OTOLOGIC DISEASE: OBSERVATIONS ON MANAGEMENT
Educational Objectives
| The goal of this program is to improve the management of Meniere’s disease and tympanic membrane
atelectasis. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Recommend conservative treatment of Meniere’s disease.
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| 2. Recognize when to utilize invasive treatment of Meniere’s disease.
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| 3. Describe invasive treatment options for Meniere’s disease.
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| 4. Review the grading of tympanic membrane atelectasis.
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| 5. Recognize when surgery is indicated for tympanic membrane atelectasis.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a
proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Dr. Rauch was recorded at the Second Annual Johns Hopkins Update in Otolaryngology–Head and Neck Surgery, held
July 18-19, 2008, in Baltimore, MD, and sponsored by the Johns Hopkins University School of Medicine, Department
of Otolaryngology, Head and Neck Surgery. Dr. Saunders was recorded at the Ultimate Colorado Mid-Winter
Meeting, held January 27-31, 2008, in Vail, CO, and sponsored by the University of Colorado, Denver, School of
Medicine, Office of Continuing Medical Education. The Audio-Digest Foundation thanks the speakers and the sponsors
for their cooperation in the production of this program.
| MENIERE’S DISEASE: A PRACTICAL APPROACH TO MANAGEMENT—Steven D. Rauch, MD,
Professor of Otology and Laryngology, Harvard Medical School, and Staff, Massachusetts Eye and Ear Infirmary,
Boston
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| Definition: triad of fluctuating and progressive sensorineural hearing loss, episodic vertigo, and tinnitus;
inner ear homeostasis—systems tightly regulated, including fluid production and recycling, incoming and
outgoing innervation and blood flow, and energy metabolism; if any of systems not functioning properly,
ear becomes unstable and no longer impervious to factors, eg, diet, weather, stress, hormones; ear functions
for hearing and balance; Meniere’s affects both hearing and balance, with intermittent symptoms;
deteriorating ear function, with interval in which performance variable and ear unreliable (Meniere’s disease);
most patients have ≈5 yr of poor ear function before diagnosis made; associated with structural
changes, but rupture theory inadequate
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| Diet: low sodium; ear vulnerable to surges in sodium; speaker has patients on no-added-salt diet (2000 to
3000 mg/day), with sodium evenly distributed across meals; has benefit in frequency of vertigo attacks,
easier compliance, and greater tolerance for dietary indiscretion; even distribution of sodium more important
than daily total; caffeine and alcohol restricted to one drink per day; replacement of fluid from sweating;
central principle to minimize surges and fluctuations; about two-thirds of patients obtain substantial
relief from vertigo, but not much relief of auditory symptoms; vestibular suppressants also used
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| Diuretic: added if patient still significantly symptomatic with vertigo after 1 to 2 mo on low-salt diet; ion
pumps for fluid management in stria vascularis and ducts of vestibular labyrinth same as those in kidneys
(modulated by diuretic); most commonly used hydrochlorothiazide (HCTZ) and triamterene (Dyazide;
Maxzide; used by most otolaryngologists) and acetazolamide (carbonic anhydrase inhibitor; used by
most neurologists); acetazolamide—thought to have migraine suppressant effect, but has unpleasant side
effects; given 2 to 4 times daily and causes tingling of fingers; changes processing of carbonated drinks;
HCTZ and triamterene—triamterene potassium-sparing diuretic; few side effects; occasionally causes fluctuation
of potassium; small chance of allergy to thiazides and acetazolamide (sulfur side chains) in patient
allergic to sulfonamide antibiotics; thiazides relatively contraindicated in gout (aggravated) and in
narrow-angle glaucoma
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| Vestibular suppressants: meclizine (eg, Antivert)—antihistamine; primary effect antiemetic; sedating; has significant
parasympathomimetic effect (eg, dry mouth, blurry vision, urinary retention); vestibular suppressant
effect weak and slow in onset (8-12 hr); lorazepam (eg, Ativan)—benzodiazepine; similar to
diazepam; short-acting; if taken sublingually (SL), effects start in 10 to 15 min and peak in 1 hr; half-
life ≈12 hr; clonazepam (Klonopin)—onset of effect ≈1 hr; half-life 4 days; lorazepam—speaker uses as
vestibular suppressant of indication for episodic vertigo; 0.5 or 1 mg SL (off-label indication and route
of administration)
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| Efficacy of conservative measures: approximately two-thirds of patients obtain relief from diet and diuretic;
of the one-third who remain symptomatic, approximately two-thirds get relief from diuretic;
this leaves 5% to 10% in whom conservative measures fail
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| Sac surgery: invented to improve endolymph drainage; size and shape of sac highly variable; no endolymph
