1. DR.KAUSHIK SUTRADHAR
PGT , DEPTT. OF ENT

2. is a disorder of the inner ear characterized by
 Acute rotatory vertigo which is unpredictible,
precipitous in nature associated with nausea
and/or vomiting.
 Hearing loss which is unilateral low-tone
fluctuant sensorineural
 Tinnitus
 Aural fullness

3.  1747 – Antonio Scarpa described anatomy of
membranous labyrinth
 1861 – Prosper Meniere described the classic
features of Meniere’s disease & attributed it to
labyrinthine causes
 1871 – Knappin theorized that dilated
membranous labyrinth to be the cause of this
disorder
 1927 – Guild described endolymphatic ciruclation
 1938 – Hallpike and Portmann described
pathology of Meniere’s disease by studying
temporal bones

6. Type I
(aka inner)
Type II
(aka outer)
With
Kinocilium
VESTIBULAR HAIR CELLS

8. • Perilymph is similar in composition to
CSF (Containing high Na and low K ions)
• Endolymph similar in composition to
intracellular fluid (Containing low Na and
high K concentration). It is secreted by
stria vascularis

9. 1.Secretory function
2.Absorptive function
3.Immune / defense function

10.  Roughly 1 in 1000 individuals are affected
 Constitutes 10% of all patients attending
vertigo clinic
 Female preponderance
 Rare in children under the age of 10
 Commonly begins between 4th and 5th
decades of life
 Bilateral Meniere’s syndrome is seen in 5% of
these patients

11.  Idiopathic
 Anatomical (small vestibular aqueduct)
 Viral infection (HSV type 1)
 Traumatic (physical, acoustic)
 Allergy
 Autoimmunity
 CSOM
 Syphilis
 Otosclerosis

12.  Longitudinal flow
 Radial flow
 Dynamic flow

13.  Was first proposed by Guild
 Striavascularis is the principal source
 This is a slow process
 Elimination occurs at the endolymphatic sac
level

14.  This is active process (energy consuming)
 Production occurs from dark vestibular cells &
planum semilunatum
 Absorption occurs at the stria vestibularis

15.  First proposed by Lawrence
 This is a combination of both longitudinal
and radial flow patterns

17.  Endolymphatic hydrops causes distortion of
membranous labyrinth
 Pressure building up in the scala media may
cause mirco ruptures of membranous
labyrinth
 This would account for the episodic nature of
the attacks
 Healing of these ruptures causes resolution of
the disorder

18.  Small amounts of excess endolymph can be
cleared by radial flow
 Larger volumes need longitudinal flow for
their clearance
 Endolymphatic sinus temporarily
accommodates excess endolymph till the sac
is ready for it
 Endolymphatic valve of Bast isolates pars
superior and prevents endolymph from
draining out of the utricle

19. The excess volume
tends to accumulate in
the apical end of the
cochlea, where the
membranes are more
lax than elsewhere,
even though the
endolymph pressure
would be similar
elsewhere in the
cochlea.

20. 1.Stage I – Patient has solely cochlear
symptoms
2. Stages II – IV – Patients have progressively
more cochlear and vestibular symptoms
3. Stage V – End stage Meniere’s disease
(dead ear)

21.  Classical Meniere’s disease
 Vestibular Meniere’s disease – vestibular
symptoms and aural pressure
 Cochlear Meniere’s disease – cochlear
symptoms and aural pressure
 Lermoyez syndrome – Reverse Meniere’s
 Tumarkin’s crisis – Utricular Meniere’s

22.  variant of Meniere’s disease
 sudden sensorineural hearing loss, which
improves during or immediately after the
attack of vertigo.
 Cause is sudden spasm of the labyrinthine
artery followed by immediate dilatation

23.  AKA Tumarkin’s drop attacks
 abrupt falling attacks of brief duration
without loss of consciousness.
 due to an enlarging utricle due to excess
endolymphatic volume

24.  Sensori neural in nature
 Fluctuating and progressive
 Affects low frequencies
 Mild low frequency conductive hearing loss
(rare)
 Profound sensori neural hearing loss (End
stage)

25.  Roaring in nature
 Could be continuous / intermittent
 Non pulsatile in nature
 Frequency of tinnitus corresponds to the
region of cochlea which has suffered the
maximum damage

26. Possible Meniere’s disease:
 Episodic vertigo without hearing loss or
 Sensorineural hearing loss, fluctuating or fixed with
dysequilibrium, but without definite episodes
 Other causes excluded
Probable Meniere’s disease:
 One definitive episode of spontaneous vertigo
 Audiometrically documented hearing loss at least during one
attack
 Tinnitus and aural fullness in the affected ear
Definitive Meniere’s disease
 Two or more definitive episodes of spontaneous vertigo one
atleast lasting for 20 mins.
Audiometrically documented hearing loss at least on
one occasion.
 Tinnitus and aural fullness in the affected ear

27.  History
1. Nature of the sensation
2. Timing of the initial spell
3. Frequency and duration of the symptoms
4. Precipitating factors
 Vestibular tests
 Complete Haemogram
 Audiometry
 Loudness recruiment
 VEMP
 Dehydration tests
 Posturography
 Electronystagmography

28.  This is abnormal growth in the perceived
intensity of sound
 This is usually positive in patients with
Meniere’s disease
 ABLB is the test used to look for the presence
of recruitment
 This test is really time consuming

29.  Alternate Binaural loudness balance test
 Tone is presented alternately between the two
ears. The level of the tone stays the same in one
ear (i.e. fixed ear) and is varied up / down in the
other ear (i.e. variable ear). The patient is asked to
report when the sound is louder in the right ear,
louder in the left ear, and when it sounds equal in
both ears.
 Loudness balance is said to have been obtained
when the patient indicates that the sound is heard
equally in both ears. The tester then records the
two levels in dB hearing level where the balance
has occurred.

