Prosper Meniere first accurately described Meniere's disease in the 19th century. He identified the site of lesion as the labyrinth. Since then, little has been added to the understanding of the disorder. The exact etiology is unknown, but theories include genetic factors, anatomical abnormalities, trauma, viral infection, allergy, and autoimmunity. The pathophysiology involves endolymphatic hydrops due to impaired absorption or excessive secretion of endolymphatic fluid leading to distention of the membranous labyrinth, starting in the cochlear duct and saccule. Dysfunction of the endolymphatic sac may also contribute by reducing fluid absorption capacity.
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
This document discusses open cavity mastoid operations, including their history, indications, techniques, and complications. Open cavity procedures involve removing the posterior wall of the external auditory canal to exteriorize the mastoid cavity. They allow for monitoring of recurrent cholesteatoma and drainage for unresectable infections. The radical and modified radical mastoidectomies developed historically to fully remove bone-invading disease while preserving hearing when possible. Key steps involve identifying and preserving the facial nerve while removing disease-affected areas. Postoperative care focuses on re-epithelialization of the cavity and monitoring for complications like infection, nerve injury, and recurrent cholesteatoma.
- Balloon sinuplasty is a minimally invasive technique for treating sinusitis using balloon catheters to dilate sinus ostia rather than conventional endoscopic sinus surgery.
- Studies show balloon sinuplasty improves symptoms in selected patients with chronic sinusitis and is safe, with minimal adverse effects. However, longer term data is still needed to define its optimal role and indications.
- While initial data is promising for symptom relief and preservation of sinus anatomy compared to traditional FESS, balloon sinuplasty may not eliminate the need for conventional sinus surgery in all patients.
This document provides an overview of endoscopic nasal anatomy. It begins with a brief introduction to endoscopy and its historical evolution. It then describes the external nose, nasal septum, lateral nasal wall including the inferior, middle, and superior turbinates. Various anatomical variations are also discussed. The paranasal sinuses, anterior skull base, and endoscopic approaches to different nasal and sinus structures like the frontal sinus and sphenoid sinus are summarized. Key landmarks and variations are highlighted to provide a concise yet comprehensive summary of the essential endoscopic nasal anatomy concepts covered in the document.
Biomarkers in head and neck cancers final ajeetAjeet Gandhi
This document provides an overview of biomarkers in head and neck cancers. It discusses how biomarkers can be used for early diagnosis, predicting response to therapy, and identifying therapeutic targets. Key points include:
- Biomarkers like HPV status, ERCC1, and beta-tubulin isoform III may help predict response to chemotherapy and radiation. HPV+ tumors have a better prognosis.
- The EGFR pathway is commonly dysregulated in head and neck cancers but targeting it has had limited success due to resistance mechanisms. EGFRvIII mutations may reduce sensitivity to cetuximab.
- Ongoing research explores using biomarkers to guide more personalized treatment, such as reducing therapy for HPV+ tumors or targeting pathways
The document discusses the use of the Hadad-Bassagasteguy (HB) flap in reconstructing anterior skull base defects after endonasal skull base surgery. The HB flap uses the vascularized nasal septal mucoperiosteum to repair defects. In a study of 53 patients who underwent HB flap reconstruction, only 2 patients (3.8%) experienced post-operative cerebrospinal fluid leaks. The study found the HB flap to be effective at preventing post-operative CSF leaks across a variety of patient profiles and skull base surgery types. The HB flap is becoming a standard technique for reconstructing anterior skull base defects due to its high success rate and versatility.
All about uncinate process of nose and paranasal sinusesBikash Shrestha
Uncinate process is one of the important landmarks during the endoscopic sinus surgery. so it is important to know about the variation of unicinate process.
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
This document discusses open cavity mastoid operations, including their history, indications, techniques, and complications. Open cavity procedures involve removing the posterior wall of the external auditory canal to exteriorize the mastoid cavity. They allow for monitoring of recurrent cholesteatoma and drainage for unresectable infections. The radical and modified radical mastoidectomies developed historically to fully remove bone-invading disease while preserving hearing when possible. Key steps involve identifying and preserving the facial nerve while removing disease-affected areas. Postoperative care focuses on re-epithelialization of the cavity and monitoring for complications like infection, nerve injury, and recurrent cholesteatoma.
- Balloon sinuplasty is a minimally invasive technique for treating sinusitis using balloon catheters to dilate sinus ostia rather than conventional endoscopic sinus surgery.
- Studies show balloon sinuplasty improves symptoms in selected patients with chronic sinusitis and is safe, with minimal adverse effects. However, longer term data is still needed to define its optimal role and indications.
- While initial data is promising for symptom relief and preservation of sinus anatomy compared to traditional FESS, balloon sinuplasty may not eliminate the need for conventional sinus surgery in all patients.
This document provides an overview of endoscopic nasal anatomy. It begins with a brief introduction to endoscopy and its historical evolution. It then describes the external nose, nasal septum, lateral nasal wall including the inferior, middle, and superior turbinates. Various anatomical variations are also discussed. The paranasal sinuses, anterior skull base, and endoscopic approaches to different nasal and sinus structures like the frontal sinus and sphenoid sinus are summarized. Key landmarks and variations are highlighted to provide a concise yet comprehensive summary of the essential endoscopic nasal anatomy concepts covered in the document.
Biomarkers in head and neck cancers final ajeetAjeet Gandhi
This document provides an overview of biomarkers in head and neck cancers. It discusses how biomarkers can be used for early diagnosis, predicting response to therapy, and identifying therapeutic targets. Key points include:
- Biomarkers like HPV status, ERCC1, and beta-tubulin isoform III may help predict response to chemotherapy and radiation. HPV+ tumors have a better prognosis.
- The EGFR pathway is commonly dysregulated in head and neck cancers but targeting it has had limited success due to resistance mechanisms. EGFRvIII mutations may reduce sensitivity to cetuximab.
- Ongoing research explores using biomarkers to guide more personalized treatment, such as reducing therapy for HPV+ tumors or targeting pathways
The document discusses the use of the Hadad-Bassagasteguy (HB) flap in reconstructing anterior skull base defects after endonasal skull base surgery. The HB flap uses the vascularized nasal septal mucoperiosteum to repair defects. In a study of 53 patients who underwent HB flap reconstruction, only 2 patients (3.8%) experienced post-operative cerebrospinal fluid leaks. The study found the HB flap to be effective at preventing post-operative CSF leaks across a variety of patient profiles and skull base surgery types. The HB flap is becoming a standard technique for reconstructing anterior skull base defects due to its high success rate and versatility.
All about uncinate process of nose and paranasal sinusesBikash Shrestha
Uncinate process is one of the important landmarks during the endoscopic sinus surgery. so it is important to know about the variation of unicinate process.
1. The petrous apex is a pyramid-shaped structure within the temporal bone that contains several vascular and neural channels.
2. Cholesterol granulomas are the most common petrous apex lesions, appearing hyperintense on T1- and T2-weighted MRI. Other developmental lesions include cholesteatomas, mucoceles, and cephaloceles.
3. Inflammatory, neoplastic, vascular, and osseous dysplasia lesions can also involve the petrous apex. Large or cranial nerve-compressing lesions may cause symptoms like hearing loss, facial weakness, or trigeminal nerve dysfunction.
This document discusses various laser and cryotherapy techniques used in ENT practice. It describes the properties and types of lasers including CO2, KTP, Nd:YAG, and diode lasers. Applications in ENT are discussed for procedures like laryngoscopy, sinus surgery, and tumor removal. Safety precautions for laser use and risks of ET tube fires are outlined. Cryotherapy and its mechanisms of tissue destruction are summarized. Indications for procedures like tumor removal and turbinate reduction are provided. Other techniques like photodynamic therapy, radiofrequency ablation, and hyperbaric oxygen therapy are briefly described.
Granulomatous diseases of the larynx- ALL DETAILS ABOUT TB, FUNGAL LARYNGITIS, SARCOIDOSIS, SYPHILIS, LEPROSY, Wegner granulomatosis, rhinoscleroma ARE GIVEN
The document discusses the radiological anatomy of the frontal sinus. It describes the complex and variable embryology and development of the frontal sinus. The frontal sinus drainage pathway is also highly variable and consists of superior and inferior compartments. The key anatomical structures that impact frontal sinus drainage include the frontal beak, frontal recess, agger nasi cells, uncinate process, bulla, and ethmoidal infundibulum. Variations in how these structures form and attach can affect how the frontal sinus drains.
The nasal valve is the narrowest part of the nasal passage located between the septum and upper lateral cartilages. Problems in this area can be due to weak or resected cartilage, or secondary to issues like septal deviations or turbinate hypertrophy. Diagnosis involves visual inspection and using probes to check for collapse or improvement from distraction. Treatment aims to restore normal anatomy and support the nasal framework using techniques like septoplasty, spreader grafts, onlay grafts, and valve suspension to correct primary or secondary valve abnormalities.
This document discusses deep neck spaces and infections. It begins by outlining the objectives and describing the anatomy of deep neck spaces in relation to the hyoid bone. These spaces include the retropharyngeal space, danger space, prevertebral space, and others. Deep neck infections like those in the parapharyngeal and retropharyngeal spaces are then described. Parapharyngeal space infections often arise from dental infections and may cause trismus and swelling below the mandible. Retropharyngeal infections risk spreading to the mediastinum and cause acute necrotizing mediastinitis, a serious complication. Diagnosis involves imaging like CT scans while treatment consists of antibiotics and surgical drainage.
1. The document discusses various deep neck spaces and infections that can arise within them, including Ludwig's angina (submandibular space infection), retropharyngeal abscess, and parapharyngeal abscess.
2. These deep neck space infections commonly arise from dental infections or tonsillitis and can spread rapidly, potentially causing airway obstruction.
3. Management involves intravenous antibiotics, incision and drainage of abscesses, and tracheostomy if needed to secure the airway. Proper identification of the involved neck space guides surgical drainage approach.
Superior semicircular canal dehiscence is a disorder where the bone between the superior semicircular canal and middle cranial fossa is absent, causing sound and pressure induced vertigo and oscillopsia. It is usually congenital or developmental and bilateral. Patients experience vestibular symptoms like vertigo when exposed to loud sounds, coughing, sneezing or straining. Diagnosis involves a CT scan and audiogram showing an air-bone gap with intact reflexes. Treatment options include avoiding triggers or surgically resurfacing the superior semicircular canal.
The document discusses the mucosal folds of the middle ear, which develop as the primitive tympanic cavity expands into the middle ear cleft between 3-7 months of fetal development. This forms four primary sacs that enlarge and replace the mesenchyme, with their walls becoming the mucosal lining of the middle ear. Mucosal folds are the planes of contact between neighboring sacs and carry ligaments and blood vessels to the ossicles. There are 10 important mucosal folds described, including the anterior and posterior malleal folds, lateral malleal ligamental fold, and tensor tympani fold. The folds divide the epitympanum (attic) and orient the progression of
This document discusses different types of fungal rhinosinusitis, including invasive and non-invasive forms. Non-invasive types include saprophytic fungal infections, fungal balls, and allergic fungal rhinosinusitis (AFRS). Invasive fungal rhinosinusitis is divided into acute/fulminant, granulomatous, and chronic types. Diagnosis involves imaging, histology, and culture. Treatment depends on type but commonly includes surgery along with long-term medical management such as steroids, antifungals, and immunotherapy.
This document discusses the history and techniques of radiotherapy in ENT. It begins with the discovery of x-rays in 1895 and progresses to modern technologies like IMRT, IGRT, proton beam therapy and SBRT. It covers the physics, biology and mechanisms of radiation therapy. Key aspects of radiotherapy for head and neck cancers like dosimetry, fractionation schedules, acute and chronic toxicities are summarized. Newer conformal techniques aim to reduce normal tissue damage while adequately treating tumors.
This is a presentation I used for my seminar on 'Phonosurgery' on 4th November, 2015. I hope they are useful to you. Constructive as well as Destructive criticism welcomed.
Narrow-band imaging (NBI) is an endoscopic imaging technique that uses specific blue and green wavelengths of light to enhance visualization of mucosal and vascular patterns. It helps identify subtle abnormalities by highlighting areas with high hemoglobin concentration. In the larynx, NBI has been used to identify recurrent respiratory papillomatosis and screen for malignancies. It provides sharper contrast than white light imaging, allowing for better detection of lesions and guidance of biopsy to suspicious areas. NBI is available for laryngoscopes and gastroscopes and is being explored for its utility in evaluating laryngeal and hypopharyngeal lesions.
