This document discusses Meniere's disease, a disorder of the inner ear that causes spontaneous episodes of vertigo, hearing loss, and tinnitus. It outlines the potential causes, clinical features, diagnostic tests, treatment options including medications, intratympanic injections, and surgical procedures like endolymphatic sac decompression or vestibular nerve sectioning. Surgical intervention is considered for patients with severe, treatment-resistant vertigo. The goal of treatment is to control vertigo attacks while preserving hearing if possible.

1. MENIERE’S DISEASE
DR ZEESHANALI

2. Pathology

3. Etiology

4. Theories
 Increase productions due to mediators
 Decrease absorption by endolymphatic sac
 Particle obstruction theory (glycoproteins)
 Narrow endolymphatic duct

5. Clinical features
 35-60 years
 Male>female
 Unilateral (later bilateral 10-40%)
 Vertigo (episodic,sudden,20min -20hrs,vagal
symptoms)
 Tullio phenomenun
 Hearing loss (fluctuating
SNHL,Diplacusis,recruitment)

6. Clinical features
 Tinnitus (low pitch roaring, change in pitch
and loudness near attack)
 Aural fullness (episodic)

7. Examination
 Otoscopy --- normal
 Nystagmus (episodic)
 fast unaffected ear
 Tunning fork ---SNHL

8. Investigations
 PTA

9. Investigation
 Recruitment test --- positive
 SISI --- > 70% (normal 15%)
 Tone decay test --- < 20dB (normal 0-15dB)

10. Investigation
 Electrocochleography
 SP/AP ratio > 30%
 Caloric test
 Reduced response on affected
side
 Glycerol test
 1.5 ml/kg flavoured diluted glycerol ..PTA done after 1-
2 hrs …10dB gain on PTA…10% gain SDT … improve
ECoG

11. Investigation
 Electronystagmography
 VEMP
 BERA
 CT scan (normal aperture 6mm but in meniere 2mm)
 MRI (rule out CP angle lesions)

14. Varients
 Cochlear hydrops
 Vestibular hydrops
 Tumarkins otolithic crisis
 Lermoyez syndrome(reverse)

15. Meniere’s synd (secondary)
 Trauma
 Viral
 Syphilis
 Cogan’s synd (autoimmune ;eye symptoms
along vestibular cochlear symptoms)
 Otosclerosis,stapectomy
 Autoimmune
 Tumour (acoustic neuroma)

16. Closest differential
‘Vertiginous migraine’
Aura
Headache
Relieved by sleep
Precipitated by stimulus

17. Diagnosis AAOHNS
 CERTAIN --- histo
 DEFINITE --- 2 episodes + PTA(finding 1 time)
+ tinnitus + aural fullness
 PROBABLE--- 1 episode + rest same
 POSSIBLE --- variants – other causes ruled
out

18. Treatment (prophylaxis)
 Reassurance
 Cessate smoking
 No added salt diet
 Avoid excess water
 Avoid coffee,tea,alcohol
 Avoid stress
 Restrict risky activities

19. Treatment (acute/abortive)
 Reassurance
 Bed rest
 Vest sedatives
 Diazepam
 Atropine s/c 0.4mg
 CARBOGEN (MEDUNA MIXTURE)
 HISTAMINE DIPHOSPHATE 2.75mg in 500ml
glucose

20. Treatment (chronic)
 Vest sedative
 Nicotinic acid 50 mg xTDS (titerate till
flushing)
 Betahistine 8-16mg xTDS
 Lasix 40 mg alternate day
 Treat allergy
 Hormonal cause(thyroid)

21. CHEMICAL LABYRINTHECTOMY

22. AMINOGLYCOSIDES
 Amikacin,dihydrostreptomycin,kanamycin ---
cochleotoxic
 Gentacin ,streptomycin(low doses)---
vestibulotoxic

23. Mechanism
 Destroy dark cells responsible for producing
endolymph
 Produce free radicles within the cells
 Disrupt DNA and proteins

