HSC Section 8_April 2017

TABLE I. Additional Interventions Performed to Control Intractable Vertigo.

Treatment

Class*

No.

Comments

ITG (n 5 95)

s/p ELSD (n 5 3)

A

73

B

12

s/p ELSD (n 5 1)

C

2

Subsequently ETG (n 5 6), labyrinthectomy (n 5 1), vestibular neurectomy (n 5 1)

F

8

ELSD (n 5 11)

A

5 2

C

Subsequently ITG (n 5 4)

F

4

Meniette (n 5 3)

A

2 1

Subsequently ETG (n 5 1)

F

ETG (n 5 7)

s/p Meniett, then chronic draining ear (n 5 1) Subsequently labyrinthectomy (n 5 2) Labyrinthectomy 1 STP † (n 5 1), intralabyrinthine tumor removal ‡ (n 5 1)

A

5

F

2 4

Labyrinthectomy (n 5 4)

A

Vestibular neurectomy (n 5 1)

A

1

*Functional classification according to the 1995 American Academy of Otolaryngology–Head and Neck Surgery guideline. † Surgery to control chronic otitis media. ‡ Translabyrinthine approach and tumor removal for incidentally detected intralabyrinthine schwannoma. ITG 5 intratympanic gentamicin injection; ELSD 5 endolymphatic sac decompression; ETG 5 exploratory tympanotomy and gentamicin application; n 5 number of patient(s); s/p 5 status post; STP 5 subtotal petrosectomy.

thickening of the round window membrane, or bone chips (Table II). Including one patient administered gen- tamicin during a tympanomastoidectomy due to chronic otitis media after trial use of the Meniett device, a total of seven patients underwent ETG. Although the bone conduction threshold was aggravated by 12.5 dB in one of the seven (14.3%) patients, the hearing level was already more than 55 dB in each patient who received ETG. Three patients finally underwent labyrinthectomies after the failure of ITG, including two patients whose vertigo was not controlled by ITG or ETG. The two did improve after the labyrinthectomy, up to class A. An intralabyrinthine schwannoma was found incidentally during the labyrinthectomy (patient 2 in Table III), and tumor removal was completed via translabyrinthine approach.

even after ITG. The remaining 8 (8.4%) patients were class F (Table I). Six patients received ETG after failure of ITG. Vestibular function on a caloric test was not suf- ficiently attenuated in four of six patients after ITG (patients 3, 4, 6, and 7 in Table II), whereas it was atte- nuated substantially but vertigo attacks were not con- trolled in two patients (patients 2 and 5 in Table II). After ETG, five of seven (71.4%) patients whose caloric function was attenuated substantially achieved class A, and the remaining two patients (patients 6 and 7), whose caloric functions were not sufficiently attenuated even after ETG, needed subsequent labyrinthectomies. We tried to determine any possible anatomical prob- lems that might obscure the passage of gentamicin. Prominent bony overhang over the round window niche was remarkable in two patients; otherwise, there was no definite suspected barrier such as mucosal thickening,

TABLE II. Changes in Vestibular Function Before ITG, After ITG, and After ETG.

Pt

CP (%) Before ITG

CP (%) After ITG

CP (%) After ETG

Class*

Dx

Comments

HIT( 1 ) †

1 2

21% 35%

–

A A

MD s/p Meniett, then chronic draining ear

62% (7 inj ‡ ) 25% (3 inj ‡ ) 44% (2 inj ‡ ) 90% (3 inj ‡ ) 28% (3 inj ‡ ) 31% (3 inj ‡ )

56%

MD

3

10%

66%

A

MD Persistent unsteadiness

4 5

46% 32%

97% 90%

A A

MD Prominent bony overhang

MD

6

15%

32%

F

EH

7

4%

29%

F

MD Prominent bony overhang

*Functional classification according to the 1995 American Academy of Otolaryngology–Head and Neck Surgery guideline. † Positive head impulse sign indicates attenuation of ipsilateral canal function after ETG. ‡ Number of intratympanic injections of gentamicin.

CP 5 canal paresis bithermal caloric test; Dx 5 diagnosis; EH 5 secondary endolymphatic hydrops; ETG 5 exploratory tympanotomy and gentamicin application; HIT 5 head impulse test; inj 5 injection; ITG 5 intratympanic gentamicin injection; MD 5 definite Menie` re’s disease; Pt 5 patient; s/p 5 status post.

Laryngoscope 125: April 2015

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

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