Tympanostomy tube placement for intractable Meniere's disease in the elderly.

BACKGROUND: The treatment of refractory elderly Meniere's disease is a challenge. AIM: To investigate the efficacy of tympanostomy tube placement in elderly patients with Meniere's disease. METHODS: 31 patients over 60 years old with Meniere's disease who had failed medical treatment and underwent tympanostomy tube placement. Vertigo control, hearing level, tinnitus, and ear fullness were recorded and analyzed preoperatively and postoperatively. RESULTS: All patients completed a 6-month follow-up. At 6 months postoperatively,complete control, substantial control and limited control of vertigo were achieved in 10 (32%), 13 (42%), and 6 (19%) patients respectively. Two patients (6%) reported no substantial improvement. Twelve patients completed a 2-year follow-up. At 2 years postoperatively, complete control, substantial control and limited control of vertigo were achieved in 3 (25%), 5 (42%), and 1 (8%) patients respectively. Three (25%) patients showed no significant improvement in vertigo. The majority of patients reported significant improvement in the functional level scale, the Dizziness Handicap Inventory scores, and ear fullness at 6 months and 2 years postoperatively. CONCLUSIONS AND SIGNIFICANCE: Tympanostomy tube placement may reduce vertigo attacks and improved the quality of life in elderly patients with Meniere's disease.

Abnormal Rhomboid Lip and Choroid Plexus Should be Valued in Microvascular Decompression for Vestibulocochlear Diseases.

BACKGROUND: Surgical outcomes for functional vestibulocochlear diseases vary, and the influencing factors are not fully understood. The role of a rhomboid lip (RL) and choroid plexus (CP) in microvascular decompression (MVD) of the vestibulocochlear nerve has not been studied. This study aims to evaluate the surgical efficacy of MVD for vestibulocochlear diseases, with and without addressing the RL and CP, to enhance our understanding of their etiology. METHODS: A total of 15 patients who underwent MVD for the vestibulocochlear nerve between 2013 and 2022 were retrospectively identified and followed up. The patients were classified into 4 categories: vestibular paroxysmia (VP), benign positional paroxysmal vertigo (BPPV), and Meniere disease (MD). The fourth was a "tinnitus" group. The relief of symptoms, recurrence, satisfaction after surgery, available relevant imaging studies, and intraoperative observation data were evaluated. RESULTS: Following MVD, 6 of the 7 patients in the VP group, the 1 patient in the BPPV group, and 1 of 2 patients in the MD group were completely relieved of vertigo. The seventh VP patient showed significant improvement. The 5 patients in the "tinnitus" group remained unchanged. Retrospectively, 4 patients from the VP, BPPV, and MD groups who underwent RL incision and CP excision were also free of vertigo, although vascular compression was not confirmed in these cases. CONCLUSIONS: MVD is generally considered a useful treatment for VP and could also be effective in managing recurrent vertigo caused by BPPV and MD. Our results highlight the potential role of an abnormal RL and CP in the development of vertigo symptoms. Patients presenting with "tinnitus" require further investigation and might not be suitable for MVD.

Development and validation of prediction model to estimate vertigo risk after endolymphatic sac decompression in Meniere's disease: a retrospective cohort study.

PURPOSE: To study the efficacy predictors of endolymphatic sac decompression (ESD) in Meniere's disease (MD), and to establish and verify the prediction model of vertigo after ESD in patients with MD. METHODS: The retrospective cohort data of 56 patients with unilateral MD who underwent ESD surgery were recorded. A stepwise regression method was used to select optimal modeling variables, and we established a logistic regression model with the outcome of vertigo after ESD. The bootstrap method was used for internal validation. RESULTS: Potential predictors included sex, age, follow-up duration, disease course, attack duration, frequency of attack, pure-tone threshold average (PTA) of the patient's speech frequency, audiogram type, glycerin test results, MD subtype, and 10-year atherosclerotic cardiovascular disease risk classification. Using the stepwise regression method, we found that the optimal modeling variables were the audiogram type and PTA of the patient's speech frequency. The prediction model based on these two variables exhibited good discrimination [area under the receiver operating characteristic curve: 0.72 (95% confidence interval: 0.57-0.86)] and acceptable calibration (Brier score 0.21). CONCLUSION: The present model based on the audiogram type and PTA of the patient's speech frequency was found to be useful in guidance of ESD efficacy prediction and surgery selection.

