- Department of Otorhinolaryngology, Fondazione Policlinico Campus Biomedico, Rome,
- Research Unit of Otorhinolaryngology, Campus Biomedico Universty, Rome,
- Departement of Neurosurgery, Umberto I General University Hospital, Ancona, Italy.
Francesca Bonifacio, Department of Otorhinolaryngology, Fondazione Policlinico Campus Biomedico, Rome, Italy.
DOI:10.25259/SNI_187_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Fabrizio Salvinelli1,2, Francesca Bonifacio1, Fabio Greco1, Giulio Cavicchioni1, Valeria Frari1, Michelangelo Pierri1, Maurizio Trivelli1, Maurizio Iacoangeli3. Endolymphatic duct and sac decompression: A new technique for Ménière’s disease treatment. 16-Sep-2022;13:418
How to cite this URL: Fabrizio Salvinelli1,2, Francesca Bonifacio1, Fabio Greco1, Giulio Cavicchioni1, Valeria Frari1, Michelangelo Pierri1, Maurizio Trivelli1, Maurizio Iacoangeli3. Endolymphatic duct and sac decompression: A new technique for Ménière’s disease treatment. 16-Sep-2022;13:418. Available from: https://surgicalneurologyint.com/surgicalint-articles/11873/
Background: The present article aims to introduce the endolymphatic duct and sac decompression technique (DASD) and to give a spotlight on its benefits in Ménière’s disease (MD) treatment.
Methods: Eighty-two patients with intractable MD which met the inclusion criteria were recruited and underwent DASD. This technique allows a meningeal decompression of the duct and the sac from the posterior cranial fossa to the labyrinthine block. The authors considered as main outcomes, the change of the dizziness handicap inventory (DHI) results, with the evaluations of the three sub-scales (Functional scale, Physical scale, and Emotional scale); ear fullness and tinnitus change on the perceptions of the patient; and hearing stage with four-Pure Tone Average (500 hz-1000 hz-2000 hz-4000 hz). The differences between the preoperative and the postoperative score were evaluated. A comparison with the literature was conducted.
Results: After a 14-month follow-up, patients that underwent DASD reported a remarkable improvement of the symptoms in all three functional scales, confirmed by the total DHI. The difference between preoperative and postoperative scores is statistically significant. The data describe an ear fullness and tinnitus improvement. The multi-frequency tonal average before and after the surgery does not suggest a worsening of the value for any of 82 patients.
Conclusion: The modification of sac surgery includes the endolymphatic duct in the decompression area allowing inner ear functional improvement, vertigo control, ear fullness improvement with minimal risk of facial nerve paralysis, and hearing loss. DASD is an improved old surgical technique.
Keywords: Endolymphatic decompression, Endolymphatic hydrops, Ménière’s disease, Vertigo
Ménière’s Disease (MD) is an idiopathic pathology of the inner ear clinically characterized by spontaneous and recurrent episodes of dizziness, vertigo, fluctuating neurosensory hearing loss, tinnitus, and ear fullness. Years before the episodes of vertigo, the patient can experience tinnitus, ear fullness, and hearing loss of the affected ear. Hearing loss is associated with episodes of vertigo in 77% of patients.[
DASD is performed in substitution of plain endolymphatic sac surgery (ELSS). The technique is not limited to sac decompression but extended to duct decompression. To get around the difficulty of recognizing the endolymphatic sac, it is mandatory to drill out all the bone over the dura, from the superior petrosal sinus to the superior limit of the jugular bulb. To decompress the ED with reasonable certainty, the dura has to be exposed as far as the arch of the posterior semicircular canal, where the ED passes. The bone paté-surgical bone dust mixed with fibrin glue-is then positioned superiorly and inferiorly to the area, where the ED resides [
In consideration of the rounded-up intraosseous ES average length of 15 mm,[
Considering the ED as a cylindrical geometric figure:
y1 = 15 mm ES length
y2 = 15 mm + 1.64 mm = 16.64 = decompression zone length (length ES + length ED)
z1 = 0.48 = minimum height to be reached at the level of the duct (point P) considered as the diameter of the cylinder.
