hearing loss develop anxiety and psychogenic dizziness in expectation of "imminent" Meniere's disease. Therefore, it is important to counsel the patients carefully that the probability of this occurring is not very high.     

Cochleosacculotomy revisited. Long-term results poorer than expected

Cochleosacculotomy has been described as a simple, efficacious treatment for relief of vertigo in patients with Meniere's disease in whom medical therapy has failed. We reviewed records of 11 elderly patients with good vestibular function who were thought to be ideal candidates for this procedure. Average follow-up was 17 months. Contrary to previous reports, long-term control of vertigo was poor, and more than 80% of the patients suffered a significant hearing loss from this procedure. Four of 11 patients required a second surgical procedure to control their vertigo. Audiometric measures revealed statistically significant postoperative increases in puretone thresholds at all frequencies and speech reception threshold, and a decrease in discrimination scores. Based on the results of this study, we no longer plan to use cochleosacculotomy for the treatment of elderly patients with Meniere's disease.     

小剂量庆大霉素鼓室内注射治疗难治性梅尼埃病眩晕的临床研究

目的：分析小剂量庆大霉素鼓室内注射治疗难治性梅尼埃病眩晕的疗效。方法：19例单侧难治性梅尼埃病患者显微镜下鼓室内注射庆大霉素,根据床旁试验（自发性眼震、摇头实验、甩头试验）,听力变化或患者主观症状来决定3周后是否需要再次注射。结果：19例患者中17例眩晕能得到控制,眩晕控制率89％,其中5例患者经1次注射后眩晕就得到控制;8例患者2次注射后眩晕达到控制,其中1例患者因不能忍受耳内肿胀感,要求进一步治疗,行内淋巴囊减压后,症状缓减;有4例患者经3次注射后眩晕得到控制;另外2例患者注射2次后眩晕无改善,要求终止治疗。2例患者注射后听力好转,14例患者注射后听力无变化,3例患者（15％）注射后听力进一步下降。结论：运用小剂量鼓室内庆大霉素注射治疗难治性梅尼埃病眩晕,1次注射后观察3周决定再次注射的必要性,结果显示这一治疗方案既能有效控制眩晕的发作,又能降低听力损伤的风险。     

Intratympanic gentamicin for control of vertigo in Meniere's disease: vestibular signs that specify completion of therapy

OBJECTIVE: To determine if a protocol of weekly intratympanic gentamicin injections administered until development of signs of unilateral vestibular hypofunction can alleviate vertigo while preserving hearing in patients with intractable vertigo caused by unilateral Meniere's disease. STUDY DESIGN: The study design was a prospective investigational protocol. SETTING: The study was performed in outpatients at a tertiary referral center. PATIENTS: Entry criteria included a diagnosis of "definite" Meniere's disease according to the 1995 report of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), intractable vertigo despite optimal medical therapy, no symptoms suggestive of Meniere's disease in the contralateral ear and serviceable hearing in the contralateral ear. The outcomes of the first 34 patients who entered the protocol are reported. INTERVENTION: A buffered gentamicin solution was injected into the middle ear at weekly intervals until development of spontaneous nystagmus, head-shaking-induced nystagmus, or head-thrust sign indicative of vestibular hypofunction in the treated ear. Main OUTCOME MEASURE: The 1995 AAO-HNS criteria for reporting treatment outcome in Meniere's disease were used. The effects of treatment were assessed in terms of control of vertigo, disability status, hearing level, and quantitative measurement of vestibular function with caloric and rotatory chair tests. RESULTS: Vertigo was controlled in 91% of the patients. Profound hearing loss occurred as a result of gentamicin injection in one patient (3%). Intratympanic gentamicin was significantly less effective in controlling vertigo in patients who had previous otologic surgery on the affected ear. Recurrence of vertigo > or = 6 months after initially complete control was noted in seven patients (22%). Vertigo in six of these patients was eliminated by additional intratympanic gentamicin injections. CONCLUSIONS: Ending weekly intratympanic gentamicin injections when clinical signs of unilateral vestibular hypofunction appear can control vertigo in most patients. Hearing loss directly attributable to gentamicin is uncommon. Treatment outcome is best in patients who have not had previous otologic surgery.     