24. Patient counsel
 Hearing loss
 Rash
 Fever
 Perioral numbness
 OSCILLOPSIA
 Renal toxicity
 Allergic reaction
 Warn about transient treatment related HL

25. Methods
 Intramuscular (treat bilateral disease)
 Intratympanic (unilateral disease)

26. Intramuscular gentamycin
 1 gm x BD 5 days
 Test for vestibulocochlear functions
 Repeat same dose if requierd
 STOP when!
 Vertigo stops
 Worsens
 Decrease caloric response
 Decrease hearing

27. Intratympanic gentamycin
 Gentacin 30mg/dl PH 6.4 x BD for 5 days or
stop at appearance of symptoms
Taped to side of neck

28. Low dose gentamycin in OPD
 40mg/dl 0.2-0.5 ml via insulin syringe
 30 minutes wait in position / no swallowing
 Seen after 7 days and evaluated

29. Conservative procedures
 Decompression of duct
 Endolymphatic shunt
 Sacculotomy (Ficks operation)….Cody tack
 Cochleosacculotomy(otic –periotic shunt)
 Meniett device therapy

30. DECOMPRESSION /SHUNT OP

31. operculum

33. Selection criteria
 Failed medical treatment
 Debilitating vertigo
 For both primary and secondary meniere
 Improvement in 76-95%
 Hearing preserving ---cochlear implantation can be
done
 Donot operate in meniere variants!

40. complications
 Rare
 2% SNHL worsens
 10-20% symptoms persists

41. COCHLEOSACCULOTOMY

42. Selection criteria
 Severe vertigo
 Tumarkin crisis
 BEST for Old patients unable to tolerate GA
 EASYTO PERFORM
 ALMOST FREE FROM MORBIDITY
 NO POST OPERATIVEVERTIGO
 Hearing preserving

45. Sometime drill lip

46. Hug the lateral wall
Feeling of give way

48. complications
 Similar to stapedectomy

49. MENIETT DEVICE THERAPY

50. MENIETT DEVICE THERAPY

51. Destructive procedures
 Section of vestibular nerve
 Ultrasonic destruction of vestibular labyrinth
 Labyrinthectomy

52. DEAFFERENTATION

53. TYPES
 Translabyrinthine vestibular neurectomy
 Retrolabyrinthine
 Retrosigmoidal

54. Counsel patient!!!
 Meniere’s disease can remit spontaneously in
70% within 08 years!!
 10-40% chance of involvement of second
ear!!
 Tinnitus may or may not resolve after
surgery!!

55. Why do it?
 Destroying the end organ can lead to better
and early compensation by the brain
 Breaking the connection between the
preganglionic and postganglionic fibres leads
to better takeover by the brain as it consider
it as a complete lesion

56. In whom to do it?
 Failed /exhausted medical and conservative
approaches for 1 year
 Vertigo severe and debilitating
 Dead ear
 Having NON SERVICEABLE HEARING
 > 50 db HL pure tone av
 SRT < 50%

57. What is the trade off?
 Taking away the intolerable vertigo and
giving tolerable feeling of imbalance or
motion tolerance in sensory deprived
situations like darkness or walking on cushion
 Younger the patient better the tolerance

66. Postop care
 Mastoid bandage /head elevation
 ITC care
 Neuroobservation 24 hrs
 24 hrs pt sits up /dangle feet
 Vestibular suppressants
 Ambulant when static compensation occurs
 ALEXANDER LAW guide us!
 When nystagmus in opposite gaze 1 degree then
discharge pt
 No driving till full compensation

67. TRANSCANAL LABYRINTHECTOMY

68. Criteria
 Same as neurectomy

76. complications
 CSF leak
 Failure to find utricle
 Injury to facial nerve
 Incomplete labyrinthectomy
 Persistent vertigo(neuroepithelial remnant)
 Perform caloric test post op to find out
 Revision surgery

77. New research
 Mostly focused on improving diagnosis via
imaging and other test battery
 No major break through in management
 Intratympanic steriod has variable success!

78. THANK YOU