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Meniere disease treatment guidelines 1999,claires ear piercing cost,i have a ringing in my left ear - New On 2016

Author: admin | 28.11.2014 | Category: Ringing In The Ears Causes

The California Hearing & Balance Center is located in the Poole Building of the Scripps Medical Campus in beautiful La Jolla, California. California Hearing and Balance Center offers the full array of treatment options for Meniere’s disease. The situation has changed greatly with gentamicin treatment in the last few years -- this document has recently been updated to reflect the very good results that have been obtained with a newer protocol - -low dose gentamicin. Disability is lessened in patients with Menieres after TTG treatment (Pfleiderer, 1998; Perez et al, 1999). A substantial advantage of TTG treatment is low cost, compared to alternative destructive treatments (i.e.
The low dose method involves using 1-2 injections of gentamicin, waiting a month between injections. In our practice in Chicago, we have had excellent results with the low-dose variant, with excellent control of dizziness (100% so far) with no hearing damage at all.
A single dose treatment was reported by at the Mayo clinic, with 84% response rate of vertigo, and no change in hearing.
The low dose of gentamicin over a prolonged time is likely to have a more uniform effect on the ear than brief, concentrated administrations (Pender, 2003), and also would seem likely to pose much lower risk to hearing. Rarely, even after 6 injections, vertigo cannot be induced and vestibular function remains normal. Figure 2: The goal of high dose intratympanic gentamicin treatment is to reduce or eliminate vestibular function from one ear.
Figure 2 above shows the expected result of high-dose gentamicin -- spontaneous nystagmus and vertigo.
The idea of the low-dose protocol is to do a small amount of permanent damage to the ear, just enough to permanently stop vertigo spells.
TTG reduces the size of the summating potential of ECochG , which is a diagnostic test for Meniere's disease (Adamonis et al, 2000). We think this conclusion is overly negative -- we think that the low dose gentamicin protocol is reasonably well established in the recent literature. When to stop treatment is also an issue, especially for the high-dose protocol with weekly injections.
In our practice in Chicago, we have had good success in using vibration induced nystagmus to decide whether or not gentamicin has had an effect. There is literature that supports the idea that VEMP's are reduced or abolished following ITG. It is very difficult to compete with the low-dose procedure in terms of results, because they are so good. Some groups have experimented with adding other agents to gentamicin, apparently in an attempt to make the solution more viscous and less likely to run down the eustachian tube as soon as the patient sits up.
Ishiyama and associates (2007) reported pathology of the inner ear in a single patient with failed ITG (several attempts), followed by a successful labyrinthectomy.
We do not think that one needs to try the numerous treatments for Meniere's that are probably placebos, as these waste time and money, and low-dose gentamicin is very effective. Commercial gentamicin, rather than being a single chemical, actually consists of 3 related compounds. Besides a stoppage of drainage pathways, abnormally enlarged fluid pathways into the ear such as the vestibular aqueduct or cochlear aqueduct may also be associated with Meniere's like symptoms. Thus, the bottom line is that in most patients with Meniere's disease in 2015, the underlying cause of Meniere's disease is unknown. Figure 3a: Audiogram (hearing test) typical of early Meniere's disease on the right side (x=left, o=right). A longer discussion of the information to be gained in testing of persons with Meniere's disease is found here. When there is sulfa allergy, one may try amiloride by itself, or ethacrinic acid (edecrin). Histamine injections (irrational treatment as histamine is broken down rapidly in the body).
What the author recommends in his practice in Chicago for medical prevention of Meniere's. These are combined with symptomatic drugs such as meclizine, benzodiazepines, and antiemetics, to be taken during attacks. In persons with severe progressive bilateral disease, the author will generally recommend a trial of high dose steroids. An emerging treatment that may eventually end up as a standard treatment is multiple injections of steroids into the middle ear. The big problem with this section is separating placebo's from slightly effective treatments.