This document summarizes juvenile respiratory papillomatosis (JORRP), a potentially life-threatening disease caused by human papillomavirus (HPV) types 6 and 11. It affects the respiratory tract from the nose to the bronchi. The main treatment is surgical debulking, while adjuvant therapies like interferon alpha, cidofovir and bevacizumab may help control disease between surgeries. While most cases resolve spontaneously, some children develop uncontrolled disease that can rarely spread to the lungs and become fatal, including potential malignant transformation of the papillomas.
The document discusses malignant lesions of the larynx, including its anatomy, epidemiology, etiology, pathological classification, staging, and treatment. It notes that laryngeal cancer management aims to balance oncological control with preserving larynx function. The most common type is well-differentiated squamous cell carcinoma. Risk factors include smoking, alcohol, HPV infection, and occupational exposures. Treatment is multidisciplinary and may involve radiation, surgery such as laser resection, or concurrent chemo-radiation depending on cancer stage, age, and patient preferences. The goal is to maximize cure while maintaining quality of life.
Perilymph Fistula can be difficult to diagnose as a standalone condition. Post-trauma symptoms such as dizziness, headache, etc. can be linked to other conditions like a traumatic brain injury with a concussion.
Otitis media with effusion (OME), also known as glue ear, is a chronic accumulation of fluid in the middle ear caused by eustachian tube dysfunction and inflammation of the middle ear mucosa. It is characterized by thick, viscous fluid in the middle ear without signs of infection. OME is commonly seen in young children, especially during winter months when upper respiratory infections are more prevalent. Treatment involves initial diagnosis by otoscopy and tympanometry, with surgical intervention of myringotomy with ventilation tube insertion if the effusion persists for more than 3 months. Adenoidectomy may provide additional benefit in resolving OME by removing a source of chronic infection in the nasopharynx.
Ménière's disease it’s definition ,etiopathogenesis and managementsritama1988
Meniere's disease is characterized by spontaneous attacks of vertigo accompanied by fluctuating hearing loss, tinnitus, and aural fullness. It is caused by endolymphatic hydrops, or a buildup of fluid in the inner ear. Attacks typically involve severe vertigo that lasts hours and progresses through irritative, paretic, and recovery phases with associated nystagmus. Hearing loss is usually low frequency and fluctuating at first but becomes progressively worse over time. The pathophysiology is thought to involve ruptures in the inner ear membranes allowing toxic endolymph to leak out and cause sustained neuron activation during attacks.
Meniere's disease is a disorder of the inner ear that causes spontaneous episodes of vertigo, fluctuating hearing loss, tinnitus, and aural fullness. It was first identified in 1861 by Prosper Meniere and is caused by endolymphatic hydrops, or excessive fluid buildup in the inner ear. The exact mechanisms are unclear but may involve disturbances in fluid homeostasis, genetics, migraine, and neuronal damage over time. Diagnosis is based on recurrent vertigo spells and hearing/balance symptoms according to established criteria. There is no cure and treatment aims to control symptoms.
1. The petrous apex is a pyramid-shaped structure within the temporal bone that contains several vascular and neural channels.
2. Cholesterol granulomas are the most common petrous apex lesions, appearing hyperintense on T1- and T2-weighted MRI. Other developmental lesions include cholesteatomas, mucoceles, and cephaloceles.
3. Inflammatory, neoplastic, vascular, and osseous dysplasia lesions can also involve the petrous apex. Large or cranial nerve-compressing lesions may cause symptoms like hearing loss, facial weakness, or trigeminal nerve dysfunction.
This document discusses various laser and cryotherapy techniques used in ENT practice. It describes the properties and types of lasers including CO2, KTP, Nd:YAG, and diode lasers. Applications in ENT are discussed for procedures like laryngoscopy, sinus surgery, and tumor removal. Safety precautions for laser use and risks of ET tube fires are outlined. Cryotherapy and its mechanisms of tissue destruction are summarized. Indications for procedures like tumor removal and turbinate reduction are provided. Other techniques like photodynamic therapy, radiofrequency ablation, and hyperbaric oxygen therapy are briefly described.
Granulomatous diseases of the larynx- ALL DETAILS ABOUT TB, FUNGAL LARYNGITIS, SARCOIDOSIS, SYPHILIS, LEPROSY, Wegner granulomatosis, rhinoscleroma ARE GIVEN
The document discusses the radiological anatomy of the frontal sinus. It describes the complex and variable embryology and development of the frontal sinus. The frontal sinus drainage pathway is also highly variable and consists of superior and inferior compartments. The key anatomical structures that impact frontal sinus drainage include the frontal beak, frontal recess, agger nasi cells, uncinate process, bulla, and ethmoidal infundibulum. Variations in how these structures form and attach can affect how the frontal sinus drains.
The nasal valve is the narrowest part of the nasal passage located between the septum and upper lateral cartilages. Problems in this area can be due to weak or resected cartilage, or secondary to issues like septal deviations or turbinate hypertrophy. Diagnosis involves visual inspection and using probes to check for collapse or improvement from distraction. Treatment aims to restore normal anatomy and support the nasal framework using techniques like septoplasty, spreader grafts, onlay grafts, and valve suspension to correct primary or secondary valve abnormalities.
This document discusses deep neck spaces and infections. It begins by outlining the objectives and describing the anatomy of deep neck spaces in relation to the hyoid bone. These spaces include the retropharyngeal space, danger space, prevertebral space, and others. Deep neck infections like those in the parapharyngeal and retropharyngeal spaces are then described. Parapharyngeal space infections often arise from dental infections and may cause trismus and swelling below the mandible. Retropharyngeal infections risk spreading to the mediastinum and cause acute necrotizing mediastinitis, a serious complication. Diagnosis involves imaging like CT scans while treatment consists of antibiotics and surgical drainage.
1. The document discusses various deep neck spaces and infections that can arise within them, including Ludwig's angina (submandibular space infection), retropharyngeal abscess, and parapharyngeal abscess.
2. These deep neck space infections commonly arise from dental infections or tonsillitis and can spread rapidly, potentially causing airway obstruction.
3. Management involves intravenous antibiotics, incision and drainage of abscesses, and tracheostomy if needed to secure the airway. Proper identification of the involved neck space guides surgical drainage approach.
Superior semicircular canal dehiscence is a disorder where the bone between the superior semicircular canal and middle cranial fossa is absent, causing sound and pressure induced vertigo and oscillopsia. It is usually congenital or developmental and bilateral. Patients experience vestibular symptoms like vertigo when exposed to loud sounds, coughing, sneezing or straining. Diagnosis involves a CT scan and audiogram showing an air-bone gap with intact reflexes. Treatment options include avoiding triggers or surgically resurfacing the superior semicircular canal.
The document discusses the mucosal folds of the middle ear, which develop as the primitive tympanic cavity expands into the middle ear cleft between 3-7 months of fetal development. This forms four primary sacs that enlarge and replace the mesenchyme, with their walls becoming the mucosal lining of the middle ear. Mucosal folds are the planes of contact between neighboring sacs and carry ligaments and blood vessels to the ossicles. There are 10 important mucosal folds described, including the anterior and posterior malleal folds, lateral malleal ligamental fold, and tensor tympani fold. The folds divide the epitympanum (attic) and orient the progression of
This document discusses different types of fungal rhinosinusitis, including invasive and non-invasive forms. Non-invasive types include saprophytic fungal infections, fungal balls, and allergic fungal rhinosinusitis (AFRS). Invasive fungal rhinosinusitis is divided into acute/fulminant, granulomatous, and chronic types. Diagnosis involves imaging, histology, and culture. Treatment depends on type but commonly includes surgery along with long-term medical management such as steroids, antifungals, and immunotherapy.
This document discusses the history and techniques of radiotherapy in ENT. It begins with the discovery of x-rays in 1895 and progresses to modern technologies like IMRT, IGRT, proton beam therapy and SBRT. It covers the physics, biology and mechanisms of radiation therapy. Key aspects of radiotherapy for head and neck cancers like dosimetry, fractionation schedules, acute and chronic toxicities are summarized. Newer conformal techniques aim to reduce normal tissue damage while adequately treating tumors.
This is a presentation I used for my seminar on 'Phonosurgery' on 4th November, 2015. I hope they are useful to you. Constructive as well as Destructive criticism welcomed.
Narrow-band imaging (NBI) is an endoscopic imaging technique that uses specific blue and green wavelengths of light to enhance visualization of mucosal and vascular patterns. It helps identify subtle abnormalities by highlighting areas with high hemoglobin concentration. In the larynx, NBI has been used to identify recurrent respiratory papillomatosis and screen for malignancies. It provides sharper contrast than white light imaging, allowing for better detection of lesions and guidance of biopsy to suspicious areas. NBI is available for laryngoscopes and gastroscopes and is being explored for its utility in evaluating laryngeal and hypopharyngeal lesions.
This document summarizes juvenile respiratory papillomatosis (JORRP), a potentially life-threatening disease caused by human papillomavirus (HPV) types 6 and 11. It affects the respiratory tract from the nose to the bronchi. The main treatment is surgical debulking, while adjuvant therapies like interferon alpha, cidofovir and bevacizumab may help control disease between surgeries. While most cases resolve spontaneously, some children develop uncontrolled disease that can rarely spread to the lungs and become fatal, including potential malignant transformation of the papillomas.
The document discusses malignant lesions of the larynx, including its anatomy, epidemiology, etiology, pathological classification, staging, and treatment. It notes that laryngeal cancer management aims to balance oncological control with preserving larynx function. The most common type is well-differentiated squamous cell carcinoma. Risk factors include smoking, alcohol, HPV infection, and occupational exposures. Treatment is multidisciplinary and may involve radiation, surgery such as laser resection, or concurrent chemo-radiation depending on cancer stage, age, and patient preferences. The goal is to maximize cure while maintaining quality of life.
Perilymph Fistula can be difficult to diagnose as a standalone condition. Post-trauma symptoms such as dizziness, headache, etc. can be linked to other conditions like a traumatic brain injury with a concussion.
Otitis media with effusion (OME), also known as glue ear, is a chronic accumulation of fluid in the middle ear caused by eustachian tube dysfunction and inflammation of the middle ear mucosa. It is characterized by thick, viscous fluid in the middle ear without signs of infection. OME is commonly seen in young children, especially during winter months when upper respiratory infections are more prevalent. Treatment involves initial diagnosis by otoscopy and tympanometry, with surgical intervention of myringotomy with ventilation tube insertion if the effusion persists for more than 3 months. Adenoidectomy may provide additional benefit in resolving OME by removing a source of chronic infection in the nasopharynx.
Ménière's disease it’s definition ,etiopathogenesis and managementsritama1988
Meniere's disease is characterized by spontaneous attacks of vertigo accompanied by fluctuating hearing loss, tinnitus, and aural fullness. It is caused by endolymphatic hydrops, or a buildup of fluid in the inner ear. Attacks typically involve severe vertigo that lasts hours and progresses through irritative, paretic, and recovery phases with associated nystagmus. Hearing loss is usually low frequency and fluctuating at first but becomes progressively worse over time. The pathophysiology is thought to involve ruptures in the inner ear membranes allowing toxic endolymph to leak out and cause sustained neuron activation during attacks.
Meniere's disease is a disorder of the inner ear that causes spontaneous episodes of vertigo, fluctuating hearing loss, tinnitus, and aural fullness. It was first identified in 1861 by Prosper Meniere and is caused by endolymphatic hydrops, or excessive fluid buildup in the inner ear. The exact mechanisms are unclear but may involve disturbances in fluid homeostasis, genetics, migraine, and neuronal damage over time. Diagnosis is based on recurrent vertigo spells and hearing/balance symptoms according to established criteria. There is no cure and treatment aims to control symptoms.
Meniere's disease is a disorder of the inner ear that causes episodes of vertigo, hearing loss, tinnitus, and aural fullness. It is thought to be caused by endolymphatic hydrops, or a buildup of fluid in the inner ear. While the exact mechanisms are unclear, it may involve disturbances in fluid homeostasis, genetics, migraines, and damage to inner ear ganglion cells. The document discusses the history, symptoms, diagnostic criteria, pathophysiology including histopathological findings, epidemiology, and experimental models of the disease.
This document discusses the history, presentation, diagnosis and management of Meniere's disease. Some key points:
- Meniere's disease was first described in 1861 and is characterized by hearing loss, tinnitus, and vertigo due to endolymphatic hydrops (fluid buildup) in the inner ear.
- Diagnosis is based on recurrent vertigo spells lasting 20 minutes to 24 hours, fluctuating hearing loss, tinnitus and aural fullness. Tests like electrocochleography and VEMPs can provide supportive evidence.
