Labyrinth Anesthesia A Forgotten but Practical Treatment Option in Ménière s Disease

Transcription

1 Original Paper ORL 2003;65:84 90 DOI: / Received: February 20, 2003 Accepted: March 6, 2003 Labyrinth Anesthesia A Forgotten but Practical Treatment Option in Ménière s Disease Oliver Adunka a Elena Moustaklis a Alexander Weber b Angelika May a Christoph von Ilberg a Wolfgang Gstoettner a Antonius C. Kierner c a ENT Department, University Clinic Frankfurt am Main, Frankfurt/M., b ENT Department, Katholisches Krankenhaus St. Josef, Kliniken Essen Süd, Essen, Germany; c ENT Department, University Clinic Vienna, Vienna, Austria Key Words Ménière s disease W Vertigo W Hearing impairment W Labyrinth anesthesia W Lidocaine Abstract The aim of this study was to determine the efficiency of labyrinth anesthesia the intratympanic instillation of lidocaine in the treatment of Ménière s disease and to recall a forgotten method. Twenty-four patients (15 male, 9 female), aged from 19.7 to 80.6 (mean: 47.8 ) with the clinical diagnosis of unilateral Ménière s disease who underwent labyrinth anesthesia in our department were included in this retrospective study. After local anesthesia of the tympanic membrane, a solution of 4% lidocaine and furfuryladenine (Kinetin) was instilled into the tympanic cavity. Patient records, a questionnaire and a physical examination were used to evaluate vertigo control, hearing loss, tinnitus, and quality of life according to the AAO-HNS criteria before and after surgery. Postoperatively, 87.5% of patients reported at least a noticeable decrease of vestibular symptoms, 66.7% of these patients were free of attacks for an average of 26.5 months. Postoperative hearing was the same or even improved in 87.5% of our patients. Tinnitus was not affected in any individual. Based on the findings presented herein, we consider labyrinth anesthesia a practicable and, due to its safety, highly recommendable therapeutic option for patients suffering from Ménière s disease. Introduction Copy 2003 S. Karger AG, Basel Ménière s disease is characterized clinically by recurrent attacks of vertigo associated with ear pressure, tinnitus and hearing loss. With progression of the disease, asymptomatic intervals become shorter and the frequency of attacks increases. The most disabling consequence for patients every day lives is the vertigo, which can lead to almost total isolation of the individuals in their homes. With time, increasing hearing impairment further diminishes the patients quality of life. The primary goal of therapy therefore is to prevent vertigo attacks and preserve hearing. Yet, in about one third of cases, conservative medical treatment fails to control vertigo episodes at an acceptable level. These patients generally undergo otologic surgery to reduce symptoms. In cases with profound hearing loss, labyrinthectomy is an easy choice, but in patients with acceptable hearing multiple options exist and none of them is truly satisfying for the patient or the ABC Fax karger@karger.ch S. Karger AG, Basel /03/ $19.50/0 Accessible online at: Dr. Oliver Adunka ENT Department, University Clinic Frankfurt am Main Theodor Stern Kai 7 D Frankfurt am Main (Germany) Tel , Fax , adunka@em.uni-frankfurt.de

2 otologist. Since the pathomechanism of Ménière s disease is still unclear, any kind of treatment is just symptomatical and based on experience. To our knowledge, there is no commonly accepted treatment algorithm at present. Three surgical therapies seem to be commonly accepted today, each of which has its specific advantages and disadvantages. The oldest therapeutical option by far is vestibular neurectomy, which was first described by Charcot [1]. With House [2] developing the middle fossa approach and Glasscock [3] and Fisch [4] including sectioning of the inferior vestibular nerve in the surgical procedure, hearing preservation and complete or