There are an immense number of placebo and probable or nearly placebo treatments for Meniere's disease. The Meniett device's status at this writing (2010) seems most likely to be a slightly effective treatment. There is a separate page on this topic, but briefly, for intractable unilateral Menieres disease cases, we often presently advise a low dose gentamicin protocol. Persons who have intractable bilateral Meniere's disease are offered a trial of steroids with a safer immunosuppressant should this be effective, a modified gentamicin protocol, and very occasionally systemic aminoglycosides to deaden both ears. In our opinion, medical treatments, including a reasonable trial of anti-migraine drugs such as verapamil or venlafaxine, should precede use of any last resort treatment. Hearing is thought to gradually decline throughout life, with roughly 50 dB loss in 10 years.
Note that it is not the overall level of sodium that is important, but whether or not it fluctuates that is important in avoiding attacks of dizziness. Gu X, Fang ZM, Liu Y, Huang ZW, Zhang R, Chen X.Diagnostic advantages of intratympanically gadolinium contrast-enhanced magnetic resonance imaging in patients with bilateral Meniere's disease. Sato G1, Sekine K, Matsuda K, Ueeda H, Horii A, Nishiike S, Kitahara T, Uno A, Imai T, Inohara H, Takeda N. The main alternative to the mechanism being destruction of dark cells is the hypothesis that there is a partial damage to the vestibular hair cells. 2004) reported that low-dose methods have significantly poorer vertigo control (66.7% overall). If low-dose does indeed reduce pressure in the inner ear, it may be that hearing will deteriorate to a lesser extent.

We routinely recommend use of half-dose gentamicin in persons having this done who are over the age of 70.
We don't think that this conjecture is correct, but it would be an interesting project for a researcher to investigate. The treatment is stopped when vertigo ensues, indicating that the gentamicin is affecting the inner ear. At this point, treatment is stopped and another method of eliminating vestibular function is used (such as labyrinthectomy).
This causes an imbalance between the two ears, and a spontaneous nystagmus or jumping of the eyes.
This made sense as in a meta-analysis of variant methods was recently reported by Chia and others (Chia, Gamst et al. There would seem to be little advantage in experimenting with streptomycin as gentamicin works very well without appreciable risk to hearing when given at long intervals.
A variant of titration method might be to continue injecting until the VEMP is greatly diminished. It is also difficult to understand the rationale of putting in a constant infusion of a drug, when it is well known from animals that gentamicin accumulates in the ear over many months. It is hard to see how a drug that goes in and out of the ear in 3 days, costs quite a bit to the insurance system, and is associated with significant risks (of perforation) could make much positive difference to a lifelong illness. We see little reason why any other procedure should be advocated, unless low-dose gentamicin has already failed. We don't think that use of steroids here is a good idea, as it seems to bring on another complication. We presume that these individuals have a better ability to either adapt to vestibular lesions or recover from them. Oddly, we have found a few major medical centers, or even entire large metropolitan areas that seem to be unaware of the low dose gentamicin option.
Examples of procedures that are probably placebos or at least only slightly effective, are the Menniett device, intratympanic steroids, and endolymphatic shunt surgery. The Effect of Intratympanic Methylprednisolone and Gentamicin Injection on Meniere's Disease.
Chemical labyrinthectomy for the worse ear of adult Nigerians with bilateral Meniere's disease: preliminary report of treatment outcomes. In our clinical practice, where we care for large numbers of Meniere's patients, the most common age of presentation is in the 6th decade.
While in the past, it was felt that plumbing problems (hydrops) in the ear were responsible for the disease, the most current opinion is that hydrops is a marker for the Meniere's disease, rather than necessarily being responsible for the symptoms. Recent evidence is against a relationship between the cochlear aqueduct and MD (Yilmazer et al, 2001). We ourselves hold this opinion, based in part on a study in which patients with Meniere's disease had a very high prevalence (about 25%) of autoimmune thyroid disease (Brenner et al, 2004). However, the evidence is against this being the main mechanism in human beings (see Kitamura et al, 1997; Nadol et al, 1995).
