Meniere's disease

Slides were prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal , for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology.
A clear and concise explanation of the basic concepts in the subject matter concerned.
He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students

1. Meniere’s Disease
Dr. Krishna Koirala
8/6/2020

2. Define Meniere’s disease
•Symptomtriadofrecurrentepisodesofvertigo
ofsuddenonset,tinnitus,hearinglossand
auralfullnesswithendolymphatichydropsas
theprincipalpathologicalfeature

3. Normal membranous labyrinth Endolymphatic Hydrops

4. What is the etiology of Meniere's disease?
What is Meniere’s syndrome? List the
causes of Meniere’s syndrome

5. Meniere’s Disease (Idiopathic Endolymphatic
Hydrops)
Increased Production of Endolymph
–Allergy
–Autoimmune
–Endocrine : Hypothyroidism,
Hypopituitarism, Diabetes,
Hyperlipoproteinemia
–Increased sympathetic activity
–Sodium and water retention
–Viral infection
•Decreased Absorption of
Endolymph
−Inner ear trauma
−Ischemia of endolymphatic sac
−Obstruction of endolymphatic
sac / duct
−Small size of endolymphatic
sac / duct

6. Secondary Endolymphatic Hydrops
(Meniere Syndrome)
•Clinically resembles Meniere’s Disease
−Chronic Otitis Media
−Cogan syndrome
−Leukemia
−Otosclerosis
−Post-stapedectomy
−Syphilis

7. Discuss the pathology of Meniere’s
disease.

8. •MembraneRuptureTheory
–EndolymphatichydropsRuptureofmembranous
labyrinthPotassiumrichendolymph(toxicto
neuraltissues)getsmixedwithperilymph
Sustaineddepolarizationandinactivationofthe
haircellsandneuronsoftheVIIInervebathedin
perilymph
•IncreasedSympatheticactivity
–Ischemiaofcochlear&vestibularendorgans
deafness+vertigo

9. Write down the clinical features of Meniere’s
disease
•Age:30-60years,F>M,Unilateral>Bilateral
•Vertigo
–Suddenonset,episodic,rotatory,lastingfor24minutesto
24hrs,associatedwithnausea,vomiting&diaphoresis
withnormallevelofconsciousnessandorientation
–Vertigocausedbyloud,lowfrequencysoundTulio
phenomenon

10. •Deafness:
–Accompaniesvertigoandimprovesaftervertigo
attack(fluctuant),sensorineural,progressive
–Intolerancetoloudsound(duetorecruitment)
–Distortionofsoundfrequency (Diplacusis
BinauralisDysharmonica)

11. •Tinnitus
–Low-pitched, roaring, non-pulsatile, intermittent or
continuous
–Increases during vertigo attacks
•Aural fullness
–Fluctuating , not relieved by swallowing
•Emotional upset and anxiety/depression

12. AAO-HNS Diagnostic Criteria (1995)
A. Vertigo:Spontaneous, >2 episodes lasting > 20 min
B. Audiogram documented sensorineural deafness
C. Tinnitus or Aural fullness in diseased ear
D. Other cases excluded

13. Meniere’s Disease variants
•Lermoyez reverse Meniere syndrome
–Deafness and tinnitus vertigo hearing improves
•Tumarkin's otolitic Catastrophe (drop attack Meniere's)
–Patient falls without vertigo / loss of consciousness
•Cochlear hydrops
–Deafness & tinnitus only
•Vestibular hydrops: vertigo only ( mimics BPPV)

14. Examination
•Otoscopy:normaltympanicmembrane
•Rinnetest:Positive(A.C.>B.C.)
•Webertest:lateralizestowardsbetterear
•A.B.C.test:reducedindiseasedear
•Nystagmus:beatstowardsaffectedearinitially
(Irritative),thentothehealthyear(Paralytic),and
againbeatingtowardstheaffectedear(Recovery)

15. Rising Curve
(7% ): Low
frequency
sensorineural
deafness
Discuss the investigations of Meniere’s disease
Flat(42%):
Uniform
sensorineural
deafness
Downsloping
curve(19%):
Sensorineural
deafnessmorein
highfrequency
•Pure Tone Audiometry