Retrolabyrinthine vestibular nerve section: efficacy in disorders other than Menière's disease

The retrolabyrinthine vestibular nerve section has evolved as an effective treatment for intractable vertigo of peripheral vestibular origin when hearing preservation is desired. This report studies the efficacy of retrolabyrinthine vestibular nerve section for control of vertigo due to causes other than Meniere's disease. This report details our experience with 42 patients with a wide variety of diagnoses. The reduced success rate of retrolabyrinthine vestibular nerve section in these patients is difficult to evaluate, as very few patients have been analyzed with respect to their specific diagnoses. Of patients who underwent retrolabyrinthine vestibular nerve section for control of vertigo, 23 patients had uncompensated vestibular neuritis and 19 others had a wide range of other diagnoses. For patients with uncompensated vestibular neuritis (n = 23), the physician record noted that 39% of patients were cured and 30% improved. This compares to our series of patients with Meniere's disease (n = 48), where 94% were cured and 2% improved. The true vestibular abnormality may be less reliably identified in patients with uncompensated vestibular neuritis, contributing to the less effective results. Since the development of a vestibular rehabilitation program, retrolabyrinthine vestibular nerve section for uncompensated vestibular neuritis has been all but abandoned. Retrolabyrinthine vestibular nerve section appears to achieve a high cure rate in patients with sensorineural hearing loss associated with their vestibular abnormalities. While retrolabyrinthine vestibular nerve section is helpful for control of vertigo in some diagnoses, a substantial incidence of persistent postoperative dysequilibrium was noted.     

Long-term effect of acetazolamide and chlorthalidone on the hearing loss of Menière's disease

A retrospective computerized analysis of the records of patients with Meniere's disease was made to evaluate the effect of acetazolamide and chlorthalidone on the rate of hearing loss. Three groups were compared as follows: (1) 79 patients treated with chlorthalidone for 5 to 13.4 years; (2) 42 patients medicated with acetazolamide between 5 and 7.8 years; and (3) a control group of 71 patients who received only intermittent symptomatic treatment for vertigo, followed for 5 to 24.1 years. In the short term, after 2 to 6 weeks of treatment, a statistically significant decrease of the average hearing loss was observed with both chlorthalidone and acetazolamide. In the long term, more than 5 years, no preventive effect on the deterioration of the hearing loss could be detected. Both acetazolamide and chlorthalidone can be useful for diagnostic purposes by causing a fluctuation of hearing, as well as for the management of the vertigo attacks, but it is not useful for the long-term prevention of the hearing deterioration in Meniere's disease.     

Use of intratympanic gentamycin for the treatment of Meniere's disease

The ablation treatment of Meniere's disease by intratympanic streptomycin applications was first reported by Schuknecht in 1957. Streptomycin and gentamycin are the most frequent aminoglycosides used for the Meniere's disease treatment. Gentamycin is responsible for the damage of vestibular dark cells causing the impairment of endolymph production. This method gives the possibility for the control of the vertigo with a potential hearing preservation. Fifteen patients with unilateral Meniere's disease who had not responded to conventional therapy, were treated by intratympanic gentamycin injections. The hearing status and the caloric test were staged before and after treatment according to the AAO-HNS guidelines. Overall results after minimum 1 year follow-up in this group were as shown below: complete vertigo control--5 patients, substantial vertigo control--8 patients, complete relief of tinnitus--10, relief of aural fullness--12 patients, hearing loss--none. According to presented results, intratympanic injections of gentamycin is the useful alternative to the surgery. This method should be consider in every patient with the unilateral Meniere's disease, who had not responded to the conventional treatment.     

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.     

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

Patients with Meniere'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 Meniere'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.     

