Acta Otolaryngol (Stockh) 1991; Suppl. 481: 617-623
Treatment of Vestibular Disorders AKINORI ITOH and EIJI SAKATA
Acta Otolaryngol Downloaded from informahealthcare.com by University of Auckland on 01/15/15 For personal use only.
From the Depurtment of Nerrrotology. Suitutnu Mediccrl School Ho.spitrrl. Suitunza. Japan
At our department, we generally perform inner ear anesthesia with lidocaine and intratympanic dexamethasone injection for treatment of patients with Meniere‘s disease or labyrinthine vertigo due to circulatory disturbances of the inner ear. having failed other conservative treatments. These treatments were performed in 322 patients who consulted us during the past 7 years, including 136 patients with Meniere’s disease and 186 patients with labyrinthine vertigo. The criteria for evaluation of the therapeutic effect included the AAOO (1972). the AAO-HNS (1985) and Sakata’s (1987) method. Both therapeutic methods were effective not only for the inhibition of vertiginous attacks. but also for the treatment of tinnitus. In the overall evaluation of therapeutic effect. dexamethasone injection was more effective than inner ear anesthesia in cases of Meniere’s disease whereas inner ear anesthesia was more effective than dexamethasone in.jection in cases of labyrinthine vertigo. When the three methods of evaluation were compared. the rate of positive effect increased in this order: the AAOO method showed fewer positive effects than the AAO-HNS method, and fewer than or equal to Sakata‘s method. For example in cases of Meniere’s disease that are resistant to drug therapy. these two therapeutic methods appear to be worthwhile before attempting surgical treatment for refractory vertigo. K q words: Meniere’s diseuse. inner eur unr.stlr~~.siri. the inrrrityrnptrnic~d c ~ x c r t n r t l r asone injerrion, euulirution of the therupeirtic e f f i ~ c t .
INTRODUCTION Meniere’s disease and labyrinthine vertigo due to circulatory disturbances of the inner ear are representative of diseases characterized by repeated spontaneous vertigo. Many patients with these diseases display resistance to drug therapy. In Meniere’s disease. for example, surgical treatment is frequently attempted in cases with symptoms that resist drug therapy, but the operative results are far from satisfactory. In our department, the treatment of these cases included inner ear anesthesia with lidocaine or intratympanic dexamethasone injection. In this report. the results of these two methods in the treatment of drug-resistance repeated vertigo during the past 7 years are summarized. Three different criteria of evaluation, the AAOO ( 1972). the AAO-HNS (1985) and Skata’s (1987) method were used. In addition. these evaluation were compared within each group of patients (1, 2, 3). SUBJECTS This study was performed between August 1981 and December 1987 on 12627 patients who consulted the out-patient clinic of this department. Of these patients, 5 157 complained of vertigo out of which 345 had Meniere’s disease, I305 labyrinthine vertigo. 128 vestibular neuritis, 663 sudden deafness, 656 paroxysmal positional vertigo. I 37 1 central nervous system lesions, and 689 vertigo due to other causes. The following group of patients was included in the study. The patients had either unilateral Meniere’s disease or unilateral labyrinthine vertigo. and the vertigo was resistant to standard drug treatment. Patients were selected in whom follow-up observation after treatment was feasible. In the present study, the evaluation of therapeutic effect was performed in 136 patients
618 A . Ztoh and E . Sakata Table I. Sirbjects of Meniere's disease and the lrrh~rinthinevertigo MATERIALS August 1981-December patients Menidre disease
N=345 the labyrinthine vertlgo due to circulatory disturbance
1987 inner ear anesthesia intratyrnpnic injection withwocaine WithDexamthasOna
I
75 ears
I
61
11361
67
119
186
142
180
Acta Otolaryngol Downloaded from informahealthcare.com by University of Auckland on 01/15/15 For personal use only.
N=1305
with Meniere's disease and in 186 patients with labyrinthine vertigo, i.e. a total of 322 patients. Among the 136 patients with Meniere's disease. 75 were treated with inner ear anesthesia and 61 with intratympanic dexamethasone injection. Among the 186 patients with labyrinthine vertigo, 67 were treated with inner ear anesthesia and I19 with the dexamethasone injection method (Table I).
METHOD Inner ear anesthesia Breakfast was withheld, and an anti-emetic and sedative drug were administered orally. With the patient in a sitting position, 0.5 ml of a 4 % lidocaine and 2 mg (0.5 ml) of dexamethasone were slowly injected into the tympanic cavity through the tympanic menbrane using a syringe with a long needle. The patient was subsequently placed in the lateral position with the affected ear upward. Beginning about 30 min after anesthesia, a mixed horizontal and rotatory nystagmus directed to the opposite side was observed for 2 or 3 h. The patients experienced vertigo and nausea. due to a transient inner ear hypofunction caused by the infiltration of the anesthetic solution into the inner ear. In most cases, the patients were readmitted, and inner ear anesthesia was performed repeatedly 4 o r 5 times at intervals of 3 or 4 days. Intratympanic dexamethasone injection Dexamethasone, 2 mg (0.5 ml), was injected into the tympanic cavity through the tympanic membrane using a technique similar to that used in the anesthesia method. Following injection, the patient was placed in a sitting position with the injected ear upward for 15 to 30 min. Unlike the anesthesia method, this method did not cause a decrease in inner ear function. This procedure was usually performed on an ambulatory basis. Dexamethasone was injected for a total of 4 or 5 times at intervals of I or 2 weeks. In both of these methods. the drug injected into the tympanic cavity was expected to be transferred to the inner ear through the round window. i.e. a kind of targeting therapy of the inner ear disease.
