Gavin Morrison MA FRCS Consultant Otolaryngologist

London Temporal Bone Course, Guy’s Hospital

13th June 2014

Rarely Required

Except for Meniere’s Disease (20%)

Meniere’s Disease

Protracted BPPV

Dehiscence of Superior Semi-circular Canal

Perilymph Fistula / perilymph leakage

Otosclerosis

When Symptoms are life disrupting – quite severe and frequent

When non-surgical management has failed to control the condition

In order to try and prevent future progression of the Condition.

Usually to stop or control Attacks of Vertigo, allowing return of confidence.

Also to improve general stability and stop periods of dizziness.

Sometimes to Stabilise or improve Hearing.

To Reduce fullness, blockage or ache.

Diet Drugs

Vestibular Rehabilitation Exercises

Meniett Device – low pressure pulse

treatment

Hearing Aids

Tinnitus Therapy

AAO-HNS Classification, 1995

Dizziness Inventory, vertigo symptom scale – Dr Lucy Yardley, J Psychosomatic Research 1992, 36 (8)731-741

Quality of Life – shortform health survey SF36 Smith D et al Laryngoscope 1997,107(9):1210-16

1 Frequency of Vertigo (FV)

FV Results A B C

D E

2 Hearing assessment 500Hz, 1,2 & 3KHz compares worst before vs. worst after surgery

3 Overall Functioning Scale 1 – 6

1 Normal, 2 Stop for a while, no plans change. 3 Have to change plans, make allowances. 4 Constantly make adjustments, barely making it. 5 Can’t work or drive, disabled. 6 Disabled over 1 year and receiving compensation

Vertigo treatment reporting standard A = 0 B = 1-40 C = 41-80 D = 81-120 E > 120 F = Secondary treatment required due to disabling

vertigo

Average no. Vertigo episodes monthly

6 month before treatment cf. 18-24 mo after.

Endolymphatic Sac Decompression and Drainage surgery

Tympanotomy for topical Gentamicin application to round window membrane

Sometimes Indicated: Osseous Labyrinthectomy

Conservative – preserves inner ear functions

Not Destructive, not ablative

Safe

Small risk (1%) of total hearing loss in operated ear.

Operation might not work

Tos &Thomsen

Sham vs. ‘Real’ Operation (Thomsen et al 1981, 1986)

Kerr

Erroneous Research:

Responsible for disadvantaging countless

thousands of Ménière's Sufferers.

Those with relatively early Meniere’s disease

The Condition and hearing is still good, fluctuant and reversible

The Anatomy allows for successful surgical access to the Endolymphatic Sac

Suitable for Bilateral Disease

Vertigo attacks, drop attacks

General Balance

Hearing & sensitivity to loud noises

Fullness in ear, headaches

Tinnitus – probably no change

One night stay in hospital, not usually dizzy afterwards

Over 80 % experience Improvement (with complete or marked vertigo control

Up to 49 % hearing improves initially

No Surgery Patients (n=68)

Sac Surgery Patients (n=63)

Partially ablative

Do pre-op calorics...

Beneficial – destroys diseased Vestibular

function

Detrimental – Tendency to lose some high frequency hearing in the operated ear

Via Direct access to rwm

Transtympanic Injections in “Office” – 30mg/ml

20 mins on side

Do not swallow

Older patients

Those with more established and advanced disease.

Those with little reversibility in hearing

Those whose hearing is already poor in the ear to be operated on.

Best for those with Unilateral Meniere’s Disease.

Elevate eardrum under general anaesthetic.

Drill bony lip of round window niche.

Clear bony trabeculae & mucosal bands.

Insert “Gelfoam” soaked in Gentamicin (25 mg/ml) wait 15-20 mins

Replace eardrum, dressing to ear canal.

Daycase procedure.

Not usually dizzy from the surgery.

