Surgical treatment of peripheral vestibular disorders aims to abolish labyrinth function or modify the underlying pathophysiology. Non-ablative procedures for Meniere's disease include intratympanic corticosteroid injections, which control vertigo in 80-96% of patients. Partially ablative procedures use intratympanic gentamicin injections, which selectively destroy hair cells while sparing hearing. Vestibular neurectomy severs the vestibular nerve, controlling vertigo in 85-95% while maintaining hearing in 80-90%. Endolymphatic decompression and plugging techniques are used to treat other conditions like BPPV, enlarged vestibular aqueduct,

1. Surgical Treatment of
Peripheral Vestibular
Disorders
By: Dr Rabiei

2. Historical Background
• Prior 1860, central disorders, cerebral congestion, as
epilepsy
• 1824, Pierre Flourens, after canal plugging, pigeons
flew in circles in the same orientation as the ablated
semicircular canal
• Prosper Meniere 1861, both vertigo and deafness
i1un1ediately after trauma to the ear
• 1871, Knapp's hypothesis that inner ear
• hydrops was simnilar to glaucoma

3. Meniere’s Disease
• Early treatments focused on destruction end
organ
• In 1904, both the techniques of eighth cranial
nerve section and labyrinthectomy
• Endolymphatic drainage was first reported by
Portmann in 1926
• 1930, Dandy proposed selective vestibular nerve
section
– High risk of deafness, facial nerve paralysis,
mortality.

4. • 1938, Hallpike and Cairns noted
endolymphatic system dilation with Meniere's
disease
• This finding was simultaneously reported by
Yanmakawa
• Subsequently, surgical treatment options
focused correct the endolymphatic dilation or
ablating the end organ.

5. Preoperative Considerations
1. Confirmation of the diagnosis
• Migraine and vestibular schwannoma
• no "gold standard" test for Meniere's disease
• Guidelines are necessary
• AAO-HNS criteria for the diagnosis of
Meniere's disease

6. 2. Results of vestibular testing, such as caloric
test, posturography, rotational testing, often do
not correlate well with the severity of patient
symptom
• Severity of symptoms can be directly assessed
through evaluation of responses on a
questionnaire such as the Dizziness handicap
Inventory

7. 3. Patient's age should be considered
– advanced age alone is not a contraindication
4. Status of the contralateral ear
• Major difficulty in assessing the efficacy of
treatment for Meniere's disease is the high
spontaneous remission rate (60-80%) of the
episodic vertigo that is a hallmark of the disease.
improvement following treatment is due
to the treatment itself or the natural
history of the disease

8. • It should be remembered that without any
therapy more than 80% of Meniere's patients
improve within 2 years
• More than 70% improve after 8 years
• Leaves 30% of patients who continue to have
symptoms that may be relieved by surgery.

9. 5. Degree of hearing loss

10. Surgical treatment two goals
• One is: abolish of the labyrinth
• Procedures that reduce or ablate vestibular
function have risk of hearing loss.
• The second goal: modification of the
underlying pathophysiology.

11. Nonablative Procedures for
Meniere's Disease
• lntratympanic Injection of Corticosteroids
– Vertigo control rates of 80 to 96%
– Dexamethasone is now a standard therapy
• Large retrospective study demonstrated satisfactory vertigo
control in 91% of patients followed for 2 years or more.
• During this period, 63% had multiple injections.
•
• At the end of the 2-year period, 70% required no further
injections, 26% continued to receive intratympanic steroids,
and 3% went on to ablative therapy.

13. Partially Ablative Procedures for
Meniere's Disease
• lntratympanic Injection of Gentamicin
–in 1957, Schuknecht described streptomycin
injection into the middle ear
–Gentamicin has a high vestibulotoxicity
relative to its cochleotoxicity
sparing hearing

14. • Diffusion through the round
window menmbrane
• concentration of gcntamicin in the
perilymph reaches 5 to 10% of
applied solution
• Elimination half-life of 75 min
• selectively concentrated in hair cells
and supporting cells

15. Mechanisms
• Destroy hair cell function
– Block ion currents through the stereocilia
– Cause adhesion of stercocilia
– Cause hair cells to degenerate
greater effect on type I than on type II hair cells
reduction in function is not as severe
as that seen after surgical
labyrinthectomy

16. • Direct injection though TM
• Inserted ventilation tube
• Catheter inserted into ME
• placing a sponge through TM
• injection directly into the RW
• Minipumps
• TM should be anesthetized.
• EMLA
lntratympanic Delivery Techniques

19. Endolymphic Decompression
• Sac surgery on vertigo control is likely less
than intratympanic gentamnicin, vestibular
nerve section, or labyrinthectomy

21. A postauricular incision is
made approximately 2 cm
posterior to the sulcus
A routine mastoidectomy
–1 cm posterior to the sigmoid
sinus
–Exposure of the posterior fossa
dura
–toward jugular bulb and
retrofacial air cells

24. Vestibular Neurectomy
• The earliest approach was the retrosigmoid 1930
• The middle fossa approach to the internal
auditory canal 1960
• Retrolabyrinthine approach 1980
The Middle fossa and Retrosigmoid approaches
remain the most commonly performed today.

26. • Vertigo control rate of about 85 to 95%
• With 80 to 90% maintaining hearing
o have a lower risk of hearing loss when
compared with gentamicin injection
Vestibular Neurectomy

29. BENIGN PAROXYSMAL
POSITIONAL VERTIGO
• Singular neurectomy was proposed by Gacek
as a treatment for refractory BPPV
– A transcanal approach
– relieves symptoms in 75 to 96% of patients
• Posterior semicircular canal occlusion was
introduced as a treatment for BPPV in 1990.

32. ENLARGED VESTIBULAR AQUEDUCT
• Most common finding on computed
tomography (CT) scan
• HL and minor trauma, same for Vertigo
• The vertigo with fluctuations in hearing,
mimicking Meniere's disease
• Despite episodes vertigo and hearing loss,
vestibular function tends to remain normal.

33. • At this time, vertigo related to
enlarged vestibular aqueduct
syndrome is not appropriately
treated by surgery.
–The endolymphatic shunt
–Extraluminal occlusion

34. PERILYMPH FISTULAE
• Three main categories
1. perilymph from the inner ear to the middle ear
2. From labyrinth by disease such cholesteatoma
3. Idiopathic bony dehiscence of the semicircular
canals
• Areas of possible fistulization are the fissula ante
fenestram and a fissure from the round window
niche to the ampulla of the posterior canal

35. • Chronic ear disease can cause fistula
– The horizontal semicircular canal was the most
common

36. SUPERIOR CANAL
DEHISCENCE SYNDROME
Third "window“
• allows the abnormal movement of endolymph
during presentation of loud sounds
– Tullio phenomenon
– characterized by autophony
– CHL
– pulsatile tinnitus

39. • The severity of the patient's symptoms and the
impact of these symptoms on lifestyle are major
determinants in the consideration of surgery for
SCD
–Surgical plugging
–Debilitating symptoms
–The middle cranial fossa approach
–Transmastoid approach

43. Thank you