Triple Canal Occlusion for the Treatment of Intractable Menière's Disease.

OBJECTIVE: Menière's disease can be a debilitating condition but in most cases the symptoms are controlled by lifestyle changes and medical management. However, some patients remain symptomatic despite medical treatment and have the option of more invasive surgical treatments. Surgical intervention for Menière's includes a range of interventions from grommet insertion, intratympanic steroids/Gentamicin, endolymphatic sac decompression, labyrinthectomy, and vestibular neurectomy. A recently described technique involves the occlusion of all three semi-circular canals as an alternative in intractable Menière's disease. STUDY DESIGN: This is a case series of three patients who underwent triple canal occlusion for the treatment of intractable Menière's disease. SETTING: Patients were selected from those who were referred to Queen Elizabeth Hospital in Birmingham, a tertiary referral center. PATIENTS: Patients who were severely symptomatic despite medical treatment who were considering ablative therapy were offered the option of triple canal occlusion as an alternative. INTERVENTION: We report a series of Menière's patients treated by triple canal occlusion, describe the rationale behind this intervention, the surgical technique, and preliminary results. MAIN OUTCOME MEASURE: Each patient was followed up for a minimum of 2 years following the procedure. The main outcomes measures were the class of vertigo control and hearing threshold levels according to the American Academy of Otolaryngology-Head and Neck Surgery guidelines. RESULTS: Of the three patients, two were men and one was woman, the age range was 45 years to 61 years old. Two patients with unilateral disease achieved class A control whereas one patient with bilateral disease achieved class B control. Two patients who underwent the procedure had little or no effect to their hearing on the treated side however one patient suffered a 30 dB hearing loss on the operative side. CONCLUSIONS: Based on our limited experience and the early reports in the literature we consider that there are potential patient benefits for triple canal occlusion for intractable Menière's disease as an alternative to vestibular neurectomy due to the reduced morbidity and long-term efficacy.

Clinical long-term effects of surgical treatment for intractable Meniere's disease: a more than 13-year follow-up after pressure treatment and further surgical treatment for intractable vertigo.

Background: Meniere's disease appears to be a complex inner ear disorder and also remains a controversial and often difficult disease as regards determination of diagnosis, pathogenesis and especially optimal treatment.Aims/objectives: To investigate the long-term effects of progressive surgical treatment in the management of the vertigo attacks of intractable Meniere's disease.Material and methods: Eighteen patients with medically intractable and active Meniere's disease were opted to try Meniett pulse generator (Meniett), endolymphatic sac decompression (ESD) and triple semicircular canal occlusion (TSCO) in order to control the attacks of vertigo. Patients were indicated on the symptom report card the maximum level of vertigo, activity and stress.Results: Of 18 patients with medically intractable and active Meniere's disease during mean 165-month follow-up, the attacks of vertigo were effectively controlled in 14 patients by Meniett (77.78%), 2 patients by Meniett and ESD (11.11%), 2 patients by Meniett, ESD and TSCO (11.11%).Conclusions and significance: It is of great importance for intractable Meniere's disease to select surgically combined treatment process including Meniett, ESD and TSCO to effectively control the attacks of vertigo and a long-term follow-up.

Meniett Therapy for Ménière's Disease: An Updated Meta-analysis.

OBJECTIVE: To re-evaluate the efficacy of Meniett therapy for the treatment of Ménière's disease (MD). DATA SOURCES: PubMed, Embase, Cochrane Library, Clinicaltrials.gov, ChiCTR, and the CNKI database were searched for articles in English and Chinese published before August 31, 2015. STUDY SELECTION: Included in this meta-analysis were studies that dealt with outcomes of Meniett therapy for the treatment of MD, including randomized controlled clinical trials, case-control studies, and prospective or retrospective cohort studies, with sample sizes of ≥ 10 subjects. DATA EXTRACTION: Keywords included endolymphatic hydrops, Ménière's disease, pressure, Meniett, and transtympanic micropressure treatment. DATA SYNTHESIS: Fourteen studies were included, involving a total of 345 MD patients. Data were analyzed using the Meta package in R. Dichotomous outcomes were expressed as risk ratios with 95% confidence intervals, and weighted mean differences with 95% confidence intervals were used to present continuous outcomes. Heterogeneity of the included studies was quantitatively assessed by χ(2) and I tests. Fixed-effects models were used for I(2) <50%; otherwise, random-effects models were used. Funnel plots were constructed to test the publication bias. CONCLUSION: This study showed that Meniett therapy may prevent vertigo attacks and substantially reduce its frequency in MD patients. It may also alleviate the functional deficit. The impact of Meniett therapy on hearing remains uncertain. The optimal effect might maintain for approximately 18 months. This meta-analysis suggested that Meniett therapy may be a useful second-line therapy in the treatment of MD.