Vestibular nerve section versus intratympanic gentamicin for Meniere's disease

OBJECTIVES/HYPOTHESIS:Vestibular nerve section and transtympanic gentamicin administration are procedures with proven efficacy in the treatment of vertigo associated with Meniere's disease refractory to medical management. Hearing loss is a known complication of each of these procedures; however, there has not been a report of hearing results of both treatments from a single institution. STUDY DESIGN: Retrospective review. METHODS: Review was made of 25 patients undergoing gentamicin injection and 39 patients undergoing vestibular nerve section for Meniere's disease. Rate of vertigo control and pretreatment and post-treatment pure-tone average values and speech discrimination scores were reported. RESULTS: The mean preoperative pure-tone average for patients having vestibular nerve section was 47.2 dB, with a speech discrimination score of 75.4%. In these patients, the postoperative pure-tone average was 49.1 dB and the speech discrimination score was 75%. Patients undergoing gentamicin injection had a mean pretreatment pure-tone average of 55.9 dB and a speech discrimination score of 62%. The post-treatment pure-tone average and speech discrimination score for the gentamicin group were 68.8 dB and 49.3%, respectively. Five of 25 patients (20%) in the gentamicin treatment group and 1 of 39 (3%) in the vestibular nerve section treatment group had an increase in bone-conduction threshold greater than 30 dB. The amount of postprocedure hearing loss was significantly greater in the gentamicin treatment group (P =.006). Control of vertigo was good to excellent in 95% of the patients treated with vestibular nerve section and in 80% of the patients treated with gentamicin. CONCLUSION: Although vestibular nerve section and transtympanic gentamicin are both acceptable treatment options for vertigo associated with Meniere's disease, gentamicin causes a higher level of hearing loss related to treatment and vestibular nerve section has higher vertigo control rates.     

经鼓室微导管持续泵入庆大霉素治疗难治性梅尼埃病

目的 观察经鼓室内微导管持续泵入庆大霉素治疗单侧难治性梅尼埃病的疗效。方法 对21例单侧难治性梅尼埃病患者经耳后进路鼓室内插入微导管，在2天内用微量泵以0．1ml／h的速度注入庆大霉素0．048g，然后观察眩晕、听力及耳鸣的变化。结果 21例平均随访23个月，眩晕完全控制18例，明显减轻3例，其中有2例复发再次治疗后眩晕消失；听力无明显改变有15例，听力平均下降5．1～7．6dB的有5例，听力平均下降10．4dB以上者1例；耳鸣消失者9例，明显减轻者6例，不变者6例。结论 经鼓室微导管持续泵入庆大霉素治疗难治性梅尼埃病，可有效地控制眩晕，改善耳鸣；对听力的损害较轻微，可作为单侧难治性梅尼埃病的首选治疗方法。     

Insertion of tympanic ventilation tubes as a treating modality for patients with Meniere's disease: a short- and long-term follow-up study in seven cases

OBJECTIVES: As a treatment for patients with Meniere's disease, insertion of a ventilating tube in tympanic membrane was carried out, and the effect of the therapeutic modality was analysed. METHODS: Seven patients (four males and three females, age ranged 35-62 years) with active Meniere's disease were placed with ventilating tubes in the affected ear and postoperative change in symptoms, i.e. incapacitating vertigo and hearing loss were investigated. Disease severity was scored and evaluated pre- and postoperatively under the guidelines proposed by the Committee on Hearing and Equilibrium in the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS, 1985). RESULTS: Of the seven cases, the number of patients and the degree in controlling vertigo after the treatment were: at 24 months (short-term) five cases with substantial, one with limited and one with insignificant control, then at 42 months (long- term) four cases with substantial, three with limited control, respectively. The degree of disability in patients at 24 and 42 months of the treatment was compatible with the level of vertigo controlling. On the other hand, patients' hearing level was not affected by the treatment. CONCLUSIONS: Exact explanation for the effect of ventilating tubes in tympanic membrane is vague and its therapeutic effect was limited. However, at least this treatment might represent a short-term effect for the reduction of persistent vertigo in some patients with Meniere's disease and so it might become a treatment option because of its simple and less-invasive procedure.     