substantial vertigo control can now be achieved in % of patients [5]. Different approaches to the internal auditory meatus were then described [6 10], but vestibular neurectomy remains an invasive procedure, with possible complications including meningitis, facial palsy, cerebrospinal fluid leakage, and hearing loss [10]. In 1927, Portmann [11] presented endolymphatic sac surgery as an additional treatment option for Ménière s disease. Since then, several surgical modifications to the primary procedure have been proposed [5]. However, the exact mechanism that influences the symptoms is still unknown. Despite these objections, endolymphatic sac decompression has been shown to control vestibular symptoms in % of cases, depending on the technique of the procedure [5]. Finally, in 1956 Schuknecht [12, 13] first reported on the treatment of Ménière s disease with parenteral application of streptomycin. By now, it is common knowledge that aminoglycosides can cause irreversible damage to the inner ear. Although different techniques for local application of streptomycin and gentamicin have been developed with a substantial or complete vertigo control in % [5], there is a high incidence of cochlear damage. In 1993 Nedzelski et al. [14] described that 27% of patients receiving intratympanic gentamicin developed a significant hearing loss and 10% of these progressed to profound deafness. Unfortunately, it seems to be almost forgotten that in 1935 Bárány [15] described a fourth, completely new treatment modality, the intravenous application of lidocaine. Later, the intratympanic instillation of local anesthetics, the labyrinth anesthesia or inner ear anesthesia, was described [16 24]. Lempert [16], Kroath [17], Rahm [18], Gejrot [19] and Ristow [20, 21] published the positive therapeutical effect of intratympanic lidocaine on vestibular symptoms. In 1985, Fradis et al. [22] reported severe to moderate vertigo control in 85.7% of cases, Table 1. Questionnaire sent to every patient 1 When did typical Ménière s disease symptoms (tinnitus, hearing loss, aural fullness and vertigo) first evolve? 2 What treatment did you receive prior to the operation performed in our department? When did you receive this very treatment and for how long? 3 How often did you have attacks prior to the labyrinth anaesthesia? 4 Do you suffer from symptoms at the moment? If yes, what are they and how often do the attacks occur? Did you suffer from vertigo attacks months after the operation? If yes, how many attacks did you have in that time? 5 Did your symptoms improve after we performed the operation? If yes, for how long were you free of vertigo attacks? 6 Would you undergo a labyrinth anesthesia again? 7 Was the choice of this operation a good decision? Were you content with it? 8 Did your hearing change? If yes, how (improved, got worse)? 9 Did you undergo another treatment after the operation? whereas in 1986, Sakata et al. [23] observed that 89.4% of patients undergoing labyrinth anesthesia felt at least a noticeable relief of vestibular symptoms. In 1991, Itoh and Sakata [24] reported similar findings after intratympanic instillation of lidocaine. Based on these papers, labyrinth anesthesia has become a standard for therapy of moderate to severe Ménière s disease in our department. The aim of this study was to retrospectively evaluate the effect of this method on the clinical course of Ménière s disease. Patients and Methods A retrospective study was carried out involving 47 patients diagnosed with Ménière s disease who underwent labyrinth anesthesia between February 1992 and January 2001 at our department. A questionnaire (table 1), including the request to contact us, was sent to all patients. Additionally, a table describing the patient s current state (with the functional-level scale according to the AAO-HNS guidelines [25]) was handed out to each patient. The patient had to pick the one that best applied. Twenty-four patients returned the questionnaire and contacted the authors personally. Patient characteristics are listed in table 2. In 18 patients, pure-tone audiometry was performed pre- and postoperatively (12 24 months after surgery) and average thresholds for 500, 1,000, 2,000 and 3,000 Hz were used for grading (AAO-HNS guidelines retrospectively (table 3). Vestibular symptoms were classified 6 months pre- and months postoperatively, regardless whether patients had undergone revision Labyrinth Anesthesia ORL 2003;65:

3 Table 2. General data and outcome of the first operation Patient Sex Ear side Age at first operation Follow-up Functional level scale 1 pre post Frequency of vertigo attacks 2 6 mth pre mth post Postoperative time without vertigo attacks mth Would you do it again? Symptoms better Operations Tube insertion 1 M D A 1 yes yes 3 yes 2 F E A 1 yes yes 2 no 3 M D A 4 yes yes 5 no 4 F B A 84 yes yes 1 yes 5 M B A 12 yes yes 2 no 6 F B B yes yes 1 no 7 M E C yes yes 1 yes 8 F E A 4 yes yes 2 yes 9 F D B yes yes 1 no 10 F D B 6 yes yes 4 no 11 F B A 24 yes yes 1 no 12 M C B 6 yes yes 1 no 13 M D B 3 noyes 1 no 14 M B B nono2 no 15 M B B yes yes 4 no 16 M B A 7 yes yes 1 no 17 M B A 28 yes yes 1 yes 18 M B A 3 10 yes yes 1 no 19 F B A 108 yes yes 2 no 20 M E B yes yes 1 no 21 M B B nono1 no 22 M B B nono1 no 23 F C A 96 yes yes 1 no 24 M B A 30 yes yes 1 no Min 4! M 11! ! A 13! A 1.0 4! no3! no1.0 18! no Max 9! F 12! ! B 10! B ! yes 20! yes 5.0 5! yes Median ! C 1! C Mean ! D 4! E 1 According to AAO-HNS criteria. 2 AAO-HNS classification. 3 Classification of vestibular symptoms 6 12 months postoperatively. 0! D 0! E surgery after the primary operation. Functional level scales [25] were evaluated before surgery and at different follow-up times postoperatively (for follow up times see table 2). All of these 24 patients (15 males and 9 females) could be included in this study. They had a history of typical Ménière s disease attacks, consisting of true rotatory vertigo with emesis in combination with fluctuating hearing impairment, tinnitus and aural fullness. In all patients conservative treatment with diuretics, vestibular suppressants, vasodilators or calcium channel blockers had failed prior to surgery. Every patient chose labyrinth anesthesia after a thorough discussion of other surgical options, including intratympanic gentamicin application, endolymphatic sac decompression and vestibular neurectomy. There was no case of bilateral disease in any patient. None of the patients had had otologic surgery prior to our treatment. All operations were performed under local anesthesia. After injection of local anesthetics for tympanoplasty, a paracentesis was performed and the tympanic cavity was filled with a solution of 4% lidocaine and furfuryladenine (kinetin). The latter was taken to enhance the permeability of the round window. Instillation was continued until patients reported vertigo with clearly visible nystagmus to the contralateral side. In 5 operations (12.2% of a total of 41 operations) a ventilation tube was inserted at the time of the first operation. Some patients received dimenhydrinat to minimize vestibular symptoms postoperatively. To prevent inflammatory reactions of the middle ear, all patients received a single shot antibiotic treatment perioperatively. Results In the 24 patients included in this study, a total of 41 labyrinth anesthesias (19 and 22 ears) were performed. The mean follow-up period at the time of the investigation was 5.3 (ranging from 1.0 to 9.9 ). 86 ORL 2003;65:84 90 Adunka/Moustaklis/Weber/May/von Ilberg/ Gstoettner/Kierner