EVALUATION Three different criteria of evaluation, the AAOO (1972). the AAO-HNS (1985) and Sakata's (1987) method were used. These evaluation methods are summarrized in Table 11.
Treatment of vestibular disorders 619
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Table 11. Criteria f o r the evalrration of the theraperrtic qirect @An00 criteria (1972) class A: 1) absence of typical spells for a definte period 2) 15dB pure-tone average increase B : 1) as in class A 2) hearing unchanged C : 1) as in class A 2) 15dB pure-tone average decrease D: failure to control definitive spells definite period : a period 10 times the average interval between spells before treatment. OAAO-HNS criteria (1985) average no. of definitive spells/mo in 24 mo period after theraphy numeric value = average no. of definitive spells/mo in 6 mo period before theraphy scoring : 0 complete control of definitive spells 1- 40 substantial control of definitive spells 41- 80 limited control of definitive spells 81-120 insignificant control of definitive spells worse control of definitive spells 121@Sakata’s criteria (1987) Excellent : absence of spells for a definite peried : improvement of spells for a definite period Good Unchanged : no effect : increase in the attacks Worse definite period : a period consisting of the mean interval of spells plus six months
RESULTS Mean age The mean age of the 136 patients with Meniere’s disease was 49.4 years (48.2 years in males and 50.3 years in females). The mean age of the 186 patients with labyrinthine vertigo was 51.9 years (50.9 years in males and 52.6 years in females). The mean age of the entire group of 322 patients was 49.7 years (49.8 years in males and 49.6 in females). Tvpe of vertigo Of the 136 patients with Meniere’s disease, 121 complained of rotatory vertigo (89%). Of the 186 patients with labyrinthine vertigo, 146 complained of rotatory vertigo (78%). Overall evaluation of the theraperrtic yffpct The overall evaluation of the therapeutic effect of the two methods are summarized in Table 111. Treatment of Meniere’s disease by inner ear anesthesia: Recurrent attacks of vertigo responded well to this treatment in 32 of 56 patients ( 5 7 % ) according to the criteria of AAOO (Class A + B + C ) , in 61 of 75 patients (81 5%) according to the criteria of the AAOHNS (numeric value from 0 to 40) and in 65 of 75 patients (87%) according to Sakata’s criteria (excellent + good). Treatment of Meniere’s disease by dexamethcrsone injection: Recurrent attacks of vertigo responded well to this treatment in 28 of 51 patients ( 5 5 56) according to the criteria ofAAOO (Class A + B + C ) , in 49 of 61 patients (80%) according to the criteria of the AAOHNS (numeric value from 0 to 40) and in 49 of 61 patients (8176) according to Sakata’s criteria (excellent + good). Treatment of labyrinthine vertigo by inner ear trnesthesia: Recurrent attacks of vertigo responded well to this treatment in 30 of 50 patients (60%) according to the criteria of
620 A . Itoh and E . Sakata
Treatment of Mihiere Disease *(inner ear anesthesia with Lidocaine)
AAOO
of
N =50
our report(1990)
N=67
% our re rt( 1990)
AAOO
AAO-HNS
Acta Otolaryngol Downloaded from informahealthcare.com by University of Auckland on 01/15/15 For personal use only.
The Labyrinthine Vertigo *Treatment (inner ear anesthesia with Lidocaine)
AAO-HNS
m
[
Y
N=67 Sakata
Sakata
p : good
E : exellant (evaluatlon) U : unchanged
W
(evaluatlon)
: worse
Treatment of Meniere Disease * (intratympanic injection with Dexamethasone)
*
Treatment of The Labyrinthine Vertigo (intratympanic injection with Dexamethasone)
, , ,, , ,
m]m] Lil\ our report( 1990)
AAOO
our rePjrt(1990)
59
21
our re Sakata
rt 1990)
AAOO
N=61
AAO-HNS
our re
o;
:
,*=I19
AAO-HNS
rt(l9W)
our re
rt 1990) W
m / / I m : 55
24
12
6
our report(1990)
Sakata
( evaluatlon )
AAOO (Class A + B + C ) . in 54 of 67 patients ( 8 4 % ) according to the criteria of the AAOHNS (numeric value from 0 to 40) and in 60 of 67 patients (89%) according to Sakata’s criteria (excellent + good). Peatment of labyrinthine vertigo by desntnethci.ron~~ injection: Recurrent attacks of vertigo responded well to this treatment in 49 of 89 patients ( 5 5 % ) according to the criteria of AAOO (Class A+B+C). in 94 of 119 patients ( 7 9 % ) according to the criteria of the AAO-HNS (numeric value from 0 to 40) and in 83 of 119 patients (78%) according to Sakata’s criteria (excellent + good). A comparison of evaluation of almost identical groups of patients using the three methods of evaluation shows this tendency: the AAOO method < the AAO-HNS method 5 Sakata’s method, in a increasing order of favorable results. Drtration o j diseuse und theraperrtic efrect: In cases of Meniere‘s disease and labyrinthine vertigo treated with the two methods (inner ear anesthesia and intratympanic dexamethasone injection) therapeutic effects were more favorable with a shorter duration of disease (the AAO-HNS and Sakata’s evaluation).
