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  Sac Surgery Patients (n=68) (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