4 Table 3. Hearing performance pre- and postoperatively Patient Patient s impression Preoperative HL in db 500 1,000 2,000 3,000 Postoperative HL in db 500 1,000 2,000 3,000 Average pre post Change AAO- HNS grading 1 Same ,8 3 2 Same 3 Same Same Same Same Worse Improved 9 Worse 10 Improved 11 Same Improved Same Same Worse Improved Improved Same Same 20 Same Same Same Same 24 Same Min 16! Same Max 5! Improved Med 3! Worse Mean Sixteen patients had pre- and postoperative pure-tone audiometry. These patients had an average 0.2 db hearing loss over 500, 1,000, 2,000 and 3,000 Hz after labyrinth anesthesia. HL = Hearing loss. Nine patients (37.5%) underwent multiple operations, with an average of 1.02 (ranging from 0.01 to 8.63 ) between each procedure. Five patients had 2, 2 patients had 4, 1 patient had 3, and 1 patient had 5 labyrinth anesthesias (table 2). The average age at first operation was 47.8 (ranging from 19.7 to 80.6 ). The time between the correct diagnosis of Ménière s disease and labyrinth anesthesia varied between 0.1 to 13.0, with an average of 3.6. Postoperatively, no complications due to the surgical procedure apart from the expected short-lasting (up to 3 days), mild rotatory vertigo could be observed in any of the patients. Patient s functional-level scales and the frequency of vertigo attacks 6 months prior to surgery were evaluated according to the AAO-HNS guidelines [25] (table 2; fig. 1, 2). Postoperative Vestibular Symptoms Postoperatively, 16 patients (66.7%) were free of vertigo attacks (complete control of definitive attacks) for 26.5 months in average (ranging from 1 to 108 months). Five patients (20.8%) reported a noticeable decrease of vestibular symptoms concerning the frequency as well as the intensity of the vertigo attacks. In 3 patients (12.5%), labyrinth anesthesia vestibular symptoms unaffected (table 2). Vertigo was also graded according to the AAO- HNS criteria [25]; 13 patients were classified A, 10 were B, and 1 patient scored C months postoperatively (fig. 1). After a successful first operation, 9 patients underwent a total of 17 relapse operations, 12 (70.6%) of which resulted in an average of 24.6 (ranging from 2 to 72) months of complete vertigo control (table 4). One operation (5.9%) did not affect vestibular symptoms and this patient underwent endolymphatic sac decompression af- Labyrinth Anesthesia ORL 2003;65:

5 Fig. 1. Pre- and postoperative vertigo control, classified according to the AAO-HNS criteria. Fig. 2. Pre- and postoperative functional-level scales, graded according to the AAO-HNS criteria. Table 4. Patient data of 17 relapse operations Patient Operation No. Age at operation Frequency of vertigo attacks 6 mth pre 1 Time since prior operation Time without vertigo attacks mth Sex Ear side D 0.10 m E f D m B m E f D f B 0.06 m B m B f Min ! A ! m 7! Max ! B ! f 10! Median ! C Mean ! D 2! E AAO-HNS classification. 88 ORL 2003;65:84 90 Adunka/Moustaklis/Weber/May/von Ilberg/ Gstoettner/Kierner

6 Patients classified their every day life restrictions due to Ménière s disease (functional-level scales) with an average score of 4.0 prior to surgery and 2.2 after 24 months (fig. 2). Discussion Fig. 3. Hearing loss prior to surgery and 2 postoperatively for 500, 1,000, 2,000 and 3,000 Hz. terwards. Four patients (23.5%) described a decrease in the intensity and frequency of vertigo attacks after the second labyrinth anesthesia. Postoperative Hearing Postoperatively, 16 patients (66.7%) reported no change in hearing performance, 5 patients (20.8%) claimed that hearing did in fact improve and 3 patients (12.5%) complained about worse hearing after labyrinth anesthesia (table 3). Preoperatively, 18 of our 24 patients underwent hearing tests. According to the AAO-HNS criteria [25], average pure-tone audiometry thresholds for 500, 1,000, 2,000 and 3,000 Hz were used. Thresholds revealed an average of 0.2 db hearing change 24 months after surgery (ranging from 30 to +25 db, median: 0.0 db difference for the average of 500, 1,000, 2,000 and 3,000 Hz; fig. 3). Hearing loss exceeded 10 db (as a mean of frequencies mentioned above) in 2 patients (8.3%). At follow-up, tinnitus was not affected in any individual. Questionnaire Answering the questionnaire (table 1) and undergoing physical examination, 20 patients (83.3%) claimed to be content and willing to undergo labyrinth anesthesia again. The intensity and frequency of their vertigo attacks had decreased dramatically. Three patients (12.5%) claimed labyrinth anesthesia not to affect their vertigo, nor would they undergo the operation again. Only 1 patient (4.2%) was content with the treatment and symptoms postoperatively but said he would not undergo labyrinth anesthesia again (functional-level scale of this patient: D pre- and B postoperatively). Since labyrinth anesthesia was first described by Bárány in 1925 [15] it has been discussed controversially and over the last decade, it seemed to be an almost forgotten treatment for moderate to severe Ménière s disease. Our department continued to offer this therapy because of the well-documented benefits for patients and its nondestructive character. As far as we know, this study is the first to show the effectiveness of labyrinth anesthesia using the AAO-HNS criteria [25]. With almost 87% of patients reporting at least a noticeable decrease in the intensity and frequency of vertigo after the first operation, this therapy has proven almost as effective as commonly used surgical procedure like endolymphatic sac decompression or vestibular neurectomy [5]. Yet, regarding side-effects like hearing impairment, labyrinth anesthesia seems to be a very safe and minimally invasive therapeutical option. Experimental papers proposed a peripheral mechanism of action of lidocaine on the inner ear [26 28]. The capacity of the inner ear melanin to accumulate drugs was first observed by Lindquist and Ullberg in 1972 [26]. In 1975, Dencker and Linquist [29] related to ototoxicity of chloroquine to the accumulation of the drug on inner ear melanin. Later, it was shown that local anesthetics like lidocaine also accumulate on inner ear melanin [27]. These findings led to the hypothesis that this mechanism might be responsible for the prolonged effect we observed in our study [28]. In the meta-analysis, Grant and Welling [5] reported on % attack control and 41 88% hearing preservation 2 after vestibular neurectomy. On the other hand, a mean of all studies regarding endolymphatic sac surgery shows that in 86% of cases, complete or substantial control of vertigo could be achieved with a hearing preservation rate of 75% [5]. Therefore the number of patients suffering from irreversible hearing impairment postoperatively ranges from 12 59% in neurectomy and 14 65% after endolymphatic sac decompression. In his study of 37 patients, Ristow [21] described that intratympanic lidocaine resulted in 33.3% worse, 39.4% better and 27.3% same hearing performance 2 after surgery. In a more recent paper, Sakata et al. [23] did not confirm any deterioration of Labyrinth Anesthesia ORL 2003;65:

7 hearing after intratympanic instillation of lidocaine. Comparing these data with our own findings (66.7% same, 20.8% better and 12.5% worse hearing), labyrinth anesthesia seems to be a very safe surgical therapy regarding postoperative hearing. Our data are further supported by the respectably high acceptance of this therapy among our patients, as demonstrated in the answers to our questionnaire. Yet, due to the fact that our department seems to be one of the few clinics worldwide performing labyrinth anesthesia, the number of patients is quite low. Nonetheless, we believe that the consistency of our findings and the fact that previous studies revealed similar results makes them convincing even with a small collective. Conclusion Based on the findings presented herein and the consistency of our results with previous reports, we consider labyrinth anesthesia a simple, practicable and, due to its safety, highly recommendable therapeutic