--- title: "Meniere's Disease Part 4 - Surgical Management" description: "ENT notes on Surgical Management of Meniere's Disease." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/menieres-disease-surgical-management-endolymphatic-sac-decompression" categories: ["Otology"] video: "https://www.youtube.com/watch?v=06YUwboQeDc" image: "https://media.theentresident.com/og-images/menieres-disease-surgical-management-endolymphatic-sac-decompression.png" --- # Meniere's Disease Part 4 - Surgical Management ENT notes on Surgical Management of Meniere's Disease. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=06YUwboQeDc ## 👂 Meniere's Disease - Surgical Management ### 🎯 Aims of Surgery 1️⃣ To **abolish or alter the function of the labyrinth** 2️⃣ To **modify the [underlying pathophysiology](https://www.theentresident.com/ent-notes-lectures/menieres-disease-causes-pathophysiology-pathology.md)** > What are the Factors Determining the Choice of Surgery in Meniere's disease? --- ### 📋 Classification of Surgical Options #### 1- Conservative Procedures (Hearing Preserved) * **Endolymphatic sac decompression** * Portmann's technique * Subarachnoid shunt (House) * Mastoid shunt (Arenberg, Morrison, Shea) * Modification of Hasegawa and Naito * Decompression without opening the sac (Shambaugh) * Paparella and Hanson technique * **Sacculotomy** * Fick's procedure * Cody's tack procedure * **Cochleosacculotomy** #### 2- Partially Destructive Procedures (Hearing Preserved) * **Vestibular nerve section** * Middle fossa approach * Retrosigmoid approach * Retrolabyrinthine approach * **Ultrasonic irradiation of the labyrinth** * **Cryosurgery** #### 3- Destructive Procedures (Hearing Not Preserved) * **Labyrinthectomy** * Transcanal approach * Transmastoid approach * **Destruction of the Scarpa's ganglion** * **Translabyrinthine section of the vestibular nerve** --- ### 🧠 Anatomy of the Endolymphatic Sac The endolymphatic sac is a **pear shaped structure** located in the **thickened portion of the posterior fossa dura**, **medial to the sigmoid sinus** and **inferior to the posterior semicircular canal**. > What are the Boundaries of the Endolymphatic Sac? > How will you identify the Endolymphatic Sac during surgery? > What is Donaldson's Line? What is the relation of Endolymphatic Sac to it? --- ### 🔍 Endolymphatic Sac Decompression (Portmann's Technique) ⭐ This is the **base technique**. All the modifications follow the same steps and differ only in the final step. **Steps** 1️⃣ **[Simple cortical mastoidectomy](https://www.theentresident.com/ent-notes-lectures/cortical-mastoidectomy.md)** 2️⃣ Identification of the four landmarks: | Order | Landmark | | --- | --- | | 1 | **Sigmoid sinus**, lying posteriorly | | 2 | **Antrum**, which is opened and enlarged, with the sigmoid sinus skeletonized and retrofacial cells exposed | | 3 | **Horizontal semicircular canal**, exposed as the aditus is opened | | 4 | **Posterior semicircular canal**, on drilling deeper | 3️⃣ **Skeletonization of the area medial to the sigmoid sinus and the mastoid segment of the facial nerve** 4️⃣ **Exposure of the posterior fossa dura** and identification of the **endolymphatic sac** 5️⃣ The dura is gently depressed away from the overlying bone of the posterior semicircular canal, noting the spot at which the dura mater is fixed to the bone of the canal by the duct 6️⃣ **Incision on the outer surface of the dura**, from behind forward 7️⃣ **Gel foam** placed in the depth of the operating field, a drain placed, and the wound closed > What is the Subarachnoid Shunt modification proposed to Endolymphatic sac decompression by House? > What is the Mastoid Shunt modification proposed to Endolymphatic sac decompression by Arenberg? > What is the Mastoid Shunt modification proposed to Endolymphatic sac decompression by Morrison? > What is the Mastoid Shunt modification proposed to Endolymphatic sac decompression by Shea? > What is the modification proposed to Endolymphatic sac decompression by Hasegawa and Naito? > What is Paparella and Hanson technique? > What are the problems encountered during Endolymphatic Sac Surgery? How will you manage them? #### ⚠️ Complications of Endolymphatic Sac Surgery * **Sensorineural deafness**, if the posterior semicircular canal is breached * Bleeding * CSF fistula * Meningitis #### ⭐ Results of Endolymphatic Sac Surgery | Outcome | Percentage | | --- | --- | | Relief from vertigo | 80 to 90% | | Improved hearing (if operated at an early stage) | 30 to 50% | | Reduced tinnitus | 25 to 30% | --- ### 🔍 Sacculotomy #### 🎯 Aim Decompression of the endolymphatic system by **puncturing the saccule**, through the **oval window**. #### Common Steps 1- **Transcanal approach**, raising the tympanomeatal flap 2- Visualization of the **stapes footplate** 3- **Fenestration through the footplate** > What is Fick's Technique? > What is Cody's Tack Technique? #### ⚠️ Complications * Recurrence of vertigo * Post-operative hearing loss --- ### 🔍 Cochleosacculotomy #### 🎯 Aim A **penetrating injury to the cochlear duct** with an associated **fracture of the osseous spiral lamina**, creating a **permanent fistula of the cochlear duct**. #### Procedure Performed under **local anaesthesia**. 