Acta Oto-Laryngologica
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Intratympanic injection in delayed endolymphatic hydrops Bo Liu, Sulin Zhang, Yangming Leng, Renhong Zhou, Jingjing Liu & Weijia Kong To cite this article: Bo Liu, Sulin Zhang, Yangming Leng, Renhong Zhou, Jingjing Liu & Weijia Kong (2015) Intratympanic injection in delayed endolymphatic hydrops, Acta OtoLaryngologica, 135:10, 1016-1021, DOI: 10.3109/00016489.2015.1052984 To link to this article: http://dx.doi.org/10.3109/00016489.2015.1052984
Published online: 08 Jun 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [Boston University]
Date: 26 October 2015, At: 01:10
Acta Oto-Laryngologica. 2015; 135: 1016–1021
ORIGINAL ARTICLE
Intratympanic injection in delayed endolymphatic hydrops
BO LIU*, SULIN ZHANG*, YANGMING LENG*, RENHONG ZHOU, JINGJING LIU & WEIJIA KONG
Downloaded by [Boston University] at 01:10 26 October 2015
Department of Otolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, PR China
Abstract Conclusions: The present study showed that intratympanic dexamethasone injection (ITD) is a promising approach for the treatment of contralateral and ipsilateral delayed endolymphatic hydrops (DEH). Moreover, intratympanic gentamicin injection (ITG), as a chemical labyrinthectomy, is a simple alternative for controlling vertigo in patients with ipsilateral DEH. Objective: This study examined the effect of ITD or ITG on DEH. Methods: Fourteen patients with DEH completed the clinical and audiovestibular evaluation. Among them, 10 cases (ipsilateral type: nine cases, contralateral type: one case) were treated with intratympanic injection. Four patients with ipsilateral DEH underwent ITG, five patients with ipsilateral type and one patient with contralateral type received ITD. All 10 cases were followed up for 8–48 months. Results: Complete and substantial vertigo control was achieved in four of nine ipsilateral DEH patients treated with ITG. In the other five ipsilateral cases who received ITD, two accomplished complete vertigo control and two had substantial control. In one case, the vertigo was not effectively controlled. One case of contralateral DEH underwent ITD and this case had complete vertigo control. The vertigo intensity, vertigo frequency, vertigo duration and the functional level scale after intratympanic injection was decreased significantly.
Keywords: Endolymphatic hydrops, inner ear, injection, dexamethasone, gentamicin
Introduction Delayed endolymphatic hydrops represents a clinical condition characterized by episodic vertigo of delayed onset, ensuing sudden and protracted standing profound sensorineural hearing impairment in one ear. The association between vertigo and hearing loss was first proposed by Kamei et al. [1] in 1971, and further dubbed ‘unilateral deafness with subsequent vertigo’ by Nadol et al. [2] and Wolfson and Leibman [3] in 1975 [3]. In 1978, Schuknecht [4] elaborated on its etiology, put forward the term of ‘delayed endolymphatic hydrops (DEH)’, and, for the first time, categorized it into two types: ipsilateral and contralateral. Ipsilateral type refers to profound hearing loss followed by vertigo at the same ear. On the other hand, with its contralateral counterpart, hearing loss develops prior to vertigo of the contralateral ear [4].
Traditionally, the medical treatment was the therapy of choice. Many surgical procedures have been proven effective for ipsilateral DEH [5]. These procedures fall into two categories: conservative (such as endolymphatic sac surgery) and destructive surgeries (for example, labyrinthectomy [4] and streptomycin perfusion [5]). For the contralateral DEH, Hicks and Wright [6] suggested that the endolymphatic sac surgery, as a conservative approach, was relatively safe in terms of hearing preservation of the only functional ear and vertigo control. Recently, some novel techniques have been developed for the treatment of DEH. Middle ear pressure treatment with the Meniett device or the tympanic membrane massage device has been used for intractable vertigo in DEH patients [7]. Pathophysiologically, DEH shares some features with Ménière’s disease, such as the endolymphatic hydrops; therefore, some therapies for Ménière’s
Correspondence: Weijia Kong, Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province, 430022, PR China. Tel: +86-27-85726900. Fax: +86-27-85776343. E-mail: [email protected] *These authors contributed equally to this work.