Hearing thresholds and FMRI of auditory cortex following eighth cranial nerve surgery.

OBJECTIVE: Determine whether auditory cortex (AC) organization changed following eighth cranial nerve surgery in adults with vestibular-cochlear nerve pathologies. We examined whether hearing thresholds before and after surgery correlated with increased ipsilateral activation of AC from the intact ear. STUDY DESIGN: During magnetic resonance imaging sessions before and 3 and 6 months after surgery, subjects listened with the intact ear to noise-like random spectrogram sounds. SETTING: Departments of Radiology and Otolaryngology of Washington University School of Medicine. SUBJECTS AND METHODS: Three patients with acoustic neuromas received Gamma Knife radiosurgery (GK); 1 patient with Meniere's disease and 5 with acoustic neuromas had surgical resections (SR); 2 of the latter also had GK. Hearing thresholds in each ear were for pure tone stimuli from 250 to 8000 Hz before and after surgery (3 and 6 months). At the same intervals, we imaged blood oxygen level-dependent responses to auditory stimulation of the intact ear using an interrupted single-event design. RESULTS: Hearing thresholds in 2 of 3 individuals treated with GK did not change. Five of 6 individuals became unilaterally deaf after SRs. Ipsilateral AC activity was present before surgery in 6 of 9 individuals with ipsilateral spatial extents greater than contralateral in 3 of 9. Greater contralateral predominance was significant especially in left compared to right ear affected individuals, including those treated by GK. CONCLUSION: Lateralization of auditory-evoked responses in AC did not change significantly after surgery possibly due to preexisting sensory loss before surgery, indicating that less than profound loss may prompt cortical reorganization.

Tenotomy of the stapedius and tensor tympani muscles reduces subjective dizziness handicap in definite Meniere's disease.

CONCLUSION: Tenotomy is a promising surgical alternative with a high reduction in dizziness handicap in the short and long term. OBJECTIVES: To investigate the immediate and the long-term effect of tenotomy of the stapedius and tensor tympani muscles on subjective dizziness as measured by the Dizziness Handicap Inventory (DHI). METHODS: A retrospective follow-up study of 42 patients with definite, unilateral Meniere's disease (19 males, 23 females, average age = 58.1 ± 14.1 years) had undergone tenotomy under general anesthesia through an endaural approach. Pre- and postoperative DHI values were compared for all patients, with postoperative follow-up ranging from 6 months to 9 years. Additionally, results were divided into three postoperative subgroups (A = 0-3 years, B = 3-6 years, C = 6-9 years). RESULTS: A statistically significant reduction of 48 DHI points, from a median preoperative DHI = 52 to DHI = 4 postoperatively, was noted (p < 0. 001). In all, 40/42 patients reported a reduction of dizziness handicap, while in 33/42 the difference was > 12 points. A statistically significant reduction of DHI scores was noted (A = 60, B = 34, C = 33) in all subgroups. It was also noted that the higher the preoperative DHI score, the greater the subjective success of the surgery.

[Short and long term results of endolymphatic sac surgery: a patient-questionnaire based study]. / Die Saccotomie in der Behandlung des M. Ménière: Beurteilung der kurz-, mittel- und langfristigen Ergebnisse anhand eines Patientenfragebogens.

INTRODUCTION: The endolymphatic sac surgery for the treatment of Meniere's disease has been described since the 1920s. The success rate of this technique in terms of vertigo control has been reported to be 50-80%. However, the value of this treatment method remained controversial. Furthermore, the reliable identification of the endolymphatic sac intraoperatively can be challenging in some cases. This study examines the short-, middle- and long-term results in a larger cohort of patients. MATERIALS AND METHODS: In 74 patients, vertigo control, tinnitus and degree of satisfaction was evaluated by means of a questionnaire retrospectively. Additionally, the diagnostic value of the electrocochleography (EcochG) was determined. RESULTS: The overall vertigo control rate was more than 70% in patients followed up for two years and has reached 81% in patients followed up for more than two years. Hearing preservation rate was 61%. Tinnitus has disappeared in 11% and improved in 23% of the patients. In 47% of the patients it was unchanged and in 19% worsened. The difference in EcochG results pre- versus postoperative was highly significant. CONCLUSIONS: ELSS is a useful tool in the management of Ménière's disease, in particular in patients that do not benefit sufficiently from conservative therapy.