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Treatment of vestibular disorders Frequency of attacks and therapeutic ejfiect: In cases of Meniere’s disease. with attacks of vertigo more than once each month, better results were obtained using intratympanic dexamethasone injection than using inner ear anesthesia (the AAOO. the AAO-HNS and Sakata’s evaluation). In cases of labyrinthine vertigo, no definite correlation was noted between the frequency of attacks and the therapeutic effects (the AAOO, the AAO-HNS and Sakata‘s evaluation). Mean of hearing level ( H L )and thcrapeiitic cflect: In cases of Meniere’s disease treated with the intratympanic dexamethasone injection. the therapeutic effects were poor in patient with severe deafness (the AAOO. the AAO-HNS and Sakata’s evaluation). In cases of labyrinthine vertigo, no definite correlation was noted between the mean of HL and the therapeutic effect with either treatment. Type of audiogram and theraperrtic effect: In cases of Meniere’s disease treated with intratympanic dexamethasone injection. better therapeutic results were obtained in patients with low tone deafness and convex-type audiogram (the AAOO evaluation). In addition to the therapeutic results on vertigo. intratympanic dexamethasone injection resulted in an improvement of hearing in patients with low tone deafness and convex-type audiogram. In cases of labyrinthine vertigo treated with both methods. poor therapeutic results were obtained in cases with flat-type audiogram (the AAOO. the AAO-HNS and Sakata’s evaluation). Tinnitus: In cases of Meniere’s disease. inner ear anesthesia resulted in an excellent effect in 39%. a good effect in 22% and no effect in 39%. giving a rate of positive effect against tinnitus of 61 %. In similar cases, dexamethasone injection resulted in an excellent effect in 45%, a good effect in 29% and no effect in 26%. giving a rate of positive effect against tinnitus of 74%. In cases of labyrinthine vertigo, inner ear anesthesia resulted in an excellent effect in 44%, a good effect in 32% and no effect in 24%. giving a rate of positive effect against tinnitus of 76%. In similar cases, dexamethasone injection resulted in an excellent effect in 36%. a good effect in 34% and no effect in 30%. giving a rate of positive effect against tinnitus of 70%. For tinnitus in Meniere’s disease, consequently. intratympanic dexamethasone injection was more effective, whereas, for tinnitus in labyrinthine vertigo. inner ear anesthesia was more effective. DISCUSSION The first attempts at clinical treatment of vertigo using an injection of lidocaine into the tympanic cavity were reported by Ristow in 1967. According to his report this method was effective in about 65% of patients with Meniere’s disease. Fradis (1985) subsequently attempted a study of inner ear anesthesia in 28 patients with Meniere’s disease. and reported a positive effect in 83.7%. Sakata (1987) attempted a study of the same method in 47 patients, and obtained a positive effect in 89%. Saitoh (1987) also attempted a study of the same method in 28 patients, and obtained a positive effect in 86.7%. In none of these studies was a decrease of hearing level noted following treatment with inner ear anesthesia. Upon injection of lidocaine into the inner ear. the patient may experience vertigo and nausea, which may persist for the first few hours following treatment due to acute impairment in the labyrinthine function. This is a transient. reversible but unpleasant side effect. Consequently, this method should be performed on in-patients.
621
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622 A . Itoh and E . Sakata To avoid this unpleasant side effect, intratympanic dexamethasone injection method using the same technique was suggested by Sakata (1987). Since this method is not accompanied by significant vertigo and nausea seen with inner ear anesthesia, it is possible to perform this method on out-patients (3). As seen in our present report, the therapeutic effect of dexamethasone injection on vertigo and tinnitus was comparable. if not equal. to the effect obtained with inner ear anesthesia. At our department, patients with Meniere’s disease or labyrinthine vertigo with repeated spontaneous rotatory vertigo resistant to various conservative treatments were first treated at the out-patient clinic using intratympanic dexamethasone injection. In cases in whom the attacks of vertigo persisted despite this treatment inner ear anesthesia was performed after hospitalization. The purpose of inner ear anesthesia is relief of the stimulated or hypersensitive state of the inner ear sensory cells. Saitoh (1987). in animal experiments using both guinea pigs and pigeons, noted mild degeneration in the sensory hair of the external hair cell of the basal to the second spiral of the cochlea in response to an injection of 4 % lidocaine into the tympanic cavity. The injection of 10% lidocaine caused a considerably more intense change involving not only the outer hair cells. but also the inner hair cells. The mechanism of action of inner ear anesthesia for the suppression of vertigo and tinnitus may include changes of the inner ear (partial destruction) adding to the reversible effect. On intratympanic dexamethasone injection. no basic studies have been performed. Steroid injection apparently does not commonly cause organic changes of the inner ear. Consequently, it is difficult to explain the persistence of the effect of steroid injection in the treatment of vertigo and tinnitus. Corticosteroids probably exert some action on the inner ear to interrupt the vicious cycle. In this method. the steroid probably reaches the inner ear by passing through the round window. improving cellular edema and any metabolic disturbances of the inner ear. Membrane stabilization and sedative actions also appeared to contribute to the suppression of the irritated or hypersensitive state of the inner ear sensory cells. In