- Treatment includes dietary sodium restriction, diuretics, medications and surgical options like intratympanic injections if conservative measures fail. The
This document discusses the evaluation and management of Meniere's disease. It begins by describing the classic symptoms of the disease - hearing loss, tinnitus, and vertigo. It then discusses the history of Meniere's disease, first described in 1861 by Prosper Meniere. A key finding is endolymphatic hydrops, an increase in inner ear fluid that causes the symptoms. The document outlines the stages of the disease and recommended tests for evaluation, including hearing tests, balance tests, and imaging. The goal of evaluation is to diagnose the disease and guide treatment, while ruling out other potential causes.
This document presents a case study of a 39-year old female patient diagnosed with Wergner's Granulomatosis (WG). She presented with left ear itching and drainage. Testing showed positive ANCA and PR3 antibodies. Imaging found lesions in the lung, ear, and sinus involvement. She was diagnosed with WG based on her clinical presentation and test results. She was treated with cyclophosphamide, corticosteroids, antibiotics, and other medications. WG is a rare autoimmune disease that involves inflammation and damage of small blood vessels. It commonly involves the upper respiratory tract, lungs, and kidneys. Without treatment, it can be fatal but prognosis has improved with immunosuppressive therapies.
This document discusses rigid endoscopic evaluation of conventional curettage adenoidectomy. It begins with an introduction stating that adenoidectomy is a common procedure in children and conventional curettage is commonly used. It then provides details on the anatomy and physiology of the adenoids, clinical presentation of adenoid hypertrophy, diagnosis, grading systems used, different surgical techniques including conventional curettage and various types of endoscopic adenoidectomy, post-operative care, and potential complications.
This document describes a case of diphtheritic polyneuropathy in a 53-year-old man who developed weakness, numbness, and bulbar palsy several weeks after a sore throat. Diphtheritic polyneuropathy results from the toxin produced by Corynebacterium diphtheriae inhibiting protein synthesis. It initially causes local effects like bulbar palsy followed by a generalized demyelinating peripheral neuropathy. The patient's symptoms followed the typical progression and resolved over several months. The diagnosis was difficult but important to differentiate from Guillain-Barré syndrome given differences in treatment and prognosis. Diphtheritic polyneuropathy highlights the need for continued vaccination and awareness of this condition.
Meniere's disease is characterized by episodes of vertigo, tinnitus, and hearing loss caused by endolymphatic hydrops, or swelling of the inner ear fluid compartments. The exact cause is unknown but may involve defective fluid absorption, vasomotor disturbances, or sodium/water retention. Diagnosis is based on symptoms and ruling out other causes. Treatment focuses on managing vertigo attacks, reducing fluid pressure through diet/diuretics, and surgery such as endolymphatic sac decompression for severe cases. Prognosis varies but many patients experience stabilization over time.
1) The document discusses various benign polypoidal etiologies of the sinonasal region including nasal polyps, antrochoanal polyps, mucoceles, and sinonasal papillomas.
2) Nasal polyps are soft tissue masses that commonly arise from the ethmoid and maxillary sinuses. Antrochoanal polyps originate in the maxillary sinus and extend into the nasal cavity and nasopharynx.
3) Mucoceles are mucus-filled cysts that develop from obstructed paranasal sinuses. Computed tomography is useful for evaluating their extent and bone changes.
4) Sinonasal papillomas include
Vocal cord nodules, polyps, and Reinke's edema are common laryngeal lesions caused by phonotrauma or repetitive vocal trauma. Vocal cord nodules appear as small, whitish lesions at the junction of the anterior and posterior vocal folds. Treatment involves speech therapy and possible microlaryngoscopy or laser excision. Vocal cord polyps are usually unilateral and pedunculated lesions located on the vocal folds. Treatment is surgical excision to confirm diagnosis and prevent recurrence. Reinke's edema causes diffuse swelling of the vocal folds and is associated with smoking. Treatment involves smoking cessation and possible surgery.
Previous year question on otosclerosis from ent based on neet pg, usmle, plab...Abhishek Gupta
Endolymphatic hydrops, seen in Meniere's disease, is a disorder of the inner ear where the endolymphatic system is distended with endolymph fluid. The document provides background information on Meniere's disease and endolymphatic hydrops, sample questions on topics like otosclerosis, and explanations of answers relating to various ear conditions. Key signs and diagnostic tests mentioned include Carhart's notch seen on audiometry in otosclerosis, and negative Rinne's test indicating conductive hearing loss.
Labyrinthitis is an inflammatory disorder of the inner ear that causes disturbances in balance and hearing. It can be caused by bacterial or viral infections invading the delicate structures of the inner ear. Patients experience vertigo, hearing loss, nausea, and imbalance. A physical exam evaluates ear function, eye movements, and neurological signs. Diagnostic tests like CT, MRI and vestibular testing help identify the cause and rule out other conditions. Treatment focuses on resolving the underlying infection with antibiotics or antivirals, and managing symptoms with rest, hydration and medications. Hearing loss outcomes vary depending on the cause, but balance symptoms typically improve over weeks with recovery of vestibular function.
This document provides information about Meniere's disease, including its definition, symptoms, diagnosis, and treatment. Some key points:
- Meniere's disease is a disorder of the inner ear that causes episodes of vertigo, hearing loss, tinnitus, and a feeling of ear fullness. It is caused by endolymphatic hydrops.
- The classic triad of symptoms includes hearing loss, tinnitus, and vertigo, though some patients may experience fewer than all three. Attacks typically last hours.
- Diagnosis is based on ruling out other causes and observing recurrent vertigo spells along with audiometric evidence of hearing loss. There are no definitive tests.
The document discusses various diseases of the inner ear, including labyrinthitis, viral labyrinthitis, toxic labyrinthitis, ototoxicity from antibiotics and other substances, neoplasms, trauma, fractures of the temporal bone, tinnitus, vertigo, and Meniere's disease. Labyrinthitis can be suppurative, viral, or toxic/serous and causes symptoms like deafness, dizziness, and vestibular dysfunction. Meniere's disease involves a buildup of endolymph fluid causing episodes of vertigo, hearing loss, and tinnitus. Treatment depends on the specific condition but may include antibiotics, steroids, surgery, and addressing the underlying
Presentation1.pptx, radiological imaging of the larngeal diseases.Abdellah Nazeer
This document provides an overview of radiological imaging and various diseases of the larynx. It begins by defining the anatomical structures of the larynx, including the supraglottis, glottis, and subglottis. It then discusses several congenital disorders like laryngomalacia, vocal fold paralysis, subglottic stenosis, hemangioma, webs, and atresia. Various inflammatory disorders are also covered such as acute and chronic laryngitis, epiglottitis, tuberculosis, scleroma, candidiasis, sarcoidosis, and laryngo-pharyngeal reflux disease. For each condition, the document discusses epidemiology, etiology, clinical presentation,
This document provides definitions and information about idiopathic sudden sensorineural hearing loss (ISSNHL). It discusses the epidemiology, potential causes including viral, vascular, autoimmune and Meniere's disease. It outlines the clinical assessment process including history, examination and investigations. Prognosis factors and treatment approaches are summarized, including steroid therapy options and complications. Standard treatment is oral corticosteroids, though intratympanic injections are gaining popularity for refractory cases to reduce side effects. More research is still needed on efficacy of treatments.
Nasal polyps are abnormal lesions that originate from the nasal mucosa or paranasal sinuses. They are most commonly caused by chronic inflammation from various sources. Nasal polyps present with symptoms like nasal obstruction, postnasal drip, and headaches. Investigations include CT scans, nasal endoscopy, and tests for conditions like cystic fibrosis. Treatment options include oral steroids, sinus surgery to remove polyps, and addressing underlying causes of inflammation. While surgery provides relief, nasal polyps often recur due to the chronic inflammatory nature of the condition.
This document summarizes a case study of two patients with objective tinnitus caused by palatal and middle-ear myoclonus. For both patients, neurological exams and MRI scans found no identifiable lesions. In the first patient, otomicroscopy and nasoendoscopy revealed synchronous movement of the soft palate and middle ear structures with the tinnitus sounds. Surgery to section the tensor tympani muscle tendons provided temporary relief but the tinnitus returned. The second patient had similar exam findings and surgery provided lasting relief of symptoms. The document reviews literature on palatal and middle-ear myoclonus and discusses unanswered questions about the nature and treatment of these conditions.
This document summarizes the condition known as Ménière's disease. It describes the typical symptoms including vertigo, tinnitus, and hearing loss. It discusses the diagnostic criteria and notes the disease is associated with endolymphatic hydrops, though the cause is unknown. It reviews treatment options including medications, surgery, and lifestyle modifications. It provides background on Prosper Ménière, the French physician who first identified and described the condition in 1861.
Mastoidectomy is a surgical procedure to access and treat infections or diseases of the mastoid air cells behind the ear. The summary describes:
1. The history of mastoidectomy dates back to ancient times, with modern improvements like the operating microscope in the 20th century.
2. There are different classifications of mastoidectomy based on the extent of air cell removal and whether the ear canal wall is intact or removed.
3. Indications for mastoidectomy include treatment of infections, drainage of abscesses, and approaches for other inner ear surgeries. Complications can include injuries to nearby structures like the dura, facial nerve or blood vessels.
Cholesteatoma is a cyst-like structure in the middle ear that grows due to the accumulation of skin cells. It can be congenital, arising from embryonic skin cell rests, or acquired through retraction pockets in the eardrum or entry of skin cells through an eardrum perforation. Acquired cholesteatomas are further classified as primary, arising in the attic region with no prior ear issues, or secondary, following ear infection. Cholesteatomas cause bone destruction through enzymes released by the surrounding granulation tissue and can lead to hearing loss, facial nerve problems, or intracranial complications if untreated. Treatment involves surgery to remove the cholesteatoma along with any infected
This document defines tympanoplasty and provides a history and overview of the procedure. It begins by defining tympanoplasty as a procedure to eradicate disease in the middle ear and reconstruct the hearing mechanism, with or without grafting of the tympanic membrane. It then discusses the history of developments in tympanoplasty techniques from the 1950s onward. The document outlines the aims, objectives, types based on various classification systems, indications, contraindications and steps of performing tympanoplasty.
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Otoacoustic emissions (OAEs) are sounds produced by the inner ear that can be measured in the ear canal. There are different types of OAEs including spontaneous, stimulus frequency, transient evoked, and distortion product OAEs. OAEs are believed to be generated by outer hair cells in the cochlea. Brainstem auditory evoked response (BERA) involves recording electrical activity in the brainstem in response to auditory stimuli. BERA can help identify lesions in the auditory nerve or brainstem by analyzing latencies and amplitudes of waves I-V. Abnormal findings on OAEs or BERA can indicate conditions such as acoustic neuromas or other inner
This document discusses chronic otitis media (COM), a long-standing middle ear infection characterized by persistent ear discharge through a perforated eardrum. It defines the two main types - tubotympanic and atticoantral disease - and describes their signs, symptoms, causes, investigations, and treatment options including medical management and surgical procedures like myringoplasty, tympanoplasty, and ossiculoplasty. COM is more common in developing nations and usually starts in childhood, affecting hearing if left untreated. Accurate diagnosis involves examination, tests like audiograms and CT scans, and ruling out complications.
This document discusses various complications that can arise from chronic suppurative otitis media (CSOM). It describes intra-cranial and extra-cranial complications, including mastoiditis, facial nerve paralysis, labyrinthitis, petrositis, subperiosteal abscesses, meningitis, brain abscesses, otitic hydrocephalus, extradural abscesses, subdural abscesses, and lateral sinus thrombosis. For each complication, it discusses the pathology, clinical features, investigations, and treatment approaches.
Orbital Complications Of Acute RhinosinusitisPrasanna Datta
An 8-year-old girl presented with left eye swelling and pain for 4 days. She had symptoms of an upper respiratory tract infection 6 days prior. On examination, her left eye was swollen and erythemic and she could not open it due to pain. CT scan showed a left lateral orbit collection and sinusitis. She underwent incision and drainage of the orbital abscess and functional endoscopic sinus surgery. Her symptoms improved after surgery. Orbital cellulitis can develop from sinusitis due to connections between the sinuses and orbit via veins. Early diagnosis and treatment is important to prevent vision loss or other complications.