flow toward sac, except under unusual circumstances; however, approximately two-thirds of patients improve
after sac surgery; initial invasive treatment spares hearing
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| Intratympanic (IT) gentamicin: while sac surgery done under general anesthesia in operating room, IT
gentamicin performed in office under local or topical anesthesia; with sac surgery, patients stay overnight
at hospital and may still feel “tipsy” or “wobbly” 2 to 4 wk later; speaker uses minimal dosing
scheme with IT gentamicin (give dose and wait 1 mo, and if patient still has attacks, give another dose
and wait another month); in speaker’s experience, 7 in 10 patients need only 1 dose (3 in 10 need second
dose); ≈5% require third dose; effects seen in 3 to 5 days and intensify up to ≈10 days after injection;
effects fade in 2 to 4 wk
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| Success rates: for sac surgery, 50% to >80% in literature (average ≈67%); with IT gentamicin, early response
very high (90%-95% initial control rate); at 2-yr follow-up, those who had sac surgery stay
same, about two-thirds of those not treated in remission, and for those treated with IT gentamicin,
about two-thirds still under control and one-third relapse; risk with total ablation increased hearing
loss; hearing deficit unlikely outcome in sac surgery (3%-5%); with IT gentamicin, hearing deficit
20%-25%, although sometimes transient; speaker still offers IT gentamicin for patients with Meniere’s
disease in both ears; most patients with Meniere’s disease eventually require hearing aid or cochlear
implant
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| Labyrinthectomy: previously done primarily for drop attacks and intractable Meniere’s disease; presently,
rarely done unless patient has had several cycles of gentamicin; preoperative to postoperative
change in vestibular function quite small; patients routinely discharged on second postoperative day
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| Vestibular neurectomy: of historical interest only; mostly done by suboccipital approach (also by middle
fossa); recovery takes weeks to months, but patients continue to improve 2 yr after treatment; vertigo
control rate with labyrinthectomy not 100%; success rate ≈90% with vestibular neurectomy; hearing
loss rate 100% after labyrinthectomy; 15% to 20% of neurectomy patients have hearing deficit; cleavage
plane between vestibular nerve and cochlear nerve variable (issue in suboccipital approach); age
issue in middle fossa surgery (confined to younger patients); risk to facial nerve low in both procedures;
intracranial procedure associated with transient facial nerve palsy; risk for facial nerve injury
<1%; cerebrospinal fluid leak seen in vestibular neurectomy (≈50% resolve with lumbar drain; ≈3%
require reoperation); chronic headache—rarely seen after labyrinthectomy (common after intracranial
procedures); cause unknown; small subset of patients in whom headache as (or more) disabling than
original vertigo; intracranial complications (eg, stroke, brain injury, meningitis) not seen in labyrinthectomy
and unlikely in vestibular neurectomy
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| Medications: betahistine (Betaserc)—not available in United States; histamine agonist; used widely in Europe
and Canada as first-line drug; not approved by Food and Drug Administration (FDA), and literature
of clinical trials not convincing; Vertigoheel—herbal preparation; in head-to-head clinical trials,
found as effective as betahistine; Lipoflavonoid—B vitamins; ineffective; no clinical research to validate
use; steroids—preliminary evidence supports use, although no prospective clinical trials done;
used by speaker in patient with Meniere’s disease in only-hearing ear, where hearing loss increasing
and treatment not effective; speaker offers patients option of intermittent dosing of IT dexamethasone,
with caveat that efficacy uncertain
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| Allergy treatments: allergy attack may exacerbate Meniere’s symptoms, but speaker does not believe allergy
causes Meniere’s disease
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| Meniett pump: 2 studies show modest benefit (two-thirds of patients improved over 4- to 6-mo follow-
up); minimally invasive; pressure equalization tube placed in eardrum; if eardrum intact, pressure
pushing drum back and forth makes patient intensely seasick; costly
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| Summary: “pamper” fragile ear; ≈90% of patients respond to conservative treatment; for those who fail
conservative treatment, disable intractable ear (invasive treatment)
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| TYMPANIC MEMBRANE ATELECTASIS: STAGING AND TREATMENT—James Saunders, MD,
MS, Assistant Professor, Division of Otolaryngology, Dartmouth Hitchcock Medical Center, Lebanon, NH
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| Characteristics: extremely common disease; study of Finnish children found that 10% had some degree
of atelectasis, and 1% to 2% of these had associated adhesions; tympanostomy tubes—increase level of
atelectasis 3% to 5% in children with previous tubes; partially contribute to atrophy of drum;
pathophysiology—eustachian tube function essential problem; negative pressure also leads to atrophy of