the overall evaluation of therapeutic effect. intratympanic dexamethasone injection was more effective than inner ear anesthesia in cases of Meniere’s disease whereas inner ear anesthesia was more effective than dexamethasone injection in cases of labyrinthine vertigo. These results may indicate a difference in the mechanism of action between these two methods of treatment of refractory inner ear disease. The AAOO. the AAO-HNS and Sakata’s method were employed to evaluate the therapeutic effects in cases of unilateral Meniere’s disease and labyrinthine vertigo. In the AAOO evaluation method, the course must be followed for a period 10 times as long as the mean duration of the attack: so sufficient statistical data could not be obtained in many cases due to inadequate follow-up, making evaluation impossible. When the three methods were to be compared, consequently, an accurate comparison was difficult because of the difference in the size of the population. However, it is possible to note certain tendencies. In the evaluation of almost all symptoms. the rate of positive effect increased in order: the AAOO less than the AAO-HNS, less than or equal to Sakata’s method. Futaki (1987) used the AAOO, the AAO-HNS and Uemura’s method in the evaluation of the therapeutic effects of surgical treatment on Meniere’s disease ( 7 . 8). A comparison of these three methods revealed a rate of positive effect of 51 % using the AAOO, 94% using the AAOHNS and 83 % using Uemura’s method (1977). The characteristics of the AAOO evaluation method include a combined evaluation of the effect on auditory function and the suppressive effect on vertigo. Consequently, the purely therapeutic effect of the treatment on vertigo could not be evaluated independently of the effect on auditory function. The requirement of an observation period 10 times as
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Treatment of vestibular disorders 623 long as the mean interval of vertiginous attacks also presents problems. Especially in conservative treatment, it is difficult to continue observation for longer periods. The AAO-HNS evaluation method is the product of further refinement and improvement. Unlike the AAOO, this method evaluates a decrease in the frequency of vertiginous attacks. A comparison of numeric values makes a detailed classification of the degree of suppression an advantage. In this method, however. a 24-month follow-up period after treatment is a significant problem. A method requiring a shorter follow-up period would be desirable. Sakata's evaluation method resulted in an evaluation of therapeutic effect similar to that of the AAO-HNS, while the latter method has the advantage of simple. readily supplied data available for statistical evaluation: a disadvantage is the possible influence of subjective evaluation factors of the intensity of vertigo. Tokumasu (1985) suggested another method of evaluation. The mean interval of attacks over a certain period before and after the initial day of treatment was calculated using a computer and the statistical significance of the difference between these two mean intervals was estimated. The length of each of these two intervals was 10 times as long as the mean attack interval over the whole period (9). In the future. such a method. using a microcomputer for the statistical analysis. will become the primary evaluation method in this field. Various methods have been employed in the past for an evaluation of the therapeutic effect of various treatments for Meniere's disease. In the present study of vertigo. the therapeutic effects of the inner ear anesthesia method and the intratyrnpanic dexamethasone injection method. attempted at our department, were statistically compared. Based on these results, effects on Meniere's disease and labyrinthine vertigo were demonstrated to be similar. In Meniere's disease, for example. these methods resulted in an outcome that was favorably compared to that obtained with surgical treatment. In the forms of Meniere's disease which are resistant to drug therapy, these two methods appear to be worthwhile before attempting surgical treatment for refractory vertigo.
REFERENCES I . Alford BR. Report of subcommittee o n equilibrium and its measurement. Meniere's disease: criteria for diagnosis and evaluation of therapy for reporting. Trans Am Acad Ophthalmol Otolaryngol 1972: 76: 14624. 2. Pearson BW, Brackmann DE. Committee on hearing and equilibrium for reporting treatment results in Meniere's disease. Otolaryngol Head Neck Surg 1985: 93: 579-81. 3. Sakata E. Itoh N. Itoh A e t al. Comparative studies of the therapeutic effect of inner ear anesthesia and middle e a r infusion of a steroid solution for Meniere's disease. Pract Otol (Kyoto) 1987: 80: 57-65. 4. Ristow W . Zur Behandlung der Menierekrankheit mittels temporarer Labyrinthanasthesie. Z Laryngol 1968: 47: 442-8. 5. Fradis M. Podoshin L, Ben-David J . Reiner B. Treatment of Meniere's disease by intratympanic injection with lidocaine. Arch Otolaryngol 1985: I I I : 491-3. 6. Saitoh Y. Muaki Y . Ishikawa T et al. Treatment of severe Meniere's disease with intratympanic injection with lidocaine. Equilibrium Res (Kyoto) 1987: 46: 207-13. 7. Uemura T, Kaneko H . Fijita H. Kobayashi R. Follow-up study of Meniere's disease with the average observation period of 8 years. Pract Otol (Kyoto) 1977: 70: 1691-6. 8. Futaki T. Comparison of several guidelines for evaluation of therapy in Meniere's disease. Equilibrium Res (Kyoto) 1987: 46: 23848. 9. Tokumasu K. Medical therapy for Meniere's disease. Oto-Rhino-Laryngology (Tokyo) 1985: 28: 357-66. Address for correspondence: Akinori Itoh, Department of Neurotology, Saitama Medical School Hospital. 38 Moro-Hongo. Moroyamacho. Iruma-gun. Saitama. 350-04 Japan
Treatment of Vestibular Disorders AKINORI ITOH and EIJI SAKATA
Acta Otolaryngol Downloaded from informahealthcare.com by University of Auckland on 01/15/15 For personal use only.
