Timothy C. Hain, MD Page last modified: November 26, 2011
The main role of last resort treatment is to manage intractable vertigo. For the most part these are surgical. Surgical treatments have not been shown to preserve hearing to any greater extent than medical treatments (Kinney et al, 1996). A review of surgical treatment has recently been published by LaRouere (1996).
This is the approach that we use at Chicago Dizziness and Hearing;
Briefly, a decision is made whether or not medical management has failed and whether or not more vigorous attempts at management are indicated.
For intractable unilateral Menieres disease cases, we often presently advise a low dose gentamicin protocol. Gentamicin is adminstered through the ear drum every month for a total of one or two administrations. We have had very good results with this procedure, and no hearing loss as yet. If this fails, then if symptoms are severe we may follow with a labyrinthectomy/BAHA combination, or in patients with good hearing and good health, vestibular neurectomy.
Persons who have intractable bilateral Meniere's disease are offered a trial of steroids with a safer immunosuppressant should this be effective, a modified gentamicin protocol, and very occasionally systemic aminoglycosides do deaden both ears.
There are certain procedures that we only rarely recommend, and for this reason we have left them out of the algorithm- -these include endolymphatic shunt procedures and "sac" procedures. The endolymphatic shunt, like all "sac" surgery, is probably a slightly effective treatment. We rarely recommend a shunt or sac procedure in our (non-surgical) practice -- we prefer low-dose gentamicin. There is a large literature about the effect (or lack of effect) of this surgical treatment (see this page for more detail). Again, overall it seems to be a "slightly effective" procedure.
The following text discusses the major branch points in the algorithm above:
|Trans (intra) tympanic injection of Gentamicin for control of intractable Meniere's disease. This method can also be used to inject steroids (see below).|
In severe cases of Meniere's disease, treatments that deaden the inner ear such as gentamicin injections or surgery may be considered. This is a last resort for persons who have severe disabling attacks. At present, we favor gentamicin for most instances where destructive treatments are being considered. Injections of gentamicin are given through the ear drum, through a small hole or through a small tube. This procedure allows one treat one side alone, without affecting the other.
We generally obtain very good results with just one or two injections. This "low-dose" gentamicin protocol has become part of our standard staged management. The risk to hearing and balance is minimal for this procedure (although there is substantial risk from older versions of this protocol).
Dizziness may reoccur one year later, requiring another series. This is because the gentamicin may only temporarily damage the hair cells, which can recover.
Nerve section for unilateral Meniere's that has not responded to low or high-dose gentamicin.
Alternatively, a surgical treatment is used in which the vestibular nerve is clipped. This operation, called a vestibular neurectomy or vestibular nerve section is very effective in eliminating vertigo. While very effective, this procedure, especially the hearing-sparing variant, is presently generally felt to be of much higher risk than gentamicin injection. We presently do not favor vestibular nerve section, except in situations where gentamicin injection has failed.
Another operation, called a labyrinthectomy is recommended in persons who have lost all usable hearing or in whom vestibular nerve section is considered too dangerous. Again, this procedure seems most applicable to situations where gentamicin has failed and hearing is already gone. In persons with unilateral disease, one can combine a labyrinthectomy with a BAHA hearing device, and end up with more usable hearing after the labyrinthectomy. Another rarely used surgical procedure, with even less morbidity but less assurance that it will be effectivce, is a "tack" procedure.
Intramuscular streptomycin for bilateral Meniere's disease that has not responded to low dose gentamicin.
For bilateral Meniere's disease, when the patient is incapacitated and it cannot be determined which ear is causing the dizziness, intramuscular streptomycin (1 gm twice/day) can be given on an outpatient basis until the first sign of ototoxicity develops (generally about a month). This treatment can generally reduce or eliminate vertigo spells without affecting hearing. This treatment however damages the inner ear and causes bilateral vestibular paresis, which has it's own set of symptoms and disability. This treatment is extremely rare as well as rather arduous.
Intratympanic steroid injections have been recently used to treat Meniere's (e.g. Shea and Ge in Otol Clin NA, 1996, 29:353-8, also Am J Otol,18:4,1997). The core methodology is to inject in enough dexamethasone solution (24 mg/ml) to fill the middle ear, on either a one-time basis or over several sessions separated by weeks or months. Thus it involves both making a hole in the ear drum (with the needle), as well as administering a drug to the inner ear (by diffusion across the round window membrane).
Use by otologic surgeons of this methodology is growing and papers supporting its use are proliferating very rapidly . Not all methods seem to work -- some comments about variant methods follows. This page -- intratympanic steroid injections -- has a little more detail.
Studies using a brief period of administration, suggest that it is no better than placebo (Silverstein et al, 1998). As steroids are neither curative nor long-lasting agents, brief intratympanic steroid treatments are obviously not able to cure Meniere's disease (Barrs, 2004; Dodson et al, 2004). The present consensus is that one-time treatment has not yet been proven effective (Doyle et al, 2005) or to have a reasonable scientific basis. The core scientific difficulty is that steroids don't make any permanent alterations to the inner ear, and that they are gone from the ear in a short period of time (Harugnani et al, 2006). Thus, the hypothesis that they can "cure" a chronic ear disorder is very hard follow. When compared head-head, intratympanic dexamethosone was far worse than intratympanic gentamicin (Casani et al, 2011). It is difficult to see why the ENT community persists in using this ineffective treatment for unilateral Meniere's disease.
On the other hand, if one has Meniere's disease in both ears (bilateral Meniere's disease), and one is not certain which one is causing dizzy attacks, it would seem reasonable to us to first try steroids. If the steroids work for 3 months, then one might reasonably move on to gentamicin. If they don't work, then either the choice of ear was wrong, both ears are active at the same time, or the diagnosis is wrong (migraine is the usual alternative confounding diagnosis in bilateral Menieres).
Studies using a long term protocol, or an "as needed" methodology (no more than 4 injections/year) suggest that their results are very good (Sennaroglu et al, 2001; Boleas et al, 2007). This makes more sense to us. If this methodology does indeed prove out, then the main issue would be to determine where this methodology belongs in the staged management of Menieres. Perhaps, after medical and prior to gentamicin treatment.
Other variant methods of administration of steroids.
Intratympanic steroids combined with a viscous osmotic agent (hyaluronic acid) that reduces endolymph volume, has also been recently reported in an uncontrolled study to be effective (Selivanova et al, 2005) in persons who have failed intravenous steroids and vasodilators. They used a protocol of every other day injections, with a maximum of 7 total, combining 8mg of dexamethasone and a 0.2 mg/ml solution of hyaluronic acid. In our view, this is simply the combination of two short-lived treatments, but because hyaluronic acid is very viscous, the combination may keep the steroids in the ear for longer periods than simple injections of an aqueous solution, and might have better results due to this effect. A comparison between steroids injected with and without hyaluronic acid would be a reasonable next step.
Bottom line: At the present writing (2010), we feel that
Return to Main Meniere's page
|© Copyright April 6, 2012 , Timothy C. Hain, M.D. All rights reserved. Last saved on April 6, 2012|