Intratympanic gentamicin therapy for vertigo in nonserviceable ears

PURPOSE: Intratympanic ototoxic agents have become a widely accepted means of managing vertigo in patients with Meniere's disease while preserving residual hearing. We investigated expanding the indications for intratympanic gentamicin to include control of vertigo in patients without serviceable hearing in the involved ear caused by a variety of end-organ pathologies. MATERIALS AND METHODS: We present a retrospective series of 6 patients suffering from vertigo caused by end-organ disease, in an ear without serviceable hearing. Two patients suffered from delayed endolymphatic hydrops, 3 from Meniere's disease, and 1 from poststapedectomy vertigo. These patients chose unilateral vestibular ablation with serial intratympanic gentamicin injection rather than labyrinthectomy for a variety of reasons. Conventional electronystagmography (ENG) testing and audiometry were completed on all patients. The ENG testing included bithermal calorics and rotational testing. All patients had a magnetic resonance image with gadolinium to exclude retrocochlear or central pathology. Rotational testing was repeated before each injection and at the conclusion of therapy to assess changes in the peripheral vestibular response. The patients' subjective response to therapy was followed. RESULTS: Follow-up has been 10 to 69 months with successful control of vertigo in all patients. CONCLUSIONS: Intratympanic gentamicin therapy offers a minimally invasive, ambulatory, low morbidity, cost-effective means of managing vertigo in patients with nonserviceable hearing.     

Hearing loss and tinnitus in Meniere's disease

OBJECTIVES: To characterize hearing loss, tinnitus and associative factors in Meniere's disease. METHODS: From our vertigo database consisting of 1356 patients, we retrieved 243 patients with Meniere's disease (MD). RESULTS: Hearing loss was the initial symptom in 13% of cases. Altogether 64% (n=133) of the patients stated that their hearing was reduced during the vertigo attack. The hearing deteriorated more likely during the vertigo attack if the vertigo attack was very intense [r(206)=0.19]. Tinnitus was the initial symptom in 5% of cases. The tinnitus was mild in 38% (n=90), moderate in 32% (n=76) and severe in 30% (n=72) of patients. The intensity of tinnitus correlated with the occurrence of drop attacks [r(237)=0.29], vertigo provoked by head positioning [r(235)=0.25], by physical activity [r(230)=0.33], or by pressure changes [r(239)=0.27]. CONCLUSION: Prolonged disease causes deterioration of hearing. Intense tinnitus is common in MD and is more often seen in late stage of the disease.     

Intratympanic gentamicin for intractable Meniere's disease

OBJECTIVE: The study aimed to analyze the results of the intratympanic injection of gentamicin as a treatment option for patients with unilateral Meniere's disease who were refractory to medical treatment. STUDY DESIGN: Prospective study in the setting of a tertiary care medical center. METHODS: Seventy-one patients with unilateral Meniere's disease according to 1995 American Academy of Otolaryngology-Head and Neck Surgery 1995 guidelines who had been unresponsive to medical therapy for at least 1 year were studied. Intratympanic injections of a prepared concentration of 27 mg/mL gentamicin were performed at weekly intervals until the development of symptoms and signs indicative of vestibular hypofunction in the treated ear. As the main outcome measure, the 1995 American Academy of Otolaryngology-Head and Neck Surgery criteria for reporting treatment outcome in Meniere's disease were used. The results of treatment were expressed in terms of control of vertigo, disability status (functional level and degree of overall impairment evaluated by the Dizziness Handicap Inventory and the University of California Los Angeles Dizziness Questionnaire), hearing level, and quantitative measurement of vestibular function. RESULTS: Vertigo was controlled in 83.1% of the 71 patients. Recurrence of vertigo spells after initially complete control was noted in 17 patients. In 13 of these patients, this was cured by another course of intratympanic injections of gentamicin. Functional level and measures of self-reported handicap were significantly and promptly lowered after treatment in the patients who attained control of vertigo. Hearing level as pure-tone average was unchanged 2 years after treatment, but hearing loss as a result of gentamicin injections occurred in 23 patients at the end of treatment and in 9 and 11 patients at 3 months and 2 years after the treatment, respectively. Vestibular function was kept normal or reduced in 49.3% of the patients, whereas in the rest of the patients vestibular areflexia was observed. Control of vertigo did not depend on the amount of vestibular damage. CONCLUSIONS: Ending weekly intratympanic injections when clinical signs of vestibular deafferentation appear can control vertigo in the majority of patients, and it is a useful alternative, together with other surgical options, for the treatment of patients with Meniere's disease who do not respond to medical treatment.     

