2. is a disorder of the inner ear characterized by
Acute rotatory vertigo which is unpredictible,
precipitous in nature associated with nausea
and/or vomiting.
Hearing loss which is unilateral low-tone
fluctuant sensorineural
Tinnitus
Aural fullness
3. 1747 – Antonio Scarpa described anatomy of
membranous labyrinth
1861 – Prosper Meniere described the classic
features of Meniere’s disease & attributed it to
labyrinthine causes
1871 – Knappin theorized that dilated
membranous labyrinth to be the cause of this
disorder
1927 – Guild described endolymphatic ciruclation
1938 – Hallpike and Portmann described
pathology of Meniere’s disease by studying
temporal bones
8. • Perilymph is similar in composition to
CSF (Containing high Na and low K ions)
• Endolymph similar in composition to
intracellular fluid (Containing low Na and
high K concentration). It is secreted by
stria vascularis
10. Roughly 1 in 1000 individuals are affected
Constitutes 10% of all patients attending
vertigo clinic
Female preponderance
Rare in children under the age of 10
Commonly begins between 4th and 5th
decades of life
Bilateral Meniere’s syndrome is seen in 5% of
these patients
13. Was first proposed by Guild
Striavascularis is the principal source
This is a slow process
Elimination occurs at the endolymphatic sac
level
14. This is active process (energy consuming)
Production occurs from dark vestibular cells &
planum semilunatum
Absorption occurs at the stria vestibularis
15. First proposed by Lawrence
This is a combination of both longitudinal
and radial flow patterns
16.
17. Endolymphatic hydrops causes distortion of
membranous labyrinth
Pressure building up in the scala media may
cause mirco ruptures of membranous
labyrinth
This would account for the episodic nature of
the attacks
Healing of these ruptures causes resolution of
the disorder
18. Small amounts of excess endolymph can be
cleared by radial flow
Larger volumes need longitudinal flow for
their clearance
Endolymphatic sinus temporarily
accommodates excess endolymph till the sac
is ready for it
Endolymphatic valve of Bast isolates pars
superior and prevents endolymph from
draining out of the utricle
19. The excess volume
tends to accumulate in
the apical end of the
cochlea, where the
membranes are more
lax than elsewhere,
even though the
endolymph pressure
would be similar
elsewhere in the
cochlea.
20. 1.Stage I – Patient has solely cochlear
symptoms
2. Stages II – IV – Patients have progressively
more cochlear and vestibular symptoms
3. Stage V – End stage Meniere’s disease
(dead ear)
22. variant of Meniere’s disease
sudden sensorineural hearing loss, which
improves during or immediately after the
attack of vertigo.
Cause is sudden spasm of the labyrinthine
artery followed by immediate dilatation
23. AKA Tumarkin’s drop attacks
abrupt falling attacks of brief duration
without loss of consciousness.
due to an enlarging utricle due to excess
endolymphatic volume
24. Sensori neural in nature
Fluctuating and progressive
Affects low frequencies
Mild low frequency conductive hearing loss
(rare)
Profound sensori neural hearing loss (End
stage)
25. Roaring in nature
Could be continuous / intermittent
Non pulsatile in nature
Frequency of tinnitus corresponds to the
region of cochlea which has suffered the
maximum damage
26. Possible Meniere’s disease:
Episodic vertigo without hearing loss or
Sensorineural hearing loss, fluctuating or fixed with
dysequilibrium, but without definite episodes
Other causes excluded
Probable Meniere’s disease:
One definitive episode of spontaneous vertigo
Audiometrically documented hearing loss at least during one
attack
Tinnitus and aural fullness in the affected ear
Definitive Meniere’s disease
Two or more definitive episodes of spontaneous vertigo one
atleast lasting for 20 mins.
Audiometrically documented hearing loss at least on
one occasion.
Tinnitus and aural fullness in the affected ear
27. History
1. Nature of the sensation
2. Timing of the initial spell
3. Frequency and duration of the symptoms
4. Precipitating factors
Vestibular tests
Complete Haemogram
Audiometry
Loudness recruiment
VEMP
Dehydration tests
Posturography
Electronystagmography
28. This is abnormal growth in the perceived
intensity of sound
This is usually positive in patients with
Meniere’s disease
ABLB is the test used to look for the presence
of recruitment
This test is really time consuming
29. Alternate Binaural loudness balance test
Tone is presented alternately between the two
ears. The level of the tone stays the same in one
ear (i.e. fixed ear) and is varied up / down in the
other ear (i.e. variable ear). The patient is asked to
report when the sound is louder in the right ear,
louder in the left ear, and when it sounds equal in
both ears.
Loudness balance is said to have been obtained
when the patient indicates that the sound is heard
equally in both ears. The tester then records the
two levels in dB hearing level where the balance
has occurred.
