THIEME Systematic Review – The Surgical Management of Vestibular Disorders 179 Endolymphatic Sac Surgery for Ménière’s Disease – Current Opinion and Literature Review Maria de Lourdes Flores García1 Carolina de la Llata Segura1 Juan Carlos Cisneros Lesser2 Carlo Pane Pianese3 1 Otorhinolaryngology Department, Grupo Otológico Médica Sur, Address for correspondence Maria de Lourdes Flores García, MD, México, DF, Mexico Puente de Piedra 150, 803-II, Toriello Guerra, Tlalpan, Ciudad de 2 Otorhinolaryngology and Neurotology Department, Instituto México, México (e-mail: marilufl[email protected]). Nacional de Rehabilitación, México, DF, Mexico 3 Otorhinolaryngology and Neurotology, Grupo Otológico Médica Sur, Neurociencias Clínicas e Investigación, Ciudad de México, DF, Mexico Int Arch Otorhinolaryngol 2017;21:179–183. Abstract Introduction The endolymphatic sac is thought to maintain the hydrostatic pressure and endolymph homeostasis for the inner ear, and its dysfunction may contribute to the pathophysiology of Ménière’s disease. Throughout the years, different surgical procedures for intractable vertigo secondary to Ménière’s disease have been described, and though many authors consider these procedures as effective, there are some who question its long-term efficacy and even those who think that vertigo control is achieved more due to a placebo effect than because of the procedure itself. Objective To review the different surgical procedures performed in the endolym- phatic sac for the treatment of Ménière’sdisease. Keywords Data Sources PubMed, MD consult and Ovid-SP databases. ► endolymphatic Data Synthesis We focus on describing the different surgical procedures performed mastoid shunt in the endolymphatic sac, such as endolymphatic sac decompression, endolymphatic ► endolymphatic sac sac enhancement, endolymphatic sac shunting and endolymphatic duct blockage, decompression their pitfalls and advantages, their results in vertigo control and the complication rates. ► endolymphatic sac The senior author also describes his experience after 30 years of performing endo- drainage lymphatic sac surgery. ► endolymphatic sac Conclusions The endolymphatic sac surgery, with all its variants, is a good option for surgery patients with incapacitating endolymphatic hydrops, providing a high percentage of ► Mé niè re’sdisease. vertigo control and hearing preservation. Introduction pressure and endolymphatic homeostasis for the inner ear and its dysfunction is thought to contribute to the patho- The association of repeated attacks of vertigo that last for physiology of Mé niè re’s disease. hours with a sense of aural fullness, fluctuating progressive Vertigo attributed to endolymphatic hydrops, whether hearing loss and tinnitus is characteristic of endolymphatic idiopathic or secondary to a known etiology, is amenable to hydrops. In most cases, it is impossible to determine an either medical or surgical treatment. Treatment is usually etiology and a diagnosis of idiopathic endolymphatic symptomatic with sedatives and antiemetics during the hydrops, or Ménière’s disease, until it is established. The acute phase, and diuretics or vasodilators for chronic control. endolymphatic sac is thought to maintain the hydrostatic Steroids are also useful either when applied directly with received DOI http://dx.doi.org/ Copyright © 2017 by Thieme-Revinter December 2, 2016 10.1055/s-0037-1599276. Publicações Ltda, Rio de Janeiro, Brazil accepted ISSN 1809-9777. February 1, 2017 180 Endolymphatic Sac Surgery for Mé niè re’sDisease García et al. transtympanic injections or systemically. The psychological vertigo in 94% of the patients, and even a significant support of these patients is also an important part of the improvement in cochlear function in 30% of them. Later, treatment. Surgical treatment is usually offered when the he called this surgical technique endolymphatic sac conservative therapy has failed and the vertigo becomes enhancement.13 Since then, others have described variations incapacitating and untreatable by other means. The surgical in the surgical technique for endolymphatic sac surgery with options include labyrinthectomy, vestibular neurectomy, variable results.3,14 endolymphatic sac surgery and transtympanic gentamicin In 1981, Thomsen et al4 performed a double-blind study, injections for a chemical labyrinthectomy.1 However, the in which they treated patients with Mé niè re’s disease either treatment options that appear to be most effective are those with endolymphatic sac decompression and shunting, or which are more invasive or that pose a greater risk for with a simple mastoidectomy as a control procedure. They hearing loss. In this case, it is desirable to recommend a could not observe any difference between the two