43 Surgery for Vertigo Flashcards
What is the general role of surgery in the treatment of vertigo?
What is the general role of surgery in the treatment of vertigo?
Most forms of vertigo are not managed surgically. Management of patients with vertigo and balance disorders demands diagnostic acumen, clinical judgment, and both medical and surgical skills. The most important step in treating vertigo is correctly diagnosing the cause. Only then can appropriate treatment recommendations be made. Though surgery is an option for some causes of vertigo, often it is not the first treatment offered. Many patients with a condition amenable to surgical treatment can attain significant improvement with conservative measures alone. However, when patients are carefully selected surgical intervention can be highly successful.
What are the most common vertigo conditions with surgical options?
What are the most common vertigo conditions with surgical options?
- Meniere’s disease
- BPPV
- Superior semicircular canal dehiscence
What are some alternatives to surgery in patients with vertigo?
What are some alternatives to surgery in patients with vertigo?
As stated, the most important step in treating vertigo is identifying the correct cause. The appropriate nonsurgical treatment is dictated by an accurate diagnosis. Some common forms of conservative management include:
- Vestibular rehabilitation therapy
- Pharmacologic therapy (diuretics, migraine medications, vestibular suppressants)
- Dietary changes
- Canalith repositioning maneuvers
Which patients should be considered for surgical intervention?
Which patients should be considered for surgical intervention?
As a general rule, surgery should only be considered for the treatment of vertigo if a patient meets the following three criteria:
- Vertigo caused by unilateral peripheral vestibular dysfunction, with absolute certainty of which side is affected
- Vertigo must be disabling.
- No signs or symptoms of central vestibular system dysfunction that could impair postoperative vestibular compensation
How does American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) advise reporting of vertigo control in Ménière’s Disease?
How does AAO-HNS advise reporting of vertigo control in Ménière’s Disease?
18 to 24 months following treatment, divide the number of episodes per 6 months by the number of episodes in the 6 months prior to treatment.
- Grade A: Complete control (0%)
- Grade B: Substantial control (1% to 40%)
- Grade C: Partial control (41% to 80%)
- Grade D: No Control (81% to 120%)
- Grade E: Worse (>120%)
- Grade F: Secondary treatment required due to disabling vertigo
What are the surgical options for the treatment of Ménière’s disease?
What are the surgical options for the treatment of Ménière’s disease?
Procedures to control vertigo in Ménière’s disease can be divided into ablative and nonablative procedures. Ablative procedures include gentamicin middle ear injections, labyrinthectomy, and vestibular nerve section. The most common nonablative procedures are endolymphatic shunt surgery and intratympanic steroid perfusion. The ablative procedures have greater vertigo control rates than the nonablative procedures but require vestibular compensation to limit post-treatment disequilibrium
What are the possible types of endolymphatic shunt surgery?
What are the possible types of endolymphatic shunt surgery?
- Shunting: Placement of synthetic shunt to drain endolymph
- Drainage: Incision of the sac to allow endolymph drainage
- Decompression: To improve sac function of endolymph absorption
Describe the Sham Surgery Trial by Thomsen et al, 1981.
Describe the Sham Surgery Trial by Thomsen et al, 1981.
- Double-blinded placebo-control study
- Compared cortical mastoidectomy without decompression versus endolymphatic shunt
- Conclusion: “We are therefore of the opinion that the impact of surgery on the symptoms of Ménière’s disease is completely nonspecific and unrelated to the actual shunt procedure.”
What is a vestibular nerve section?
What is a vestibular nerve section?
A vestibular nerve section is a procedure in which the vestibular division of the eighth cranial nerve is selectively divided to remove vestibular function from the affected side (Figure 43-1). The approaches that can be used to perform vestibular nerve section include:
- Middle fossa
- Retrolabyrinthine
- Retrosigmoid
- Translabyrinthine
What are the potential complications of vestibular nerve section?
What are the potential complications of vestibular nerve section?
- Facial paralysis
- Hearing loss
- CSF leak
- Persistent disequilibrium
What is the most reliable treatment for vertigo due to Ménière’s disease?
What is the most reliable treatment for vertigo due to Ménière’s disease?
Labyrinthectomy is the most reliable surgical treatment, but hearing is sacrificed. In this procedure, all of the vestibular neuroepithelium can be removed. This effectively ends all aberrant information produced by the diseased ear, but hearing function cannot be preserved.
What is benign paroxysmal positional vertigo (BPPV) and when is the treatment surgical?
What is benign paroxysmal positional vertigo (BPPV) and when is the treatment surgical?
BPPV is a condition in which free-floating otolith particles within semicircular canals activate the canal ampulla and cause vertigo during head movements. These particles can often be repositioned with maneuvers such as the Epley maneuver. Recurrence is common but maneuvers can be repeated as often as needed. However, if the symptoms are intractable or recurrences are frequent, surgery can be considered. The surgical options available include:
- Posterior semicircular canal occlusion: This procedure plugs the posterior semicircular canal, preventing free-floating particles from activating the canal ampulla (Figure 43-2).
- Vestibular neurectomy: This procedure eliminates all vestibular function from the affected ear and is rarely used for BPPV.
- Singular neurectomy: This procedure removes the innervation to the posterior canal ampulla. It was the first surgical procedure for BPPV but is technically difficult and carries a significant risk of hearing loss.
What is Tullio’s phenomenon?
What is Tullio’s phenomenon?
- Sound-induced dizziness, vertigo, or nystagmus
- First described by Tullio in 1928. He demonstrated that fenestration of the bony labyrinth renders it sound sensitive.
- Can also happen in syphilis or Lyme disease
What is semicircular canal dehiscence?
What is semicircular canal dehiscence?
Semicircular canal dehiscence is a thinning or complete absence of the temporal bone overlying the superior semicircular canal (Figure 43-3).
What are the characteristic clinical symptoms of superior semicircular canal dehiscence (SSCD)?
What are the characteristic clinical symptoms of (SSCD)?
- Sound, pressure, or vibration induced vertigo
- Hearing loss: usually a low-frequency conductive loss with better than 0-dB bone conduction threshold
- Autophony (voice seems unusually loud) and a “blocked ear” feeling