eardrum; loss of collagen layer then causes collapse of tympanic membrane with even minor changes in
pressure
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| Grading scale: grade I—atrophy and retraction of drum without adhesions or involvement of underlying
structures; grade II—contact with incus but does not involve promontory; grade III—involvement of
incus and promontory; grade IV—adhesive otitis; thin atrophic drum draped over structures; middle ear
space completely collapsed, with no aeration in middle ear; grade V—secondary issues, eg, perforation,
pending cholesteatoma, deep retraction; advanced disease; problems with grading system—does not take
into account considerations in deciding whether to perform surgery (ie, presence of bone erosion, level
of hearing loss, and density of adhesions); also does not account for focal collapse onto promontory
(focal atrophy in interior anterior eardrum; occurs in ≈50% of low-grade cases)
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| Potential problems: ≈10% of low-grade atelectasis cases progress to higher-grade atelectasis, ≈10% of
which deteriorate into possible cholesteatomas; risk for cholesteatoma, depending on grading scale,
2% to 10%; other problems include bone erosion and hearing loss
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| Treatment: sinus surgery if patient “sinus cripple”; adenoidectomy in children; if early cholesteatoma
present, perform surgery (also if perforation and hearing loss present); surgery not considered in mild
cases with minimal adhesion onto incus and good hearing; tympanostomy tubes—no studies looking at
permanent tympanostomy tubes; tympanoplasty—≈70% improvement seen; study showed ≈48% had
improvement in hearing; study looking at rigid tympanoplasty showed long-term ventilation required
in ≈20% of patients, with no recurrent atelectasis; cartilage shield graft (thin sliver of cartilage over incus
and stapes for protection); no indication that mastoidectomy decreases risk for collapse; arguments
against surgery—≈50% of cases resolve spontaneously or remain stable; risk for cholesteatoma in low-
grade atelectasis very low; tympanostomy alone not cure-all; tubes aggravate atrophy of drum; risk for
hearing loss, particularly with tympanoplasty
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| Laser surgery: with patient on masked-ventilation anesthesia, segments pop up and nonadherent thin
atrophic segments visible for laser coagulation; one of problems with potassium titanyl phosphate
(KTP) laser lack of uptake when used on thin atrophic drum; uptake increased by dyeing tympanic
membrane with methylene blue or brilliant green; be sparing with use of laser (causes more thermal
damage than actually seen at time); hydrolysis of adhesions done by performing small myringotomy
and inserting modified suction tube; syringe with short intravenous tubing filled with saline and fitted
inside end of suction tube; saline helps to break up adhesions; if ineffective, speaker takes blunt-tipped
probe and raises promontory adhesions, avoiding ossicles; results—≈50% of tubes extruded within first
6 mo; follow patients closely for tube extrusion in first 6 mo; perforation biggest complication; overall,
hearing improved
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| Speaker’s preferred grading scale: grade I—atelectasis without any adhesion, erosion, or conductive
hearing loss; grade II—involves either incus or promontory, with no erosion or conductive hearing loss;
grade III—involves incus and promontory, with no erosion or significant conductive hearing loss; grade
IV—adhesion at 2 sites with either erosion of ossicles or significant hearing loss; grade V—
“shrink wrap” eardrum; grade VI—incipient cholesteatoma or perforation
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Suggested Reading
Barakate M et al: Combined approach tympanoplasty for cholesteatoma: impact of middle-ear endoscopy. J Laryngol Otol
122:120, 2008; de Beer BA et al: Hearing loss in young adults who had ventilation tube insertion in childhood. Ann Otol
Rhinol Laryngol 113:438, 2004; Gates GA et al: Meniett clinical trial: long-term follow-up. Arch Otolaryngol Head Neck
Surg 132:1311, 2006; Havia M et al: Progression of symptoms of dizziness in Ménière’s disease. Arch Otolaryngol Head
Neck Surg 130:431, 2004; Keles E et al: Meniere's disease and allergy: allergens and cytokines. J Laryngol Otol 118:688,
2004; Kitahara T et al: Surgical management of special cases of intractable Meniere's disease: unilateral cases with intact
canals and bilateral cases. Ann Otol Rhinol Laryngol 113:399, 2004; Lehnen N et al: Head impulse test reveals residual
semicircular canal function after vestibular neurectomy. Neurology 62:2294, 2004; Nejadkazem M et al: Intratympanic
membrane cholesteatoma after tympanoplasty with the underlay technique. Arch Otolaryngol Head Neck Surg 134:501, 2008;
Sen P et al: Ménière disease patient information and support: which website? J Laryngol Otol 117:780, 2003; Smith WK
et al: Intratympanic gentamicin treatment in Meniere's disease: patients' experiences and outcomes. J Laryngol Otol 120:730,
2006; Suryanarayanan R et al: Long-term results of gentamicin inner ear perfusion in Ménière’s disease. J Laryngol
Otol 118:489, 2004.
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