Meniere’s DiseaseMeniere’s Disease

DEFINITIONDEFINITION

Disease of inner earDisease of inner ear

Distention of endolymphatic systemDistention of endolymphatic system VertigoVertigo Sensorineural hearing lossSensorineural hearing loss TinnitusTinnitus

HistoryHistory1861 – Prosper Meniere 1861 – Prosper Meniere describes classic symptomsdescribes classic symptoms

1938 – Hallpike and Portman 1938 – Hallpike and Portman confirm endolymphatic hydropsconfirm endolymphatic hydrops

AGE AGE DISTRIBUTIONDISTRIBUTION AND AND INCIDENCEINCIDENCE

35-60 yrs35-60 yrs

Females : Male 3:2Females : Male 3:2

FamilialFamilial

Unilateral / bilateralUnilateral / bilateral

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Normal membranous labyrinth Dilated membranous labyrinth in Meniere's disease (Hydrops)

PathophysiologyPathophysiology

Theories behind endolymphatic hydropsTheories behind endolymphatic hydrops Obstruction of endolymphatic duct/sacObstruction of endolymphatic duct/sac Hypoplasia of endolymphatic duct/sacHypoplasia of endolymphatic duct/sac Alteration of absorption of endolymphAlteration of absorption of endolymph Alteration in production of endolymphAlteration in production of endolymph Autoimmune insult Autoimmune insult Vascular originVascular origin Viral etiologyViral etiology

AETIOLOGY (primary causes)AETIOLOGY (primary causes)

GeneticGenetic

Anatomical (small vestibular aqueduct)Anatomical (small vestibular aqueduct)

Traumatic (physical, acoustic)Traumatic (physical, acoustic)

Viral infection (HSV type 1)Viral infection (HSV type 1)

AllergyAllergy

AutoimmunityAutoimmunity

AETIOLOGY (secondary causes)AETIOLOGY (secondary causes)

Developmental insultDevelopmental insult

Metabolic statesMetabolic states (DM, hypothyroidism, hyperlipidaemia)(DM, hypothyroidism, hyperlipidaemia)

SyphilisSyphilis

CSOMCSOM

OtosclerosisOtosclerosis

Abnormal fluid balanceAbnormal fluid balance

CLINICAL FEATURESCLINICAL FEATURES

VertigoVertigo EpisodicEpisodic NystagmusNystagmus

Hearing lossHearing loss SensorineuralSensorineural ProgressiveProgressive

TinnitusTinnitus Continuous / intermittentContinuous / intermittent

Aural fullnessAural fullness

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Vestibular neuronitisVestibular neuronitis

Benign paroxysmal positional vertigoBenign paroxysmal positional vertigo

Vestibular schwannomaVestibular schwannoma

Vertibrobasilar insufficiencyVertibrobasilar insufficiency

EXAMINATIONEXAMINATION

Otoscopy:Otoscopy: NormalNormal

Nystagmus:Nystagmus: During acute attacksDuring acute attacks

Tuning fork tests:Tuning fork tests: RinnieRinnie PositivePositive WeberWeber Lateralized to better earLateralized to better ear ABCABC Reduced in affected earReduced in affected ear

Complete neurological examinationComplete neurological examination

INVESTIGATIONSINVESTIGATIONSAssessment of cochlear functionAssessment of cochlear function PTAPTA

Rising

Flat

Falling

INVESTIGATIONSINVESTIGATIONS

Speial audiometric testsSpeial audiometric tests

Evoked response audiometryEvoked response audiometry

Transtympanic electrocochleographyTranstympanic electrocochleography

INVESTIGATIONSINVESTIGATIONS

Assessment of vestibular functionAssessment of vestibular functionMetabolic screeningMetabolic screening CBC-ESRCBC-ESR UREA / ELETROLYTESUREA / ELETROLYTES VDRL / TPHAVDRL / TPHA BSRBSR GTTGTT CHOLESTEROL / TGCHOLESTEROL / TG TFTTFT

TREATMENTTREATMENT

MEDICAL TREATMENTMEDICAL TREATMENTAcute TherapyAcute Therapy

Medical TreatmentMedical TreatmentSymptomatic reliefSymptomatic relief Salt restrictionSalt restriction Avoid caffeine, nicotine, alcohol, high-Avoid caffeine, nicotine, alcohol, high-

carbohydrate substances, high-carbohydrate substances, high-cholesterol/triglyceride foodscholesterol/triglyceride foods

Vestibular suppressantsVestibular suppressants DiureticsDiuretics Vasodilators (Betahistine)Vasodilators (Betahistine) SteroidsSteroids

Hearing aidsHearing aids

Chemical ablation of Chemical ablation of vestibular functionvestibular function

Intratympanic gentamicin / streptomycinIntratympanic gentamicin / streptomycin

Surgical TherapySurgical Therapy

Endolymphatic Sac SurgeryEndolymphatic Sac Surgery

Decompression:Decompression:

Removal of bone overlying the sacRemoval of bone overlying the sac Shunting:Shunting:

Placement of synthetic shunt to drain Placement of synthetic shunt to drain endolymph into mastoidendolymph into mastoid

Drainage:Drainage:

Incision of the sac to allow drainageIncision of the sac to allow drainage Removal of sac:Removal of sac:

Excision of the sacExcision of the sac

Endolymphatic Sac SurgeryEndolymphatic Sac Surgery

Vestibular Nerve SectionVestibular Nerve Section

Approaches: Approaches: Middle FossaMiddle Fossa Retrolabyrinthine/RetrosigmoidRetrolabyrinthine/Retrosigmoid TranscanalTranscanal

ComplicationsComplications Damage to facial nerveDamage to facial nerve Damage to cochlear nerveDamage to cochlear nerve CSF leak (about 13%)CSF leak (about 13%)

Ultrasonic destruction of Ultrasonic destruction of vestibular labyrinthvestibular labyrinth

LabyrinthectomyLabyrinthectomy

Approaches: Approaches: TranscanalTranscanal TransmastoidTransmastoid

THANK YOUTHANK YOU