Significance of endolymphatic sac surgery with and/or without simultaneous cochlea implant surgery in respect of vertigo control and speech perception in patients with Menière's disease.

PURPOSE: The focus on treating patients with Menière's Disease (MD) lies on the reduction of vertigo attacks and the preservation of sensory function. Endolympathic hydrops is considered as an epiphenomenon in MD, which can potentially be altered by endolymphatic sac surgery (ESS). Purpose of the study was to investigate the influences on vertigo control through manipulation of the perilymphatic system with or without ESS. METHODS: Retrospective data analysis of 86 consecutive patients with MD according to current diagnostic criteria after endolymphatic sac surgery alone (ESSalone; n = 45), cochlear implantation (CI) alone (CIalone; n = 12), and ESS with CI (ESS + CI; n = 29), treated at a tertiary referral center. MAIN OUTCOME MEASURES: vertigo control, speech perception pre- and postoperatively. RESULTS: Gender, side, and preoperative treatment were similar in all groups. Age was younger in the ESSalone-group with 56.2 ± 13.0 years (CIalone = 64.2 ± 11.4 years; ESS + CI = 63.1 ± 9.7 years). Definitive MD was present in all the CIalone, in 79.3% of the ESS + CI and in 59.6% of the ESSalone-patients. Likewise, vertigo control rate was 100% in the CIalone, 89.7% in the ESS + CI and 66.0% in the ESSalone-group. CONCLUSIONS: Vertigo control was improved in all three groups, however, superior in groups treated with CI, potentially contributed by the manipulation of both the endo- and perilymphatic systems. A more systematic characterization of the patients with larger case numbers and documentation of follow up data would be needed to evaluate a clinical effect more properly.

Treatment of Meniere's disease with simultaneous triple semicircular canal occlusion and cochlear implantation.

OBJECTIVE: Report three cases of simultaneous triple semicircular canal occlusion (TSCO) and cochlear implantation (CI) as the treatment of intractable Meniere's disease (MD). CASE REPORTS: Patients with MD can present occasionally with intractable vertigo and profound sensorineural hearing loss (SNHL). TSCO and CI have been proposed to control vertigo and restore profound deafness in patients with MD separately. However, a few studies have reported simultaneous TSCO and CI in the same surgical procedure for the treatment of MD. In the present study, we described three patients with MD showing incapacitating vertigo and severe SNHL who underwent simultaneous TSCO and CI after examinations of auditory system, vestibular system, and imaging. Their symptoms were significantly alleviated during the follow-up period. CONCLUSION: The combined TSCO and CI remains a viable treatment option which is effective for the control of vertigo as well as the restoring of hearing in patients with MD.

Endolymphatic Duct and Sac Decompression: A New Life for an Old Technique.

BACKGROUND: Ménière's disease is an inner ear disorder causing recurrent vertigo, hearing loss, and tinnitus. Diagnosis is based on the variability of the symptoms over time and absence of radiological abnormalities. Medical therapy is effective only in a small percentage of patients. Surgical strategies remain controversial. In this article, we revisit a surgical technique neglected over the years: endolymphatic sac surgery. METHODS: Fifty-four patients affected by Ménière's disease underwent endolymphatic duct and sac decompression. According to the American Academy of Otolaryngology-Head and Neck Surgery criteria, vertigo control was evaluated with follow-up at 6 months, 1 year, and 2 years from the intervention. Hearing results were evaluated before the surgery and at 2 years of follow-up using the pure tone average. The results were compared with similar techniques of endolymphatic sac surgery described in the literature. RESULTS: According to the American Academy of Otolaryngology-Head and Neck Surgery criteria classification, 2 years after surgery, 87% patients achieved complete control of vertigo (class A). The hearing remained stable in 93.5% of patients. The results appear compatible with other publications data regarding endolymphatic sac surgeries. CONCLUSION: The duct and endolymphatic sac decompression allows the control of vertigo and preserves hearing from the pathological effects of Ménière's disease. The revised technique allows the functional restoration of endolymphatic homeostasis.