Medial olivocochlear bundle activation and perceived auditory intensity in humans.

In order to test the hypothesis of a role of cochlear efferent activity in intensity perception in humans, loudness functions, loudness integration, and loudness summation were measured in the absence and in the presence of contralateral noise in normal-hearing subjects. Additionally, relationships with the effect of the noise on evoked otoacoustic emissions (EOAEs) were tested, and comparisons with vestibular neurotomy patients were performed. Overall, the results failed to demonstrate significant effects of contralateral noise stimulation on loudness functions and loudness integration. Furthermore, no significant differences were found in vestibular neurotomy patients. A significant effect of contralateral noise on loudness summation was noted, but was not related to the effect on otoacoustic emissions. The present results fail to support the notion that efferent influences onto the cochlear compression have a significant perceptual effect.

Characteristics of tone burst-evoked myogenic potentials in the sternocleidomastoid muscles.

HYPOTHESIS: Optimum stimulus parameters for tone burst-evoked myogenic responses can be defined. These optimized responses will be similar to those evoked by clicks in the same subjects. BACKGROUND: Loud tones give rise to myogenic responses in the anterior neck muscles, similar to click-evoked potentials, and are likely to be saccular in origin. METHODS: Tone burst-evoked and click-evoked myogenic potentials were measured from the sternocleidomastoid muscles of 12 normal subjects (6 men, 6 women) during tonic activation. The effects of tone burst frequency and duration were systematically investigated. Thresholds were measured and compared with click thresholds for the same subjects. Patients with specific lesions were studied using both stimuli. RESULTS: Tone burst-evoked responses showed frequency tuning, with the largest reflex amplitudes at either 500 Hz or 1 kHz. As the stimulus duration was increased, using a constant repetition rate, there was an increase in the reflex amplitudes followed by a decline. The overall optimum stimulus duration was 7 milliseconds. The mean tone burst threshold was 114.4-dB sound pressure level. Stimulus thresholds for click-evoked and tone burst-evoked responses were significantly correlated. Tone burst-evoked and click-evoked responses were present after stimulation of the affected ears of subjects with profound sensorineural hearing loss. Four subjects who had previously undergone vestibular neurectomy had an absence of click and tone burst-evoked responses on the side of the lesion, confirming their vestibular dependence. CONCLUSION: Tone burst-evoked myogenic responses are similar to click-evoked responses but require lower absolute stimulus intensities. To be certain of an optimum response, a stimulus duration of 7 milliseconds, an adequate intensity, and frequencies of both 500 Hz and 1 kHz should be used.

Vestibular projections in the human cortex.

There is considerable evidence from studies on cats and monkeys that several cortical areas such as area 2v at the tip of the intraparietal sulcus, area 3av in the sulcus centralis, the parietoinsular vestibular cortex adjacent to the posterior insula (PIVC) and area 7 in the inferior parietal lobule are involved in the processing of vestibular information. Microelectrode recordings from these areas have shown that: (1) most of these cortical neurons are connected trisynaptically to the labyrinthine endorgans and (2) they receive converging vestibular, visual and somatosensory inputs. These data suggest that a multimodal cortical system is involved in postural and gaze control. In humans, recent positron emission tomography (PET) scans and functional magnetic resonance imaging (fMRI) studies have largely confirmed these data. However, because of the limited temporal resolution of these two methods, the minimum time of arrival of labyrinthine inputs from the vestibular hair cells to these cortical areas has not yet been determined. In this study, we used the evoked potential method to attempt to answer this question. Due to its excellent temporal resolution, this method is ideal for the investigation of the tri- or polysynaptic nature of the vestibulocortical pathways. Eleven volunteer patients, who underwent a vestibular neurectomy due to intractable Meniere's disease (MD) or acoustic neurinoma resection, were included in this experiment. Patients were anesthetized and the vestibular nerve was electrically stimulated. The evoked potentials were recorded by 30 subcutaneous active electrodes located on the scalp. The brain electrical source imaging (BESA) program (version 2.0, 1995) was used to calculate dipole sources. The latency period for the activation of five distinct cortical zones, including the prefrontal and/or the frontal lobe, the ipsilateral temporoparietal cortex, the anterior portion of the supplementary motor area (SMA) and the contralateral parietal cortex, was 6 ms. The short latency period recorded for each of these areas indicates that several trisynaptic pathways, passing through the vestibular nuclei and the thalamic neurons, link the primary vestibular afferents to the cortex. We suggest that all these areas, including the prefrontal area, process egomotion information and may be involved in planning motor synergies to counteract loss of equilibrium.

