HSC Section 8_April 2017

The Laryngoscope

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

4) or vestibular neurectomy (n

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:

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.

However, no consensus has been reached for the

management of Menie`re’s disease.

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,

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.

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.

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

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

DOI: 10.1002/lary.25009

Laryngoscope 125: April 2015

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

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