[AUDITORY OUTCOMES OF COCHLEAR IMPLANTATION IN MENIERE'S DISEASE].

BACKGROUND: Cochlear implants are valuable in the auditory rehabilitation of patients with severe to profound hearing loss. However, there is limited data on the outcomes of cochlear implantation in patients with Meniere's disease (MD). OBJECTIVES: In this study, we aim to evaluate the auditory outcomes of cochlear implantation in patients with MD. METHODS: A retrospective case series of patients with MD and severe to profound sensorineural hearing loss (SNHL), who underwent cochlear implantation at a tertiary academic center between 2006-2017. Patient's clinical characteristics and audiometric data were reviewed. RESULTS: The study included 20 ears in 19 patients with MD who underwent cochlear implantation with available pre- and postoperative audiometric data. There were 10 males and 9 females with a mean age of 63 years and a mean follow-up duration of 70.8 months. Pre- and post-implant CNC word recognition scores were 18.31% and 66.89%, respectively (p<0.001). Pre- and post-implant AzBio and/or HINT sentence recognition scores were 12.25% and 68.28% in quiet, respectively (p<0.001), and 18.25% and 63.43% in noise, respectively (p<0.001). CONCLUSIONS: Cochlear implantation resulted in an improvement of word and sentence recognition scores in MD patients. These results support the role of cochlear implants in the auditory rehabilitation of MD. DISCUSSION: Dr. Samy received research support from Cochlear Corporation.

Does labyrinthectomy have an impact on hearing in the contralateral ear during long-term follow-up?

OBJECTIVE: To quantify contralateral hearing outcomes after labyrinthectomy for unilateral Ménière's disease (MD). STUDY DESIGN: Retrospective case series. SETTING: Tertiary neurotology referral center. PATIENTS: Labyrinth removal for the management of MD or translabyrinthine (TLAB) acoustic neuroma resection between 2008 and 2012. MAIN OUTCOME MEASURE: Long-term hearing changes via pure tone averages (PTA). RESULTS: Upon comparison of low-frequency PTA (250, 500, 1000 Hz), MD patients experienced a greater degree of hearing loss during the follow-up period when compared to the TLAB lab group (7.54 ± 2.11 dB vs 2.39 ± 1.10 dB, p = 0.035). This difference as attributable to 12 (28.6 %) MD patients experiencing a ≥30 dB increase in low-frequency PTA, whereas none (0.0 %) of the TLAB surpassed this threshold. CONCLUSIONS: At 10 years post-labyrinthectomy there is a heightened risk for MD patients to develop low-frequency sensorineural hearing loss. Clinicians should monitor for audiometric changes through regular testing in the decade following labyrinth removal.

Recent surgical advances and continued controversies in medically refractory Meniere's disease.

PURPOSE OF REVIEW: Meniere's disease is caused by hydropic changes in the endolymphatic system, and manifests as a collection of vertigo, hearing loss, tinnitus, and aural fullness. Although high-quality clinical practice guidelines exist for the diagnosis and initial management of Meniere's disease, there is no strong consensus for treatment of medically refractory Meniere's disease. This review summarizes treatment options and highlights controversies surrounding surgical treatment of Meniere's disease. RECENT FINDINGS: Intratympanic steroid and intratympanic gentamicin injections continue to be widely used as in-office therapies in medically refractory Meniere's disease. Despite historical controversy surrounding the use of endolymphatic sac (ELS) surgery, the use of ELS decompression has been widely adopted by the international neurotologic community due to high vertigo control rate, coupled with low risk of audiovestibular loss. Wider decompression of the sac and surgical manipulation of the endolymphatic duct may impact outcome and are the subject of discussion. An emerging surgical technique called Triple Semicircular Canal Occlusion (TSCO) holds promise as a partially ablative procedure with high vertigo control rate in Meniere's disease. Cochlear implants may be placed in active Meniere's disease patients, or during an ablative surgery such as labyrinthectomy. SUMMARY: For the medically refractory Meniere's disease patient, treatment options include intratympanic steroid injection, endolymphatic sac decompression, medical or surgical labyrinthectomy, and vestibular nerve section. TSCO holds promise as an emerging partially ablative procedure. Cochlear implants maintain an important role in the rehabilitation of hearing loss associated with Meniere's disease.