[Tullio phenomenon after cochlear implantation]. / Tullio-Phänomen nach Kochlearimplantation.

The Tullio phenomenon is defined as an acoustically inducible vestibular disorder that was first described in 1929. In an animal experiment Tullio provoked acoustic oscillations at the labyrinth followed by signs of imbalance. In the literature this phenomenon can be found in healthy but sensitive persons as well as in patients with Meniere's disease and patients with lesions between the stapes, footplate and the membranous labyrinth caused by fractures, stapes dislocations, labyrinthitis or perilymphatic fistulas. In this case report a patient complained about vertigo after cochlear implantation provoked by acoustical stimulation at a sound pressure level above 90 dB independent of the cochlear implant (CI). During tympanoscopy we found scar tissue surrounding the ossicles after CI. After disconnecting the ossicular chain no vertigo or nystagmus could be provoked. After CI regular ENT examinations and appropriate explorations of postoperative complaints are necessary. Vertigo especially requires very careful diagnostic procedures.

On the role of the olivocochlear bundle in hearing: 16 case studies.

Earlier we presented data (Scharf et al. (1994) Hear. Res. 75, 11-26) from a young patient (S.B.) who had undergone a vestibular neurotomy, during which the olivocochlear bundle (OCB) was severed. Those data are complemented by measurements on 15 other patients-some like S.B. with normal audiometric thresholds, none with a loss greater than 35 dB at experimental frequencies. Comparisons of performance for the same ear before and after surgery or between the operated and healthy ears do not provide evidence that the lack of OCB input impairs the following psychoacoustical functions: (1) detection of tonal signals, (2) intensity discrimination, (3) frequency selectivity, (4) loudness adaptation, (5) frequency discrimination within a tonal series, (6) in-head lateralization. Data on single-tone frequency discrimination are equivocal. These mostly negative results apply to listening both in the quiet and, where relevant, in noise. The only clear change in hearing after a vestibular neurotomy is that most patients detect signals at unexpected frequencies better than before. This change suggests an impaired ability to focus attention in the frequency domain. Although limited in scope, our finding that human hearing without OCB input is essentially normal agrees with much of the relevant literature on animal behavior and with the patients' self-reports.

Vestibular evoked myogenic potentials in the sternomastoid muscle are not of lateral canal origin.

We studied vestibular evoked myogenic potentials in 6 patients after unilateral vestibular neurectomy and in 22 patients after unilateral vestibular neuritis and unilateral absent caloric responses. We found that the ipsilesional vestibular evoked potentials were abolished in every patient after unilateral vestibular neurectomy. In vestibular neuritis patients we found that the ipsilesional vestibular evoked potentials were absent in some but not in all cases. These findings confirm that the p13-n23 potential is of vestibular origin and also show that it is not of lateral canal origin.

On the role of the olivocochlear bundle in hearing: a case study.

A young patient with normal pure-tone thresholds in both ears underwent a unilateral vestibular neurotomy in January 1992 to relieve severe vertigo ascribed to Ménière's disease. Evidence is provided that the whole vestibular nerve including the olivocochlear bundle (OCB) was sectioned. Just prior to the surgery, the patient was examined in several psychoacoustic tests involving mainly signal detection and selective attention. Over the next 20 months, he was reexamined in those same tests. The patient's ability to detect expected tones in the quiet (including audiograms) or in noise was the same as before the surgery. The one change was a marked improvement in the detection of unexpected signals in noise, which appears to reflect impaired selective attention. During those 20 months, new tests were also performed on discrimination, loudness, pitch, lateralization, and temporary threshold shift. On these tests, the only differences between the operated and unoperated ears concerned binaural diplacusis and loudness adaptation close to threshold, but these differences may well have been present prior to the surgery. Except with respect to what is probably selective attention, we uncovered no other clear role for the OCB in hearing. This outcome agrees with limited measurements on other patients, with their subjective reports, and with a number of published neurophysiological observations.

Intraoperative electrocochleography of endolymphatic hydrops surgery using clicks and tone bursts.

