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SURGICAL TREATMENT IN MENIERES DISEASES

Surgery may be recommended when all other treatments have failed to relieve dizziness. Every effort is made to conserve hearing. Therefore, the type of surgery depends on the amount of hearing loss in the affected ear. Depending on the type of surgery, there is an excellent chance of controlling the attacks of vertigo. These attacks may be replaced by a feeling of unsteadiness or lightheadedness for a period of 6-12 months until the brain and the opposite ear take over balance function. Procedures may include: 1. Endolymphatic sac procedures. 2. Vestibular nerve section. 3. Labyrinthectomy. Endolymphatic sac procedures. The endolymphatic sac plays a role in regulating inner ear fluid levels. These surgical procedures may alleviate vertigo by decreasing fluid production or increasing fluid absorption. In endolymphatic sac decompression, a small portion of bone is removed from over the endolymphatic sac. In some cases, this procedure is coupled with the placement of a shunt, a tube that drains excess fluid from your inner ear. Of the surgical options, this is the most conservative operation with minimal risk to hearing. Unfortunately, control of vertigo occurs in only 50-60% of patients undergoing this operation. There is no way ahead of time to predict who will or will not respond favorably. In some patients, there may be an immediate noticeable improvement in ear pressure and tinnitus, while in others there may be no improvement at all. Since the surgery causes irritation to the ear, dizziness and ear sysmptoms may continue for several months. Overall, there is a 60% chance of controlling the vertigo attacks, a 20% chance that the attacks will remain the same and a 20% chance that the attacks will be worse. There is a 2% chance of total deafness in the operated ear. Even if hearing is lost, dizziness often still improves. Because the nerve of facial movement (facial nerve) lies next to the inner ear, there is also a small chance that a temporary weakness of the face could occur for several days or weeks after surgery. This generally recovers completely, but not always. Few procedures in otologic surgery have been as controversial as endolymphatic sac surgery. Opinions vary from those who conclude the procedure is effective in over 80% of cases to those who believe it is nothing more than a placebo procedure.

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Under general anesthesia, an incision is made behind the ear. The mastoid bone is entered and the endolymphatic sac is decompressed, meaning that the bony covering is removed. The sac is then opened and a shunt tube is inserted. The fluid that would normally enter the sac is shunted away from the inner ear and into the cavity created by the surgery where it is reabsorbed. Exposure of the endolymphatic sac is essentially an extended mastoidectomy. Thin egg-shelled bone is removed from the posterior fossa dura and sigmoid sinus. The endolymphatic sac is distinguished from the dura by color and texture differences (sac is thicker and whiter than surrounding tissue). In endolympahtic sac decompression, the procedure is terminatied following removal of all the bone overlying the sac. Shunt procedures involve incising the lateral leaf of the sac and inseting a drainage tube into the internal lumen of the endolymphatic duct. Shunts can drain into the subarachnoid space or the mastoid space Typically, endolymphatic sac decompression incurs the same risks as standard mastoidectomy does. Endolymphatic sac shunt carries a higher risk of cerebrospinal fluid complications (leakage, meningitis) when it penetrates into the subarachnoid space. This procedure takes about 2 hours to perform and patients can either go home the same day or the next day. The ear may protrude slightly shortly after surgery but should return to its original position in the next two to three weeks. Numbness around the ear is common and can last for several months.

Vestibular nerve section. (Vestibular Neurectomy or VNS) This procedure involves cutting the nerve that connects balance and movement sensors in your inner ear to the brain (vestibular nerve). This procedure usually corrects problems with

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vertigo while attempting to preserve hearing in the affected ear. This procedure is done in patients with serviceable hearing. This is an operation to divide the balance nerves and interrupt the connection between the inner ear and the brain. 90-95% of patients who undergo this operation will not have another spell of vertigo. After the operation, dysequilibrium lasts until the brain learns to compensate and adapt to the lack of input from one inner ear. The more patients use their balance system after surgery, the less time this adaptation process takes. There are three different approaches or ways to get to the vestibular nerves. The middle fossa approach is the least commonly used and involves an incision above the ear followed by removal of bone over the brain. The roof of the canal through which the balance nerves run is removed and the nerves are then divided. Another approach is the retrolabyrinthine approach which involves incisions behind the ear similar to the endolymphatic shunt procedure. The covering of the brain or dura is opened and spinal fluid is drained. The balance nerves are then divided. A third approach is the retrosigmoid (aka suboccipital) approach which involves an incision further behind the ear and removal of bone over the covering of the brain. Spinal fluid is drained and the balance nerves are visualized and then divided. The fibers of the hearing and balance nerves run very closely together. Infrequently some hearing loss may occur. Depending on the level of hearing present, the hearing can be monitored during the course of the operation. The facial nerve is the nerve that sends messages to the facial muscles to contract. This nerve lies close to the hearing and balance nerves. Just like hearing, the status of facial nerve functioning can also be monitored.

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Labyrinthectomy. With this procedure, the surgeon removes the balance portion of the inner ear, thereby removing both balance and hearing function from the affected ear. This procedure is performed only if you already have near-total or total hearing loss in your affected ear (without serviceable hearing). This is an operation to surgically remove a portion of the inner ear. Nearly all patients will be vertigo-free after a labyrinthectomy. Total and complete hearing loss will result in the operated ear. There is no effect on the hearing in the unoperated ear. This is an operation that is recommended to patients that recieve no useful hearing in the dysfunctional ear. Just as in vestibular neurectomy, after the operation dysequilibrium lasts until the brain learns to compensate and adapt to the lack of input from one inner ear. The operation requires general anesthesia, 3-4 day hospitalization, and an incision behind the ear. Using a high powered drill, the mastoid bone is entered and the semicircular canals are removed. Labyrinthectomy has the advantage of a high cure rate (greater than 95%) and is useful in patients whose diseased-side hearing has been destroyed. Labyrinthectomy involves ablation of the diseased inner ear organs but does not require entry into the cranial cavity. Since craniotomy is not required, there is less danger of a CSF leak and meningitis. Therefore, it is less complex than vestibular nerve sectioning.

REFERENCES www.nidcd.nih.gov/staticresources/health/hearing/meineresfs.pdf http://www.mayoclinic.com/health/menieresdisease/DS00535/DSECTION=treatments-and-drugs Otorhinolaryngology for students, Department of otolaryngology faculty of medicine university of Alexandria Egypt. http://www.oocities.org/gotmenieres/labyrinthectomy.htm http://emedicine.medscape.com/article/2051423-overview