z=decompression zone height (bone-patè)
For l = y2-y1
The authors hypothesize that to decompress the ED (P1), it is necessary to have a height of about 4.8 mm of bone-pate to be placed between the posterior semi-circular canal and the upper extremity and dura mather (z). Using the currently available data in the literature regarding the ES,[
Furthermore, by arranging bone-paté in two points, beyond ES cranial margin, and beyond ES caudal margin (x), it is possible to include these structures in the decompression area. The authors have identified a prismatic area that represents the approximate decompression zone [
The observational self-controlled case study was conducted retrospectively at the Otolaryngology Department of the Campus Bio-Medico University on patients that underwent DASD. All the patients who met the criteria for MD according to the Classification Committee of the Bárány [
Exclusion criteria for DASD are patients older than 75 years (due to meningeal fragility), patients that cannot sustain general anesthesia, or suffering complete hearing loss of the affected ear. All patients underwent an ear Computed Tomography scan (CT scan) and brain magnetic resonance imaging to exclude inner ear pathologies and APC expansive formations.
Two patients showing signs of chronic otitis media will first undergo tympanoplasty and then DASD; the presence of a not well-pneumatized mastoid increases the difficulty of the intervention but does not represent a criterion of exclusion.
The authors administered the dizziness handicap inventory (DHI) questionnaire in an 82 patients consecutive cohort to evaluate postoperative and preoperative condition retrospectively. The DHI is a questionnaire validated in Italian[
The average follow-up from the intervention date is 14.96 months. Statistical analysis was carried out with GraphPad software Inc. and the Shapiro–Wilk test was used to evaluate the normality of the sample. Discontinuous variables are listed with median and range (IQR). The difference between the preoperative and postoperative values was analyzed with the Wilcoxon signed–rank test. The authors performed a comparison with the literature and found two publications, in which DHI was used to evaluate ELSS,[
In the case of the study by Bojrab et al., the authors do not report data on the standard deviations, these data were extracted from “
The Wilcoxon signed–rank test showed that the scoring difference between the preoperative and the postoperative of each DHI question is statistically significant (P < 0.001) [
Considering the follow-up obtained, 89% (73 of 82) of the patients achieved control of vertigo, 8% (7 of 82) underwent further surgery (neurectomy, Intratympanic Gentamicin), the remaining 3% (2 of 82) did not achieve symptoms control but refused to undergo further interventions. Among the residual symptoms, the “blocked crises” are reported: the patient experiences prodromal symptoms (tinnitus and fullness that increase in intensity) with brief light-headedness, without leading to vertigo. The comparison of the multi-frequency average of hearing thresholds is described [
The literature describes the different ELSS techniques: endolymphatic mastoid sac shunt and endolymphatic sac decompression without incision are described in some works with similar results among them;[
Failure of ELSS is related to the intrinsic intraoperative difficulty to recognize the endolymphatic sac; landmarks for its recognition are described in dissections of temporal bones reports.[
The wide decompression of the sigmoid sinus is fundamental to allow vertigo control in 90% of cases.[
Considering the young age of many of the patients, despite the good results in the literature on intratympanic gentamicin administration (ITG), the authors prefer not to expose patients even to the related 10% risk of hearing loss. Studies report different percentages of symptoms control for ITG: 75[
Todays’, debate is still based on the placebo effect related to any surgical procedure on the ear of the MD patient.[
This trend is possibly due to inherent difficulties with ELSS. Furthermore, ITG is supposedly performed more often for its easiness, replicability, and chain of work optimization. A consequent bias loop is established where less ELSS are performed, less data are provided, and less research is published.
For the authors, the goal and innovation of this technique are represented by the ED decompression. The duct and sac should be seen as a unitary system, but their organic and structural link is often underestimated. This hypothesis is based on the histopathological evidence of Linthicum et al.[
In this case series, treatment failure in 11% of cases are not associated with the frequency of preoperative vertigo nor with the duration of the disease; however, further data are needed.
The authors compared the results of this study with the literature using the DHI scale as a common differentiator. The initial good results appear to worsen during follow-up.[
DASD allows MD patients to obtain vertigo control, as well as improvement of the inner ear function. In addition, DASD helps to reduce ear fullness, with no relevant risk of hearing worsening in the postoperative time, lower rate of intraoperative complication, and shorter postoperative hospital stay and no irreversible vestibular deficits as expected from other techniques. DASD reduces the destructive effects of the MD on the cochlea and the labyrinths.
Institutional Review Board (IRB) permission obtained for the study.
There are no conflicts of interest.
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