HSC Section 8_April 2017

Reprinted by permission of Laryngoscope. 2015; 125(4):972-978.

The Laryngoscope V C 2014 The American Laryngological, Rhinological and Otological Society, Inc.

Management of Intractable Menie`re’s Disease After Intratympanic Injection of Gentamicin

Yoon C. Rah, MD; Jae J. Han, MD; Jaehong Park, MD; Byung Y. Choi, MD, PhD; Ja-Won Koo, MD, PhD

Objectives/Hypothesis: 1) To evaluate the efficacy of, and problems with, intratympanic gentamicin injection (ITG) in medically intractable definite Menie`re’s disease (MD) and secondary endolymphatic hydrops (EH); and 2) to review the ves- tibular status and treatment options of intractable vertigo even after ITG. Study Design: Retrospective case review and survey. Methods: 780 patients with definite MD and secondary EH were enrolled. Long-term outcomes and problems of applied treatment options including ITG and exploratory tympanotomy and gentamicin application (ETG) were analyzed. Results: Of the 780 patients, 95 patients received ITG. Class A and B control of vertigo was achieved in 85 (89.5%) patients; two patients were class C and eight patients were class F (ETG: 6; labyrinthectomy: 1; vestibular neurectomy: 1). Among seven patients who received ETG including 1 patient who skipped ITG due to chronic otitis media, five patients improved to class A, show- ing a 71.4% success rate; and labyrinthectomies were performed subsequently in the two remaining patients. Vertigo was con- trolled (class A) in all the patients who received labyrinthectomies (n 5 4) or vestibular neurectomy (n 5 1). Eight patients (8.4%) experienced more than 10 dB worsening, and two patients (2.1%) progressed to bilateral Menie`re’s disease. Conclusion: ITG failed to control vertigo in 10.5% of cases. ETG may be a reasonable option to facilitate the delivery of gentamicin into the inner ear by direct application of gentamicin over the round window and the oval window. Labyrinthec- tomy and vestibular neurectomy still have roles in the era of ITG. Key Words: Gentamicin, intratympanic injection, Menie`re’s disease, vertigo. Level of Evidence: 4. Laryngoscope , 125:972–978, 2015

INTRODUCTION Menie`re’s disease is a clinically defined disorder, characterized by recurrent episodic vertigo with aural fullness, tinnitus, and sensorineural hearing loss. Medi- cal management such as salt restriction, diuretics, beta histine, and corticosteroids is usually tried as a first step. 1,2 About 60% to 87% of patients with Menie`re’s dis- ease have been reported to maintain their normal daily activities with such medical management. 3,4 Surgical intervention may be considered for those patients who still have disabling attacks despite medical manage- ment. 5 However, no consensus has been reached for the management of Menie`re’s disease. 6 Among additional interventions for Menie`re’s dis- ease intractable to medical treatments, intratympanic injection of gentamicin (ITG) seems to have gained pop- ularity with its convenient application; it is now widely performed for the control of vertigo in most patients, with reported success rates of 83% to 91%. 7–10 However, From the Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Ja-Won Koo, MD, PhD, Professor, Depart- ment of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463–707, Republic of Korea; E-mail: jwkoo99@snu.ac.kr

a certain proportion of patients suffer from several clin- ical problems such as hearing loss and progression to bilateral disease after ITG. 9,10 Moreover, a significant portion of patients (5%–15%) have been reported to experience recurrent attacks of vertigo even after ITG. 9–12 There is a need to determine the most effective and safe protocol(s) for these patients. However, most sur- geons face difficulties in choosing subsequent procedures because a labyrinthectomy results in complete loss of cochlear function, and vestibular neurectomy may have surgical risks associated with the craniotomy. 13 Crane et al. explored the middle ear space in eight cases who were refractory to ITG. They found some suspect middle ear pathologies and achieved good results by eradicating those problems and direct application of gentamicin dur- ing middle ear exploration. 14 In this study, we reviewed the efficacy and prob- lems of ITG in both definite Menie`re’s disease (MD) and secondary endolymphatic hydrops (EH). We also reviewed the vestibular status of the intractable patients, even after ITG, and their management options.

MATERIALS AND METHODS Selection of the Patients

In total, 667 patients were diagnosed with definite MD and 113 patients were diagnosed with secondary EH from March 2003 to April 2012, based on the 1995 guideline of the

DOI: 10.1002/lary.25009

Laryngoscope 125: April 2015

Rah et al.: Intractable Menie` re’s Disease

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