Endoscopic ear surgery has progressed significantly over the past century alongside improvements in microscopy and endoscopy. While microscopy revolutionized ear surgery in the 1950s-60s by enabling binocular visualization, endoscopy offers additional advantages for procedures with narrow surgical corridors like the external auditory canal. These include a wider field of view around corners and the ability to perform surgery using only the ear canal as an access point. This preserves normal anatomy and decreases the need for bone removal. The 1990s saw early adoption of endoscopy for procedures like second look mastoidectomies. Its use expanded in the 2000s as more surgeons incorporated the techniques. Today, endoscopy provides an alternative to microscopic visualization for select otologic
Navigating Neck : Important Land marks During SurgeryPrasanna Datta
The document provides information on the location and relationships of various cranial nerves in the neck. It discusses the locations of CN VII, IX-XII and their anatomical relationships. It also addresses surgical landmarks for lymph node levels and variations in nerve locations that are important to consider during neck dissection procedures.
1. Nasal masses can present with symptoms like nasal obstruction, rhinorrhea, congestion, hyposmia, and epistaxis. Physical examination may reveal facial swelling, proptosis, or diplopia depending on site and extent of the mass.
2. Nasal masses can be anatomical variants, inflammatory/infectious, congenital/developmental, or neoplasms. Common nasal masses include nasal polyps, inverted papilloma, juvenile angiofibroma, and lymphocytic hypophysitis.
3. Diagnostic evaluation includes nasal endoscopy, CT scan, and biopsy. CT is helpful for surgical planning. Differential diagnosis depends on clinical features and may
1. The patient presented with a neck lump, swelling or mass. A thorough history and physical examination was performed, including inspection of oral cavity and neck examination.
2. Diagnostic tests including bloodwork, imaging like ultrasound and biopsy if needed were used to characterize the mass and narrow the differential diagnosis. Common non-malignant causes included cysts, infections and congenital masses.
3. Malignant causes were also considered like lymphomas and metastatic lymph nodes, with further workup to identify a potential primary source. Treatment options varied depending on the diagnosis.
This document provides an overview of nasal polyps, including their definition, history, etiology, classification, clinical presentation, management, and theories of pathogenesis. Some key points:
- Nasal polyps are sacs of edematous nasal mucosa that can cause nasal obstruction. They were first described over 4000 years ago in ancient Egypt.
- Nasal polyps are classified as simple/inflammatory, fungal, or malignant. Common types include ethmoidal and antrochoanal polyps.
- Theories of pathogenesis include adenoma fibroma theory, necrotizing ethmoiditis, glandular hyperplasia, and epithelial rupture theory. Allergies and infections are also implicated
This document summarizes the history, indications, techniques, and adjuvant therapies for tonsillectomy. It discusses the evolution of tonsillectomy from ancient techniques using fingers and knives to modern methods utilizing instruments like the tonsillotome. Key indications for tonsillectomy outlined include recurrent infection, sleep disorders, and airway obstruction. Innovative techniques described are intracapsular tonsillectomy using microdebriders or lasers, as well as coblation and harmonic scalpel methods. Studies show these new techniques reduce postoperative pain and recovery time compared to electrocautery. Adjuvant therapies explored are local anesthetics like bupivacaine and perioperative steroids like dexamethas
The document discusses the use of lasers in otolaryngology. It begins with an introduction to lasers and their principles. It then describes different types of lasers used including CO2, Nd:YAG, KTP, argon lasers and their properties. Applications of lasers in ENT are discussed including uses in otology like stapes surgery, external auditory canal procedures and middle ear surgery. Rhinology procedures like turbinate reduction and septal surgery are also covered. Uses of lasers in oral cavity, pharynx, larynx and neck are summarized. Safety considerations with lasers and their delivery systems are provided.
Orbit is a quadrilateral pyramidal cavity containing the eye. It has thin walls that are susceptible to infection, inflammation and neoplasia from adjacent sinonasal structures. Key surgical anatomy includes thin medial and inferior walls, lacrimal apparatus, extraocular muscles and neurovascular supply. Sinonasal pathology such as mucocoeles, chronic dacrocystitis and tumors can spread to the orbit. Trauma or endoscopic sinus surgery can also cause orbital complications requiring reconstruction or decompression. Imaging guides management of orbital pathology and involvement in sinonasal disease.
This document provides an overview of imaging techniques for the ear, nose, paranasal sinuses, and larynx. It describes various radiographic views for visualizing different structures, including the lateral, Caldwell, Waters, and submental vertical views. Computed tomography is described as the gold standard for preoperative evaluation. CT protocols include coronal and axial scans. Anatomical structures seen on different views and cuts are outlined in detail. Common anatomical variations are also discussed, along with the Keros classification system for olfactory fossa depth.
This document provides an overview of tumor staging for head and neck cancers. It describes the major sites in the upper aerodigestive tract including the oral cavity, oropharynx, hypopharynx, larynx, nasopharynx, and nasal cavity/paranasal sinuses. For each site, it discusses patterns of spread and common treatments. It also introduces the TNM staging system and neck lymph node levels used to classify head and neck cancers.
Vocal fold polyps are one of the most common benign laryngeal lesions. They are generally caused by phonotrauma but can also be associated with smoking, gastroesophageal reflux, or respiratory activities. Histologically, polyps show swelling in the lamina propria and an increase in blood vessels. While some studies find no difference between polyp and nodule histology, others demonstrate morphological changes in polyp tissue. Surgery is often used to treat polyps but recent research shows speech therapy can also be effective as primary treatment, with total or partial regression of lesions in some cases. The literature review found discrepancies but also notable progress in otolaryngologic techniques and effectiveness of speech therapy as initial treatment
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- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
1. 0
Otolarynbgoo9gy personal | Etiology of Meniere's disease 0
It is nearly 150 years since Prosper
Meniere described this condition
accurately. His description of the
disorder still holds good. This book is
being released as a tribute to this man
Meniere’s
disease
Second Edition Incorporating
recent advances
Dr T Balasubramanian
2. 1 drtbalu’s Otolaryngology online
Meniere’s disease
By
Dr. T. Balasubramanian M.S. D.L.O.
History:
In late 19th century Prosper Meniere described a condition characterized by ear
block, tinnitus, and vertigo. He even correctly identified the site of lesion to be
labyrinth. It wont be a understatement to say that precious little has been added to
the knowledge and understanding of the disorder since then. Prosper Meniere infact
lived far ahead of his time. He was born in 1799 in France. In 1848 he began to
translate the text book on hearing loss authored by Kramer. The book was written
in German. This kindled his interest in otology.
In his classical seminal reports he goes on to describe a series of patients who
presented with neural deafness, with hearing loss greater for low frequencies.
Deafness was commonly unilateral in these patients. These patients usually present
with tinnitus, vertigo, nausea and vomiting. He reported that these patients had a
normal ear drum. He also reported that these symptoms were completely reversible.
3. 2 drtbalu’s Otolaryngology online
Prosper Meniere
It was Galen during 130 - 200 AD who coined the term labyrinth because he had
faced tremendous difficulties trying to fathom the functioning of inner ear.
Galen
Studies of Egyptian Papyruses have demonstrated the emperic therapies devised by
Greek physicians like Hippocrates to manage tinnitus / heaing loss etc.
The popular belief that inner ear is filled with ear was disproved by Domenico
Cotugno (1736-1822). He successfully demonstrated the presence of inner ear fluid
and christened it as endolymph. Cotugno was successful because he used fresh
specimen in his dissection. He also demonstrated the presence of vestibulat
aqueduct.
Antonio scarpa in 1747 described the correct anatomy of the membranous
labyrinth. He named the fluid filling the membranous labyrinth as Scarpa's fluid.
4. 3 drtbalu’s Otolaryngology online
Antonio Scarpa
It was Erasmus Darwin grandfather of Charles Darwin was the first to associate
vertigo and tinnitus with inner ear pathology.
It was Georges Portmann who evolved the procedure "Endolymphatic sac
decompression" as a treatment modality for Meniere's disease.
Georges Portmann
5. 4 drtbalu’s Otolaryngology online
Walter Dandy was the first to treat Meniere's disease by sectioning the vestibular
nerve. This procedure produced instant relief from tinnitus. The fact that Dandy
was a trained neurosurgeon helped him in this procedure.
Incidence:
Incidence of Meniere’s syndrome in the general population is highly variable.
Crude estimates put the value to be 8 per 100,000 individuals.
Studies have demonstrated a significant female predominance.
Meniere’s syndrome is rare in children. It is commonly seen in adults.
Etiology of Meniere's disease
The exact etiology of Meniere's disease is unknown, however various etiologies have
been suspected.
Etiological factors of Meniere's disease:
1. Genetic
2. Anatomical causes
3. Traumatic
4. Viral infection
5. Allergy
6. Autoimmunity
7. Psychosomatic and personality disorders
Etiological features of secondary endolymphatic hydrops:
6. 5 drtbalu’s Otolaryngology online
1. Developmental insult
2. Abnormal metabolic / endocrine states
3. Syphilis
4. CSOM
5. Viral infection
6. Autoimmunity
7. Otosclerosis
8. Abnormal fluid balance
9. Leukemia
Genetic causes:
Familial tendency has been observed in nearly 20% of patients with Meniere's
disease. Studies have demonstrated that Meniere's disease is attributable to a
mutation on chromosome 6. Transmission is supposedly autosomal dominant in
nature.
Anatomical causes:
1. Small vestibular aqueduct: Radiological studies of patients with Meniere's disease
demonstrated a smaller vestibular aqueduct in nearly 10% of patients.
Considerable difficulty was experienced in visualizing the endolymphatic duct / sac
in ears affected by Meniere's disease.
7. 6 drtbalu’s Otolaryngology online
CT temporal bone showing narrow endolymphatic duct
2. Reduction in the rugose portion of the endolymphatic sac has been detected in a
significant number of Meniere's disease patients.
Traumatic causes:
Association between Meniere’s disease and trauma (physical / acoustic) has been
implicated in Meniere's related symptoms. Trauma may cause biochemical
dysfunction in the cells of the membranous labyrinth, or may simply cause release of
debris into the endolymph causing obstruction of the endolymphatic duct / sac.
Viral infection:
Damage to the endolymphatic sac and duct by viral infection has been proposed as
an etiological mechanism in Meniere's disease. Neurotrophic viruses have been
implicated in this process. Researches in Sweden have identified a higher reactivity
to herpes simplex virus type I in patients with Meniere’s disease. DNA of herpes
virus has been isolated from the endolymphatic sac of affected individuals.
Circulating levels of group specific proteins of enterovirus VP1 have been found to
be elevated in patients with active disease. Absence of the protein can be correlated
with remission.
8. 7 drtbalu’s Otolaryngology online
Allergy:
Nearly 80% of patients with Meniere's disease have history of childhood allergy.
Both food and inhalant allergens have been implicated. Treatment of allergy with
immunotherapy caused a remission of the disease in majority of these patients. IgE
changes have not been demonstrated in these patients causing a doubt regarding
this etiological factor.
Autoimmunity:
Autoimmunity as an etiological factor has been considered in Meniere's disease. The
endolymphatic sac has been shown to contain immunoglobulin and lymphocytes and
is capable of generating immune response. Immunoglobulins have been found to be
deposited in the walls and the luminal fluid of endolymphatic sacs of Meniere's
disease. Elevated levels of immune complexes have been demonstrated in nearly
20% of patients with bilateral Meniere's disease. ESR has been found to be elevated.
Circulating immune complexes have been found to be elevated in Meniere's disease.
Antibodies directed against type II collagen have been found in the serum of these
patients.
Psychosomatic features:
Patients with Meniere's disease have an increased incidence of personality
disorders.
Secondary hydrops possible etiological factors involved:
Developmental insult:
Developmental insults can cause symptomatic endolymphatic hydrops. Mondini's
deformity is commonly associated with secondary Meniere's disease. The true
Mondini deformity occurs secondary to an arrest at the seventh week. Only the
basilar turn of the cochlea has undergone complete development. Typically the
interscalar septum or osseous spiral lamina is incomplete; resulting in a confluency
of the apical and middle cochlea turns (incomplete partition). The vestibule and
semicircular canal may or may not be normal.
9. 8 drtbalu’s Otolaryngology online
CT scan showing cochlear aplasia (Mondini deformity)
Abnormal metabolic / endocrine states:
Certain abnormal metabolic and endocrine states predispose to the development of
seconday hydrops. Both high and low blood glucose levels have been associated with
dysfunction of inner ear. The hearing may fluctuate with blood glucose levels. It has
been demonstrated that induced hypoglycemia resulted in a decrease in potassium
concentration of endolymph associated with a rise in endolymphatic sodium levels.
These changes resemble the changes seen in Meniere's disease.
Hyperlipoprotenemia has been associated with Meniere's like symptoms.
