Surgical Therapy for Vertigo Attacks in Meniere's Disease
Patients who have intractable vestibular symptoms and unremitting attacks of vertigo even after treatment with medication, are usually considered candidates for surgery. While surgery may help vestibular symptoms, it usually has little effect on hearing loss, tinnitus, or aural fullness, though some types of surgery are reported to modestly improve hearing. 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 attacks.
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
These procedures are used in an attempt to preserve hearing function and include:
- Decompression of the endolymphatic sac
- Vestibular neurectomy
- The Meniett pump
Decompression of the Endolymphatic Sac
This is an outpatient procedure that takes about 1 to 2 hours. The operation is designed to uncover the endolymphatic sac. The sac is opened and either stented, uncovered or decompressed, or even removed. Although this operation has the lowest chance for major complications, it is also the least effective overall. The percentage of patients with significant vertigo control at 2-5 years is 50%. Approximately 75% of the patients who have this operation do not feel the need to proceed with more aggressive surgical options.
The most common complications with this procedure are bleeding, infection, hearing loss (5%), persistent balance problems (50%), facial nerve injury with resultant facial paralysis (1:1000), change or loss of sense of taste, cerebrospinal fluid leak, meningitis (both very rare), and no improvement in vertigo attacks (50%). Typically the recovery period is short and some people go back to work within several days (on average, within 1-2 weeks). Some have suggested that this operation is no better than a placebo procedure and that it should not be done at all. However, surveys of neuro-otologists indicate that it is still the most commonly done procedure.
This procedure takes approximately 3-4 hours and involves severing the vestibular nerve, which destroys the balance mechanism in that ear but usually preserves hearing. It requires a stay in the intensive care unit (usually overnight) and then a 3-7 day hospital admission. Patients will usually experience a severe attack of vertigo that gradually improves. The quicker the patient is up and walking, the faster the recovery. The percentage of patients with significant vertigo control at 2-5 years is 91-93%.
Complications to consider are bleeding, infection, hearing loss (10%), persistent vertigo (3-7%), facial nerve injury with resultant facial paralysis (1:1000), and change or loss of sense of taste. The risk of cerebrospinal fluid leakage and meningitis are higher with this procedure than with others because of working inside the brain. The return to work is usually within 4-8 weeks. Typically, the younger the patient, the more rapid the recovery. Many patients report that even years after surgery, they may still feel dizzy with a rapid head turn or if they step off a curb.