From the Depurtment of Nerrrotology. Suitutnu Mediccrl School Ho.spitrrl. Suitunza. Japan
At our department, we generally perform inner ear anesthesia with lidocaine and intratympanic dexamethasone injection for treatment of patients with Meniere‘s disease or labyrinthine vertigo due to circulatory disturbances of the inner ear. having failed other conservative treatments. These treatments were performed in 322 patients who consulted us during the past 7 years, including 136 patients with Meniere’s disease and 186 patients with labyrinthine vertigo. The criteria for evaluation of the therapeutic effect included the AAOO (1972). the AAO-HNS (1985) and Sakata’s (1987) method. Both therapeutic methods were effective not only for the inhibition of vertiginous attacks. but also for the treatment of tinnitus. In the overall evaluation of therapeutic effect. dexamethasone injection was more effective than inner ear anesthesia in cases of Meniere’s disease whereas inner ear anesthesia was more effective than dexamethasone in.jection in cases of labyrinthine vertigo. When the three methods of evaluation were compared. the rate of positive effect increased in this order: the AAOO method showed fewer positive effects than the AAO-HNS method, and fewer than or equal to Sakata‘s method. For example in cases of Meniere’s disease that are resistant to drug therapy. these two therapeutic methods appear to be worthwhile before attempting surgical treatment for refractory vertigo. K q words: Meniere’s diseuse. inner eur unr.stlr~~.siri. the inrrrityrnptrnic~d c ~ x c r t n r t l r asone injerrion, euulirution of the therupeirtic e f f i ~ c t .
INTRODUCTION Meniere’s disease and labyrinthine vertigo due to circulatory disturbances of the inner ear are representative of diseases characterized by repeated spontaneous vertigo. Many patients with these diseases display resistance to drug therapy. In Meniere’s disease. for example, surgical treatment is frequently attempted in cases with symptoms that resist drug therapy, but the operative results are far from satisfactory. In our department, the treatment of these cases included inner ear anesthesia with lidocaine or intratympanic dexamethasone injection. In this report. the results of these two methods in the treatment of drug-resistance repeated vertigo during the past 7 years are summarized. Three different criteria of evaluation, the AAOO ( 1972). the AAO-HNS (1985) and Skata’s (1987) method were used. In addition. these evaluation were compared within each group of patients (1, 2, 3). SUBJECTS This study was performed between August 1981 and December 1987 on 12627 patients who consulted the out-patient clinic of this department. Of these patients, 5 157 complained of vertigo out of which 345 had Meniere’s disease, I305 labyrinthine vertigo. 128 vestibular neuritis, 663 sudden deafness, 656 paroxysmal positional vertigo. I 37 1 central nervous system lesions, and 689 vertigo due to other causes. The following group of patients was included in the study. The patients had either unilateral Meniere’s disease or unilateral labyrinthine vertigo. and the vertigo was resistant to standard drug treatment. Patients were selected in whom follow-up observation after treatment was feasible. In the present study, the evaluation of therapeutic effect was performed in 136 patients
618 A . Ztoh and E . Sakata Table I. Sirbjects of Meniere's disease and the lrrh~rinthinevertigo MATERIALS August 1981-December patients Menidre disease
N=345 the labyrinthine vertlgo due to circulatory disturbance
1987 inner ear anesthesia intratyrnpnic injection withwocaine WithDexamthasOna
I
75 ears
I
61
11361
67
119
186
142
180
Acta Otolaryngol Downloaded from informahealthcare.com by University of Auckland on 01/15/15 For personal use only.
N=1305
with Meniere's disease and in 186 patients with labyrinthine vertigo, i.e. a total of 322 patients. Among the 136 patients with Meniere's disease. 75 were treated with inner ear anesthesia and 61 with intratympanic dexamethasone injection. Among the 186 patients with labyrinthine vertigo, 67 were treated with inner ear anesthesia and I19 with the dexamethasone injection method (Table I).
METHOD Inner ear anesthesia Breakfast was withheld, and an anti-emetic and sedative drug were administered orally. With the patient in a sitting position, 0.5 ml of a 4 % lidocaine and 2 mg (0.5 ml) of dexamethasone were slowly injected into the tympanic cavity through the tympanic menbrane using a syringe with a long needle. The patient was subsequently placed in the lateral position with the affected ear upward. Beginning about 30 min after anesthesia, a mixed horizontal and rotatory nystagmus directed to the opposite side was observed for 2 or 3 h. The patients experienced vertigo and nausea. due to a transient inner ear hypofunction caused by the infiltration of the anesthetic solution into the inner ear. In most cases, the patients were readmitted, and inner ear anesthesia was performed repeatedly 4 o r 5 times at intervals of 3 or 4 days. Intratympanic dexamethasone injection Dexamethasone, 2 mg (0.5 ml), was injected into the tympanic cavity through the tympanic membrane using a technique similar to that used in the anesthesia method. Following injection, the patient was placed in a sitting position with the injected ear upward for 15 to 30 min. Unlike the anesthesia method, this method did not cause a decrease in inner ear function. This procedure was usually performed on an ambulatory basis. Dexamethasone was injected for a total of 4 or 5 times at intervals of I or 2 weeks. In both of these methods. the drug injected into the tympanic cavity was expected to be transferred to the inner ear through the round window. i.e. a kind of targeting therapy of the inner ear disease.