Endocrine disorders causing secondary hydrops:
1. Hypothyroidism
2. Nephrogenic diabetes insipidus
3. Adrenal insufficiency
Syphilis:
Syphilis is a known cause of endolymphatic hydrops. This could be caused due to
the inner ear's reaction to syphilitic organism.
Chronic otitis media:
10. 9 drtbalu’s Otolaryngology online
Endolymphatic hydrops have been observed in patients with CSOM. This could be
caused due to the effect of otitis media on the inner ear due to percolation of
infectious products / toxins and other associated enzymes. These substances could
migrate into the inner ear through the round window membrane.
Otosclerosis:
Patients with otosclerosis could develop secondary hydrops. This could possibly due
to otosclerotic bone impinging on the vestibular aqueduct, or due to biochemical
alteration of perilymph and endolymph. Paperella introduced the term otoscerotic
inner ear syndrome to describe this problem.
Abnormal fluid balance:
Haemodialysis has been reported to precipitate endolymphatic hydrops in
contralateral ear of a patient with Meniere's syndrome. This could be explained by
the fact that sudden changes in the plasma osmolality caused by dialysis affects the
predisposed ear.
Pathophysiology of Meniere's disease
Meniere's disease by definition is idiopathic endolymphatic hydrops characterised
by roaring tinnitus, vertigo, fluctuating hearing loss. Even though sometimes
erroneously used interchangeably, meniere's disease is different from
endolymphatic hydrops. It should be borne in mind that the term endolymphatic
hydrops indicates the underlying pathophysiological mechanism of Meniere's
disease. Endolymphatic hydrops can infact be classified as primary and secondary
according to the causative factors involved. Primary endolymphatic hydrops is
infact the classic Meniere’s disease where in the underlying etiology is unknown. In
11. 10 drtbalu’s Otolaryngology online
secondary hydrops the etiopathogenesis of the underlying disorder is clearly
elucitable.
American academy of ophthalmology and otolaryngology committee on equilibrium
defined Meniere's disease as follows: “a disease of the membranous inner ear
characterized by deafness, vertigo and usually tinnitus which has as its pathologic
correlate hydropic distention of the endolymphatic system".
Etiology and pathophysiology of Meniere's disease is still unclear. Most commonly
accepted theory being overdistension of the membranous labyrinth due to excessive
endolymphatic fluid volume. This accumulation of endolymph may be caused by
impaired absorption of endolymph in the endolymphatic duct and sac, or excessive
secretion of endolymph. These hypotheses are based on demonstrable presence of
endolymphatic hydrops in patients with signs and symptoms of Meniere's disease. It
has also been demonstrated that these patients have reduced vascularization and
fibrosis of perisaccular tissue causing a reduction in the absorptive capacity of the
endolymphatic sac. Experimentally also it has been clearly demonstrated that
obliteration of endolymphatic sac will induce endolymphatic hydrops.
Which portion of the membranous labyrinth gets affected early in Meniere's
disease?
Studies have clearly demonstrated that early increase in the volume of
endolymphatic fluid (relative to the perilymphatic compartment) occurs in the pars
inferior portion of the membranous labyrinth. This portion includes cochlear duct
and saccule. In advanced stages of the disease the whole of the membranous
labyrinth can be involved. Cochlear hydrops was seen in all patients of Meniere's
disease and saccular hydrops was seen in most. Utricular hydrops was rarely seen.
12. 11 drtbalu’s Otolaryngology online
The degree of endolymphatic space expansion is highly variable. The endolymphatic
space bulged in the region of helicotrema in half of the cases, while saccule bulged
against the foot plate in 60% of cases, into a semicircular canal usually horizontal in
1/3 of cases.
Fibrous adhesions can form between the saccule and the undersurface of the
stapedial foot plate. This contact may explain Hennebert's sign (subjective vertigo,
tonic eye deviation and nystagmus observed during a pressure induced excursion of
the foot plate). It may also explain the "Tullio phenomenon" which is experienced
by some meniere's patients.
Diagram showing the membranous labyrinth
Anatomically, endolymphatic sac has two portions: Intraosseous and extraosseous.
The intraosseous portion of the endolymphatic sac is found within the bony walls of
vestibular aqueduct. Extraosseous portion of the sac is partially lodged in the
duramater of the posterior cranial fossa. Involvement of the sac starts initially at the
level of intraosseous portion since this area has very little space to expand.
Dix and Hallpike first proposed that dysfunction of endolymphatic sac as the
contributing factor for the development of Meniere's disease. They demonstrated
the absence of loose perisaccular connective tissue in these patients. Since this
concept of perisaccular fibrosis has been given importance by various authors sac
decompression and shunting procedures have been advocated as surgical modalities
of managing Meniere's disease.
13. 12 drtbalu’s Otolaryngology online
Altered glycoprotein metabolism:
Recently lot of interest has been focused on the altered glycoprotein metabolism as a
causative factor of Meniere's disease. Ikeda and Sando demonstrated significant
increase of intraluminal precipitate in the sac of patients with Meniere's disease.
Glycoproteins found inside the sac is secreted by its lining epithelium. These cells
have well developed rough endoplasmic reticulum indicating its secretary ability. It
has also been shown that accumulation of endolymphatic sac glycoproteins could
lead to dysregulation of inner ear fluid homeostasis.
14. 13 drtbalu’s Otolaryngology online
Diagrammatic representation of secretory apparatus of endolymphatic sac
The inner ear is devoid of lymphatics. The functions of lymphatics are performed by
endolymph circulating the membranous labyrinth. The endolymphatic sac has been
demonstrated to secrete proteins. These proteins have been classified into two
different classes i.e. immunoproteins and glycoproteins. The immunoproteins are
responsible for the immunodefence of the inner ear. The glycoproteins on the other
hand are very hydrophilic, and has been shown to suck out the contents of a cell
when applied on it. The glycoproteins within the sac can relocate water from the
perisac tissues to the interior of the sac causing an increase in the volume of
endolymphatic fluid generated.
Role of Saccin in the pathogenesis of endolymphatic hydrops:
15. 14 drtbalu’s Otolaryngology online
Qvortrup etal managed to isolate a natriuretic hormone (saccin) from the
endolymphatic sac. It has been demonstrated that this hormone increases the
amount of glycoproteins secreted by the endolymphatic sac lining epithelial cells.
Qvortrup even postulates that saccin could be the driving force for movement and
secretion of endolymphatic fluid.
Functions of endolymphatic sac:
Study of functions of endolymphatic sac will help us to understand the
pathophysiology of Meniere's disease. Basic functions of endolymphatic sac include:
1 Resorption of water content from endolymph
2. Participates in ionic exchange with endolymph
3. Removal of metabolic and cellular debris which includes otoconia
4. Secretions of glycoproteins to attract extra fluid
5. Secretion of Saccin to increase endolymph production
Endolymphatic fluid circulation:
Studies pertaining to flow of endolymph have postulated three types of flow: 1.
Radial flow and 2. Longitudinal flow, 3. Dynamic flow
Radial flow: In this type endolymph was postulated to be secreted and absorbed by
stria vascularis. In this type of flow the turn over of fluid was supposedly very slow.
Longitudinal flow: This theory postulates that endolymph as being actively secreted
and absorbed at the level of endolymphatic sac.
Dynamic flow theory: Lundquist combined both the theories of radial and
longitudinal flow to come out with a new dynamic flow theroy. He theorized that
functioning of endolymphatic sac can be explaine only be combining both these
theories. He concluded that ionic exchange occurred during radial flow, and
absorption of water content and removal of debris during longitudinal flow.
Endolymphatic flow from the apical region of the cochlea along the cochlear duct
and down to the endolymphatic sac appears to be effected osmotically. The
osmolality of endolymph gradually increases from the apex to the basal turn of the
cochlea. This osmotic gradiant is maintained by stria vascularis.
Role of endolymphatic sac in Meniere's disease:
16. 15 drtbalu’s Otolaryngology online
Endolymphatic drainage into the sac appears to be active rather than a passive
process. The osmotic gradiant within the cochlea is associated with glycoprotein
production within the endolymphatic sac . If the sac does not receive any endolymph
and becomes relatively dry, it starts to secrete saccin. Presence of saccin increases
the amount of endolymph in the cochlea promoting a faster longitudinal flow. It also
secretes glycoprotein to attract fluid osmotically.
Stages of Meniere's disease and their possible pathogenesis:
Any theory postulating the pathogenesis of Meniere's disease should be able to
explain the clinical stages of Meniere's disease, Lermoyez's syndrome and
Tumarkin attacks. It should also be able to explain the vertigo that occurs in
congenital syphilis and secondary endolymphatic hydrops.
In early stages of meniere's disease, attacks of vertigo commonly predominate.
Hearing is affected only transiently. During this stage the sac is said to be
functioning well and has the ability to completely clear the duct. Hydrops occurs
only briefly before each attack of vertigo and is completely cleared after each
episode.
In later stages of Meniere's disease, glycoprotein secretion causes some amount of
functional damage within the sac reducing its ability to reabsorb excess fluid.
During this stage there is persistent endolymphatic hydrops within the cochlea. The
attacks of vertigo presists in these patients and hearing also does not immediatly
improve since it is very difficult for all the excess fluid to drain through the
narrowed duct.
In some ears (Lermoyez's syndrome) cochlear function improves even during the
initial clearance of endolymph. These ears theoretically should have larger
vestibular aqueducts.
Burnt out stage (Late stage) the endolymphatic sac is no longer capable of clearing
the fluid. Once the duct is blocked completely, there can no longer be any acute
vertigo. In these patients continuing secretion of saccin will increase the hydrops
within the ear adversely affecting the patient's hearing.
Hydrops seen to start at the pars inferior portion
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Hydrops seen progressing. Silt is seen inside the sac
Empty sac senses it is empty and secretes glycoproteins and saccin
Fully developed hydrops
Predisposing factors for development of Meniere's disease:
1. Fibrosis of endolymphatic sac and vestibular epithelia
2. Altered glycoprotein metabolism
3. Inner ear viral infection
4. Tightly adherent dura in the region of endolymphatic sac
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5. Lack of periaqueductal pneumatization
6. Anterior / medial displacement of lateral sinus causing a reduction in the size of
Trautmann's triangle. This displacement also causes impediment to the venous
drainage locally resulting in a disruption of hydrodynamics of the region.
Currently accepted theory explaining the pathogenesis of Meniere’s disease is the
drainage theory.
Drainage theory:
This theory makes a sincere attempt to encompass all the previously mentioned
aspects of anatomy, physiology and pathophysiology.
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According to drainage theory the excess endolymph volume which is present in
endolymphatic hydrops accumulate in the apical end of cochlea, where the
membranes are more lax than elsewhere. When the situation is normal mild
increase in the volume of endolymph can be removed by radial fold whereas larger
increase in its volume needs an intact longitudinal flow for efficient removal. When
the excess volume of endolymph reaches the endolymphatic duct the sinus can
temporarily accommodate the excess volume which the sac is not prepared to
receive. This excess of fluid can usually be removed without causing any vestibular
disturbance as the endolymphatic valve of Bast isolates the pars superior and
prevents endolymphatic fluid draining out of the utricle. If the bony endolymphatic
duct is narrow / occluded by accumulation of debris, endolymph may build up
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excessively in the endolymphatic duct during the longitudinal flow. Overflow begins
to occur opening the valve of Bast so that endolymph enters the pars superior. This
excessive volume of endolymph entering the saccule distorts the crista in one
direction causing vertigo to occur. As the excess endolymph is cleared, the amount
of endolymph decreases and the stretched cristae reduces in size, thereby causing a
reversal in the direction of nystagmus. Progression of the disease decreases the
functionality of the sac due to damage to the cells lining the sac. During the late
stages of the disease, the valve of Bast remains patent and during the longitudinal
flow a sudden drainage of endolymph from the utricle causing drop attacks to occur
(Tumarkin’s crisis).
Endolymphatic fluid circulation
A clear understanding of circulation of endolymph will help us in understanding the
pathophysiology of Meniere's disease. Endolymph is predominantly derived from
striavascularis. The planum semilunatum and dark vestibular cells contribute a
small amount. Endolymph can also be produced as an ultrafiltrate from perilymph
fluid across the labyrinthine membranes.
Lawrence hypothesis of endolymphatic fluid circulation:
According to Lawrence endolymphatic fluid circulation is both radial and
longitudinal. Longitudinal flow starts with the production of endolymph in the stria
vascularis of the cochlea, circulation occurs in the scala media through the ductus
reuniensto the saccular duct, from where it proceeds into the vestibular labyrinth.
