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Menieres Disease and VertigoMenieres diseaseoIn 1861,Prosper Meniere described a condition which now bears his name.oIt is a disorder of the inner ear oIt causes episodes of vertigo,ringing (tinnitus),a feeling of fullness or pressure in the ear,and fluctuating hearing loss.oIt affect the entire labyrinth,includes both the semicircular canals and the cochlea.Clinical featureso episodic vertigoo fluctuating deafnesso fluctuating tinnituso aural fullnessIncidenceo Great Britain：1/636/yearo Sweden：46/100 000/yearo Japan：increased dramaticallyo Africa：uncommono racial variation?(Caucasians and Blacks)o Peak Onset:4th and 5th decade Pathophysiologyo Labyrinth is divided into two parts(bony,membranous).Including cochlear,vestibuli,three semicircular canals(Reissners membrane,basilar membrane,organ of Corti,scala vestibuli,scala medial,scala tympanic,utricle and saccule).o Endolymph and perilymphpathophysiologyPathophysiologyo Endolymphatic hydropsnormalhydropspathophysiologyo Traditional thinking on the origin of Menieres disease:The most prevalent opinion is that an acute attack of Menieres disease results from fluctuating pressure of the fluid within the inner ear.A system of membranes,called the membranous labyrinth,contains a fluid called endolymph.The membranes can become dilated like a balloon when pressure increases.This is called hydrops.One way for this to happen is when the drainage system,called the endolymphatic duct or sac is blocked.pathophysiologyo cochlear hydrops and saccular hydrops,was seen in most,but utricular hydrops was uncommonpathophysiologyMechanical distortion and increased tension sensorineural hearing lossvestibular organ vestibule dysfunctionPossible MechanismsAuto-immunevirusischemicEtiologyo Unknowno allergy:81%of patients with MD had a history of childhood allergy,and 87%had significant symptoms of a systemic disorder suggesting allergyo autoimmunity:immunological abnormalities immunoglobulins lymphocytes in endolymphatic sacEtiologyo Genetic:14-20%familial tendencyo Anatomical:small vestibular aqueduct(congenital abnormity、infection、genetic)o Traumatic:biochemical dysfunction in the membranous labyrinth cells,debris into endolymph obstruct the endolym-phatic duct and sacEtiologyo Viral infection:higher antibody reactivity to herpes simplex virus type Io dysfunction of autonomic nervous system o abnormal metabolic and endocrine states Clinical manifestationso Typical presenting history:episodic attacks of rotatory vertigo(96.2%)tinnitus(91.1%)hearing loss(87.7)aural pressure(74.1%)Clinical manifestations1.Vertigo Vertigo begins suddenly Asssociated with vegetative signs：pallor、nausea、diarrhoea、vomiting、Accompanied by tinnitus、hearing loss and fullness Clinical manifestations Head movement exacerbates the symptoms Length of attacks is variable,most episodes lasting 2-3 hrs During attack,patient has a normal level of consciousness Horizontal nystagmus Clinical manifestations2.Tinnitus continuous or intermittent usually more marked before and during an attack 3.Deafness sensorineural hearing loss fluctuant and progressive low frequency hearing loss to high frequency hearing loss Clinical manifestationsClinical manifestations4.FullnessDiagnosisHistoryPhysical ExamAudiogramVEMPsECoGVNGBlood testsMRIinvestigations1.horizontal rotatory nystagmus2.Tympanic membrane、midle ear and eustachian tube functions Investigations(assessment of cochlear function)3.pure tone audiometry 4050%most often demonstrate a flat audiograminvestigations(assessment of vestibular function)Static Vestibular Balance Nystagmus:Check direction Check for torsional component Check for gaze suppressionFrenzel眼镜检查眼镜检查investigations(assessment of vestibular function)o 94%patients abnormal reactions to the caloric test o Evaluation of the reaction is based on the maximum speed of the slow phase of the generated nystagmus investigations An ENG(electronystagmogram)may be performed to evaluate balance function.In a darkened room,eye movements are recorded as warm and cool water or air are gently introduced into each ear canal.Since the eyes and ears work in coordination through the nervous system,measurement of eye movements can be used to test the balance system.In about 50 percent of patients,the balance function is reduced in the affected ear.investigations electronystagmogram检查检查(investigations)(investigations)o Rotatory Chair检查检查()Sense of balance is maintained oDizziness,vertigo,and motion sickness all relate to the sense of balance and equilibrium.Your sense of balance is maintained by a complex interaction of the following parts of the nervous system:o The inner ear(also called the labyrinth),which monitors the directions of motion,such as turning,rolling,forward-backward,side-to-side,and up-and-down motions.The eyes,which monitor where the body is in space(i.e.,upside down,right side up,etc.)and also directions of motion.oThe pressure receptors