Surgical treatment of Menière's disease since Thomsen

The effects of Thomsen's 1981 report of a controlled double-blind study on the surgical treatment of Meniere's disease were studied by reviewing the current literature and Thomsen's subsequent reports. The current surgical literature was found to contain reasonable support for the continued use of endolymphatic shunt procedures despite the criticism of such procedures by Thomsen. Surgical therapy for Meniere's disease continues to be divided into auditory sparing or conservative procedures and auditory ablative or destructive procedures. Conservation procedures are important because approximately 30% of patients with Meniere's disease progress to bilateral involvement. Endolymphatic sac procedures continue to be classified as conservative. Important findings in the current literature are reports of long-term follow-up of patients after sac surgery. These question the long-term control of hearing loss but support the use of the procedure due to its low morbidity and consistent control of vertigo. Other authors have described the different types of endolymphatic procedures and confirm their equal effectiveness. The results of middle fossa and retrolabyrinthine vestibular neurectomy were also reviewed, and its continued control of vertigo were affirmed. The increased number of severity of complications (compared with endolymphatic shunt procedures) were noted. Finally, a strategy for surgical treatment of Meniere's disease, beginning with the patient with uncontrollable vertigo, is presented.     

梅尼埃病首发症状的临床分析

目的了解梅尼埃病患者的性别、首发的年龄、症状,并根据首发症状进行临床分类。方法回顾分析准确提供首发症状的145例梅尼埃病患者,按照耳聋和（或）耳鸣（耳蜗症状）、半规管（旋转性眩晕）和耳石器症状（倾到或平衡障碍）进行分类。结果首发症状依次为耳鸣45例、耳蜗加眩晕症状30例、眩晕28例、耳鸣加耳聋27例、听力下降9例、耳石器症状6例。累及耳蜗及前庭系统30例;累及耳蜗81例：累及半规管28例：累及耳石器6例。小于20岁和大于60岁年龄组患者数最少。男性高发年龄较女性高发年龄早10年,男性和女性在30-49岁年龄段发病例数最多。三种类型梅尼埃病临床首发症状与典型症状出现的间隔差异均较大。结论梅尼埃病耳蜗受累明显高于前庭,首发症状耳鸣最常见,其次是听力下降,再次为眩晕,倾倒的出现率最低。对不典型病例的早期诊断酌情选择纯音测听、耳蜗电图、前庭双温试验和前庭诱发的肌源性电位等检查。     

Production of diagnostic rules from a neurotologic database with decision trees

A decision tree is an artificial intelligence program that is adaptive and is closely related to a neural network, but can handle missing or nondecisive data in decision-making. Data on patients with Meniere's disease, vestibular schwannoma, traumatic vertigo, sudden deafness, benign paroxysmal positional vertigo, and vestibular neuritis were retrieved from the database of the otoneurologic expert system ONE for the development and testing of the accuracy of decision trees in the diagnostic workup. Decision trees were constructed separately for each disease. The accuracies of the best decision trees were 94%, 95%, 99%, 99%, 100%, and 100% for the respective diseases. The most important questions concerned the presence of vertigo, hearing loss, and tinnitus; duration of vertigo; frequency of vertigo attacks; severity of rotational vertigo; onset and type of hearing loss; and occurrence of head injury in relation to the timing of onset of vertigo. Meniere's disease was the most difficult to classify correctly. The validity and structure of the decision trees are easily comprehended and can be used outside the expert system.     

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.