Elimination of endolymph occurs via circulation through the vestibular aqueduct
and onto the endolymphatic sac, where its absorption takes place. Radial flow
results from the production of endolymph in the dark vestibular cells and planum
semilunatum with local absorption. Lawrence also suggested that both longitudinal
(slow process) and radial (rapid process) circulations occur concurrently in a
subject. These circulations are subject to both hydrostatic and osmotic pressure
gradiants.
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Role of endolymphatic sac in the pathophysiology
of Meniere’s disease current concepts:
The role of endolymphatic sac in the pathophysiology of Meniere’s disease has been
extensively studied. Studies have shown that endolymphatic sac is lined by uneven
epithelium characterized by the presence of crypts and folds. These crypts and folds
tend to increase the surface area of the mucosal lining of the sac. Endolymphatic
sac contains a variety of ion transporters and aquaporins thus stressing its role in
the maintenance of the electrolyte composition of the endolymphatic sac.
Experiments have shown that the endolymphatic sac is highly sensitive to
endolymph volume manipulations. When the volume of endolymph increases the
concentration of luminal potassium increases and sodium concentration is
decreased. When the volume of endolymph is decreased luminal potassium
concentration is decreased and the luminal sodium concentration undergoes
corresponding increase. Endolymphatic sac is capable of bidirectional response
being capable of secretion and absorption of endolymph under necessitating
conditions.
Morphological studies have demonstrated that the appearance of the sac differs
between its two functional states.
Normal sac: Demonstrates a stainable homogenous substance could be seen filling
the distal regions of the sac lumen.
When the volume of endolymph increases the homogenous substance within the
lumen of the sac disappears, the dark cells present in the epithelium appears to be
activated and in some areas appear to cover the apical surfaces of light cells. This is
known as “veiling effect”.
When there is reduction in the volume of endolymph either by osmotic dehydration
or by endolymph withdrawal the luminal substance becomes darker and is present
throughout the lumen of the sac and in addition the light cells become enlarged and
activated.
How exactly the sac is able to perceive the volume changes in the endolymph has
been bothering us for nearly 150 years. Studies have failed to demonstrate the
presence of mechanoreceptor cell within the sac. The location of the sac is not
conducive to sensitive mechanoreception, as it is directly influenced CSF pressure
fluctuations and vascular pulsations of sigmoid sinus. Attempts to measure
intraluminal pressure within the sac have demonstrated it to be a noisy place due to
these pressure fluctuations. Hence detection of endolymphatic volume occurs not at
the level of endolymphatic sac but at the level of endolymphatic sinus. The
endolymphatic sinus is a small membranous bulb located where the endolymphatic
sac enters the vestibule.
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Schematic representation showing how endolymphatic sinus perceives changes in
the endolymphatic volume.
When the volume of endolymph is normal, pressure elevations in the vestibule
produce only small movements of endolymph into the sac before the endolymphatic
sinus membrane occludes the endolymphatic duct. On the contrary if the
endolymph volume is elevated and the sinus is dilated, a pressure elevation in the
vestibule results in larger volumes of endolymph forced into the sac before the duct
is occluded. This counteracts the increased volume of endolymph in the system.
Since the membrane constituting the endolymphatic sinus is highly compliant in
nature it would result in greater distention of the sinus. In this state positive
pressure applied to the vestibule would drive greater amounts of endolymph into the
sac before the flow gets occluded by the dilated endolymphatic sinus membrane.
Sources of pressure fluctuations in the inner ear fluids are numerous. For this to
occur there should be pressure differential between the CSF and the endolymphatic
fluid. Changes in CSF pressure occurs during:
1. Breathing
2. Heart beat
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3. Postural movements
4. Coughing
5. Sneezing
These changes in CSF pressure are faithfully transmitted to the endolymphatic
system via the cochlear aqueduct. If the volume of endolymph exceeds the capacity
of the sac to reabsorb then the endolymphatic sinus becomes over dilated and is not
in a position to function as a regulator of the volume of endolymph. This scenario
causes irreparable damage to the inner ear.
Clinical manifestations of Meniere's
disease
Clinical manifestations of Meniere's disease:
1. Episodic attacks of rotatory vertigo
2. Ipsilateral hearing loss
3. Aural fullness
4. Roaring tinnitus
Episodic vertigo: Is always associated with vegetative signs such as nausea and
vomiting. This is supposed to be the most debilitating symptom manifested by the
patient.
The vertigo begins all of a sudden in a otherwise normal individual. It is
accompanied by pallor, sweating, nausea, diarrhoea and vomiting. During the
attack the patient is fully consious, oriented in time and space. The patient suffers
no residual neurological symptoms after the attack is over. If there is diplopia then
it could be due to acute vertigo causing it. The general rule of the thumb is that
attacks of vertigo in Meniere's disease last somewhere between 24 minutes and 24
hours. The frequency of these attacks are also highly variable. Patients with severe
hydrops suffer attacks on a daily basis while others have long quiescent periods in
between attacks.
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After the acute phase is over, the symptoms gradually subside, and the patient
invariably falls asleep. Some patients may complain of dysequilibrium and motion
intolerance within the first 24 hours after the initial attack.
Meniere's disease variants:
In variants of menier's disease like Lermoyez syndrome the vertiginous episode is
preceded by increasing levels of tinnitus and hearing loss. Unlike in classic
Meniere's disease, the hearing loss and tinnitus dramatically resolve during or
shortly after the onset of vertigo.
In another variant of Meniere's disease like Tumarkin's crisis (Drop attacks)
sudden unexplained falls occur without vertigo or loss of consiousness. These
patients describe the sensation as being pushed, or thrown to the ground. Tumarkin
who first described this variant postulated that this could be caused due to acute
dysfunction of otolith organs. Sudden changes in the output of gravity reference
information from the otolith organs cause this condition.
Meyerhoff described another variant of Meniere's disease (abnormal
oculovestibular response). These patients experienced vertigo, with all its
accompanying vegetative symptoms like nausea when exposed to optokinetic stimuli
such as riding in a train or car. Most of these patients have aural fullness, tinnitus,
fluctuating hearing loss. Most of these patients had abnormal
electronystagmography.
Cochlear Meniere's disease is another variant. This disorder is characterised by
fluctuating hearing loss. There is no vertigo in this variant.
Nystagmus: These patients manifested nystagmus. To start with they had nystagmus
beating towards the affected side (irritative nystagmus). This lasts for 20 seconds.
After a short time the nystagmus changes it direction towards the healthy ear
(Paralytic nystagmus). Hours after the attack, the auditory and vestibular
symptoms subside, the nystagmus reverses again beating towards the affected ear
(recovery nystagmus). This recovery nystagmus may be horizontal, or rotatory.
Since rotatory nystagmus are not visible in ENG a careful observation of the eye
movements should be made in these patients. Recovery nystagmus may constitute an
important localizing sign in these patients.
These changing types of nystagmus can be accounted by the membrane rupture
theory of Meniere's disease pathophysiology. Developing hydrops cause distention
of the whole of the endolymphatic system causing the membrane to rupture. As soon
as the membrane ruptures, the perilymphatic potassium starts to rise initially. This
initially has an excitatory effect on the first order vestibular neurons causing
irritative nystagmus. There after the concentration of potassium keeps on increasing
casuing a blockade of action potentials at the level of these first order vestibular
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neurons causing paralytic nystagmus. This is seen within minutes of the attack. The
recovery nystagmus may be the result of vestibular adaptation.
Shea's symptomatic classification of Meniere's disease:
Stage I: The patient has solely cochlear symptoms
Stages II - IV:These patients have progressively more cochlear and vestibular
symptoms
Stage V: End stage Meniere's disease.
Hearing loss:
This is sensorineural in nature and is a cardinal feature of Meniere's disease. The
hearing loss is typically fluctuating and progressive. Hearing may infact flucutate
significantly during the early phases of the disease. The deafness is classically known
to involve lower frequencies as compared with s/n loss caused by noise exposure
which involves higher frequencies. End stage Meniere's disease is characterised by
profound sensorineural hearing loss.
Diplacusis is the common complaint in a majority of Meniere's disease patients.
Here the same frequency sound is perceived to be different by both the ears.
Tinnitus:
Tinnitus in a Menier's patient is highly variable. It is commonly roaring in nature.
It could infact be the first symptom of the attack. It could be continuous /
intermittent. It is invariably non pulsatile in nature. The pitch of the tinnitus usually
corresponds to the region of cochlea having the most severe hearing loss.
Aural fullness:
This is one of the most important symptoms of Meniere's disease. This is mostly
caused by enlarging membranous labyrinth. This pressure symptom is limited
usually to one ear.
Diagnostic criteria for Meniere's disease
Meniere's disease is diagnosed only with a high degree of suspicion. The following
are the pointers that could help in the diagnosis of Meniere's disease.
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Meniere's disease can be dignosed by:
1. Vertigo: Vertigo is spontaneous, lasting minutes to hours. It could be recurrent,
and if recurrent the patient must have atleast 2 episodes within 20 minutes. These
episodes should be accompanied by nystagmus.
2. Hearing loss: In frequencies (200, 500, 1000 Hz) 15 dB. Hearing loss is
sensorineural in nature covering the lower frequencies. When compared with the
other ear, it should be less by 25 dB in all the frequency ranges studied
audiometrically.
3. Tinnitus: Roaring in nature
4. Aural fullness.
Criteria for diagnosis of Meniere's disease:
Possible Meniere's disease:
1. Episodic vertigo of Meniere's type without documented hearing loss
2. Fluctuating hearing loss with dysequilibrium but without definite episodes
Probable Meniere's disease:
1. One definitive episode of vertigo
2. Audiometrically documented hearing loss atleast on one occasion
3. Tinnitus / aural fullness in the treated ear
Definite Meniere's disease:
1. Two or more definitive episodes of spontaneous vertigo one atleast lasting for 20
minutes
2. Audiometrically documented hearing loss atleast on one occasion
3. Tinnitus and aural fullness in the treated ear.
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Department of otolaryngology University Hospital Groningen evolved the following
definition of Meniere's disease:
- A sensorineural (cochlear) hearing loss combined with
- Tinnitus present now or in the past and
- Vertigo attacks (atleast two, present now or in the past) and
- Exclusion of other pathology following Groningen protocol
Hearing loss: Groningen criteria lays down that hearing loss when present should
be sensorineural in nature. The conductive component should be absent and this
fact should be proved by a puretone audiogram and impedence audiometry.
Sensorineural loss being defined as hearing loss of 20 dB or worse at one of the 6
measured thresholds (0.25 KHz, 0.5 KHz, 1 KHz, 2 KHz, 4 KHz, and 8 KHz) ranges.
Vertigo: Is characterized by paroxysmal attacks of dizziness with a sense of
rotation. These attacks are usually accompanied by nausea and vomiting. At least
two epizodes of vertigo / dizziness should be reported by the patient during the
course of the illness. One of the attacks should have lasted for more than 5 minutes.
Inbetween these attacks there may be associated periods of unsteadiness.
Affected / Unaffected ears: When sensorineural deafness and h/o tinnitus is present
in an ear then the ear is considered to be affected by Meniere's disease. It is not
required that all three finding should be present at the time of investigation. But
deafness should be present at the time of investigation to consider the ear to be an
affected one. When sensori neural hearing loss and tinnitus is absent then the ear is
considered to be unaffected.
Modern definition of Meniere’s disease in its diagnosis helps in:
1. Guiding the optimal treatment modality
2. To ascertain the prognosis of the disease
Currently 2 critical feature of Meniere’s disease have been used to identify whether
the patient is suffering from Meniere’s disease or not. These features include
instability of hearing and balance and involvement of both these system. The old
nomenclature cochlear and vestibular Meniere has been abandoned since 1985. The
pattern of involvement can range between auditory dominant and vestibular
dominant symptoms.
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Investigations
Audiological assessment: It is very important to assess cochlear function in a patient
with Meniere's disease. Cochlear function can easily be assessed by pure tone
audiometry. Patients with meniere's diseased usually manifest with a flat
audiometry curve. Most of these patients have low frequency sensori neural hearing
loss.
Audiogram showing low frequency s/n loss
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Other pure tone audiometric features seen in Meniere's disease include:
1. Peaked pattern
2. Downward sloping pattern
Serial audiometry performed over a period of time may demonstrate fluctuating
hearing loss. Fluctuations are often seen in the frequency range between 250 - 1000
Hz. Special audiometric tests needs to be performed to ascertain whether the
hearing loss is a cochlear or hair cell related disease. Presence of recruitment can be
demonstrated by alternate binaural loudness balance test in unilateral disease, or
SISI test in unilateral / bilateral disorders.
Stapedius reflex tresholds: Are within normal limits in these patients.
