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Patients who have intractable vestibular symptoms (imbalance) and unremitting attacks of vertigo even after treatment with medication are usually considered candidates for surgery. While surgery may help vertigo, it is not associated with improvement in hearing, tinnitus, or aural fullness. The goal of surgery for Meniere's disease is to relieve vertigo while preserving hearing as much as possible. The risks of surgical treatment, especially the potential for exacerbating hearing loss, must be weighed against the severity of distress caused by the vertigo attacks. Some of the risk factors that a patient must consider before choosing one type of surgery over another include:

• Level of residual hearing in the affected ear
• Level of hearing in the contralateral ear
• Intensity of vertigo
• Surgical outcomes
• Postsurgical quality of life
• Age
• Health status

Regardless of the surgical procedure the patient may ultimately choose, it is of utmost importance that they choose a neurosurgeon or otologic (ear) surgeon who has considerable experience with that particular procedure. The lowest complication rates of surgical procedures are associated with highly trained surgeons and medical institutions that have experience caring for patients that undergo that procedure. Currently, there are no universally accepted guidelines regarding which surgical procedure should be performed before trying another and recommendations are based typically on the experience of the surgeon or otolaryngologist, risk factors mentioned above, and patient preference.

There are two basic types of surgical procedure used to control vertigo attacks in patients with Meniere's disease:

• Conservative surgical procedures
• Ablative (destructive) procedures

Conservative Surgical Procedures

Conservative surgery is performed in an attempt to keep all organs of the inner ear intact while controlling vertigo and preserving the patient's hearing and vestibular function.

Endolymphatic Sac Surgery

Endolymphatic sac surgery is the most conservative of the surgical procedures for Meniere's disease. It aims to reverse endolymphatic pressure while preserving hearing. It is an outpatient procedure that takes about 1 to 2 hours. Typically the recovery period is short and some people go back to work within several weeks (average 1-2 weeks).

Candidates for this surgery include patients who experience:

• Early unilateral Meniere's disease
• Intractable (not responsive to medical therapy), frequent, and severe vertigo
• Fluctuations in hearing

The operation has several variations and is designed to decompress the endolymphatic sac from overlying bone and/or place a stent to aid in drainage of excess endolymphatic fluid. The restoration of normal pressure is thought to relieve vertigo symptoms. Although this operation has the lowest chance for major complications, it is also the least effective.

Symptom relief as described in the medical literature is highly variable and ranges from being very successful (up to 75% of patients) to being nothing more than a placebo effect. Up to 60% of patients report significant vertigo control at 2-5 years. Approximately 75% of the patients who have this operation do not feel the need to proceed with more aggressive surgical options. Surgical decompression has little or no affect on hearing and/or balance.

The major advantages of this surgical procedure include: