Abstract Otology 2000 D12-1

Christiane I. Messias Dr.med., Carlos A. Oliveira Prof.Dr.

Department of Otolaryngology Brasília University Medical School Campus Univ. Darcy Ribeiro BR-Brasília- D.F.

In 1992 we described a patient with classic Ménière's syndrome. His four daughters and three of his four sons also had the syndrome. The proband's incapacitating vertigo and drop attacks were much improved after an endolymphatic sac enhancement procedure. Headache was present in all affected siblings. In 1997 we described a similar family. This time the associated headache was characterized as migraine in most patients. For the last two years (1997-1998) we selected from our outpatient department all patients displaying classic Ménière's syndrome and carefully searched for other family members affected by the symptoms. We collected 8 patients with the classic Ménière's syndrome (episodic vertigo, tinnitus, fluctuant hearing loss, pressure in the ear). Three had enough siblings affected by the syndrome to characterize an autosomal dominant genetic transmission, 2 had other family members affected but not enough to characterize the mode of transmission and 3 had no other family members affected. Migraine was present in all three families and in 2 sporadic cases. Audiometry and ENG were performed on all affected siblings. Although we see a large number of dizzy patients typical Ménière's syndrome is uncommon in Brasília. Indeed in the last 22 years only 15 endolymphatic sac procedures were performed in our clinic. Among 8 patients with the classic syndrome seen in 2 years 38% had an autosomal dominant pattern of genetic transmission and 25% had other family members affected. We believe a strong case can be made for a genetic etiology in idiopathic Ménière's syndrome (Ménière's disease).

Abstract Otology 2000 D12-2

Levent Sennaroglu MD, Gonca Sennaroglu MD, Bulent Gursel MD

Department of Otolaryngology Head and Neck Surgery Hacettepe University TR-Ankara

Intractable vertigo in Ménière's Disease still presents a challenging situation for the otolaryngologist. In the presence of serviceable hearing, treatment options include intratympanic steroids, intratympanic gentamicin, vestibular nerve section, and endolymphatic sac decompression. As there is no established treatment which is universally agreed upon, the debate is still going on. In this investigation intratympanic dexametasone, gentamicin and endolymphatic sac decompression are compared in intractable vertigo. All patients were given medical treatment (salt and caffeine restriction, vasodilator (betahistine hydrochloride BetasercR), diuretic (acetazolamide, DiamoxR and encouragement to eliminate nicotine) for at least six months and only those who did not benefit from this regimen and still had disabling vertigo attacks were included in this study. Dexametasone was applied through ventilation tube in 24 patients, intratympanic gentamicin to 16 patients, while 25 patients underwent endolymphatic sac surgery. Satisfactory control of vertigo was 72%, 50% and 52% respectively for the three modality. Two patients in the gentamicine group had total hearing loss. In the dexametasone group hearing level remained the same in 46% of the patients with 16% increase and 38 % decrease (30% 10dB and 8% 20 dB). To conclude we believe that strict adherence to the medical treatment at least six months improves the vestibular symptoms in the vast majority of the patients and they do not need further procedures. If the vertiginous symptoms still persist after six months intratympanic steroids can be started. After three months if there is no further improvement, patients with profound sensorineural hearing loss undergo intratympanic gentamicin. ESD is reserved for patients with good hearing. If ESD also fails patients with good hearing may undergo vestibular nerve section while patients with nonservicable hearing become candidates for labyrinthectomy.

Abstract Otology 2000 D12-3

Sertac Yetiser MD, Mustafa Kertmen Prof.Dr.med., Yalcin Ozkaptan Prof.Dr.med., Ahmet Dundar Prof.Dr.med.

Dept. of ORL & HNS Gulhane Medical School TR-Etlik, Ankara

The ideal treatment which prevents the progress in Ménière's disease has not been developed yet. For patients with incapacitating unilateral Ménière's disease who are resistant to medical therapy, chemical ablation of vestibular function with intratympanic gentamicin has been recommended recently since it can be done easily as an outpatient procedure without the risk of cochlear damage due to adjusted dosing. However, central compensation after ablation of unilateral vestibular function varies in each patient and is the major concern since it may result with result with prolonged inability to work and restricted social life. This study presents a long-term folow-up of 17 patients who were treated with an application of intratympanic gentamicin since 1995. The compensation process was followed by clinically and by periodic ENG recording. 1ml of 30mg/cc pH adjusted gentamisin solution was injected into the middle ear through the tympanic membrane for 3 consecutive days if the patient's hearing level is better than 40dB and SD score is greater than 60%. However, 1ml of 40mg/cc gentamicin was given if the patient has hearing threshold worse than 40 dB and SD score less than 60%. Their hearing level was followed by audiogram on daily basis during the therapy. After completion of therapy, patients were encouraged to come to interview for clinical and electrophysiological evaluation twice a month. Their response to therapy was noted according to their sex, age, hearing level, presence of bilateral occurence, their occupation, visual ability, the severity and the duration of symptoms. It was found that it lasted more than 10 months in 1 patient who is 65 years old and it took almost one and a half year in another one who is 77 years old. Additionally, even minimal involvement in the counterlateral ear is a considerable factor which delays the balance improvement. On the other hand, two patients ho have unilateral loss of vision never developed compensation for 16 and 18 months. It was found that dosing, the severity of symptoms (tinnitus, hearing level, previous form of vertigo) and sex have no role in compensatory period but the age and the quality of vision. This result may propose a rationale for patient selection to ablative therapy or initiation of vestibular adaptation tests prior to gentamicin application.