Speech discrimination thresholds: Closely resemble pure tone thresholds in most
patients. Poor speech discrimination out of proportion to the pure tone thresholds
should arouse suspicion of retro cochlear lesion. The phenomenon known as' roll
over' a marked decrease in discrimination is seen in retrocochlear lesions.
Evoked response audiometry:
Evoked response audiometry has been found to be instrumental in the diagnosis of
Meniere's disease. This test determines the electrial activity occurring in the cochlea
and central auditory pathways in response to sound stimuli.
Electrocochleography: Belongs to the battery of tests under evoked response
audiometry. It evaluates the evoked potential activity of the cochlea and 8th cranial
nerve. Electrocochleography is the best existing objective test for Meniere' s disease.
This test measures the electrical events generated either within the cochlea or by
primary afferent neurons. The recorded potentials include: Cochlear microphonic
potential and summating potential from cochlea, and the whole nerve action
potential from the cochlear division of 8th nerve.
Cochlear microphonics is an alternating current, the polarity of which is identical to
that of the auditory stimulus. It is infact thought to be the sum of the individual hair
cell intracellular potentials. Most of the cochlear microphonic potential is produced
by outer hair cells within the first few millimeters of the basal turn of cochlea. In
patients with Meniere's disease these cochlear microphonic potentials are small and
distorted. In some patients a marked 'after ringing' (a sinusoidal wave) of the
cochlear microphonic is seen.
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Cochlear microphonic recording from a patient with Meniere's disease
Summating potential: This potential is of short latency (0.3 msec) and is usually
present at high stinulus intensities. It is actually a DC shift from the base line of
response, generally in a negative direction. This potential occurs for the entire
duration of the stimulus. Major component of summating potential is derived from
the asymmetry in the vibration induced deflection of the basilar membrane. In
normal ears, at high stimulus intensities, the basilar membrane vibrates more
upwards towards the scala media than down wards generating a negative
summating potential. Endolymphatic hydrops accentuates this asymmetry by
stretching and stiffening the basilar membrane, limiting its downward vibration.
This mechanical deformtiy of the basilar membrane is greatest at its basal end and
this is the region where the majority of summating potentials are generated from.
The normal upgowing asymmetry is enhanced, leading to a negative summating
potential of increased amplitude and width.
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Normal summating potential
Evoked action potential: This is a compound action potential representing the
synchronous firing of multiple cochlear neurons derived mainly from the basal turn
of the cochlea. A click stimulus because of its faster rise time, will stimualte more of
the basilar membrane than frequency specific tone bursts.
In Meniere's disease, the common findings on electrocochleography include:
1. Increased summating potential and action potential ratio: A summating potential
/action potential ratio of up to 1:3 is within normal range, a higher ratio is
suggestive of hydrops.
2. Widened summating potential and action potential complex: The normal width of
the summating potential / action potential complex is 1.2 - 1.8 ms and a widening of
greater than 2ms is usually significant.
3. Small distorted cochlear microphonic.
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Glycerol dehydration test:
This test was originally introduced by Klockhoff and Lindblom in 1966. The drug
initially used to cause dehydration was chlorthalidone which promoted sodium
excretion without appreciable potassium loss. Pure tone audiometry was performed
before and after the administration of the diuretic. A rise in threshold of atleast
10dB in three consecutive octave bands were considered diagnostic of Meniere's
disease. This test became sensitive when it was combined with transtympanic
electrocochleography. Glycerol was later substituted for chlorthalidone. During
glycerol dehydration the marked negative summating potential is seen to decrease.
Positive result to glycerol testing can occur if the patient has a fluctuating hearing
loss due to endolymphatic hydrops. Glycerol is administered orally in doses of 1.5
mg /kg body weight in the fasting state, and the test can only be considered positive
only if there is an increase in serum osmolality of atleast 10 mOs/kg to verify the
effectiveness of the dehydration process. After one hour the amplitude of the action
potential appeared to diminish by 12%.
Side effects of glycerol administration:
1. Headache
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2. Nausea / vomiting
3. Drowsiness
EcocG performed before and after glycerol administration
Glycerol can also be adminsitered parenterally to shorten the duration of the test.
Intravenous administration is performed using 200 ml of 10% glycerol solution.
Acelazolamide test:
This is also another one of the dehydration tests used in the diagnosis of Meniere's
disease. This drug is carbonic anhdrase inhibitor. It has been used to increase the
cochlear hydrops. This test is hence also known as "reverse glycerol test".
Azetazolamide 500 mg in aqueous is injected intravenously over one minute, and
electro cochleogram is recorded continuously for 45 minutes. Pure tone audiometry
and speech audiometry are also performed. Ecocg showed an enhanced negative
summating potential within 10 - 15 minutes of drug infusion, reversing towards the
pre-infusion base line level and 45 - 60 minutes. No change was seen in normal
individuals or in those with other cochleo vestibular pathologies. This test is useful
in patients who have intense vomiting when glycerol is adminsitered.
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Ecocg recording before / after acetazolamide injection
It must be accepted there is currently no test is available which could diagnose
Meniere's disease 100% of the time. The tests described above can at best be
considered presumptive.
Caloric test:
This demonstrated directional preponderance, labyrinthine weakness, or
labyrinthin asymmetry. This test should atmost be considered as a nonspecific test.
This test infact probes the functioning of the lateral semicircular canal ignoring the
other portions of the labyrinth which are commonly involved in Meniere's disease.
The sensitivity of caloric test may also be somewhat compromised by central
compensatory mechanisms. Caloric test in patients with Meniere's disease will show
a loss only when the amount of loss is too high to be compensated by central
mechanisms. In caloric tests the stimulus used is low frequency in nature.
VEMP:
Vestibular evoked myogenic potentials are believed to be generated by sacculo
collic reflex. In this reflex the afferent limb of the reflex pathway is caused by
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stimulation of acoustic sensitive cells in the saccule that responds to loud, brief
monaural stimuli which stimulates the inferior vestibular nerve. The efferent limb
terminates in the fibers of sternomastoid muscle causing it to contract. Myographic
recordings from sternomastoid muscle in response to stimulation of the saccule
reflect saccular function. The greatest sensitivity to VEMP occurs in the frequency
range of 200 – 1000 Hz. Since Meniere’s disease is associated with cochleo saccular
hydrops presence of VEMP reflexes indicate the saccular function. VEMP
responses in individuals with Meniere’s disease show altered frequency tuning, such
that the greatest sensitivity of the sacculocollic reflex seems to occur at higher
frequencies and across broader frequency ranges compared with normal subjects
Differential diagnosis of Meniere's disease
The diagnosis of Meniere's is by exclusion. There are many disorders that could
mimic this condition. Before considering the differential diagnosis the variants of
Meneire's disease should be excluded.
Various differential diagnosis of Meniere's include:
Central causes:
1. Acoustic neuroma
2. Multiple sclerosis
3. Vascular loop compression syndrome
4. Aneurysm
5. Arnold chiari malformation
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6. Brain stem tumors
7. Cervical vertigo
8. TIA
Peripheral causes:
1. BPPV
2. Labyrinthitis
3. Autoimmune ear disease
4. Perilymph fistula
5. Otosclerosis
6. Migraine induced vertigo
Metabolic causes:
1. Diabetes
2. Hyper / Hypothyroidism
3. Syphilis
4. Cogan's syndrome
5. Anemia
6. Autoimmune disorders
It is very easy to make the diagnosis when all the four classic features of Meniere's
disease is present in a patient. Unfortunately it is usually not the case. Many
variants of Meniere’s should be considered.
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Medical management
Medical management of Meniere's disease includes:
1. Dietary management
2. Physiotherapy
3. Psychological support
4. Pharmacologic intervention
Dietary management:
This includes reduction of sodium in the diet. Infact it was Frustenberg in 1934 who
introduced a low salt diet for patients with Meniere's disease. Pathophysiology of
Meniere's disease is enlargement of membranous labyrinth due to excess
accumualtion of endolymphatic fluid. Any attempt to reduce this fluid level will help
in alleviate the symptoms of the patient.
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Medical managment is mainly used to treat patients during the acute phase of the
attack. Vestibular suppresants are commonly used. Drugs used to control attacks of
vertigo have varying levels of anticholinergic, antiemetic and sedative properties.
Drugs used to alleviate symptoms include phenothiazines (prochlorpherazineand
perphenazine), antihistamines like ( cinnarizine, cyclizine, dimenhydrinate, and
meclizine hydrochloride), benzodiazepines like (lorazepam and diazepam).
Vestibular suppressants:
Diazepam: when used acts as vestibular depressant. It also alleviates the anxiety
associated with this disorder. The beneficial effects of diazepam ib vestibular system
is presumed to be due to an increase in the cerebellar GABA-ergic system.
Stimulation of cerebellar GABA-ergic system mediates inhibition on the vestibular
response. This drug is very useful in alleviating vertigo especially when associated
with anxiety. Usual dose is 5 mg administered orally every 3 hours. The initial dose
may also be administered intravenously.
Antiemetic drugs:
Drugs belonging to this group helps to alleviate vomiting in Meniere's disease.
Anticholinergic drugs:
Glycopyrrolate an anticholinergic drug when combined with diazepam is helpful in
controlling inner ear symptoms of nausea and vomiting. In adults it is administered
in doses of 1-2 mg. It may also be administered as intramuscular injection (0.1 - 0.2
mg) every 4 hours. Side effects (reversible) of this drug includes dry mouth,
distortion of visual acuity, exacerbation of symptoms in patients with prostatic
hypertrophy. This drug is contraindicated in patients with glaucoma and prostatic
hypertrophy.
Antidopaminergic drugs:
Droperidol: This is an antidopaminergic drug used to alleviate the symptoms of
Meniere's disease. This drug is aministered in doses of 2.5 - 10 mg orally in adults. If
administered intravenously it is given as 5 mg bolus. This drug has fewer incidence
of side effects like extrapyramidal symptoms / sedation / hypotension.
Prochlorperazine: This drug belongs to phenothiazine group. It is used as an
antiemetic and a potentiator of analgesic and hypnotic drugs. Usual recommeded
dose is 10 mg given orally or intramuscularly every 4 - 6 hours in adults. This drug
has excellent antiemitic effect.
Antihistamines:
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Dimenhydrinate: is useful in preventing and treating vertigo associated with
Meniere's disease. It is also very effective in controlling nausea and vomiting. Only
side effect of this drug is its propensity to cause drowsiness. It is administered as 50 -
100 mg doses thrice a day. This drug can also be adminsitered intramuscularly /
intravenously.
Diphenhydramine: This drug is not useful in treating acute vertigo. It may be useful
in prevention of vertigo. The usual duration of action is 4-6 hours. Usually this drug
is administered as an initial loading dose of 50 mg orally.
Meclizine: This drug is one of the most useful antiemetics to prevent / treat nausea
and vomiting assocaited with vertigo of vestibular origin. It has a slower onset and a
longer duration of action (24 hours). For vertigo the usual dose administered in
adults is 25 - 100 mg daily in divided doses. Side effects of this drug include:
drowsiness, blurred vision, drowsiness.
Promethazine: This drug has pronounced antihistaminic activity in addition to its
strong central cholinergic blocking activity. It is effective in the treatment of vertigo
and motion sickness. It is adminsitered usually in doses of 25 mg every 4 to 6 hours.
One major advantage of this drug is that it can be adminsitered rectally, when
severe vomiting prevents its effective oral administration. Most common side effect
of this drug is sedation.
Maintenance therapy:
The goal of maintenance therapy is
1. To prevent acute attacks of vertigo
2. To maintain hearing in Meniere's disease
This therapy usually includes dietary modifications combined with pharmacological
intervention.
Dietary modifications: The mainstay of diet modifications is to reduce sodium
intake. A very low sodium intake or low sodium diet is usually recommended. A
strict low sodium diet means a daily allowance of 1500 mg. This is a very stringent
diet and patients find it very difficult to comply with this diet. A more practical
approach would be to advise the patient to avoid excessively salty food. Restrictions
are also imposed on the intake of caffeine, nicotine and alcohol.
Diuretics:
The use of diuretics in the maintenance therapy is based on the supposition that
these drugs can alter the fluid balance of inner ear, leading to a depletion of
endolymph and a correction of hydrops. In 1934 Furstenburg demonstrated that the
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symptoms of Meniere's disease were due to retention of sodium. He went on to
recommend a low sodium diet / use of diuretics to control Meniere's disease. Boles in
1975 demonstrated that most patients had their vertigo controlled with an 800 -
1000 mg of sodium diet / day.