Seventy-seven ears of patients with Menière's disease (n = 69) and other ears with secondary endolymphatic hydrops (n = 8) underwent valved shunt surgery, and were monitored with intraoperative electrocochleography (ECoG) using clicks stimuli (n = 77), and both clicks and tone bursts (n = 37). Of the 41 ears in which the "baseline" measurement was > 35% summating potential to action potential (SP/AP) amplitude click ratio, 23 ears (56%) showed a significant ratio decrease (improvement). Twenty-six ears out of the 37 that were monitored by both clicks and tone bursts had abnormal absolute SP tone bursts amplitudes at "baseline" and 8 ears (31%) changed to normal at "closing". When tone burst ECoG information is combined with click stimuli, our basic understanding of click ECoG is enhanced and our ability to assess electrophysiologic changes intraoperatively is improved.

Intraoperative electrocochleographic monitoring of inner ear surgery for endolymphatic hydrops. A review of cases.

The purpose of this review of cases was to determine whether or not the SP/AP amplitude ratio changes during unidirectional inner ear valved shunt surgery for the decompression of the hydropic labyrinth in Meniere's disease. A series of 62 patients underwent shunt surgery over a 20 month period. In 43 cases (43 ears), ECoG responses were successfully recorded throughout the duration of surgery. A pair of two-tailed paired t-tests were computed for SP/AP amplitude ratios acquired during intraoperative ECoG monitoring at the baseline and closing stage of surgery. The first t-test compared the mean SP/AP amplitude ratios at baseline and closing for those cases in which the SP/AP amplitude ratio at baseline was abnormal (baseline > 35%). The t was significant, t(19) = 4.63, p < 0.01). The second t-test compared the mean SP/AP amplitude ratios at baseline and closing for those cases in which the SP/AP amplitude ratio at baseline was WNL (baseline < or = 35%). The t was insignificant, t(20) = 0.31, p > 0.05. Variations between baseline and closing measurements were categorized as either a reduction, no change (very stable over time), or an increase in the SP/AP amplitude ratio. A change in the SP/AP amplitude ratio from baseline to closing of > or = 7% (x = 2%, SD = 2%) was considered statistically significant. Overall (43 cases), 49% of the variations fell into the no change category, with 42% and 9% of the cases placed in the reduction and increase categories, respectively. Of the cases (22) in which the baseline measurement was outside the limits of normal, 64% showed a reduction, 32% showed no change, and 4% showed an increase in the SP/AP amplitude ratio at closing. Changes in the SP/AP amplitude were observed at various stages of the surgical procedure. Reductions were found at each of the five surgical steps identified, with the majority of the changes almost evenly divided between the stages of mastoid drilling and opening sac. Increases in the SP/AP amplitude ratio were found in four cases. The increases were observed during drilling of the mastoid bone in two cases and sac decompression and opening the sac in the remaining cases.

The use of intraoperative electrocochleography in Meniére's surgery.

Intra-operative electrocochleography was undertaken during surgery for Meniére's disease. It was found that the electrocochleogram (ECoG) provided a stable measure which accurately reflected changes within the inner ear during surgery. During salt osmosis of the round window, a rapid change in the summating potential versus action potential ratio (SP/AP) occurred which showed when the endolymphatic hydrops (ELH) had been altered. During a modified cochleostomy procedure, the ECoG showed when the cochlear duct had been ruptured. Forty ears were monitored during endolymphatic sac surgery. Twenty-five of these ears showed stable ECochG which did not alter at any time during the procedure; however, 8 of these ears showed normal SP/AP ratios during the surgery despite having been abnormal in the week prior to surgery. The SP/AP ratio was reduced in 8 ears, increased in 3 ears and showed other changes which were probably due to unstable electrode positioning in 4 ears. It was concluded that endolymphatic sac or duct surgery altered the inner ear physiology in a significant number of ears affected by endolymphatic hydrops.

Promontory stimulation following labyrinthectomy: implications for cochlear implantation.

Transtympanic electric promontory stimulation is a psychoacoustic test used to assess residual acoustic neurons in profound sensorineural hearing loss. The test was performed in six patients who had previously undergone transmastoid (N = 5) or transcanal-oval window (N = 1) labyrinthectomy as a means of determining the feasibility of future cochlear implantation. Four patients had unilateral Meniere's disease, one had labyrinthitis, and one had delayed onset vertigo. All patients perceived a definite auditory sensation in the labyrinthectomized ear during stimulation. The results of threshold, dynamic range, and difference limen testing were similar to those obtained during preoperative stimulation of cochlear implant candidates (N = 12) who subsequently became successful users. There was no evidence of response degradations as the time following labyrinthectomy increased. The results of this study suggest the possibility of successful cochlear implantation following labyrinthectomy. Supporting histologic data are reviewed.