Gentamicin is more vestibulotoxic than cochleotoxic at low doses

Directly Damages the Vestibular Hair Cells

Selective damage to Dark Cells in Stria Vascularis and planum semilunatum of cristae – decreasing endolymph production

Vertigo Attacks Drop attacks

Fullness Distortion and Hypersensitivty to loud

sounds

Tinnitus ? (worse when high frequency HL) Risk of Significant or Total Hearing Loss Partial Recovery of ototoxicity over 1 year Possible need for further Gentamicin treatment (in

clinic)

Complete Control of Vertigo – 73 % Effective control (Complete + substantial)

of Vertigo – 90 %

25 % Chance of hearing loss (typically 15 dB worse)

7 % Chance of profound hearing loss

Higher chance of preserving hearing if incomplete caloric ablation but slightly lower chance of fully controlling the vertigo

Vestibular Nerve Section

More invasive and still risks hearing loss

Osseous Labyrinthectomy

Very good for unilateral disease with very poor hearing

BEWARE – ablative operations should not be undertaken on both ears

Transtympanic Dexamethasone - vertigo control only 50- 60 % with repeated treatments.

Hearing 35 % better short term

VNS - Hearing worse in up to 1/3 patients

- Average drop in hearing 25 dB

Both operations can be highly successful and tend to be under-utilised.

Unilateral disease is very successfully treated.

Avoid Destructive procedures in the young & for any bilateral disease

Bilateral active Meniere’s Disease remains our greatest challenge.

Indications

Long term intractable disease

5 years +

Continuous or frequent episodes

Not responded to Repeated Epley / modified Epley manoeuvres

Abolition or near cure of bppv

Risk of severe SNHL

Expectation for vertigo and nystagmus post-op

Settles over 4 weeks

Requires vestib rehab.

Symptoms

Vertigo on movements

Autophony – hears eyeballs, joints, chewing

Tullio - noise induced vertigo

Straining, sneezing - vertigo

Pulsatile tinnitus

Signs

Conductive HL

Neg. Rinne 512 and 256 hz

Fistula Test

Investigations

Bone Cond at 256 & 500 Hz = -5 to 10 dB

Nystagmus on sound test 500Hz 110 dB Frenzels - (fast down & torsional)

VEMPs

MRI

Multipalanar fine slice CT - Poschel plane - coronal

Conservative

Vestibular Rehab

Psychology & Avoidance

Surgery

Resurfacing of SSSC

Occlusion of SSSC

Middle Fossa – easy - Invasive - prolonged recovery

Transmastoid – easier recovery but more demanding surgery

Ease of Surgerical access – CT

Recurrence of symptoms

Cure from symptoms ?

Post operative Recovery

Risk of Hearing Loss

Transmastoid – remember to occlude both sides of dehiscence.

As for posterior canal surgery

Expect vertigo and rehab. over a few months

Round window Fistula – Not nec dizzy

Oval Window Fistula – dizzy

Third Window Fistula – dizzy

Causes

Iatrogenic after Footplate or Stapes surgery

Barotrauma

Cholestaeatoma

¼ patients have some dizziness

Most do not have endolymphatic Hydrops

Types of Dizziness

Vague or brief dizziness - resolves after stapedectomy

BPPV – improves after Epley manoeuvre and after stapedectomy

True Endolymphatic Hydrops

Post Operative Endolymphatic Hydrops With fistula

Delayed

Simulated Post-op Hydrops

Dizziness for secondary Endolymphatic Hydrops

DO NOT OPERATE

Vague dizziness or from BPPV

Stapes Surgery “cures” it

Last 200 referrals with Otosclerosis

Presentation with clinical picture of associated Hydrops in 11 cases

Incidence at presentation = 5.5 %

Dilated Saccule or Reissner’s membrane in contact with footplate

Intraoperative or post operative rupture

Poor cochlear function & Good hearing in other ear

Bone conduction worse than 45dB at 500 Hz and high frequency loss (House group 1984)

Usually following LP or Epidural

Headaches on standing up, relieved by lying

Flat or Low freq. SNHL

Vertgo

2o E Hydrops

Management: Blood patch