Hydrochlorthiazide: This diuretic causes natriuresis and kaliuresis by blocking
sodium reabsorption in the loop of Henle. Potassium supplementation is required in
patients using this drug. Side effects of this drug include: hypokalemia,
hyperglycemia, hypotension, and hyperuricemia. It is usually adminstered as 50 mg
tabs orally / day in adults. Potassium supplements is usually required in these
patients.
Dyazide: Is a potassium sparing diuretic. It can be convenietly administered as a
single daily dose.
Frusemide: This is a loop diuretic. It is a very potent diuretic. It can cause
electrolyte and volume depletion more rapidly than other diuretics. It usually causes
hypokalemia. Usual adult dose is 10 - 80 mg/day. The duration of action lasts for
about 4 hours.
Amiloride: This is a potassium sparing diuretic acting on the distal tube of Henle.
Its diuretic potency is highly limited. It is usually used in combination with other
diuretics in order to minimize potassium loss.
Carbonic anhydrase inhibitors:
Acetazolamide: Is a carbonic anhydrase inhibitor. It causes a decrease in the sodium
- hydrogen exchange in the renal tubule inducing diuresis.
Methazolamied: Is another carbonic anhydrase inhibitor shown to be effective in
controlling symptoms of Meniere's disease. This drug is usually administered in
doses of 50 mg / day, 5 days a week for 3 months.
Medical ablative therapy:
Aminoglycosides: Ototoxic effects of aminoglycosides are well documented.
Streptomycin and gentamycin are predominantly vestibulotoxic. Intramuscular
injections of streptomycin administered twice daily for periods of days to weeks
have been used in patients with debilitating bilateral disease / unilateral disease in
the only hearing ear. Complete ablation causes disabling oscillopsia. Many authors
have suggested lower doses and fewer injections to achieve partial ablation, thereby
reducing the incidence of severe ataxia. Currently the recommended daily dose is 1
g of streptomycin intramuscularly 5 days a week until vestibular ablation occurs as
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manifested by absence of ice water caloric test. Intratympanic injections of these
drugs have also been used with success.
Vasodilators:
The use of vasodilators is based on the idea that Meniere's disease results from
ischemia of the stria vascularis. Betahistine has been used with varying degrees of
success. This drug can be used for short term control of vertigo and for maintenance
therapy.
Nicotinic acid is another vasodilator which when administered 30 minutes before
meals in doses of 50 - 400 mg helps in resolving the acute crisis associated with
Meniere's disease.
Calcium channel blockers:
Nimodepine a highly lipophilic drug is very useful in the medical management of
Menierie's disease. It readily crosses the blood brain barrier. This drug is useful in
patients who have failed diuretic medical therapy.
ACE inhibitors:
These are very effective vasodilators. These drugs block the rening angiotensin
aldosterone system. They produce vasodilatation by blocking angiotensin II induced
vasoconstriction.
Lipoflavins and vitamins:
Combination of lipoflavins and vitamins have been tried as a managment modality
with varying degrees of success.
Restricting tea and coffee intake to once daily will help these patients in reducing
endolymphatic fluid volume. Ingestion of excessive amounts of caffeine and alcohol
cause enormous fluid shifts in the physiological fluid compartments.
Middle ear effusion of dexamethasone
and streptomycin
There is a common conception that Meniere's disease could be an immune mediated
disorder. Dexamethasone injection hence is supposed to play an important role in
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the management of this disorder. Dexamethasone in the normal course does not
cross the blood labyrinth barrier in significant quantities. Perfusion around round
window membrane is a must for adequate doses of dexamethasone to reach the
inner ear in significant quantities.
Technique of injection: The ear drum is anesthetised with a topical anesthetic cream
( 2.5% xylocaine and 2.5% prilocaine). Two holes are made in the inferior quadrant
of the ear drum either with a myringotome / argon laser. Care is taken to make one
of the openings in the area corresponding to the round window niche. This opening
should be large enough to remove any adhesions that could block access to the
round window membrane. Approximately 0.5 cc of hyaluron, containing 16 mg of
dexamethasone / ml is injected into the round window niche filling the middle ear
cavity. The patient is made to remain lying with the perfused ear up for 3 hours.
This injection is repeated during the course of next two days. After three perfusions
the ear drum holes are covered with a moist gelfoam. The patient also should
receive concurrent doses of 0.25 mg of dexamethasone by mouth for atleast a month.
If dexamethasone perfusion proves ineffective then streptomycin is combined with
it. About 120 mg of streptomycin / ml of hyaluron plus 16 mg of dexamethasone for
intratympanic medication protocol. This protocol is also continued for 3 days
consequtively.
Intratympanic injections of gentamycin has also been tried out with varying degrees
of success. This drug is preferred because of its greater degree of vestibular
selectivity.
Drug delivery modalities include:
1. Intratympanic injections
2. Gelfoam delivery
3. Silverstein micro wick (This wick is inserted in the the middle ear cavity via a
myringotomy opening). This wick is expected to tranmit the medication
administered in the external auditory canal into the middle ear cavity.
4. Microcatheter delivery for continuous infusion of gentamycin
Surgical Management
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Surgical management of Meniere's disease is reserved for those patients who fail to
respond to conservative medical management. They constitue 10 - 20% of the over
all number.
Surgical therapy in the managment of Meniere's disease has a long history.
1. In 1877 Gowers reported that simple blistering behind the ear caused a marked
reduction in the vertigo in patients with Meniere's disease.
2. Babinski in 1903 proposed lumbar puncture as a management modality in
treatment of Meniere's disease.
3. Crockett in 1903 removed stapes as a treatment modality of Meniere's disease
4. Lake in 1905 described labyrinthectomy as treatment of vertigo associated with
Meniere's disease
5. Parry first performed the first intracranial 8th nerve section to treat Meniere's
disease via middle cranial fossa approach
6. In 1907 T.W. Parry described the use of Seton to treat Meniere's disease. Seton is
a thread / tape placed in a subcutaneous tract fashioned over the nape of a neck on
the side of the affected ear.
7. Cervical sympathectomy was performed as a treatment modality by Seymour
Surgical procedures can be classified as:
1. Procedures involving hearing / vestibular preservation
2. Procedures involving hearing preservation and vestibular ablation
3. Procedures involving ablation of 8th nerve
4. Procedures involving chemical ablation of the vestibular end organ
5. Procedures involving non chemical ablation of the vestibular end organ
6. Procedures involving hearing and vestibular ablation
Procedures involving hearing and vestibular function:
Surgeries described under this head attempts to reverse the pathology involved in
the hydrops and restores normal endolymphatic volume and pressure.
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These include endolymphatic sac procedures, Cody's surgery and Fick
cochleosacculotomies.
Procedures on endolymphatic sac:
In 1926, Portmann performed the first surgery on the endolymphatic sac
decompression to treat Meniere's disease.
Endolymphatic sac enhancement: This procedure involves just exposing the
endolymphatic sac and duct. Patient's symptoms improve by this simple surgical
procedure. The effectiveness of this procedure can be accounted by increased blood
supply to the periductal tissues surrounding the sac. This increased blood supply
flushes out endolymph and debris from the sac reducing its volume.
Endolymphatic sac decompression:
Portmann's operation is otherwise known as endolymphatic sac decompression.
This procedure involved opening the sac. Drainage of endolymph from the sac
drains into the subarachnoid space. Shambough advocated wide decompression of
the sac by removing the bone overlying it and the adjacent posterior fossa dura.
Shea inserted a teflon film through the opening in the sac to keep it patent.
Extended mastoidectomy is performed. Care is taken to skeletonize posterior fossa
dura, sigmoid sinus and posterior semicircular canal. The endolymphatic sac is
distinguished from the posterior fossa dura by differences in its color and texture.
The sac looks whiter and thicker than the surrounding dura. Anatomical landmark
for location of the sac is Donaldson's line. This is an imaginary line passing from the
centre of the horizontal canal cutting through the posterior canal. The sac usually
lies below this line.
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Figure showing the position of the sac
Lateral leaf of the sac can be incised. Teflon shunts can be inserted to keep the
fistula patent.
One way Arenberg valve can also be introduced in place of teflon shunts.
This surgical procedure is safe. Hearing and balance mechanisms are preserved.
Critics of this procedure question the ability of low volume low pressure sytem to
decompress through the fistula created. Proponents of this surgical procedure say
that it works by producing surgical trauma which causes an increase in blood flow.
This increased blood flow clears the sac from debris and excess endolymph.
Cody's tack procedure:
This procedure again is designed to create a fistula in the saccule via the oval
window in the hope of decompressing the sac. In this procedure a sharp tack is
placed through the membranous attachments of the foot plate. This tack will
perforate the saccule when it starts to enlarge during acute phase of Meniere's
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disease causing it to drain its secretions thus decompressing it. This surgical
procedure has been abandoned because of its inconstent results.
Figure showing Cody's procedure
Non chemical ablation of vestibular end organ:
Ultrasonic radiation when applied to the labyrinth ablates the vestibular function
while preserving hearing. Ultrasound energy is applied to the inner ear must be
applied by placing the probe over the thinned out portion of the lateral canal or on
the round window. When ultrasonic probe is applied to the thinned out lateral canal
wall, is associated with irritative nystagmus for the first half hour, then there is a
period of no nystagmus. This is followed by paralytic nystagmus.
Vestibular ablation could also be performed by using a cryoprobe. The cryoprobe is
cooled to -160 degrees centigrade and is applied to the lateral canal which has been
exposed after mastoidectomy. Cryo probe is applied for three cycles of 2 minutes
each. These procedures have not found favour because of the high incidence of
recurrent vertigo.
Ablation of 8th nerve:
In 1904 R.H. Perry performed the first 8th nerve division for persistant aural
vertigo. In 1928 Dandy used suboccipital approach to section the 8th nerve.
Mckenzie in 1936 popularized selective sectioning of the vestibular component of
8th nerve. He also showed that by selectively sectioning the vestibular component
vertigo could be controlled with excellent preservation of hearing. House in 1961
exposed the internal acoustic meatus through middle cranial fossa. He sectioned the
nerve medial to scarpa's ganglion. Sectioning of the nerve medial to the ganglion
reduces the incidence of neuroma formation.
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Fisch in 1984 proposed a variation of middle fossa approach called the
transtemporal supralabyrinthine approach. This procedure involves removal of the
root of the zygoma and roof of epitympanum, inaddition to as much bone as possible
from above the labyrinth itself. This approach provides better exposure to the
internal acoustic meatus, with minimal degree of temporal lobe retraction.
Labyrinthectomy:
This procedure is a highly destructive surgery. It is used in patients with Meniere's
disease associated with severe degree of hearing loss. The labyrinth is exposed after
performing mastoidectomy. All the three semicircular canals are drilled out
exposing the membranous labyrinth. The membranous labyrinth can be opened up
and its inner contents sucked out using suction.
Vibrator therapy
Vibrator therapy has been approved by FDA as a treatment modality for Menierie's
disease. Vibrations are produced by Meniett Device. This device is a low pressure
pulse generator whose vibrations are used as a treatment modality for Meniere's
disease.
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Meniett device
Major advantages of this treatment modality are:
1. Non destructive
2. Non invasive
3. Safe
4. Portable
5. Does not require post therapy rehabilitation
The ear plug of the Meniett device is used to plug the external auditory canal. The
device then performs a leakage test to ascertain whether the external canal has been
sealed properly by the ear plug. Once the leakage test is performed and no leakage
has been detected, the device will transmit the vibrations through the external
auditory canal. Patient must undergo grommet insertion prior to this treatment.
The vibrations of the devise gets transmitted to the middle ear cavity through the
ventilation tube. These vibrations then influence the inner ear fluid mechanism via
oval and round windows.
The actual mechanism of this vibrator therapy is still unknown. One possible theory
is that vibrations reaching the membranous labyrinth agitates and pushes
endolymph out of the endolymphatic sac.
Treatment plan:
1. Patient should be confirmed of having Meniere's disease
2. Ventilation tube should be inserted prior to treatment
3. Initially patient undergoes training to use the device
4. The treatment is self administered by the patient.
4. It is adminstered thrice a day, 5 minutes each time
5. The treatment schedule is continued for 5 weeks
Who should receive vibrator therapy?
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1. Classic unilateral Meniere's disease
2. Intense vestibular and cochlear symptoms
3. Failed medical therapy
4. Bilateral Meniere's disease
5. Over 65 years of age
6. Imbalance, aural fullness and tinnitus after gentamicin treatment
Contraindications for vibrator therapy:
1. Perilymph fistula
2. Acoustic neuroma / brain tumor
3. Retrocochlear damage
4. Low pressure hydrocephalus