Intratympanic gentamicin treatment menieres disease,clip on earring backs uk,tinnitus can get worse zip - Easy Way

27.05.2014
Destructive treatments of vertigo refer to medical or surgical procedures that deaden the inner ear.
Destructive treatments all involve a trade-off between partial or full immunity to vertigo due to fluctuation of the inner ear, and overall inner ear function.
Gentamicin injection into the ear is presently the most common destructive procedure for vertigo. A substantial advantage of gentamicin injections is low cost, compared to surgical procedures.
Injections of gentamicin are given through the ear drum, by way of a small needle (see Figure 1). After treatment is stopped, vertigo usually lasts from seven to ten days, but may take as long as a month to resolve. We believe, based on pharmacokinetic considerations, that protocols where the gentamicin is administered gradually, on a once-per-week schedule (or less frequently), are less risky to hearing than protocols where a large amount of medication is administered over a week or less. A single dose treatment was reported by Driscoll et al (1997) at the Mayo clinic, with 84% response rate in terms of vertigo, and no change in hearing.
Injection of gentamicin directly into the vestibular system, rather than through the tympanic membrane or round window may result in less damage to the cochlear hair cells responsible for hearing (Lii, 2004).
Some studies suggest transtympanic dexamethasone treatment (dexamethasone is a steroid, and not related to gentamicin). Nearly all major medical centers now offer transtympanic gentamicin treatment through their otolaryngology service. If gentamicin injections fail, there are surgical treatments available: vestibular nerve section and labyrinthectomy. A vestibular nerve section describes the process of cutting the vestibular part of the cochleovestibular cranial nerve. The usual reason for a vestibular nerve section is control of unilateral Meniere’s disease, where there is some hearing (better than 80 dB PTA).
The vestibular nerve may be sectioned (cut or severed) via the middle fossa, retrolabyrinthine, and retrosigmoid approaches, with similar efficacy. Figure 2 is a picture of the inner ear which can be used to appreciate the route of the most common operation, the retrolabyrinthine approach. The middle fossa approach is similar, but access to the cranial cavity is obtained with the assistance of a neurosurgeon, from a slightly higher location. Although 95% of patients are satisfied with the procedure immediately after their surgery, there are substantial risk of a serious complication in all of the described surgical procedures.
Although from the name of the procedure one would expect that the entire vestibular nerve would be cut, in reality this is not always possible. About 10% of cases with retrolabyrinthine nerve sections develop a cerebrospinal fluid (CSF) leak, which is treated with continuous lumbar drainage for several days. The facial nerve (#7 on the diagram above) runs adjacent to the vestibular nerve, and it can be damaged by procedures that intend to damage the vestibular nerve. Beck C, Schmidt CL (1978) Ten years experience with intratympanically applied Streptomycin (gentamicin) in the therapy of morbus Meniere. Magnusson M, Pagdan S, Karlberg M, Johansson R.(1991) Delayed onset of ototoxic effects of Gentamicin in treatment of Meniere’s disease. Odkvist LM, Bergholtz LM, Lundren A (1984) Topical gentamicin therapy for disabling Meniere’s disease. Yamasaki T, Hayashi M, Hayashi N, Kozaki H (1988) Intratympanic gentamicin therapy for Meniere’s disease placed by tubal catheter with systemic isosorbide. The American Hearing Research Foundation is a non-profit foundation that funds research into hearing loss and balance disorders related to the inner ear and is also committed to educating the public about these health issues.
They are considered when it is clear that vertigo is coming from the inner ear, that the vertigo cannot be otherwise controlled, and generally also when the disease process is confined to one ear.
All persons with destructive treatment can expect to have worse inner ear function than a normal person with two functioning inner ears.
Surgical procedures (vestibular nerve section and labyrinthectomy) are also available, but these days they are falling from favor. Most authors find that the control of vertigo is comparable to surgical vestibular nerve section (about 90%).
This process may be called either transtympanic gentamicin treatment (TTG) or intratympanic gentamicin treatment.
The treatment is stopped when vertigo ensues, indicating that the gentamicin is affecting the inner ear. As protocols evolve, the percentage of treatments associated with hearing reduction continues to gradually be reduced; however, there is still some risk of hearing loss.