Those who present to the doctor with more severe hearing impairments at onset, usually do worse than those who have milder hearing impairments (Sato et al, 2014). Although Ondansetron isn't as strong as phenergan or compazine, and doesn't always work, it also doesn't have much side effects either. All of the above diuretics have sulfa in them, which persons with sulfa allergies may be unable to tolerate. Loop diuretics such as Edecrin should be used in low doses and with caution because they are ototoxic.
If there is a significant improvement in hearing, then there is an attempt to switch to Enbrel (an immunosuppressant with less side effects than steroids), with the thought that in this situation an autoimmune disorder is more probable. There is nothing wrong with a placebo, if it provides some benefit (presumably psychological), and you can afford to do this. This treatment requires a surgical procedure (insertion of a ventilation tube) and purchase of a very expensive device (the pressure machine). Gentamicin is administered through the ear drum every month for a total of one or two administrations. The difficulty in pregnancy is that there should be an effort to avoid medications that might cause birth defects or otherwise injure the unborn child. Vertigo spells are generally thought to persist for decades, although with a gradual decline after roughly the first decade (Huppert et al, 2010). It is not necessary or wise to lower your salt intake to amounts barely able to sustain life.
Psychological characteristics of patients with Meniere's disease compared with patients with vertigo, tinnitus or hearing loss. Several authors have reported that tinnitus or fullness may improve substantially after TTG (e.g. Most authors find that the control of vertigo is comparable to vestibular nerve section (about 90%). The low dose variant is relatively new, and there is not nearly as much data concerning outcome as the high-dose variant. Recent studies in animals suggest that the type-I hair cells are the most sensitive, and the type-II hair cells are more resilient. In other words, the treatment is continued until there is evidence of damage to the inner ear. It should be noted, however, that small mammals like this have much thinner round window membranes than humans, and therefore may get a much larger amount of gentamicin over the same period of time. We have also noted that all patients with successful low or high-dose gentamicin have strong vibration induced nystagmus. However, we have encountered one patient, who had migraine misdiagnosed as Meniere's, and who had 2 injections of gentamicin. 2004), the weekly titration method of delivery had the best results with both the best vertigo control and a trend towards less overall hearing loss. However, there are sometimes situations where one wants to get a lot of drug in fast, and accept more risk to hearing. As has been mentioned already - - given the clear superiority of small-dose gentamicin over multiple dose protocols, there no longer seems to be any reason to give more than 1-2 injections, so titration is not really an issue. A problem with this idea is that the injection itself might cause a conductive hearing loss that interferes with the VEMP.

They suggested that potential sources of recurrent vertigo in the patient include the contralateral ear (unlikely as labyrinthectomy worked), the saccule of the ipsilateral side (unlikely that saccule was spared by a drug that affected rest of the inner ear), and the severely damaged utricle (again unlikely).
This good experience is similar to the experience of others, even when they are less cautions than we are(Olusesi et al, 2014).
It is best to go somewhere else if your otologist suggests that you will need 4 injections, or wants to repeat the injections in less than 1 month. It would be interesting to know if use of the compound that is most vestibulotoxic might cause better results than the mixture of compounds. We think Meniere's disease should more properly be called Meniere's syndrome, but we will use the two terms as if they were the same. This probably reflects the age distribution of Meniere's in Chicago Illinois, which of course is also a function of the age of the population in Chicago.
Enlarged vestibular aqueducts are one of the most commonly identified inner ear bony malformations in children with sensorineural hearing loss of unknown cause (Oh et al, 2001).
On the other hand, Ruckenstein and others recently obtained a large number of autoimmune blood tests in a group of 40 patients with unilateral Meniere's disease including CBC, ANA, Anti-Sjoegren, RF, Complement, antiphospholipid antibody, western blot for heat shock protein, MHA (syphilis test), and Lyme. Rather, it seems that Meniere's disease damages both hair cells and nerve fibers in humans. Should MRI scanners become even more powerful in the future, this could be an important test.
Oddly, there is sometimes a discrepency between OAE tests and audiometry in the low-frequency SNHL of Meniere's. Van Deelen and Huizing studied the use of diuretics in Meniere's disease in a double-blind, placebo controlled trial, and reported that it reduces vestibular complaints, but has no significant effect on hearing (1986). Because Menieres and Migraine are very often combined, this medication's main role may be to treat the migraine associated vertigo that can be confused with or accompany Menieres disease.
