Timothy C. Hain, M
What are Surgical Treatments of Vertigo?
Contraindications to Surgical Treatment
There are relatively few times when surgery is appropriate for dizziness. Most dizziness either can be treated effectively medically, or there is no treatment at all. Surgical treatments that are available can be broken down into corrective and destructive types.
Unfortunately, there are relatively few instances where surgery can be viewed as a corrective procedure for vertigo. Interestingly, in nearly if not all cases where there is a proposed corrective surgery, either the process of diagnosis is controversial, or the treatment itself is controversial. This suggests that caution is appropriate when a corrective procedure is proposed.
In perilymph fistula, surgery may be used to plug a leak in the inner ear. Both the diagnostic process and the treatment are somewhat controversial. Recently, a new type of fistula has been described involving dehiscence of the superior semicircular canal. Whether or not surgery will be effective for this syndrome is presently uncertain.
In the microvascular compression syndrome, surgery may be used to move a blood vessel off of the vestibular nerve. Again, there is considerable controversy about diagnosis and treatment and we would advise caution and judicious second opinions before proceeding with such surgery.
In Meniere’s disease, shunt surgery is intended to improve inner ear plumbing. There is controversy primarily in regard to whether this procedure is effective. The consensus at this writing 9/2012, is that shunt surgery is modestly effective for several years. It compares unfavorably with transtympanic gentamicin (see destructive procedures).
All treatments for Meniere’s disease must be compared with the natural history the disease, where 60% of patients are in remission by six months. The most common type of shunt surgery consists of putting in a small tube or plastic sheet into the endolymphatic sac. Another procedure is termed endolymphatic sac enhancement, a procedure which includes lateral sinus decompression (Sajjadi, Paparella and Williams, 1998).
Shunt surgery is generally felt to be ineffective when viewed over five years although it may improve the situation for two years. The most disturbing report came out of the Danish Sham Study, where individuals treated with placebo fared better than those with shunts. There is also good evidence that tubes placed in the sac close up by four years. Nevertheless, it is possible that procedures that either destroy the sac or remove surrounding bone through which lymphocytes migrate into the sac might alter the immune function enough to cause a remission of Meniere’s disease.
To summarize, at this writing, shunt surgery may have some short-term benefit, and the mechanism of the benefit may relate to immune modulation.
Destructive treatments are designed to eliminate vertigo, possibly sacrificing hearing. These procedures are appropriate for consideration when medical treatment and vestibular rehabilitation has failed to control vertigo symptoms. Indications are generally much clearer for destructive treatment than for corrective treatments, and results are better.
For Meniere’s disease, destructive procedures are associated with better control of vertigo than shunt surgery, showing good control in over 90% of patients followed for five or more years. The vestibular nerve may be sectioned via the middle fossa, retrolabyrinthine, and retrosigmoid approaches, with similar efficacy. Transtympanic gentamicin treatment(Figure 1) is a rapidly growing outpatient procedure that offers similar results to vestibular nerve section but with much less risk. Labyrinthectomy is appropriate for patients in whom there is no hearing in the ear which is causing vertigo and offers excellent control of vertigo, with fewer complications than nerve section. Labyrinthectomy can be performed in combination with vestibular nerve resection, which may provide better outcomes than labyrinthectomy alone (De La Cruz, 2007). For a thorough discussion of the surgical treatment of Meniere’s disease see Teufert et al. (2010) and Cawthorne (2009).
New surgical techniques currently in development include selective posterior semicircular canal laser deafferentation, which has only been tested in animals and small clinical trials (Naguib, 2005; Nomura, 2002) and selective microsurgical vestibular neurectomy (SMVN). SMVN has proven effective for intractable vertigo in a small study of nine patients, with the added benefit of hearing preservation (Bademci, 2004). The placement of ventilation tubes in patients with Meniere’s disease provided short term relief (of 24 months) in a small group of patients (Sugawara, 2003).
Removal of the acoustic tumor in acoustic neuroma surgery generally results in elimination of vertigo, as the nerve is usually sectioned.
In individuals who fail fistula surgery (for perilymph fistula), a destructive treatment also seems reasonable when symptoms are disabling.
For Benign Paroxysmal Positional Vertigo, selective posterior canal plugging offers a reasonable surgical approach to intractable symptoms. Singular neurectomy, an older procedure, is less popular because it produces hearing loss in 7 to 17% of patients and fails in 8 to 12%.
We generally do not think that destructive treatments are appropriate for vestibular neuritis, but there are occasional exceptions, when medical treatment fails and symptoms are severe. We also do not feel that destructive treatments are indicated when the diagnosis is unclear. Destructive treatments are risky for continued vertigo when there is impairment of central adaptation, such as seniors and in people with pre-existing cerebellar problems.
Vestibular rehabilitation therapy is appropriate in all patients who have had destructive treatment.
Figure 1 is courtesy of Northwestern University.
Bademci G, Bata F et al. Selective microsurgical vestibular neurectomy: an option in the treatment of intractable vertigo and related microsurgical landmarks. Min Inv Neurosurg. 47(1):54-7, 204.
De La Cruz A, Borne Teufert K, Berliner KI. Transmastoid labyrinthectomy versus translabyrinthine vestibular nerve resection: does cutting the vestibular nerve make a difference in outcome? Otol & Neurotol. 28(6):801-8, 2007.
Naguib MB. Experimental selective posterior semicircular canal laser deafferentation. J Laryn Otol. 119(5):381-4, 2004.
Nomura Y. Argon laser irradiation of the semicircular canal in two patients with benign paroxysmal positional vertigo. J Laryng Otol. 116(9):723-5, 2002.
Sajjadi H, Paparella MM, Williams W. Endolymphatic sac enhancement surgery in elderly patients with Meniere’s disease. ENT Journal, 975-981, 1998
Sugawara K, Kitamura K et al. Insertion of tympanic ventilation tubes as a treating modality for patietns with Meniere’s disease: a short- and long-term follow-up study in seven cases. Auris, Nasus, Laryns. 30(1):25-8, 2003.
Teufert KB, Doherty J. Endolymphatic sac shunt, labyrinthectomy, and vestibular nerve section in Meniere’s disease. Otolaryngol Clin North Am. 2010 Oct;43(5):109