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Medical Treatment
Once a diagnosis of Meniere’s disease is established, non-surgical treatments are attempted as first-line therapy to control the vertigo and other symptoms. Lifestyle modifications are recommended, including a low salt diet, reduction/avoidance of caffeine and alcohol, and control of stress. Medications such as a diuretic (water pill) may be prescribed to eliminate excess fluid. Since Meniere’s disease can be precipitated by environmental and food allergies, allergy testing and treatment are often recommended. While medications can be given during times of disabling vertigo episodes (e.g. Meclizine/Antivert, Phenergan, and Valium), it is best to otherwise avoid vertigo suppressant medications since they can delay overall recovery. Vestibular rehabilitation by a specially trained therapist has been proven to be extremely useful in speeding recovery and improving balance.
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Surgical Treatment
For many sufferers of Meniere’s disease, reasonable control of the symptoms can be attained with medical therapy as described above. However, for some individuals adequate relief cannot be achieved without surgical intervention. Several surgical alternatives exist which vary in invasiveness, affects on hearing, and rate of success. Surgical options include Gentamicin treatment of the inner ear, endolymphatic sac surgery, vestibular neurectomy, and labyrinthectomy. Your physician will determine surgical options based largely upon the severity of the vertigo and other Meniere’s symptoms, hearing status, condition of the unaffected ear, and overall medical status. If Meniere’s disease is present in both ears, surgical treatment is typically not used due to the possibility of complete loss of vestibular and/or hearing function in both ears.
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Minimally Invasive MicroWick Treatment
The ideal surgical treatment should be minimally invasive, require no more than local anesthesia, and have low chances of side effects, such as hearing loss. In response to these goals, a minimally invasive procedure involving perfusion of the inner ear with medications has been extensively researched, becoming the most popular surgical treatment of Meniere’s disease over the past decade. The goal of the procedure is to treat the affected ear with a drug toxic to the vestibular (balance) system to induce a complete vestibular deficit on the treated side while minimizing hearing loss. If this goal is achieved, the elimination of the fluctuating vestibular inputs from the diseased inner ear to the brain eliminates associated feelings of vertigo, thus allowing the opposite ear to take over for balance. The advantages of placing medications directly into the inner ear include: 1) the diseased ear is treated directly without affecting the entire body; 2) a higher inner ear concentration of medication can be obtained; and 3) general body side effects of the drug are prevented.
A new technique to perfuse the inner ear involves use of endoscopes and the Silverstein MicroWick, a medication delivery device approved by the FDA in 1999. Dr. Jackson has extensively researched the applications and results of the MicroWick, resulting in numerous publications and several chapters in his recently published book on minimally invasive ear surgery. The MicroWick is a sponge-like device that allows direct and precise delivery of medication to the round window membrane, which separates the middle and inner ear. When the patient self-administers the medication into the ear canal, the MicroWick absorbs the medication and transports it to the round window membrane where it perfuses directly into the inner ear fluids. This method is similar to the current concept of self-treatment for eye disease using medicated eye drops.
The MicroWick placement procedure can be performed in the office using local anesthesia, thus avoiding the inconvenience, time, and cost of an operating room. As a first step, a small 2 mm hole is created in the eardrum overlying the round window membrane. The middle ear is examined with an endoscope to determine if there are any obstructing membranes over the round window which might prevent the instilled medications from reaching the inner ear. Any such membranes are removed if present. A small ventilation tube is inserted into the eardrum opening, and the MicroWick is placed. The MicroWick is saturated with the drug Gentamicin, allowing delivery of a high concentration of medication to the round window membrane for perfusion into the inner ear fluids. Patients are directed to self-administer medication from an ear dropper bottle into the ear three times daily.
At the end of each treatment week, hearing and vestibular/balance testing are completed, followed by a visit with the physician. The usual length of treatment is 2-4 weeks. When the physician deems appropriate, the MicroWick and tube are removed in the office and the treatment is complete.
As indicated in our studies and publications, of 92 patients with Meniere’s disease who used the MicroWick to self-treat the inner ear with Gentamicin, vertigo symptoms were relieved in 85% of the patients. Pressure in the ear was relieved or improved in 67%, while tinnitus was relieved or improved in 57% of patients. While 36% of patients experienced progression of their hearing loss in the treated ear, the majority was not bothered by the worsened hearing as long as the vertigo was relieved. In summary, this new technique of patient self-treatment using the MicroWick to deliver medications to the inner ear is minimally invasive, inexpensive, safe, effective, and well tolerated for treating Meniere’s disease and other inner ear conditions.
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Endolymphatic Sac Surgery
A surgical treatment for Meniere’s disease which is nondestructive to hearing and balance includes the endolymphatic sac procedures. The goal of these procedures is to relieve inner ear fluid pressure. The benefits of these procedures are debated in the medical literature. At the Ear Institute of Texas, the surgeons do not routinely use endolymphatic sac procedures based upon their current review of the medical literature.
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Vestibular Neurectomy
If disabling vertigo persists in Meniere’s disease despite one or more treatments with Gentamicin perfusion of the inner ear, other more aggressive surgical alternatives exist. If hearing is still at a useful level, posterior fossa microsurgical vestibular neurectomy is highly successful at eliminating vertigo while allowing hearing preservation. The goal of the procedure is to cut the balance nerve between the inner ear and brainstem, which stops the brain from receiving abnormal impulses from the diseased inner ear.
The procedure is frequently performed by both a neurotologist and neurosurgeon. After the nerves are exposed near the brainstem, the surgeons must use high-powered magnification to identify the separation between the hearing and balance portions of the eighth cranial nerve. The balance (vestibular) nerve is selectively transected. After the surgery, the patient is kept in the hospital to recover for usually a 3-5 day period. Patients are expected to experience a short (1-2 day) period of vertigo, which is aggressively treated with medications. Prolonged imbalance may persist, which is usually effectively treated with vestibular therapy.
Vertigo cure rates have been excellent after vestibular neurectomy, with 93% of patients reporting that they are free of vertigo and would recommend the procedure to another patient. Hearing preservation rates have been excellent. Although vestibular neurectomy is an invasive neurosurgical type operation, complication rates have been minimal.
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Labyrinthectomy
When hearing is poor and not worth saving, labyrinthectomy is a recommended treatment for controlling vertigo. The procedure involves removal of the inner ear membranes, once again to keep the abnormal inputs from the diseased inner ear from reaching the brain. The surgery can be performed through the ear canal or through a mastoidectomy approach. The vertigo cure rates are very high, but complete loss of hearing in the treated ear is expected since the inner ear is destroyed. A short period of vertigo is expected after the operation, and for this reason patients are kept in the hospital and treated with anti-vertigo medications for usually 1-3 days after the operation. Vestibular therapy hastens recovery of balance function following the surgery.
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Risks and Potential Complications
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Summary
At the Ear Institute of Texas, we can offer patients with Meniere’s disease a variety of effective medical and surgical treatment options. When the vertigo of Meniere’s disease is disabling and is not controlled with medical therapy, we offer a wide range of surgical treatment options, including innovative new surgical techniques. These techniques range from new minimally invasive endoscopic procedures to neurosurgical operations. Meniere’s patients no longer need to hear the old adage, "you have to learn to live with it.'' Today, we can offer patients a high chance of relief from vertigo.
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