(Received 16 March 2015; accepted 14 May 2015) ISSN 0001-6489 print/ISSN 1651-2251 online 2015 Informa Healthcare DOI: 10.3109/00016489.2015.1052984
Downloaded by [Boston University] at 01:10 26 October 2015
Intratympanic infusion in delayed endolymphatic hydrops disease are expected to work as well for DEH. Over the past decades, the intratympanic injection has been one of the primary treatments for Ménière’s disease. Generally, there are two kinds of medications for intratympanic injection: aminoglycosides and steroids. Intratympanic aminoglycoside injection, designed to destroy labyrinth, was also used for the treatment of DEH [5]. Bauer et al. [8] intratympanically injected gentamicin to the ear with profound sensorineural hearing loss, and effectively controlled vertigo. Meanwhile, the intratympanic dexamethasone injection (ITD) is another major treatment for Ménière’s disease [9]. Previous studies demonstrated that ITD was effective for controlling vertigo [10]. To our knowledge, no study has been reported regarding ITD for the treatment of DEH, and whether the DEH patients can benefit from intratympanic steroid infusion warrants further study. In this study, the patients with DEH were intratympanically injected gentamicin or dexamethasone, with an attempt to know if these two agents can effectively control vertigo. Patients and methods Patients From 2009–2014, 14 patients were diagnosed with DEH in our outpatient department. They all underwent a comprehensive clinical assessment and medical therapy. According to previously reported criteria [7], DEH is defined as precedent and long-standing profound sensorineural hearing loss in one ear, with a pure-tone average (PTA) of 500 Hz, 1 kHz, and 2 kHz greater than 90 dB and, after years, a delayed episode vertigo develops without fluctuating hearing loss in the same ear (ipsilateral DEH), or with fluctuating hearing loss in the opposite ear (contralateral DEH). Patients with central nervous system disorder, systemic disease, migraine, head trauma, and drug consumption were excluded. This study was conducted in strict accordance with the Declaration of Helsinki. The project was approved by the ethical committee of Union Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China. Informed consent was obtained from each patient. Audiometry and vestibular testing All patients were subjected to a complete neurotological assessment, audiography, acoustic immitance measurement, caloric test, and images exams. Hearing level was determined in terms of the average threshold at 500 Hz, 1 kHz, and 2 kHz. The
1017
spontaneous nystagmus was determined and caloric test performed by means of vedionystagmugraphy. With caloric test, the unilateral weakness (UW) was defined as a ratio greater than 30% between the difference of maximum slow phase velocity (SPV) of two ears (SPVleft – SPVright) and the sum of SPV of two ears (Jongkees’ formula). The Dix-Hallpike and Roll tests were also vedionystagmugraphically conducted. All patients received the magnetic resonance imaging scan on the internal auditory canal and cerebellopontine angle to rule out the spaceoccupying lesions. Intratympanic injection All 14 patients with DEH were initially treated with medications, including the diuretics, betahistine, or vasodilators for at least 6 months. Among them, 10 failed to respond to medical treatment and then were given intratympanic injection. Information about vertigo spells, hearing loss, tinnitus, aural fullness, and vestibular drop attack (Tumarkin crises) during the 6 months before the intratympanic injection was recorded. In this study, only one case of contralateral DEH received the ITD in the ear opposite to the preceding ear with hearing loss. The other nine cases of ipsilateral DEH underwent the intratympanic gentamicin injection (ITG) or ITD treatment. Four patients received ITG, and five were treated with ITD. Intratympanic injection was given in an office setting. Local anesthesia was achieved by filling the external ear canal with 2.5% lidocaine. The medicine was injected into the middle ear cavity of the affected side via the posterior–inferior quadrant of the tympanic membrane. Then, the patients were instructed to assume a supine position with the head tilted toward the non-injection side for at least 30 min, and they were asked not to swallow or talk to avoid the clearance of the drug through the eustachian tube. A concentration of 40 mg/mL gentamicin sulfate was buffered to reach a final concentration of 20 mg/ mL. Gentamicin was given by following a titration protocol. In this study, ITG was discontinued when the ‘constant vestibular symptoms’ such as disequilibrium, a substantially different Ménière-like vertigo attack, developed [11]. Four patients with ipsilateral DEH received intratympanic gentamicin injection into the affected ear on a weekly basis. They received two injections and manifested ‘constant vestibular symptoms’ and the treatment was withdrawn. The same procedure was employed for the dexamethasone (5 mg/mL) perfusion and a fixed protocol was followed, with one injection a week for 4 consecutive weeks.