EVALUATION Three different criteria of evaluation, the AAOO (1972). the AAO-HNS (1985) and Sakata's (1987) method were used. These evaluation methods are summarrized in Table 11.
Treatment of vestibular disorders 619
Acta Otolaryngol Downloaded from informahealthcare.com by University of Auckland on 01/15/15 For personal use only.
Table 11. Criteria f o r the evalrration of the theraperrtic qirect @An00 criteria (1972) class A: 1) absence of typical spells for a definte period 2) 15dB pure-tone average increase B : 1) as in class A 2) hearing unchanged C : 1) as in class A 2) 15dB pure-tone average decrease D: failure to control definitive spells definite period : a period 10 times the average interval between spells before treatment. OAAO-HNS criteria (1985) average no. of definitive spells/mo in 24 mo period after theraphy numeric value = average no. of definitive spells/mo in 6 mo period before theraphy scoring : 0 complete control of definitive spells 1- 40 substantial control of definitive spells 41- 80 limited control of definitive spells 81-120 insignificant control of definitive spells worse control of definitive spells 121@Sakata’s criteria (1987) Excellent : absence of spells for a definite peried : improvement of spells for a definite period Good Unchanged : no effect : increase in the attacks Worse definite period : a period consisting of the mean interval of spells plus six months
RESULTS Mean age The mean age of the 136 patients with Meniere’s disease was 49.4 years (48.2 years in males and 50.3 years in females). The mean age of the 186 patients with labyrinthine vertigo was 51.9 years (50.9 years in males and 52.6 years in females). The mean age of the entire group of 322 patients was 49.7 years (49.8 years in males and 49.6 in females). Tvpe of vertigo Of the 136 patients with Meniere’s disease, 121 complained of rotatory vertigo (89%). Of the 186 patients with labyrinthine vertigo, 146 complained of rotatory vertigo (78%). Overall evaluation of the theraperrtic yffpct The overall evaluation of the therapeutic effect of the two methods are summarized in Table 111. Treatment of Meniere’s disease by inner ear anesthesia: Recurrent attacks of vertigo responded well to this treatment in 32 of 56 patients ( 5 7 % ) according to the criteria of AAOO (Class A + B + C ) , in 61 of 75 patients (81 5%) according to the criteria of the AAOHNS (numeric value from 0 to 40) and in 65 of 75 patients (87%) according to Sakata’s criteria (excellent + good). Treatment of Meniere’s disease by dexamethcrsone injection: Recurrent attacks of vertigo responded well to this treatment in 28 of 51 patients ( 5 5 56) according to the criteria ofAAOO (Class A + B + C ) , in 49 of 61 patients (80%) according to the criteria of the AAOHNS (numeric value from 0 to 40) and in 49 of 61 patients (8176) according to Sakata’s criteria (excellent + good). Treatment of labyrinthine vertigo by inner ear trnesthesia: Recurrent attacks of vertigo responded well to this treatment in 30 of 50 patients (60%) according to the criteria of
620 A . Itoh and E . Sakata
Treatment of Mihiere Disease *(inner ear anesthesia with Lidocaine)
AAOO
of
N =50
our report(1990)
N=67
% our re rt( 1990)
AAOO
AAO-HNS
Acta Otolaryngol Downloaded from informahealthcare.com by University of Auckland on 01/15/15 For personal use only.
The Labyrinthine Vertigo *Treatment (inner ear anesthesia with Lidocaine)
AAO-HNS
m
[
Y
N=67 Sakata
Sakata
p : good
E : exellant (evaluatlon) U : unchanged
W
(evaluatlon)
: worse
Treatment of Meniere Disease * (intratympanic injection with Dexamethasone)
*
Treatment of The Labyrinthine Vertigo (intratympanic injection with Dexamethasone)
, , ,, , ,
m]m] Lil\ our report( 1990)
AAOO
our rePjrt(1990)
59
21
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rt 1990)
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AAO-HNS
our re
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:
,*=I19
AAO-HNS
rt(l9W)
our re
rt 1990) W
m / / I m : 55
24
12
6
our report(1990)
Sakata
( evaluatlon )
AAOO (Class A + B + C ) . in 54 of 67 patients ( 8 4 % ) according to the criteria of the AAOHNS (numeric value from 0 to 40) and in 60 of 67 patients (89%) according to Sakata’s criteria (excellent + good). Peatment of labyrinthine vertigo by desntnethci.ron~~ injection: Recurrent attacks of vertigo responded well to this treatment in 49 of 89 patients ( 5 5 % ) according to the criteria of AAOO (Class A+B+C). in 94 of 119 patients ( 7 9 % ) according to the criteria of the AAO-HNS (numeric value from 0 to 40) and in 83 of 119 patients (78%) according to Sakata’s criteria (excellent + good). A comparison of evaluation of almost identical groups of patients using the three methods of evaluation shows this tendency: the AAOO method < the AAO-HNS method 5 Sakata’s method, in a increasing order of favorable results. Drtration o j diseuse und theraperrtic efrect: In cases of Meniere‘s disease and labyrinthine vertigo treated with the two methods (inner ear anesthesia and intratympanic dexamethasone injection) therapeutic effects were more favorable with a shorter duration of disease (the AAO-HNS and Sakata’s evaluation).