30.  Increased summating potential / action
potential ratio. 1:3 is normal
 Widened summating potential / action
potential complex. A widening of greater
than 2 ms is significant
 Small distorted cochlear microphonics

31.  Vestibular evoked myogenic potential
 Measures the relaxation of sternomastoid muscle in
response to ipsilateral click stimulus
 Brief high intensity ipsilateral clicks produce large
short latency inhibitory potentials (VEMP) in the
toncially contracted Ipsilateral sternomastoid muscle
 This test is due to the presence of vestibulo collic
reflex
 Afferent arises from sound responsive cells in the
saccule, conducted via the inferior vestibular nerve.
 Efferent is via vestibulo spinal tract
 Normal responses are composed of biphasic
(positive-negative) waves
 VEMP reveals saccular dysfunction

32.  Glycerol
 Mannitol
 Frusemide
 Isosorbide
 These tests involve the subject ingesting
glycerol or mannitol and observing for a
change in symptoms and a measurable
improvement in hearing
Tests are positive if there is pure tone
improvement of 10dB or more at two / more
frequencies between 200-2000Hz

33.  First introduced by Klockhoff and Lindblom –
1966
 Glycerol is administered in doses of 1.5 mg/kg
body wt in empty stomach
 Serum osmolality should increase at least by 10
mos/kg
 Side effects include Headache, Nausea, vomiting,
drowsiness
 PTA is performed 2-3 hours after administration
 False positivity is rare
 Positivity depends on the phase of the disease

34.  Antibodies to 68-kDa protein has been noted
in many patients with meniere’s disease

37. the aim is to decrease the production or accumulation of
the endolymph
CONSERATIVE
 Dietary sodium restriction (1mg/day)
 Restriction of caffeine and nicotine like substances
 Diuretics like bendroflurazide,dyazide, chlorthalidone
 Betahistine
histamine analogue with weak H1, H2 agonistic and
moderate H3 antagonistic action
causes improved microvascular circulation in striae
vascularis
inhibition of vestibular nuclei activity
 Calcium agonists

38.  Steroids
1. Topical application via tympanostomy tubes
2. Shea et al reported 35.4% hearing
improvement and complete vertigo control
in 63.4% cases treated with 16 mg
intratympanic and 16 mg i.v.
dexamethasone for three consecutive days
followed by oral dexamethasone
3. Silverstein microwick can be used for
intratympanic drug administration

39.  Intratympanic injection of aminoglycosides
a form of chemical labyrinthectomy,
gentamycin therapy ablates the vestibular
“dark cells” of the secretory epithelium thus
decreasing endolymph production
response to this is measured by in response
to rapid, rotatory head thrusts
 Alternobaric oxygen therapy

40.  Local overpressure therapy by means of Meniett
device which applies intermittent micropressure
to the inner ear via a tympanostomy tube

41. 1. Diagnosis should be confirmed
2. Ventilation tube should be inserted
3. Patient should be trained for self
administration of the treatment
4. Usually administered thrice a day about 5
mins each time
5. Treatment lasts for 5 weeks

42. 1. Classic unilateral Meniere’s disease
2. Intense vestibular / cochlear symptoms
3. Failed medical therapy
4. Over 65 years of age
5. Imbalance / aural fullness / tinnitus after
gentamycin treatment

43. 1. Perilymph fistula
2. Acoustic neuroma / brain tumor
3. Retrocochlear damage
4. Low pressure hydrocephalus

44. 1. Isordil
2. ϒ – globulin
3. Urea
4. Glycerol
5. Lithium
6. Anticholinergics – Glycopyrrolate 1-2 mg /day
7. Antidopaminergics – Droperidol 2.5 – 10 mg orally /
day
8. Leuprolide acetate – Blocks normal sex hormone
production
9. Innovar – A combination of droperidol and fentanyl
can be used to suppress vestibular symptoms (can
replace endolymphatic sac surgery)

45.  Endolymph decompression
 First described by portmann 1926
 Via the round window by otic-periotic shunt that
perforates the basilar membrane
 Cochleosacculotomy creates a fracture dislocation of
osseous spiral lamina
both these procedures have highdegree of hearing
loss
1. Helpful in treating debilitated patients
2. Involves disruption of osseous spiral lamina
3. Angular pick introduced via round window towards
oval window. It will accommodate 3 mm long pick
4. After perforation the pick is withdrawn and the round
window is sealed by fat

46.  Simple decompression
 Cannulation of endolymphatic duct
 Endolymphatic drainage to the subarachnoid
space
 Drainage to mastoid
 Removal of extraosseous portion of the sac

47. 1. Labyrinthectomy
2. Translabyrinthine vestibular neurectomy
3. Retrolabyrinthine vestibular neurinectomy
4. Retrosigmoid vestibular neurinectomy
5. Middle cranial fossa vestibular neurinectomy

48.  Vestibular neurectomy
1. more complete vertigo control than shunt
procedures
2. Lower risk of hearing loss than gentamicin
therapy
3. Middle fossa approach, risk of facial nerve
injury is higher
4. Suboccipital approach
 Labyrinthectomy
1. Transcanal approach
2. Transmastoid approach, more common

49.  Vestibular rehabilatation
Cawthorne-Cooksey exercises