1️⃣ **Transcanal approach**, elevating the tympanomeatal flap 2️⃣ Exposure of the **oval window and round window** 3️⃣ The **round window niche** is removed with a small cutting bur, to fully visualize the round window membrane 4️⃣ A **3 mm right angled pick** is introduced through the round window and passed to a depth of about **3 mm** 👉 This passage carries through the **cochlear partition**, causing fracture and disruption of the **osseous spiral lamina and the cochlear duct** 5️⃣ The **tip of the pick** comes to lie at the centre of the oval window, with rupture of the dilated saccule ⭐ The cochlear duct is thus punctured and drained into the perilymph, creating an **otic-periotic shunt**. #### ⚠️ Complications * Recurrence of vertigo * Post-operative hearing loss ⭐ Because of these complications, **sacculotomy and cochleosacculotomy are not commonly performed now**. --- ### 🔍 Vestibular Nerve Section Selective sectioning of the **vestibular nerve**, which is responsible for the vertigo, while **preserving the cochlear nerve** and hence the hearing. Three approaches: 1️⃣ Middle fossa approach 2️⃣ Retrosigmoid approach 3️⃣ Retrolabyrinthine approach > What are the steps of Middle fossa approach to Vestibular Nerve Section? > What are the advantages and disadvantages of Middle fossa approach to Vestibular Nerve Section? > What are the steps of Retrosigmoid approach to Vestibular Nerve Section? > What are the advantages and disadvantages of Retrosigmoid approach to Vestibular Nerve Section? > What are the steps of Retrolabyrinthine approach to Vestibular Nerve Section? > What are the advantages and disadvantages of Retrolabyrinthine approach to Vestibular Nerve Section? --- ### 🔍 Ultrasonic Irradiation of the Labyrinth A **selective labyrinthectomy**, in which the **semicircular canals are destroyed** while the **organ of Corti is preserved**, allowing preservation of hearing. **Procedure** * A probe delivers **ultrasonic irradiation to the round window** through a **tympanotomy incision** **🧠 Mechanism** The ultrasonic radiation is absorbed and **heat is given off**, dissipating quickly through the inner ear fluids. 👉 **Thermal and mechanical injury** causes selective injury to the **membranous labyrinth**, controlling vertigo while preserving cochlear function. --- ### 🔍 Cryosurgery * A temperature of **minus 160 degrees Celsius** is applied to the **lateral semicircular canal** * **Controlled freezing** causes vestibular hair cell and nerve injury, producing **unilateral vestibular hypofunction** 👉 Helps control recurrent vertigo. ⚠️ **Limitation:** Hearing preservation is **unpredictable**, which is why this approach is not popular. --- ### 🔍 Labyrinthectomy **Complete destruction of the membranous labyrinth**, destroying both **cochlear and vestibular function**. **📌 Indication** 👉 Only when the cochlear function is **no longer serviceable** Two approaches: **A- Transcanal Approach** > What are the steps of Transcanal Approach to Labyrinthectomy? **❌ Limitations** * Poor access to the **posterior semicircular canal**, which lies medial to the facial nerve, so **complete ablation may not be achieved** * Technically more difficult * **Small operative field** **B- Transmastoid Approach** > What are the steps of Transmastoid Approach to Labyrinthectomy? **✅ Advantages** * Very good **direct visualization** of the vestibular end organs * Excellent exposure and operative field --- ### 🔍 Destruction of the Scarpa's Ganglion 📌 The Scarpa's ganglion is also known as the **vestibular ganglion**. #### 🎯 Aim To **abolish abnormal vestibular afference** by destroying the vestibular ganglion, thereby relieving recurrent vertigo. > What is the mechanism of action of destruction of Scarpa's ganglion in treatment of Meniere's disease? #### ⚠️ Complications * Sensorineural hearing loss * Facial nerve injury * Persistent imbalance --- ### 🔍 Translabyrinthine Section of the Vestibular Nerve **Procedure** * A **translabyrinthine approach through the mastoid and then through the labyrinth** * The **internal auditory canal is exposed** * The **vestibular nerve is divided** ⚠️ As the **labyrinth is sacrificed**, there is **no residual hearing** in the operated ear. ⭐ This is the difference from the middle fossa, retrosigmoid and retrolabyrinthine approaches, in which hearing is preserved. > What is the indication of Translabyrinthine Section of the Vestibular Nerve? --- ### 🧠 Viva Pearls * The aims of surgery are to abolish or alter labyrinthine function and modify the underlying pathophysiology. * Surgical options are classified as conservative, partially destructive and destructive. * The basic endolymphatic sac decompression technique was described by Portmann. * Opening the posterior semicircular canal during sac surgery causes total deafness. * Endolymphatic sac surgery relieves vertigo in 80 to 90% of patients. * Sacculotomy decompresses the endolymphatic system by puncturing the saccule through the oval window. * Cochleosacculotomy creates an otic-periotic shunt. * Vestibular nerve section preserves hearing by sparing the cochlear nerve. * Ultrasonic irradiation destroys the semicircular canals while preserving the organ of Corti. * Cryosurgery uses a temperature of minus 160 degrees Celsius applied to the lateral semicircular canal. * Labyrinthectomy is indicated only when hearing is non-serviceable. * Scarpa's ganglion is the vestibular ganglion. * Translabyrinthine vestibular nerve section leaves no residual hearing in the operated ear. --- ## About This Note This free ENT note on Meniere's Disease Part 4 - Surgical Management was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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