1018
B. Liu et al. improvement, in terms of including the vertigo intensity, vertigo frequency, vertigo duration, and functional levels, was evaluated by Wilcoxon Signed Ranks Test. The difference in efficacy between the ITG and ITD was compared by non-parametric Mann-Whitney U-test. A p < 0.05 was considered to be statistically significant.
Downloaded by [Boston University] at 01:10 26 October 2015
Follow-up and outcome evaluation All 10 subjects receiving the intratympanic injection were followed-up for a period of time ranging from 8 months to 4 years. Given the similarities between DEH and Ménière’s disease in terms of symptoms, we assessed the vertigo control against the Ménière’s disease guideline proposed by the Committee on Hearing and Equilibrium of American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) in 1995 [12]. A symptom was not counted as a vertigo attack if a patient did not report vertigo but only exhibited mild imbalance or unsteadiness. All patients receiving intratympanic injection had been followed up by the time this paper was prepared. The vertigo score was calculated by multiplying by 100 the quotient between the average number of spells per month over the 6 months before the last telephone interview and the average number of monthly spells over the 6 months period before the treatment. The vertigo control was rated on a 6-point scale (A–F) according to the guidelines of 1995 [12]. The perceived benefit, including the vertigo relief, functional levels, and duration, intensity, and frequency of vertigo attacks, was recorded.
Results Clinical manifestations and audio-vestibular evaluation The clinical features and audio-vestibular data are listed in Table I. Of the 14 patients included, six were male and eight were female, with a mean age of 28 years (range = 16–47 years). According to the aforementioned diagnostic criteria, 13 were ipsilateral DEH and one contralateral DEH on the basis of their clinical manifestations and audiological findings. Clinical symptoms included hearing loss and vertigo in all 14 cases (100%), nausea and vomiting in nine9 cases (64.3%), tinnitus in 11 cases (78.6%), and aural fullness in five cases (35.7%). Vestibular drop attack occurred in two cases (patients 9 and10) before the intratympanic injection (14.3%). All 14 patients had profound hearing loss (>90 dB) in one ear. For the better ear, the PTA of 500 Hz, 1 kHz, and 2 kHz was
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Intratympanic injection in delayed endolymphatic hydrops Bo Liu, Sulin Zhang, Yangming Leng, Renhong Zhou, Jingjing Liu & Weijia Kong To cite this article: Bo Liu, Sulin Zhang, Yangming Leng, Renhong Zhou, Jingjing Liu & Weijia Kong (2015) Intratympanic injection in delayed endolymphatic hydrops, Acta OtoLaryngologica, 135:10, 1016-1021, DOI: 10.3109/00016489.2015.1052984 To link to this article: http://dx.doi.org/10.3109/00016489.2015.1052984
Published online: 08 Jun 2015.
Submit your article to this journal
Article views: 66
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [Boston University]
Date: 26 October 2015, At: 01:10
Acta Oto-Laryngologica. 2015; 135: 1016–1021
ORIGINAL ARTICLE
Intratympanic injection in delayed endolymphatic hydrops
BO LIU*, SULIN ZHANG*, YANGMING LENG*, RENHONG ZHOU, JINGJING LIU & WEIJIA KONG
Downloaded by [Boston University] at 01:10 26 October 2015
Department of Otolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, PR China
Abstract Conclusions: The present study showed that intratympanic dexamethasone injection (ITD) is a promising approach for the treatment of contralateral and ipsilateral delayed endolymphatic hydrops (DEH). Moreover, intratympanic gentamicin injection (ITG), as a chemical labyrinthectomy, is a simple alternative for controlling vertigo in patients with ipsilateral DEH. Objective: This study examined the effect of ITD or ITG on DEH. Methods: Fourteen patients with DEH completed the clinical and audiovestibular evaluation. Among them, 10 cases (ipsilateral type: nine cases, contralateral type: one case) were treated with intratympanic injection. Four patients with ipsilateral DEH underwent ITG, five patients with ipsilateral type and one patient with contralateral type received ITD. All 10 cases were followed up for 8–48 months. Results: Complete and substantial vertigo control was achieved in four of nine ipsilateral DEH patients treated with ITG. In the other five ipsilateral cases who received ITD, two accomplished complete vertigo control and two had substantial control. In one case, the vertigo was not effectively controlled. One case of contralateral DEH underwent ITD and this case had complete vertigo control. The vertigo intensity, vertigo frequency, vertigo duration and the functional level scale after intratympanic injection was decreased significantly.
