menieres disease

MENIERES DISEASEDr. Pradeep Divakaran Specialist ENT surgeon

Ménière disease was first described in 1861 by the French physician Prosper Ménière.

Endolymphatic hydrops Disorder of inner ear where the

endolymphatic system is distended

Episodic Vertigo low frequency SNHL Low pitched Tinnitus Aural Fullness

Characterised by

Distention of endolymphatic system

Affecting the cochlear duct and the saccule , and to some extent utricle and saccule

Pathology

Distention of endolymphatic system

Increased production or decreased absorption

Etiologies

Postulates are 1.defective absorption Ishemia of the endolymphatic sac poor vascularity and poor absorption

2. vasomotor disturbances

Sympathetic over activity - spasm of the of internal auditory artery – cochlear and vestibular neuroendothelial dysfunction (deafness and vertigo )

Etiology of MD is not known

Anoxia of stria vascularis- causes transudation and increased production of endolymph

3 . Allergy :food stuff or inhalant – inner ear produces excess endolymph

50% of MD suffering from allergy (food or inhalational )

4. Sodium and water retention : increased production of endolymph

5.Auto immune and viral etiologies

Vertigo episodic vertigo accopmpanied by nausea and vomiting

with nystagmus Sudden onset, comes in clusters with

spontaneous remission and for weeks months or years

Vagal disturbances abd. Cramps ,diarrhoea cold sweats . Pal;lor and bradycardia

Tullio phenomenon

Clinical features

Usually accompanies vertigo or may precede it fluctuating hearing loss- Normal hearing after

the attack and during remission Recurrent attacks leading to slow and

permanent deterioration of hearing Intolerance to loud sound

Hearing loss- SNHL

Low pitched roaring or hissing type Aggravated during attack May persists during remission

Change in the character of the tinnitus may be a warning symptom of a new attack

Tinnitus

It may accompany or precedes the vertigo

Aural fullness

Otoscopy normal Nystagmus only during acute attack TFT: SNHL

signs

PTA low frequency SNHL

INVESTIGATIONS

SPEECH AUDIOMETRY

55-85% is normally during remissions and much impaired during and immediately following attack

Recruitment positive

SISI better than 70%

Tone decay less than 20 db

Shows cochlear nature of the disease than retro cochlear

Special audiometry tests

Dehydrating agent ,when given orally will reduce endolymph

1.5mg /kg with water PTA and speech discrimination recorded

before and after 1-2 hours 10 db improvement in PTA 10 % gain in speech discrimination No improvement for tinnitus and sense of

fullness Diagnostic and prognostic value

Glycerol test

General measures Cessation of smoking Low salt diet Avoid excessive intake of water Avoid coffee tea and alcohol Stress releving methods Avoid activities requiring body balance Flying , underwater diving.heights

Management

Reassurance Bed rest Vestibular sedatives Prochlorperazine / promethazine Diazepam

Mangement of acute attack

Carbogen inhalation 5% co2 +95%o2 Histamine drip - histamine diphosphate

2.75mg dissolved in 500 ml glucose given IV

Vasodialators

Vestibular sedatives Prochoperazine 10 mg Vasodilators Diuretics Propantheline bromide Elimination of allergen Hormonal replacement Intratympanic gentamycin therapy

Mx of chronic phase

1. COSERVATIVE PROCEDURES 2. DESTRUCTIVE PROCEDURES

Surgical management

Endolymphatic sac decompression

CONSERVATIVE PROCEDURES

Endolymphatic shunt operation

Sacculotomy

Vestibular nerve section

Ultrasonic destruction of vestibular labyrinth

Labyrinthectomy 1.Through LSCC By transmastoid approach 2. Oval window through trans canal approach

Destructive procedure

MENIETT DEVICE