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Treatment of vestibular disorders Frequency of attacks and therapeutic ejfiect: In cases of Meniere’s disease. with attacks of vertigo more than once each month, better results were obtained using intratympanic dexamethasone injection than using inner ear anesthesia (the AAOO. the AAO-HNS and Sakata’s evaluation). In cases of labyrinthine vertigo, no definite correlation was noted between the frequency of attacks and the therapeutic effects (the AAOO, the AAO-HNS and Sakata‘s evaluation). Mean of hearing level ( H L )and thcrapeiitic cflect: In cases of Meniere’s disease treated with the intratympanic dexamethasone injection. the therapeutic effects were poor in patient with severe deafness (the AAOO. the AAO-HNS and Sakata’s evaluation). In cases of labyrinthine vertigo, no definite correlation was noted between the mean of HL and the therapeutic effect with either treatment. Type of audiogram and theraperrtic effect: In cases of Meniere’s disease treated with intratympanic dexamethasone injection. better therapeutic results were obtained in patients with low tone deafness and convex-type audiogram (the AAOO evaluation). In addition to the therapeutic results on vertigo. intratympanic dexamethasone injection resulted in an improvement of hearing in patients with low tone deafness and convex-type audiogram. In cases of labyrinthine vertigo treated with both methods. poor therapeutic results were obtained in cases with flat-type audiogram (the AAOO. the AAO-HNS and Sakata’s evaluation). Tinnitus: In cases of Meniere’s disease. inner ear anesthesia resulted in an excellent effect in 39%. a good effect in 22% and no effect in 39%. giving a rate of positive effect against tinnitus of 61 %. In similar cases, dexamethasone injection resulted in an excellent effect in 45%, a good effect in 29% and no effect in 26%. giving a rate of positive effect against tinnitus of 74%. In cases of labyrinthine vertigo, inner ear anesthesia resulted in an excellent effect in 44%, a good effect in 32% and no effect in 24%. giving a rate of positive effect against tinnitus of 76%. In similar cases, dexamethasone injection resulted in an excellent effect in 36%. a good effect in 34% and no effect in 30%. giving a rate of positive effect against tinnitus of 70%. For tinnitus in Meniere’s disease, consequently. intratympanic dexamethasone injection was more effective, whereas, for tinnitus in labyrinthine vertigo. inner ear anesthesia was more effective. DISCUSSION The first attempts at clinical treatment of vertigo using an injection of lidocaine into the tympanic cavity were reported by Ristow in 1967. According to his report this method was effective in about 65% of patients with Meniere’s disease. Fradis (1985) subsequently attempted a study of inner ear anesthesia in 28 patients with Meniere’s disease. and reported a positive effect in 83.7%. Sakata (1987) attempted a study of the same method in 47 patients, and obtained a positive effect in 89%. Saitoh (1987) also attempted a study of the same method in 28 patients, and obtained a positive effect in 86.7%. In none of these studies was a decrease of hearing level noted following treatment with inner ear anesthesia. Upon injection of lidocaine into the inner ear. the patient may experience vertigo and nausea, which may persist for the first few hours following treatment due to acute impairment in the labyrinthine function. This is a transient. reversible but unpleasant side effect. Consequently, this method should be performed on in-patients.
621
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622 A . Itoh and E . Sakata To avoid this unpleasant side effect, intratympanic dexamethasone injection method using the same technique was suggested by Sakata (1987). Since this method is not accompanied by significant vertigo and nausea seen with inner ear anesthesia, it is possible to perform this method on out-patients (3). As seen in our present report, the therapeutic effect of dexamethasone injection on vertigo and tinnitus was comparable. if not equal. to the effect obtained with inner ear anesthesia. At our department, patients with Meniere’s disease or labyrinthine vertigo with repeated spontaneous rotatory vertigo resistant to various conservative treatments were first treated at the out-patient clinic using intratympanic dexamethasone injection. In cases in whom the attacks of vertigo persisted despite this treatment inner ear anesthesia was performed after hospitalization. The purpose of inner ear anesthesia is relief of the stimulated or hypersensitive state of the inner ear sensory cells. Saitoh (1987). in animal experiments using both guinea pigs and pigeons, noted mild degeneration in the sensory hair of the external hair cell of the basal to the second spiral of the cochlea in response to an injection of 4 % lidocaine into the tympanic cavity. The injection of 10% lidocaine caused a considerably more intense change involving not only the outer hair cells. but also the inner hair cells. The mechanism of action of inner ear anesthesia for the suppression of vertigo and tinnitus may include changes of the inner ear (partial destruction) adding to the reversible effect. On intratympanic dexamethasone injection. no basic studies have been performed. Steroid injection apparently does not commonly cause organic changes of the inner ear. Consequently, it is difficult to explain the persistence of the effect of steroid injection in the treatment of vertigo and tinnitus. Corticosteroids probably exert some action on the inner ear to interrupt the vicious cycle. In this method. the steroid probably reaches the inner ear by passing through the round window. improving cellular edema and any metabolic disturbances of the inner ear. Membrane stabilization and sedative actions also appeared to contribute to