Keywords: Endolymphatic hydrops, inner ear, injection, dexamethasone, gentamicin
Introduction Delayed endolymphatic hydrops represents a clinical condition characterized by episodic vertigo of delayed onset, ensuing sudden and protracted standing profound sensorineural hearing impairment in one ear. The association between vertigo and hearing loss was first proposed by Kamei et al. [1] in 1971, and further dubbed ‘unilateral deafness with subsequent vertigo’ by Nadol et al. [2] and Wolfson and Leibman [3] in 1975 [3]. In 1978, Schuknecht [4] elaborated on its etiology, put forward the term of ‘delayed endolymphatic hydrops (DEH)’, and, for the first time, categorized it into two types: ipsilateral and contralateral. Ipsilateral type refers to profound hearing loss followed by vertigo at the same ear. On the other hand, with its contralateral counterpart, hearing loss develops prior to vertigo of the contralateral ear [4].
Traditionally, the medical treatment was the therapy of choice. Many surgical procedures have been proven effective for ipsilateral DEH [5]. These procedures fall into two categories: conservative (such as endolymphatic sac surgery) and destructive surgeries (for example, labyrinthectomy [4] and streptomycin perfusion [5]). For the contralateral DEH, Hicks and Wright [6] suggested that the endolymphatic sac surgery, as a conservative approach, was relatively safe in terms of hearing preservation of the only functional ear and vertigo control. Recently, some novel techniques have been developed for the treatment of DEH. Middle ear pressure treatment with the Meniett device or the tympanic membrane massage device has been used for intractable vertigo in DEH patients [7]. Pathophysiologically, DEH shares some features with Ménière’s disease, such as the endolymphatic hydrops; therefore, some therapies for Ménière’s
Correspondence: Weijia Kong, Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province, 430022, PR China. Tel: +86-27-85726900. Fax: +86-27-85776343. E-mail: [email protected] *These authors contributed equally to this work.
(Received 16 March 2015; accepted 14 May 2015) ISSN 0001-6489 print/ISSN 1651-2251 online 2015 Informa Healthcare DOI: 10.3109/00016489.2015.1052984
Downloaded by [Boston University] at 01:10 26 October 2015
Intratympanic infusion in delayed endolymphatic hydrops disease are expected to work as well for DEH. Over the past decades, the intratympanic injection has been one of the primary treatments for Ménière’s disease. Generally, there are two kinds of medications for intratympanic injection: aminoglycosides and steroids. Intratympanic aminoglycoside injection, designed to destroy labyrinth, was also used for the treatment of DEH [5]. Bauer et al. [8] intratympanically injected gentamicin to the ear with profound sensorineural hearing loss, and effectively controlled vertigo. Meanwhile, the intratympanic dexamethasone injection (ITD) is another major treatment for Ménière’s disease [9]. Previous studies demonstrated that ITD was effective for controlling vertigo [10]. To our knowledge, no study has been reported regarding ITD for the treatment of DEH, and whether the DEH patients can benefit from intratympanic steroid infusion warrants further study. In this study, the patients with DEH were intratympanically injected gentamicin or dexamethasone, with an attempt to know if these two agents can effectively control vertigo. Patients and methods Patients From 2009–2014, 14 patients were diagnosed with DEH in our outpatient department. They all underwent a comprehensive clinical assessment and medical therapy. According to previously reported criteria [7], DEH is defined as precedent and long-standing profound sensorineural hearing loss in one ear, with a pure-tone average (PTA) of 500 Hz, 1 kHz, and 2 kHz greater than 90 dB and, after years, a delayed episode vertigo develops without fluctuating hearing loss in the same ear (ipsilateral DEH), or with fluctuating hearing loss in the opposite ear (contralateral DEH). Patients with central nervous system disorder, systemic disease, migraine, head trauma, and drug consumption were excluded. This study was conducted in strict accordance with the Declaration of Helsinki. The project was approved by the ethical committee of Union Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China. Informed consent was obtained from each patient. Audiometry and vestibular testing All patients were subjected to a complete neurotological assessment, audiography, acoustic immitance measurement, caloric test, and images exams. Hearing level was determined in terms of the average threshold at 500 Hz, 1 kHz, and 2 kHz. The
1017