Endolymphatic Duct Blockage as a Surgical Treatment Option for Ménière's Disease.

Endolymphatic duct blockage is a relatively new treatment option for Ménière's disease, aiming to reduce vertigo attacks while sparing hearing and equilibrium. After a regular mastoidectomy, the posterior semicircular canal is identified, and Donaldson's line is determined. This is a line through the horizontal semicircular canal, crossing the posterior semicircular canal. The endolymphatic sac is usually found at this site under the posterior semicircular canal. The bone of the endolymphatic sac and the dura are thinned until the sac is skeletonized, after which the endolymphatic duct is identified. The duct is then blocked with a titanium clip. Using a computerized tomography (CT) scan, the position is confirmed. Follow-up visits take place 1 week, 6 weeks and 1 year after surgery. To this day, only one prospective trial assessing this method has been conducted, comparing this new method to endolymphatic sac decompression. Results of the duct blockage are promising, with 96.5% of the patients free of vertigo after 2 years. However, further research is required.

Triple Semicircular Canal Plugging versus Labyrinthectomy for Meniere Disease: A Retrospective Study.

OBJECTIVES: The study goals were to compare the long-term efficacy of semicircular canal plugging (SCP) with labyrinthectomy in the treatment of advanced Meniere's disease (MD). STUDY DESIGN: A retrospective study. SETTING: Single tertiary medical center. METHODS: A total of 116 MD patients (TSCP group of 90; labyrinthectomy group of 26) with complete medical documents in Shandong Provincial ENT Hospital, from March 2017 to March 2019 were retrospectively analyzed, including a battery of auditory and vestibular function tests, recovery time from imbalance and function level scores (FLS). RESULTS: The total control rate of vertigo in the TSCP group was 96.7% (87/90). The rate of hearing loss was 23.3% (21/90). The control rate of vertigo in the labyrinthectomy group was 100% (26/26). All patients lost their auditory function after labyrinthectomy with a 100% hearing loss rate. There was no significant difference in the vertigo control rate between the two groups (P > 0.05). The hearing loss rate in the TSCP group was significantly lower than that in the labyrinthectomy group (P < 0.00). The median time recovered from imbalance was 15 days in TSCP group and 21 days in labyrinthectomy group, which is significantly different (P < 0.05). There was no significant difference in the FLS between the two groups (P > 0.05). CONCLUSIONS: Compared to labyrinthectomy, TSCP can preserve hearing at a high probability; meanwhile, otolith organ function preservation benefits patients from faster vestibular compensation. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:3178-3184, 2023.

Surgical interventions for Ménière's disease.

BACKGROUND: Ménière's disease is a condition that causes recurrent episodes of vertigo, associated with hearing loss and tinnitus. First-line treatments often involve dietary or lifestyle changes, medication or local (intratympanic) treatments. However, surgery may also be considered for people with persistent or severe symptoms. The efficacy of different surgical interventions at preventing vertigo attacks, and their associated symptoms, is currently unclear. OBJECTIVES: To evaluate the benefits and harms of surgical interventions versus placebo or no treatment in people with Ménière's disease. SEARCH METHODS: The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 September 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable Ménière's disease comparing ventilation tubes, endolymphatic sac surgery, semi-circular canal plugging/obliteration, vestibular nerve section or labyrinthectomy with either placebo (sham surgery) or no treatment. We excluded studies with follow-up of less than three months, or with a cross-over design (unless data from the first phase of the study could be identified).  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) change in hearing, 6) change in tinnitus and 7) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We used GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: We included two studies with a total of 178 participants. One evaluated ventilation tubes compared to no treatment, the other evaluated endolymphatic sac decompression compared to sham surgery.  Ventilation tubes We included a single RCT of 148 participants with definite Ménière's disease. It was conducted in a single centre in Japan from 2010 to 2013. Participants either received ventilation tubes with standard medical treatment, or standard medical treatment alone, and were followed up for two years. Some data were reported on the number of participants in whom vertigo resolved, and the effect of the intervention on hearing. Our other primary and secondary outcomes were not reported in this study. This is a single, small study and for all outcomes the certainty of evidence was low or very low. We are unable to draw meaningful conclusions from the numerical results. Endolymphatic sac decompression We also included one RCT of 30 participants that compared endolymphatic sac decompression with sham surgery. This was a single-centre study conducted in Denmark during the 1980s. Follow-up was predominantly conducted at one year, but additional follow-up continued for up to nine years in some participants. Some data were reported on hearing and vertigo (both improvement in vertigo and change in vertigo), but our other outcomes of interest were not reported. Again, this is a single, very small study and we rated the certainty of the evidence as very low for all outcomes. We are therefore unable to draw meaningful conclusions from the numerical results.  AUTHORS' CONCLUSIONS: We are unable to draw clear conclusions about the efficacy of these surgical interventions for Ménière's disease. We identified evidence for only two of our five proposed comparisons, and we assessed all the evidence as low- or very low-certainty. This means that we have very low confidence that the effects reported are accurate estimates of the true effect of these interventions. Many of the outcomes that we planned to assess were not reported by the studies, such as the impact on quality of life, and adverse effects of the interventions. Consensus on the appropriate outcomes to measure in studies of Ménière's disease is needed (i.e. a core outcome set) in order to guide future studies in this area and enable meta-analyses of the results. This must include appropriate consideration of the potential harms of treatment, as well as the benefits.