Of course this strategy should rationally be adjusted to the variability in hearing, as in any undertaking, one's confidence that a particular result has been obtained depends both on the size of the effect as well as the underlying variability in the effect. However, we don't think that placebos that are billed to health care insurance providers should be supported.
Bilaterality of the condition gradually increases with time, but in most the symptoms in the opposite ear are minor.
TTG treatment is also intrinsically of very low risk, especially compared to nerve section. However, right now, in our practice in Chicago as well as in other highly specialized settings, the low-dose protocol has become routine, as we think that it has even less risk and very good results. We also see no logical reason to combine dexamethasone (an intratympanic steroid) with streptomycin (an ototoxic antibiotic). As vibration works so well, and we would not think that someone should be even doing gentamicin injections without the capability to do video-frenzel goggles, this idea doesn't seem to us to be worth pursuing. It would also be interesting to know if different drug companies versions of gentamicin vary in their composition. It is a little older than the typical age of presentation of vestibular migraine which is in the 5th decade, much older than the reported highest prevalence age for non-vestibular migraine (about 35), and similar to the age of presentation of BPPV. The vestibular aqueduct extends from the medial wall of the vestibule to the posterior surface of the petrous temporal bone. Only elevations in the antiphospholipid antibody test were found 27% of patients, above the expected 6-9%. Studies of humans are handicapped by the possibility that Meniere's is the final common pathway of a variety of illnesses of the ear. Potential reasons are an exitatory nystagmus, Bechterew's phenomenon (recovery nystagmus), Meniere's involving the opposite ear, and stronger vestibular responses on the side with hydrops due to hydrodynamic factors associated with hydrops. Another new MRI approach involves injecting gadolinium through the ear drum, and then a MRI scan (Gu et al, 2014). The same cannot always be said for meclizine, lorazepam and klonazepam, phenergan or compazine.
Much room for improvement in these algorithms is needed -perhaps involving daily hearing monitoring using an internet protocol. The treatments briefly discussed below are (probably) not placebos, but they are high in cost (because they are surgical), and low in benefit (because the literature suggests low or no efficacy). Compared to labyrinthectomy, TTG treatment is also lower in risk because there is no need for general anesthesia. Because this procedure works so well, the experiments of the past that we detail below have all become somewhat irrelevant. It seems much more logical to us to use these one at a time rather than mixing them together. As the problem in the past has mainly been hearing toxicity, procedures that are aimed to increase the dose delivered to the ear would seem irrational unless the ear is already deaf.
Herbert Silverstein is a pioneer in the treatment of Meniere’s Disease and has been honored by a number of societies for his contributions to the biochemistry of the disease and inventing new ways to treat it. Most persons with enlarged vestibular aqueducts with ear disorders have hearing loss, but occasionally there is an association with vestibular problems (Shessel and Nedzelski, 1992). This technique is plausible, but we are doubtful that the diagnostic gain justifies injecting gadolinium dye into the middle ear. Kundu (2006) were unable to come to a conclusion as to efficacy as no papers published up to 2006 were adequate for meta-analysis. We are unenthused about the addition of steroids to gentamicin, or steroids to streptomycin (as discussed above). Meniere’s Disease can be quite debilitating and typically involves a combination of symptoms. There may be a genetic link between enlarged vestibular aqueduct and Pendred syndrome, which is a congenital thyroid disorder. They concluded that it is unlikely that autoimmune etiologies play a significant role in their population of unilateral Meniere's (Ruckenstein, 2002). Another interpretation of their data is that they may simply not have had an appropriate marker for autoimmune involvement, as well as unilateral Meniere's may have less autoimmune cause than bilateral.
Silverstein and his wife, Beth – who has suffered with Meniere’s Disease – sat down with Heidi Godman on WSRQ’s Healthcheck program recently to talk about causes, symptoms, risk factors, diagnosis and both surgical and non-surgical treatment options.

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