16. •Speech Audiometry
–Score 50 -80 %
•A.B.L.B.
–Presence of Recruitment
(Rapid increase in loudness
above the Threshold level)

17. •S.I.S.I.:Positive(>70%score)
–Presentationofatone20dBabovethreshold,
followedbyaseriesof200millisecondtones1dB
louder
–Percentageofsmallincrementsdetectedbythe
subjectisthesmallincrementsensitivityindex
–Perceptionoftheseincrementsindicatescochlear
damage
•ToneDecayTest:Negative(decay<20dB)

18. AP represents the summed response of the synchronous firing of
the nerve fibers
SP is thedirect current(DC) response of the hair cells as they move
in conjunction with the basilar membrane

19. •Transtympanic Electro-cochleography
–Summation Potential : Compound Action Potential
ratio > 30 %
–Widened waveform of SP/ AP complex (>2 mS)
–Distorted cochlear microphonics

21. •Bithermal Caloric Test
•Ipsilateral canal paresis in 75 % cases
•Contralateral directional preponderance
•Glycerol Test
•Do P.T.A. & speech audiogram
•Glycerol (1 .5 ml / Kg), mixed in lemon juice given orally
and audiometry repeated after 2 hrs
•Test is positive if
•Pure Tone threshold improves > 10 dB
•Speech Discrimination Score increases > 15 %
•S.P. / A.P. ratio in ECOG > 15 %

22. Treatment

23. Discuss the treatment of acute attack of
Meniere’s disease
•Reassurance,bedrest,headsupport
•Vestibularsedatives
–Inj.Prochlorperazine(Stemetil):12.5mgI.V.,
T.I.D.
–Inj.Promethazine(Phenergan):25mgI.V.,T.I.D.
–Inj.Diazepam(Calmpose):5mgI.V.stat
•IntravenousFluids

24. Non-surgical treatment
•Discussion
•Reassurance
•Avoidtea,coffee,chocolate,allergens,stress,
smoking,alcohol
•Diet
•Lowsalt(1.5g/day),lessfluids,Exercise
•VestibularDepressants
•Cinnarizine,Prochlorperazine

25. •Cochlear Vasodilators
•Betahistine, Xanthinol nicotinate, Carbogen (5 % CO
2
+ 95
% O
2
), L.M.W. Dextran, Histamine drip
•Diuretics
•Thiazide + Triamterene
•Dexamethasone / Ig G
•Decreases auto-immunity
•Dehydration by hyperosmolar fluids
•Hormone replacement therapy

26. Meniett Device
•Lowpressurepulsegenerator
•Pressurepulsestransmittedto
roundwindowviagrommet
displacesendolymphandthus
relievesendolymphatichydrops
•Usedfor5min,TID

27. Chemical Labyrinthectomy
•Transtympanicinjectionofototoxicdrugs
•Intra-tympanicdruginstillationviagrommetor
Silversteinmicrowick
•Trans-tympanicdrugperfusion
•Drugsusedare
−Gentamicin(vestibulotoxic)
−Dexamethasone(anti-inflammatory)

28. Trans-tympanic injectionIntra-tympanic instillation

29. Silverstein microwick

30. Trans-tympanic Drug perfusion

31. Surgical Treatment:
•Endolymphatic sac decompression
•Endolymphatic sac shunting into subarachnoid space or
mastoid cavity
•Sacculotomy
–Fick’s needle puncture of footplate
–Cody’s tack puncture of footplate
•Cochlear duct piercing via round window

32. Decompression Surgery

33. Vestibular Surgery
•Denervation of vestibule by vestibular neurectomy
via middle cranial fossa
•Destruction of vestibule (via round window or lateral
semicircular canal) by cryo -probe or ultrasound
probe

34. Vestibular Destruction
Ultrasound Probe

35. Vestibular Neurectomy

36. Total Destructive Surgery
•Destroys both cochlear & vestibular functions
•Done in patients with severe deafness
•Types of surgery are
–Section of vestibular + cochlear nerves
–Total Labyrinthectomy

37. Total Destructive Surgery

38. Lines of Treatment

39. Treatment Ladder