Untargeted Metabolomic Analysis in Endolymphatic Sac Luminal Fluid from Patients with Meniere's Disease.

Dysfunction of the endolymphatic sac (ES) is one of the etiologies of Meniere's disease (MD), the mechanism of which remains unclear. The aim of the present study was to explore the molecular pathological characteristics of ES during the development of MD. Metabolomic profiling of ES luminal fluid from patients with MD and patients with acoustic neuroma (AN) was performed. Diluted ES luminal fluid (ELF) samples were obtained from 10 patients who underwent endolymphatic duct blockage for the treatment of intractable MD and from 6 patients who underwent translabyrinthine surgery for AN. ELF analysis was performed using liquid chromatography-mass spectrometry before the raw data were normalized and subjected to subsequent statistical analysis by MetaboAnalyst. Using thresholds of P ≤ 0.05 and variable important in projection > 1, a total of 111 differential metabolites were screened in the ELF, including 52 metabolites in negative mode and 59 in positive mode. Furthermore, 15 differentially altered metabolites corresponding to 15 compound names were identified using a Student's t-test, including 7 significant increased metabolites and 8 significant decreased metabolites. Moreover, two differentially altered metabolites, hyaluronic acid (HA) and 4-hydroxynonenal (4-HNE), were validated to be upregulated in the epithelial lining of the ES, as well as in the subepithelial connective-tissue in patients with MD comparing with that in patients with AN. Among these differentially altered metabolites, an upregulated expression of HA detected in the ES lumen of the patients with MD was supposed to be associated with the increased endolymph in ES, while an increased level of 4-HNE found in the ELF of the patients with MD provided direct evidence to support that oxidative damage and inflammatory lesions underlie the mechanism of MD. Furthermore, citrate and ethylenediaminetetraacetic acid were detected to be decreased substantially in the ELF of the patients with MD, suggesting the elevated endolymphatic Ca2+ in the ears with chronic endolymphatic hydrops is likely to be associated with the reduction of these two chelators of Ca2+ in ES. The results in the present study indicate metabolomic analysis in the ELF of the patients with MD can potentially improve our understanding on the molecular pathophysiological mechanism in the ES during the development of MD.

Vestibular and audiometric results after endolymphatic mastoid shunt surgery in patients with Menière's disease.

