What is the invasive treatment for vertigo to restore hearing, especially in conditions like Meniere's disease?

Invasive Treatments for Vertigo in Meniere's Disease

For patients with Meniere's disease who have failed conservative therapy, intratympanic gentamicin is the preferred invasive treatment for controlling vertigo, while labyrinthectomy with potential cochlear implantation is the most definitive surgical option for patients with non-usable hearing. 1

Intratympanic Therapies (Less Invasive Options)

Intratympanic Gentamicin

• First-line invasive treatment for patients who have failed conservative therapies 1
• Achieves approximately 73.6% complete vertigo control rate across studies 2
• Works by chemical ablation of vestibular function while potentially preserving hearing 1
• Different administration methods include:
  • Titration therapy: highest efficacy (81.7% vertigo control) 1
  • Weekly titration: lowest hearing loss risk (13.1%) 1
  • Multiple daily dosing: higher risk of hearing loss (34.7%) 1
• Not recommended for patients with bilateral Meniere's disease due to risk of bilateral vestibular hypofunction 1

Intratympanic Steroids

• May be offered to patients with active Meniere's disease not responsive to non-invasive treatments 2
• Shows 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy 2
• Lower risk to hearing than gentamicin but may be less effective for vertigo control 3

Surgical Options (More Invasive)

Labyrinthectomy

• Most definitive surgical procedure for vertigo control (>95% success rate) 1
• Only recommended for patients with non-usable hearing (PTA >60 dB and speech discrimination <50%) 1
• Converts dynamic fluctuating disease to static state, eliminating vertigo attacks 1
• Particularly beneficial for patients with Tumarkin's otolithic crises (drop attacks) 1
• Case series show 97% complete vertigo control 1
• Major drawbacks include:
  • Complete hearing loss in the affected ear 1
  • Risk of prolonged postural instability 1
  • Possible worsening of tinnitus 1

Hearing Restoration After Labyrinthectomy

• Cochlear implantation can now be performed simultaneously with labyrinthectomy 1
• Some patients achieve high consonant-nucleus-consonant scores up to 85% with cochlear implants 1
• This approach reduces duration of deafness and provides hearing rehabilitation 1

Vestibular Nerve Section

• Alternative for patients with usable hearing who have failed less invasive treatments 1
• Success rates of approximately 85% for vertigo control 4
• May preserve residual hearing but carries risk of hearing deterioration 5
• Complications include facial nerve injury, headache, and risks associated with craniotomy 1
• Only recommended for select cases with active vertigo unresponsive to all therapies, usable hearing, no contralateral disease 1

Treatment Algorithm Based on Hearing Status

For Patients with Usable Hearing:

1. Start with intratympanic steroids 2, 3
2. If unsuccessful after 3 months, consider intratympanic gentamicin with careful titration 1, 3
3. If still unsuccessful, consider vestibular nerve section as last resort 3, 4

For Patients with Non-usable Hearing:

1. Intratympanic gentamicin as first invasive option 1, 3
2. If unsuccessful, proceed to labyrinthectomy (potentially with simultaneous cochlear implantation) 1, 3

Important Considerations

• Assess contralateral ear vestibular function before any ablative procedure to avoid bilateral vestibular hypofunction 1
• The absence of vestibular-evoked myogenic potentials (VEMPs) is a reliable predictor of vertigo control after gentamicin treatment 1
• Elderly patients or those with occupational requirements should have detailed discussion about potential for prolonged imbalance after ablative procedures 1
• Current Cochrane review indicates limited high-quality evidence for surgical interventions, highlighting the need for more rigorous studies 6
• Shared decision-making is essential, considering the patient's specific symptoms, hearing status, and quality of life impact 1