Abstract Otology 2000 D12-4

Sertac Yetiser MD, Mustafa Kertmen Prof.Dr.med., Yalcin Ozkaptan Prof.Dr.med., Ahmet Dundar Prof.Dr.med.

Dept. of ORL & HNS Gulhane Medical School TR-Etlik, Ankara

Detection of hydrops in patients with Ménière's disease having normal or near to normal hearing and presenting unpredictable symptoms with great variability of severity, periodicity and duration is the major concern in reaching the accurate diagnosis and assessment of any particular treatment. Diverging results after repeated recordings of EcocG bring some questions on reliability of this test. In order to investigate the level of vestibular hydrops, electronystagmographic evaluation of patients with Ménière's disease before and after Furosemide application which is administered intravenously as a potent natriuretic agent has been reviewed. The relation between the improvement in caloric response and the periodicity of vertigo, duration of disease, age and sex of patients has been systematically documented. 40 subjects (20 patients with Ménière's disease [13 definite with vestibular symptoms, 7 possible Ménière; 2 cochlear with mild hearing loss, 5 vestibular with 2 attacks] and 20 adults with no symptom as control group) have participated in this study. Before and 30 min. after administration of 20 mgr Furosemide, both ears were tested with air caloric ENG given at +52°C for 9sec with a flow rate of 15lt/min. Slow phase velocity of each recording was particularly analyzed. The test was accepted as positive after injection if the slow phase velocity of maximum nystagmus was found to be elevated more than 9.4%. No correlation between the active status of the disease and the level of positive response on the test has been found. There is also no correlation between the duration of the disease and the results. However, the level of canal paresis is greater and if the beginning of the disease is more than a year and the involved ear gives better improvement on ENG after Furosemide injection if the disease is less than 6 months. It has been concluded that this test may only be used for a particular group of Ménière patients.

Abstract Otology 2000 D12-5

David W. White MD

Eastern Oklahoma Hearing and Balance Center USA-Tulsa OK

Retrolabyrinthine/retrosigmoid vestibular neurectomy (RL/RSIG VN) has been widely used for the treatment of severe vertigo. Out of the series of RL/RSIG vestibular neurectomies performed at our center, there have been a series of special situations which occurred both while planning and during surgery. Failure to address these situations could have resulted in complications, altered outcomes or even termination of the planned procedure. These unique situations will be presented. The steps used in evaluation and management of each situation will be discussed. Actual case photographs, diagrams and CT scans will be used to demonstrate the specific situation and the technique used in solving the problem.

Abstract Otology 2000 D12-6

Olivera Miskovska MD, Ilija Filipce MD, R. Sundovski MD, Sandre Gjorsevski MD

ENT Department Medical Center Bitola MAZ-Bitola

Every otorinolaryngologist is confronted by the problem of therapy for Ménière's disease. Although the classic triad of symptoms of episodic vertigo, tinnitus, and fluctuating sensorineural hearing loss are well recognized an effective method for relief from these disabling attacks is not known. Medical and surgical treatment of Ménière's disease are controversial. This paper discusses the current options for the treatment of disabling vertigo. Medical therapy is effective in controlling symptoms in the majority of patients. Surgical treatment is reserved for those patients who continue to have disabling vertigo despite medical treatment. Several of the surgical procedures discussed also have aplication for dizinness of other aetiologies such as post-traumatic vertigo, post-surgical vertigo, and persistence of disabling symptoms folowing an episode of vestibular neuronitis. The surgical treatment of benign positional vertigo, vascular loops, and perylymphatic fistula is also briefly discussed.

Abstract Otology 2000 D12-7

Alan G. Kerr MD (1), Joseph G. Toner MD (2)

(1) Eye and Ear Clinic Victoria H IRL-Belfast
(2) ENT Opd Belfast City Hospital IRL-Belfast

Over the years we have often been surprised at how many patients have been free from dizziness between the date of surgery being planned and the date of admission. We started a prospective study in May 1994 in those who had prolonged incapacitating episodic vertigo. We offered surgery but not without a waiting period of 6 to 8 weeks. We reassured the patients that they would not have to continue indefintely with the problems of their vertigo. We then saw them 6-8 weeks later. This survery has now run for over five years. During that time we saw 23 patients with incapacitating vertigo whom we thought should be offered surgery. Six to eight weeks later, 12 had had a dramatic improvement in vertigo, most not having had any further attacks. Eleven of these have continued to be free from incapacitating vertigo. Two who had not settled by the first review have subsequently done so. What is happening? Maybe the indications for surgery are too low, but we don't think so. Maybe the incidence of attacks of vertigo in Meniere's disease reaches a crescendo just before going into remission and we are catching that point. Maybe something physical happens within the inner ear. Are we simply looking at the natural history of the disease and is this what is happening with the so called conservative operations? Continued follow up is required to find out how this group will do in the long term.