option for patients suffering from Ménière s disease. However, a prospective multicenter-study with a bigger group of patients will be needed to further support our conclusions. References 1 Charcot JM: De la maladie de Ménière. Prog Med Paris 1874;2: House WF: Surgical exposure of the internal auditory canal and its contents through the middle cranial fossa. Laryngoscope 1961;71: Glasscock ME: Vestibular nerve section. Arch Otolaryngol Head Neck Surg 1973;97: Fisch U: Vestibular and cochlear neurectomy. Trans Am Acad Ophthalmol Otolaryngol 1977; 78: Grant IL, Welling DB: The treatment of hearing loss in Ménière s disease. Otolaryngol Clin North Am 1997;30: Silverstein H, Norrell H: Retrolabyrinthine surgery: A direct approach to the cerebellopontine angle. Otolaryngol Head Neck Surg 1980; 88: Hitselberger WE, Pulec JL: Trigeminal nerve (posterior root) retrolabyrinthine selective section. Operative procedure for intractable pain. Arch Otolaryngol 1972;96: Thomsen J, Tos M: Surgery of acoustic neuromas. Preliminary experience with a translabyrinthine approach. Acta Neurol Scand 1977;56: Magnan J, Bremond G, Chays A, Gignac D, Florence A: Vestibular neurotomy by retrosigmoid approach: Technique, indications and results. Am J Otol 1991;12: Thomsen J, Berner B, Tos M: Vestibular neurectomy. Auris Nasus Larynx 2000;27: Portmann G: Vertigo, surgical treatment of opening of the saccus endolymphaticus. Arch Otolaryngol Head Neck Surg 1927;6: Schuknecht HF: Ablation therapy for the relief of Ménière s disease. Laryngoscope 1956;66: Wilson W, Schuknecht HF: Update on the use of streptomycin therapy for Ménière s disease. Am J Otol 1980;2: Nedzelski JM, Chiong CM, Fradet G, Schessel DA, Bryce GE, Pfleiderer AG: Intratympanic gentamicin instillation as treatment of unilateral Ménière s disease: Update of an ongoing study. Am J Otol 1993;14: Bárány B: Die Beeinflussung des Ohrensausens durch intravenös injizierte Lokalanästhetica. Acta Otolaryngol 1935;23: Lempert J: Tympanosympathectomy, a surgical technic for releaf of tinnitus aurium. Arch Otolaryngol 1946;43: Kroath F: Transtympanale Injektion zur Behandlung des Ménière schen Syndroms. Z Laryngol 1960;34: Rahm WE: The effect of anesthetics upon the ear. Ann ORL 1962;79: Gejrot T: Intravenous xylocaine in the treatment of attacks of Ménière s disease. Acta Otolaryngol 1963;188(suppl): Ristow W: Der Einfluss der Schleimhautanästhetika auf das Vestibularsystem und seine therapeutische Wirkung; in Loebell H, Jakobi H (eds): Zwanglose Schriftenreihe. Leipzig, J.A. Barth, 1964, Heft Ristow W: Zur Behandlung der Ménière- Krankheit mittels temporärer Labyrinthanästhesie. Z Laryngol Rhinol 1968;47: Fradis M, Podoshin L, Ben-David J, Reiner B: Treatment of Ménière s disease by intratympanic injection with lidocaine. Arch Otolaryngol 1985;111: Sakata E, Kitago Y, Murata Y, Teramoto K: Behandlung der Ménièreschen Krankheit. Paukenhöhleninfusion von Lidocain- und Steroidlösung. Auris Nasus Larynx 1986;13: Itoh A, Sakata E: Treatment of vestibular disorders. Acta Otolaryngol 1991;481: Anon. Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Ménière s disease. American Academy of Otolaryngology-Head and Neck Foundation, Inc. Otolaryngol Head Neck Surg 1995; 113: Lindquist NG, Ullberg S: The melanin affinity of chloroquine and chlorpromazine studied by whole body autoradiography. Acta Pharmacol Toxicol 1972;2(suppl 2): Englesson S, Larsson B, Lytthens L, Lindquist NG, Stahle J: Accumulation of 14 C-lidocaine in the inner ear. Acta Otolaryngol 1976;82: Lyttkens L, Larsson B, Göller H, Englesson S, Stahle J: Melanin capacity to accumulate drugs in the internal ear. A study on lidocaine, bupivacaine and chlorpromazine. Acta Otolaryngol 1979;88: Dencker L, Lindquist NG: Distribution of labeled chloroquine in the inner ear. Arch Otolaryngol 1975;101: ORL 2003;65:84 90 Adunka/Moustaklis/Weber/May/von Ilberg/ Gstoettner/Kierner