groups. procedure that offers a high likelihood of vertigo control with However, a significant reduction in symptoms was reported maximum hearing preservation.2 in both groups, and 70% of all patients were classified as Few surgical procedures in otology are as controversial as successfull considering the criteria used at that time. The endolymphatic sac decompression. This surgical procedure study concluded that the surgical procedure had no effect offers the possibility of controlling vertigo with a minimal whatsoever in the resolution of symptoms from Mé niè re’s risk of morbidity by decreasing the amount of pressure in the disease and that its efficacy was produced by a placebo effect. endolymphatic space. A large number of authors think of it as The patients were reexamined 3 years after surgery, and it safe and effective. The average success rate for vertigo control was still not possible to demonstrate any differences be- with this technique, considering different studies, is around tween the sham and the active surgery.5 A few years later, in 80%.3 Because of the low rates of hearing loss associated with 1996, Sö demann et al15 suggested that the endolymphatic this procedure, it is considered a conservative treatment. sac surgery was an excellent first choice in the treatment of However, there are some who question its long-term effi- uncontrollable vertigo because of its low complication rate, cacy, and even those who think that the vertigo control which, once again, shows how controversial this procedure achieved after surgery is more due to a placebo effect than really is. During the next year, other positive findings in favor – because of the procedure itself.4 6 Despite this controversy, of this procedure appeared; for instance, in 2005, Durland many surgeons around the world still recommend the en- et al2 reported that this surgical procedure improves the dolymphatic sac decompression. perception of symptoms and the quality of life. In 2006, Convert et al16 reported a 10-year follow-up of patients Review of the Literature operated by endolymphatic sac decompression. They observed a resolution of vertigo episodes in 64.5% of their The first surgical procedure for treating Mé niè re’sdisease patients, with improved hearing in 14.8% of them. Goto was described in 19277,8 by Portmann, who made a small et al17 and Kim et al18 reported similar results for vertigo incision to open the endolymphatic sac with the objective of control in recent years. decreasing the endolymphatic pressure. In 1938, Hallpike In a systematic review and meta-analysis from 2014 by and Cairns9 demonstrated the pathological findings of Sood et al,19 current endolymphatic surgical techniques endolymphatic hydrops in temporal bones taken postmor- were analyzed, as well as their efficacy in controlling vertigo tem from patients with long lasting Mé niè re’s disease. Their and maintaining hearing. This study demonstrated that both findings in the inner ear, which suggested an augmented procedures, endolymphatic sac decompression alone or with endolymphatic pressure that could provoke ischemia of the a mastoid shunt, were effective to control vertigo in the short sensory terminal endings in the lateral walls of the mem- term (between 12 and 24 months of follow-up) and in the branous labyrinth, gave more credit to the surgical procedure long term (> 24 months) in 75% of the patients with described by Portmann. In 1962, William House10 described Mé niè re’s disease who had no success with medical therapy. good results by performing a subarachnoid shunt to drain the There was a trend towards sac decompression alone over endolymphatic hydrops. This renewed the interest in the shunting procedures to provide better vertigo control, as technique, but it was not until 1967, when Kimura11 reliably well as better hearing preservation, although this was not reproduced an endolymphatic hydrops in guinea pigs by statistically significant. It was also noted that when shunting, obliterating the endolymphatic duct and sac, that this type of there was a statistically significant difference in hearing surgery really caught the attention of a larger group of preservation between shunting with and without Silastic surgeons. Since then, various shunting techniques emerged, (Dow Corning, Midland, Michigan, USA), against the use of including subarachnoid shunts and mastoid shunts. In 1976, Silastic. Paparella12 described a technique in which he emphasized It is known that Mé niè re’s disease might have an immu- the need of making a wide dural incision to expose and nological basis and that the endolymphatic sac itself may be decompress the endolymphatic sac and duct completely, the target of immunological complexes. This supports both avoiding the posterior semicircular canal.