in the joints of the lower extremities and the spine,which tell what part of the body is down and touching the ground.The muscle and joint sensory receptors(also called proprioception)tell what parts of the body are moving.The central nervous system(the brain and spinal cord),which processes all the information from the four other systems to maintain balance and equilibrium.oThe symptoms of motion sickness and dizziness appear when the central nervous system receives conflicting messages from the other four systems.Differential diagnosis of Menieres syndromeo Trauma acoustic trauma,temporal bone fracture,surgical trauma to the inner earo Autoimmune autoimmune inner ear disease,Cogans disease,Lupuso Infectious chronic otitis media,syphilis,labyrinthitis(viral or bacterial)o Metabolic otosclerosis,Pagets disease,hyperlipidemiaCogans Syndromeo Interstitial keratitiso vertigo,tinnitus,SNHLo positive LTT to corneal antigenDifferential diagnosis of Menieres syndromeo Neoplastic acoustic neuroma,leukemia,o Congenital/Developmental Mondinis dysplasia large vestibular aqueduct syndrome,congenital deafness,jugular bulb diverticulumo Endocrine thyroid disease,diabeteso Idiopathic perilymphatic fistula,Menieres diseaseacoustic neuromaMeningioma FeaturesClassificationTreatmentso Precise etiology of MD remains obscure,it is therefore not surprising that no cure for the disorder exists o Most paper on therapy for MD have poor or absent controls between the therapy and placeboo A good dorctor-patient relationship be established Management Principle 1、adjust autonomic nervous function2、reduce hydrops3、improve the hypoxemia of inner ear4、psychotherapyManagementManagemento four step approach 1、dietary changes：elimination of caffeine and reduction of sodium intake.2、medical therapy：control of any identified underlying medical problems(such as hypothyroidism or diabetes),maintenance diuretic therapy and use of vestibular suppressant medication during acute spells 3、conservative surgical therapy 4、ablative surgical therapyManagement1、medical therapy:1)vestibular sedatives；vertigo is due to a sudden asymmetry in vestibular input to the central nervous system chlorpromazine、diphenhydramine 2)Diuretics:reduce endolymphatic accumulation hydrochlorthiazide 3)vasodilators：MD is the result of strial ischaemia or endolymphatic sac hypoperfusion：nicotinic acid、betahistine Endolymphatic Sac SurgeryTreatment with Aminoglycosideso Aminoglycosides are a family of antibiotics that are toxic to sensory hair cells in the inner earo Streptomycin and gentamycin are predominantly toxic to the vestibular labyrinth(as opposed to cochlea),hence are most suitable to be used in the the treatment of MDo Various techniques have been used to administer aminoglycosides to the inner ear:systemic administration,transtympanic injection,and the placement of gelfoam soaked in aminoglycosides into the round window niche Medical TherapySteroids90%Perfusion via round window microcatheters placement 圆窗龛圆窗龛Perfusion via round window microcatheters placementIntratympanic Gentamicin Vestibular Nerve SectionLabyrinthectomy Other causes of labyrinthine vertigo Vestibular neuronitis is occasionally seen in adults,more commonly in the winter months.It is usually regarded as transient infection(viral)of the ganglion of Scarpa Sudden deafness with vertigoBenign positional vertigo(BPV)is considered to be due to a degenerative condition of the utricular and saccular maculae.The attackslast a few seconds only and are brought on by head movement,particularly lying back in bed.BPVBPVBPVBPVBPVo Vertebro-basilar insufficiency may br the cause of major but momentary attacks of vertigo.The symptome of sudden vertigo may be caused by rotation of the neck or hyperextension,for example when the patient looks up to admire an architectural feature immediately overhead.o Ototoxic drugs,streptomycin and its analogues,in certain cases,destroy labyrinthine function in small doses.o Vascular accidents of the labyrinth(thrombosis,haemorrhage or embolism)cause severe vertigo,passing off after a period of weeks or months o Suppurative labyrinthitis causes severe vertugoo Traumatic labyrinthitis may complicate fractures of the petrous bone,or other labyrinthine injuryo Post-operative labyrinthithis very occasionally follows fenestrationo Syphilitic labyrinthitis very rare,but dont forget the spirochaeteo Neoplasm of the labyrinth,carcinoma or glomus tumour may spread from the middle ear,there may by direct extension from the cranium or meninges,secondary deposits may occur,vertigu is severeo Acoustic neuroma Vertugo may be slight and transient,or absent.It is not a prominent feature o Geniculate herpes(herpes oticus,Ramsay Hunts syndrome),may be associated with transient vertigoo Wax,when moistened,swells and may compress the tympanic membrane,causing vertigoo Eustachian obstruction occasionally causes vertigo谢谢 谢！谢！
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