spontaneous nystagmus was determined and caloric test performed by means of vedionystagmugraphy. With caloric test, the unilateral weakness (UW) was defined as a ratio greater than 30% between the difference of maximum slow phase velocity (SPV) of two ears (SPVleft – SPVright) and the sum of SPV of two ears (Jongkees’ formula). The Dix-Hallpike and Roll tests were also vedionystagmugraphically conducted. All patients received the magnetic resonance imaging scan on the internal auditory canal and cerebellopontine angle to rule out the spaceoccupying lesions. Intratympanic injection All 14 patients with DEH were initially treated with medications, including the diuretics, betahistine, or vasodilators for at least 6 months. Among them, 10 failed to respond to medical treatment and then were given intratympanic injection. Information about vertigo spells, hearing loss, tinnitus, aural fullness, and vestibular drop attack (Tumarkin crises) during the 6 months before the intratympanic injection was recorded. In this study, only one case of contralateral DEH received the ITD in the ear opposite to the preceding ear with hearing loss. The other nine cases of ipsilateral DEH underwent the intratympanic gentamicin injection (ITG) or ITD treatment. Four patients received ITG, and five were treated with ITD. Intratympanic injection was given in an office setting. Local anesthesia was achieved by filling the external ear canal with 2.5% lidocaine. The medicine was injected into the middle ear cavity of the affected side via the posterior–inferior quadrant of the tympanic membrane. Then, the patients were instructed to assume a supine position with the head tilted toward the non-injection side for at least 30 min, and they were asked not to swallow or talk to avoid the clearance of the drug through the eustachian tube. A concentration of 40 mg/mL gentamicin sulfate was buffered to reach a final concentration of 20 mg/ mL. Gentamicin was given by following a titration protocol. In this study, ITG was discontinued when the ‘constant vestibular symptoms’ such as disequilibrium, a substantially different Ménière-like vertigo attack, developed [11]. Four patients with ipsilateral DEH received intratympanic gentamicin injection into the affected ear on a weekly basis. They received two injections and manifested ‘constant vestibular symptoms’ and the treatment was withdrawn. The same procedure was employed for the dexamethasone (5 mg/mL) perfusion and a fixed protocol was followed, with one injection a week for 4 consecutive weeks.
1018
B. Liu et al. improvement, in terms of including the vertigo intensity, vertigo frequency, vertigo duration, and functional levels, was evaluated by Wilcoxon Signed Ranks Test. The difference in efficacy between the ITG and ITD was compared by non-parametric Mann-Whitney U-test. A p < 0.05 was considered to be statistically significant.
Downloaded by [Boston University] at 01:10 26 October 2015
Follow-up and outcome evaluation All 10 subjects receiving the intratympanic injection were followed-up for a period of time ranging from 8 months to 4 years. Given the similarities between DEH and Ménière’s disease in terms of symptoms, we assessed the vertigo control against the Ménière’s disease guideline proposed by the Committee on Hearing and Equilibrium of American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) in 1995 [12]. A symptom was not counted as a vertigo attack if a patient did not report vertigo but only exhibited mild imbalance or unsteadiness. All patients receiving intratympanic injection had been followed up by the time this paper was prepared. The vertigo score was calculated by multiplying by 100 the quotient between the average number of spells per month over the 6 months before the last telephone interview and the average number of monthly spells over the 6 months period before the treatment. The vertigo control was rated on a 6-point scale (A–F) according to the guidelines of 1995 [12]. The perceived benefit, including the vertigo relief, functional levels, and duration, intensity, and frequency of vertigo attacks, was recorded.
Results Clinical manifestations and audio-vestibular evaluation The clinical features and audio-vestibular data are listed in Table I. Of the 14 patients included, six were male and eight were female, with a mean age of 28 years (range = 16–47 years). According to the aforementioned diagnostic criteria, 13 were ipsilateral DEH and one contralateral DEH on the basis of their clinical manifestations and audiological findings. Clinical symptoms included hearing loss and vertigo in all 14 cases (100%), nausea and vomiting in nine9 cases (64.3%), tinnitus in 11 cases (78.6%), and aural fullness in five cases (35.7%). Vestibular drop attack occurred in two cases (patients 9 and10) before the intratympanic injection (14.3%). All 14 patients had profound hearing loss (>90 dB) in one ear. For the better ear, the PTA of 500 Hz, 1 kHz, and 2 kHz was