30. Increased summating potential / action
potential ratio. 1:3 is normal
Widened summating potential / action
potential complex. A widening of greater
than 2 ms is significant
Small distorted cochlear microphonics
31. Vestibular evoked myogenic potential
Measures the relaxation of sternomastoid muscle in
response to ipsilateral click stimulus
Brief high intensity ipsilateral clicks produce large
short latency inhibitory potentials (VEMP) in the
toncially contracted Ipsilateral sternomastoid muscle
This test is due to the presence of vestibulo collic
reflex
Afferent arises from sound responsive cells in the
saccule, conducted via the inferior vestibular nerve.
Efferent is via vestibulo spinal tract
Normal responses are composed of biphasic
(positive-negative) waves
VEMP reveals saccular dysfunction
32. Glycerol
Mannitol
Frusemide
Isosorbide
These tests involve the subject ingesting
glycerol or mannitol and observing for a
change in symptoms and a measurable
improvement in hearing
Tests are positive if there is pure tone
improvement of 10dB or more at two / more
frequencies between 200-2000Hz
33. First introduced by Klockhoff and Lindblom –
1966
Glycerol is administered in doses of 1.5 mg/kg
body wt in empty stomach
Serum osmolality should increase at least by 10
mos/kg
Side effects include Headache, Nausea, vomiting,
drowsiness
PTA is performed 2-3 hours after administration
False positivity is rare
Positivity depends on the phase of the disease
34. Antibodies to 68-kDa protein has been noted
in many patients with meniere’s disease
35.
36.
37. the aim is to decrease the production or accumulation of
the endolymph
CONSERATIVE
Dietary sodium restriction (1mg/day)
Restriction of caffeine and nicotine like substances
Diuretics like bendroflurazide,dyazide, chlorthalidone
Betahistine
histamine analogue with weak H1, H2 agonistic and
moderate H3 antagonistic action
causes improved microvascular circulation in striae
vascularis
inhibition of vestibular nuclei activity
Calcium agonists
38. Steroids
1. Topical application via tympanostomy tubes
2. Shea et al reported 35.4% hearing
improvement and complete vertigo control
in 63.4% cases treated with 16 mg
intratympanic and 16 mg i.v.
dexamethasone for three consecutive days
followed by oral dexamethasone
3. Silverstein microwick can be used for
intratympanic drug administration
39. Intratympanic injection of aminoglycosides
a form of chemical labyrinthectomy,
gentamycin therapy ablates the vestibular
“dark cells” of the secretory epithelium thus
decreasing endolymph production
response to this is measured by in response
to rapid, rotatory head thrusts
Alternobaric oxygen therapy
40. Local overpressure therapy by means of Meniett
device which applies intermittent micropressure
to the inner ear via a tympanostomy tube
41. 1. Diagnosis should be confirmed
2. Ventilation tube should be inserted
3. Patient should be trained for self
administration of the treatment
4. Usually administered thrice a day about 5
mins each time
5. Treatment lasts for 5 weeks
42. 1. Classic unilateral Meniere’s disease
2. Intense vestibular / cochlear symptoms
3. Failed medical therapy
4. Over 65 years of age
5. Imbalance / aural fullness / tinnitus after
gentamycin treatment
44. 1. Isordil
2. ϒ – globulin
3. Urea
4. Glycerol
5. Lithium
6. Anticholinergics – Glycopyrrolate 1-2 mg /day
7. Antidopaminergics – Droperidol 2.5 – 10 mg orally /
day
8. Leuprolide acetate – Blocks normal sex hormone
production
9. Innovar – A combination of droperidol and fentanyl
can be used to suppress vestibular symptoms (can
replace endolymphatic sac surgery)
45. Endolymph decompression
First described by portmann 1926
Via the round window by otic-periotic shunt that
perforates the basilar membrane
Cochleosacculotomy creates a fracture dislocation of
osseous spiral lamina
both these procedures have highdegree of hearing
loss
1. Helpful in treating debilitated patients
2. Involves disruption of osseous spiral lamina
3. Angular pick introduced via round window towards
oval window. It will accommodate 3 mm long pick
4. After perforation the pick is withdrawn and the round
window is sealed by fat
46. Simple decompression
Cannulation of endolymphatic duct
Endolymphatic drainage to the subarachnoid
space
Drainage to mastoid
Removal of extraosseous portion of the sac
48. Vestibular neurectomy
1. more complete vertigo control than shunt
procedures
2. Lower risk of hearing loss than gentamicin
therapy
3. Middle fossa approach, risk of facial nerve
injury is higher
4. Suboccipital approach
Labyrinthectomy
1. Transcanal approach
2. Transmastoid approach, more common
Nature: sense of motion can be rotatory, linear, change in orientation relative to vertical vertigo indicates problem in peripheral vestibular system
Horizontal movements ndicate scc problems while drop attacks indicate otolith dysfunction
Timing: after serious illness -ototoxic drugs , starting or stopping drugs, changing dosage
Trauma or infection positional vertigo stapes surgery perilymphatic fistula
Girl having menarche might have initial spell of dizziness hormone related
Frequency n duration:short term spells >bppv,scc dehiscence,perilymphatic fistula….medium length upto 4 hrs meniers…..longer ones migraine
