SURGICAL MANAGEMENT OF MENIERE'S DISEASE

1. Dr. Bikram Babu Karki
PG ENT – HNS, MCOMS
SURGICAL TREATMENT OF MENIERE’S
DISEASE

2. Indications
No definite criteria
Severity of symptoms
Who fail to maximal medical therapy
Points to be considered before surgery
Age , Risks of surgery
Preop hearing, Status of contralateral ear
Effectiveness of central compensation

3. A. Hearing preservation + Balance preservation:
1. Sacculotomy by puncture of footplate
2. Cochlear duct piercing via round window
3. Endolymphatic sac decompression / shunting
B. Hearing preservation + Balance ablation:
1. Chemical labyrinthectomy
2. Vestibular neurectomy
3. Vestibular end organ destruction by USG / cryoprobe
C. Hearing ablation + Balance ablation:
1. Section of 8th nerve
2. Total labyrinthectomy
SURGERY

4. A. Procedures involving Hearing and
Vestibular preservation

5. 1. Sacculotomy:
 Fick’s needle puncture of footplate
 Cody’s tack puncture of footplate
2. Cochlear duct piercing via round window
3. Endolymphatic sac decompression (Portmann)
4. Endolymphatic sac shunting:
- Mastoid cavity or,
- Into sub-arachnoid space
3.

6. 1. Sacculotomy
a. Fick’s Sacculotomy - Fick in 1964 - considered
using a needle to puncture the saccule through
the stapes footplate
b. Cody’s tack Operation - later variation - leaving
a sharp prosthesis in footplate that ruptured the
saccule each time it expanded
Long-term follow-up of patients shows an
unacceptable degree of hearing loss

7. 2. Endolymphatic decompression via round
window.
a. Otic-periotic shunt
b. cochleosacculotomy

8. 1. Otic-periotic shunt
 Tube placed through the R.W membrane that
perforate the basilar membrane

9. b. Cochleosacculotomy
 Aims to creates a fracture dislocation of osseous
spiral lamina, (and hence a permanent fistulization
of the endolymph containing cochlear duct ) by
inserting a hook through the RW membrane
 High degree of hearing loss

10. 3. Endolymphatic sac surgery :
 Surgery begins with simple mastoidectomy
 Identification of tegmen, sigmoid sinus, and facial
ridge

11. Once these landmarks are established,
Horizontal and posterior canals should be
skeletonized and
The bone over the posterior fossa thinned

12.  last shell of bone covering the posterior fossa
dura (PFD) and sigmoid sinus (SS) is removed

13.  Superior edge of ES is identified
 It usually lies at or below Donaldson's line, which
extends posteriorly along the plane of the
horizontal canal and bisects the posterior canal

14.  Procedure from this point varies according to which
endolymphatic surgery is planned
 Decompression of Sac requires only that the
bone of the posterior fossa plate be removed

15.  Using microscissors, the lateral wall of the
endolymphatic sac is separated

16. 4. Endolymphatic sac shunting:
 Shunting to mastoid
 Endolymphatic shunting is most simply performed
by incising the exposed sac and placing a stent to
keep the incision open

17.  The popular Paparella and Hanson technique
involves opening the edge of the sac, lysing any
intraluminal adhesions, and probing the duct to
insure that it is patent

18.  A “T”-shaped piece of silicone(silastic) is coiled and
placed into a lateral incision in the endolymphatic sac
to create a drainage path to the mastoid cavity

19. Shunting to subarachnoid space
 After exposing and opening lateral wall of ES
 Medial wall of Sac is incised to open
lateral prolongation of basal cistern

20.  A silicone shunt is inserted to maintain drainage
path between ES and basal cistern
 lateral ES is carefully closed with a fascia graft
to prevent CSF leak

21. B. Procedures involving hearing preservation
and vestibular ablation

22. 1. Chemical labyrinthectomy
2. Vestibular neurectomy
3. Vestibular end organ destruction
by USG /cryoprobe

23. Vestibular nerve in internal auditory canal
VESTIBULAR NEURECTOMY

24.  Earliest approach was Retrosigmoid -
Walter Dandy - 1930s
 Terms retrosigmoid and suboccipital are now
used interchangeably
 Middle fossa approach to the internal
auditory canal and superior vestibular nerve -
William House - 1960s and
 later modified to include inferior vestibular nerve
section

25.  A retrolabyrinthine approach - introduced in 1980
 A transmeatal cochleovestibular neurectomy –
- abandoned due to superior exposure and more
consistent results afforded by other approaches
 Most commonly performed today
Middle fossa approach
Retrosigmoid approach

26.  Vertigo control success rate : 80-95%
 Procedure offers much greater vertigo control
rates than EL shunt procedures
 More invasive
 Technically challenging
 Lower risk of hearing loss in comparision to
gentamycin inj.

