Surgery

In four out of five people non-surgical measures are sufficient to control symptoms. For those affected by long-term vestibular conditions (e.g. Ménière’s / endolymphatic hydrops), if the vertigo remains a problem there are several surgical procedures which can be undertaken to help control vertigo.

Surgery is considered when medical (non-surgical) management fails. There are a number of factors which need to be considered, such as how long have the symptoms been present and how frequent and severe are the vertigo attacks? 

Balance disorders are not fatal or terminal, but they do destroy quality of life, so the patient perspective should be considered. What is happening to the patient’s day-to-day life, their ability to work and their family and personal relationships? What are the emotional and psychological effects of what is happening to them?

The surgical therapy of Ménière’s disease include procedures which aim to (1) reverse the high fluid pressure, (2) destroy the balance organ but preserve the hearing or (3) destroy both balance and hearing.

Surgical Procedures:

Intratympanic Steroids

Steroids to treat Meniere’s are injected into the inner ear either directly through the eardrum or through a grommet. Injection directly into the inner ear produces a much higher concentration of the drug compared to the steroids being taken orally. Steroids work in an anti-inflammatory nature and may have an advantage over the gentamicin treatment as they are not known to decrease hearing or cause dizziness.
 
Read the results of the recent clinical trial in Refractory Ménière’s disease comparing Transtympanic Gentamicin vs. Transtympanic Steroids at Charing Cross Hospital.
 
Intratympanic Steroid Therapy Information Sheet

Intratympanic Gentamicin

Gentamicin is an antibiotic belonging to a family of drugs called aminoglycosides. Gentamicin aims to destroy the balance organ or reduce and modify its function so the patient does not get attacks dizziness. Gentamicin is usually administered by injection through the tympanic membrane using a variety of techniques. Some doctors place a plastic tube into the eardrum, others use a small pipe through which the drug is placed and others use a very fine needle to inject it through. Depending on the technique used, one or more treatments are given. The end result is a pool of gentamicin sitting in the middle ear. This passes through into the inner ear and destroys the cells that register movement in the balance organ. It is like cutting the wire leading from a faulty light switch thereby preventing the light from flashing on and off. The main side effect is loss of hearing in the treated ear only. For some the hearing loss may be mild, but may result in total hearing loss for some. Any hearing loss is usually permanent. In general those with more established or more advanced Ménière’s disease, those who already have poor hearing with little reversibility, therefore the patient would feel there is little less to lose if you do lose your hearing. To be considered for treatment the patient would have to have been correctly investigated to exclude any underlying condition that may mimic Ménière’s disease. The attacks would have to be severe and frequent enough to have a major impact on the quality of life. If a person only has one or two attacks a year, even if they are severe, then the effect of a treatment may be worse then the attack. Following the destruction of one balance organ the initial spinning dizziness is followed by a period of general unsteadiness. In elderly patients this can often take a long time to recover, and in a small number the balance may never fully recover for all areas of vigorous activity. Vestibular rehabilitation may be offered.
 
Patient Case Study
 
Read the results of the recent clinical trial in Refractory Ménière’s disease comparing Transtympanic Gentamicin vs. Transtympanic Steroids at Charing Cross Hospital.
 

Endolymphatic sac surgery

Endolymphatic sac surgery is a surgical operation on the endolymphatic sac of the inner ear. A small amount of bone is removed from around the endolymphatic sac, which aims to reduce the pressure of the fluid in the sac. The procedure is performed under general anaesthesia and there are several variations.

Labyrinthectomy

A labyrinthectomy is a surgical procedure which destroys both the hearing and vestibular functions of the inner ear. It is performed either by drilling out the bone and removing all of the labyrinth (known as an osseous labyrinthectomy), or by opening up the inner ear and destroying some of the soft tissue within it. There is about a 95-98% success rate of ending vertigo attacks with the labyrinthectomy. Deafness needs to be taken into consideration as this procedure destroys the hearing function, so a labyrinthectomy will not usually be offered if there is still good hearing in the affected ear.

Vestibular Neurectomy

The vestibular neurectomy is usually only offered as a last resort to the most severely affected patients. This procedure cuts the balance nerve to the brain. If repeated endolymphatic sac surgery and/or gentamicin fails and if there is still useful hearing in the ear then the neurectomy may be considered as an option. It requires specific expertise and training to do a vestibular neurectomy. The balance nerve is cut, preserving the hearing nerve. It is important to understand that there is an inherent risk of cutting the facial nerve as this is also in the same place as the hearing and balance nerves.

Grommets

A grommet is another name for a tympanostomy tube. Grommets are inserted into the eardrum to allow air into the middle ear space. There should be air in the middle ear space because it is connected at the back of the nose to the Eustachian tube. It is thought that it is possible that the pressure in the two systems might be different and grommets will allow that pressure to equalise. A grommet can be useful for disorders of the middle ear (the space behind the eardrum) and is commonly used for glue ear in children. Like all of the surgical interventions it is controversial and many people feel that it does not add any real evidence of success. Nonetheless there are patients who do seem to enter remission following grommet insertion. It’s also integral for patients who want to use the Meniett device.
 
There are different treatment measures to help you manage dizziness. It is important to discuss the treatments available with your health professional and find the best option for you. The Ménière's Society recommends that you always consult your GP, consultant or therapist for professional guidance before you begin, change, temporarily suspend or discontinue any treatment, medication, exercise or diet. The Society cannot advise on individual cases nor accept any liability resulting from the use of any treatments referred to on this website.

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