PURPOSE: Treatment of Menière's Disease (MD) comprises an array of both non-destructive and destructive treatment options. In patients who are therapy-refractory to non-destructive medical treatment, endolymphatic mastoid shunt surgery (EMSS) is both recommended and debated controversially. The aim of this study was to investigate safety in terms of hearing, vestibular function, complication rate, and efficacy with regards to vertigo control of EMSS in patients with MD according to the current diagnostic criteria of 2015. METHODS: Retrospective analysis of 47 consecutive patients with definite or probable MD with description of demographic parameters, pre- and postoperative MD treatment, pre- and postoperative audiometric (pure tone audiometry) and vestibular (caloric testing) results. The parameters were compared between patients with and without postoperative vertigo control. RESULTS: 31/47 patients (66.0%) had improved vertigo control postoperatively. Postoperative hearing and vestibular preservation were predominantly stable. No significant differences between patients with improved vertigo control and patients with no change or worse vertigo episodes were found. In the treatment refractory group, 4 patients required a revision EMSS and 6 a destructive MD treatment (5 gentamicin intratympanically, 1 labyrinthectomy). No peri- or postsurgical complications were reported. CONCLUSIONS: EMSS was found to be beneficial in two thirds of the patients with definite or probable Morbus Menière and a safe procedure regarding hearing and vestibular preservation with no postoperative complications. Therefore, EMSS should be considered before inducing destructive treatment options, such as intratympanic gentamicin application or labyrinthectomy.

Endolymphatic Sac Surgery: Understanding the Historical Influence of Circumstance and Statistics.

In 1981, Danish physician Jens Thomsen conducted the first and only documented sham-controlled surgical trial in the history of otolaryngology. This trial is historically significant as it was the first in the field to use a methodologically sound study design to address a frustratingly complex disorder such as Ménière's disease. Despite this, historical interpretations of this work have varied, and questions about the results have been raised. We review the fascinating historical context of this landmark trial and detail how it was influenced by the rise of the randomized controlled trial. We examine how subsequent statistical analyses and interpretations of this historical work have affected surgical treatment paradigms in Ménière's disease, and we look forward to suggest the legacy of this work as a sham-controlled surgical trial in otolaryngology.

Is endolymphatic sac surgery an efficient treatment of Menière's disease patients? A systematic literature search and meta-analysis.

PURPOSE: The purpose of this work is to assess the treatment efficiency of endolymphatic sac surgery in patients with Menière's disease. METHODS: This study provides a systematic literature review and meta-analysis based on the guidelines of the Cochrane Collaboration and the Preferred Reporting Items for Systematic reviews and Meta-Analyses protocol. The main inclusion criteria of the literature review were the classification categories according to the American Academy of Otolaryngology-Head and Neck Surgery guidelines of 1985 and 1995. RESULTS: An effect of 9.25 dB postoperative weighted average hearing loss in surgically treated individuals is classified as "clinically not significant" according to American Academy of Otolaryngology-Head and Neck Surgery 85/95. In contrast, the deterioration by 26.23% in speech comprehension is considered as "clinically significant." An improvement of functional level scale assessment by two categories and vertigo control by assessment in category B can be observed. CONCLUSION: The findings of this meta-analysis indicate that endolymphatic sac surgery may be beneficial as a treatment for Menière's disease in terms of a positive impact on functional level scale and vertigo control while yielding a negative impact on pure tone average hearing loss and on speech comprehension.

Meniere's Disease Patients with Distinct Sac Pathoanatomic Findings React Differently to Endolymphatic Duct Blockage.

OBJECTIVES: To explore the possible difference in response to endolymphatic duct blockage (EDB) treatment in patients with Meniere's disease (MD) with distinct pathoanatomic characteristics of the sac. METHODS: In a total of 24 patients with MD receiving EDB treatment, the dynamics of the vertigo attack, hearing, vestibular function, and endolymph hydrops (EH) before surgery and 40 months following surgery in patients with normoplastic extraosseous portion of endolymphatic sac (eES) were compared with that in patients with atrophic eES. RESULTS: A higher prevalence of complete vertigo control, better cochlear and vestibular function, and lower endolymph to vestibule-volume ratio were found in patients with normoplastic eES than in those with atrophic eES. Moreover, the reversal of EH was found in a total of six patients in normoplastic eES group, but no reversal of EH was detected in the atrophic eES group after surgery. CONCLUSIONS: A difference in response to EDB treatment was shown in the MD patients with normoplastic eES and those with atrophic eES; the reversal of EH was found in the normoplastic eES group, but not in the atrophic eES group after surgery, suggesting two distinct pathologies in the eESs may underlie the pathogenesis of EH in two subgroups of MD patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2761-2769, 2023.