the suppression of the irritated or hypersensitive state of the inner ear sensory cells. In the overall evaluation of therapeutic effect. intratympanic dexamethasone injection was more effective than inner ear anesthesia in cases of Meniere’s disease whereas inner ear anesthesia was more effective than dexamethasone injection in cases of labyrinthine vertigo. These results may indicate a difference in the mechanism of action between these two methods of treatment of refractory inner ear disease. The AAOO. the AAO-HNS and Sakata’s method were employed to evaluate the therapeutic effects in cases of unilateral Meniere’s disease and labyrinthine vertigo. In the AAOO evaluation method, the course must be followed for a period 10 times as long as the mean duration of the attack: so sufficient statistical data could not be obtained in many cases due to inadequate follow-up, making evaluation impossible. When the three methods were to be compared, consequently, an accurate comparison was difficult because of the difference in the size of the population. However, it is possible to note certain tendencies. In the evaluation of almost all symptoms. the rate of positive effect increased in order: the AAOO less than the AAO-HNS, less than or equal to Sakata’s method. Futaki (1987) used the AAOO, the AAO-HNS and Uemura’s method in the evaluation of the therapeutic effects of surgical treatment on Meniere’s disease ( 7 . 8). A comparison of these three methods revealed a rate of positive effect of 51 % using the AAOO, 94% using the AAOHNS and 83 % using Uemura’s method (1977). The characteristics of the AAOO evaluation method include a combined evaluation of the effect on auditory function and the suppressive effect on vertigo. Consequently, the purely therapeutic effect of the treatment on vertigo could not be evaluated independently of the effect on auditory function. The requirement of an observation period 10 times as
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Treatment of vestibular disorders 623 long as the mean interval of vertiginous attacks also presents problems. Especially in conservative treatment, it is difficult to continue observation for longer periods. The AAO-HNS evaluation method is the product of further refinement and improvement. Unlike the AAOO, this method evaluates a decrease in the frequency of vertiginous attacks. A comparison of numeric values makes a detailed classification of the degree of suppression an advantage. In this method, however. a 24-month follow-up period after treatment is a significant problem. A method requiring a shorter follow-up period would be desirable. Sakata's evaluation method resulted in an evaluation of therapeutic effect similar to that of the AAO-HNS, while the latter method has the advantage of simple. readily supplied data available for statistical evaluation: a disadvantage is the possible influence of subjective evaluation factors of the intensity of vertigo. Tokumasu (1985) suggested another method of evaluation. The mean interval of attacks over a certain period before and after the initial day of treatment was calculated using a computer and the statistical significance of the difference between these two mean intervals was estimated. The length of each of these two intervals was 10 times as long as the mean attack interval over the whole period (9). In the future. such a method. using a microcomputer for the statistical analysis. will become the primary evaluation method in this field. Various methods have been employed in the past for an evaluation of the therapeutic effect of various treatments for Meniere's disease. In the present study of vertigo. the therapeutic effects of the inner ear anesthesia method and the intratyrnpanic dexamethasone injection method. attempted at our department, were statistically compared. Based on these results, effects on Meniere's disease and labyrinthine vertigo were demonstrated to be similar. In Meniere's disease, for example. these methods resulted in an outcome that was favorably compared to that obtained with surgical treatment. In the forms of Meniere's disease which are resistant to drug therapy, these two methods appear to be worthwhile before attempting surgical treatment for refractory vertigo.
REFERENCES I . Alford BR. Report of subcommittee o n equilibrium and its measurement. Meniere's disease: criteria for diagnosis and evaluation of therapy for reporting. Trans Am Acad Ophthalmol Otolaryngol 1972: 76: 14624. 2. Pearson BW, Brackmann DE. Committee on hearing and equilibrium for reporting treatment results in Meniere's disease. Otolaryngol Head Neck Surg 1985: 93: 579-81. 3. Sakata E. Itoh N. Itoh A e t al. Comparative studies of the therapeutic effect of inner ear anesthesia and middle e a r infusion of a steroid solution for Meniere's disease. Pract Otol (Kyoto) 1987: 80: 57-65. 4. Ristow W . Zur Behandlung der Menierekrankheit mittels temporarer Labyrinthanasthesie. Z Laryngol 1968: 47: 442-8. 5. Fradis M. Podoshin L, Ben-David J . Reiner B. Treatment of Meniere's disease by intratympanic injection with lidocaine. Arch Otolaryngol 1985: I I I : 491-3. 6. Saitoh Y. Muaki Y . Ishikawa T et al. Treatment of severe Meniere's disease with intratympanic injection with lidocaine. Equilibrium Res (Kyoto) 1987: 46: 207-13. 7. Uemura T, Kaneko H . Fijita H. Kobayashi R. Follow-up study of Meniere's disease with the average observation period of 8 years. Pract Otol (Kyoto) 1977: 70: 1691-6. 8. Futaki T. Comparison of several guidelines for evaluation of therapy in Meniere's disease. Equilibrium Res (Kyoto) 1987: 46: 23848. 9. Tokumasu K. Medical therapy for Meniere's disease. Oto-Rhino-Laryngology (Tokyo) 1985: 28: 357-66. Address for correspondence: Akinori Itoh, Department of Neurotology, Saitama Medical School Hospital. 38 Moro-Hongo. Moroyamacho. Iruma-gun. Saitama. 350-04 Japan