27. 1. Middle cranial fossa approach

28.  Vertical incision - above auricle and
temporalis muscle is freed from squamous portion
of temporal bone

29.  Small craniotomy is made - squamous portion of
temporal bone

30.  Middle fossa dura is elevated and
 Fisch or House-Urban retractor is used to maintain
temporal lobe elevation

31.  SCC (arcuate eminence) and geniculate ganglion
are identified on floor of middle fossa as landmarks
for IAC

32.  IAC is unroofed using a diamond bur
The bar-shaded areas are the locations for drilling

33.  Dissection is carried out to lateral extent of canal
to identify "Bill's bar," which divides facial nerve
(anterior) from superior vestibular nerve (posterior)

34.  Dura of posterior aspect of canal is incised and
superior vestibular nerve is identified

35.  As superior vestibular nerve is retracted, inferior
vestibular nerve can be identified, taking care to
avoid internal auditory artery and cochlear nerve

36.  Upon nerve sectioning, the internal auditory
canal can be covered with fascia, the bone flap
replaced, and the incision closed

37. Advantage
 FN & SVN separated by Bill’s bar
 Less injury to cochlear nerve
 Minimal dural violation
Disadvantage
 FN injury (highest among all approach)
temporary paresis ~33%
 Temporal lobe retraction

38. 2. Retrosigmoid (Suboccipital)
approach

39.  Procedure begins with Suboccipital craniotomy
done behind lateral sinus
 Anterior limit is sigmoid sinus
 Posterior fossa dura is opened

40.  Cerebellum is retracted to give exposure to CP
angle and petrous ridge
 Cistern is decompressed with an incision that
allows cerebellum to fall medially obviating
retraction

41.  Facial,cochlear and vestibular nerves identified and
superior and inferior vestibular nerve is resected
 Then dura is reaproximated
 Bone flap is replaced and covered as wound is
closed

42. Retrosigmoid approach to vestibular nerve section. The cerebellum is
retracted medially giving a view of the superior and inferior vestibular nerves
.A, The posterior fossa is exposed and nerves are identified.
B, The superior vestibular nerve is separated from the more anterior facial nerve
C, The superior vestibular nerve has been sectioned

43. Advantage
 Good exposure
 Less CSF leak
 Preferred by neurologists (temporal bone
dissection not required)
Disadvantage
 Poor proximity to nerve from depth of wound
 Retraction of cerebellum
 Postoperative headache

44. C. Procedures involving hearing and
vestibular ablation

45. LABYRINTHECTOMY :
 Most destructive procedure - destroys both
hearing and vestibular function
 Ideal candidates
 No functional hearing and
 Failed more conservative treatments, such as
gentamicin injection
 Higher rate of vertigo control than vestibular
neurectomy – 98%

46. 2 approaches :
1. Transcanal labyrinthectomy (Oval window
labyrinthectomy)
 Relatively non- invasive
 Quick by approaching inner ear by EAC
 Incomplete removal of neuroepithelium
2. Transmastoid labyrinthectomy
 Gold standard for surgical ablation of vestibular function
 Affords much better exposure and is more popular
 Removal of all neuroepithelium under microscopic vision

47. 1. Transcanal labyrinthectomy :
 Procedure begins by elevating a tympanomeatal
flap to enter the middle ear
 Incus and stapes removed to expose oval window

48.  Variation on this basic technique involves drilling
out promontory to connect oval and round window
 Removal of promontory bone and stapes provides
wide exposure of the vestibule

49.  Hook is then inserted into vestibule to remove
Utricular neuroepithelium (UN) from the elliptical
recess of the vestibule
 Saccule and utricle are identified and removed

50. Limitations :
1. Poor access to posterior canal, located medial to
facial nerve; thus, complete ablation may not be
achieved
2. Limited exposure also makes the procedure more
technically difficult than the transmastoid
approach

51. 2. Transmastoid labyrinthectomy :
More commonly performed
Has advantage of allowing direct visualization of
vestibular end organs

52.  Procedure begins with standard postaurlcular
incision
 Standard mastoidectomy in which horizontal canal
and facial ridge are identified
.

53.  Drilling superior to Horizontal SCC between
labyrinth and tegmen allows identification of
Superior SCC
 Posterior canal is identified posterior to horizontal
SCC

54.  Canals can then be blue-lined and followed
medially to vestibule while removing neuroepithelium
under direct vision

55.  Complete loss of hearing is an expected outcome
of labyrinthectomy
 However, it may be possible to preserve hearing
by packing SCC with bone wax and using diamond
bur to remove the canal while preserving the
vestibule