Hearing is generally unaffected or worsened, and may continue to worsen even after vertigo spells are stopped. Streptomycin injection has been tried in two published studies (for example, Schuknecht, 1951), with much worse hearing results than gentamicin. These results are attributed to claims that gentamicin destroys the endolymph secreting dark cells before destroying the sensory vestibular epithelium (Beck, 1978). If the diagnosis still appears to be sustainable, then one may wish to consider more radical procedures such as vestibular nerve section or labyrinthectomy.
However, recall that the treatment series, for persons with usable hearing on the side to be treated, requires four to six weeks to complete. On extremely rare occasions it is performed for other reasons such as recurrent vestibular neuritis. Surgical treatment is traditionally felt to be indicated when the patient is incapacitated with unilateral Meniere’s disease and quality of life is affected. This entails an attempt to cut the nerve(labeled #8 on the right side of this diagram) going through the mastoid sinus (behind the plane of the picture) and the cranial cavity to get access.
In the retrosigmoid approach, access to the nerve is obtained by going through the posterior (back of head) part of the skull. All available procedures — retrolabyrinthine, retrosigmoid, and middle-fossa have significant risks.
According to Eisenmen (2001) there is evidence for retained vestibular function in about half of patients following nerve section or labyrinthectomy. In one study, a high rate of disability and more frequent vertigo attacks were factors associated with a poorer result (Teufert, 2007). This complication is rare in recent times due to better surgical technique and the availability of facial nerve monitors. Approximately 25% of patients undergoing this procedure develop severe headaches requiring medication two years later.
It is appropriate for patients in whom there is no hearing in the ear which is causing vertigo. In one small study, patients who had labyrinthectomy concurrently with nerve section experienced greater improvement in disability and imbalance than patients who underwent labyrinthectomy alone (De la Cruz, 2007).
The greatest amount of interest right now is in refining the technique of gentamicin treatment.
Intratympanic gentamicin for Meniere’s disease: the effect on quality of life as assessed by Glasgow benefit inventory. Auditory results after vestibular nerve section and intratympanic gentamicin for Meniere’s disease.
Low-dose intratympanic gentamicin and the treatment of Meniere’s disease: preliminary results. Intratympanic gentamicin for control over vertigo in Meniere’s disease: vestibular signs that specify completion of therpay.
Intratympanic gentamicin installation as treatment of unilateral Meniere’s disease: update of an ongoing study. Intratympanic gentamicin for treatment of intractable Meniere’s disease: a preliminary report. Patients’ subjective evaluations of quality of life related to disease-specific symptoms, sense of coherence and treatment in Meniere’s disease. Persistent dizziness after surgical treatment of vertigo: an exploratory study of prognostic factors. Destructive treatments are usually a last resort treatment for persons who have severe cases of episodic vertigo, such as due to Meniere’s disease. As these procedures are nearly always done for vertigo, in general, there is an attempt to preserve hearing.
Gentamicin injections are also intrinsically of very low risk, especially compared to nerve section. Rarely, even after six injections, vertigo cannot be induced and vestibular function remains normal. Currently, there is risk of approximately 30% that a patient will develop a mild reduction in hearing (Blakeley et al., 2009). Tinnitus is also generally unaffected but some recent studies report reduction in tinnitus.
This may be caused by the relative selectivity of gentamicin for the vestibular hair cell, compared to dihydro-streptomycin. Variant procedures where gentamicin is administered less frequently (such as once-per-month), or in a more dilute solution than is conventional also seem well worth considering.


It may be worth trying in situations where all else has been tried and there is little to loose.
The patient might have a central disorder (such as Migraine), the patient might have a nerve disorder (such as microvascular compression), or the patient might have bilateral Meniere’s disease. It is common for Meniere’s disease attacks to return one or two years after the first TTG treatment. Before having transtympanic gentamicin treatment, we also think that it is prudent to try all reasonable medical avenues of treatment. Relative contraindications are bilateral vestibular disease, old age, poor medical condition, or central nervous system involvement. 2007 demonstrated that labyrinthectomy and vestibular nerve section provide similar control of vertigo, however the authors reported that the latter showed more improvement with regard to imbalance and functional disability .
Historically 20% of patients eventually have had surgery done (Silverstein and Rosenberg, 1992), but with the advent of transtympanic gentamicin treatment, operative treatments are being replaced by outpatient procedures. Some of the fibers of the vestibular nerve run very close to the cochlear (hearing nerve), and because of this they may be spared.
Neurosurgical procedures intrinsically have considerably more risk than those where the brain is not exposed. Labyrinthectomy offers excellent control of vertigo, with fewer complications than nerve section. Methods of reducing the amount of hearing impairment, and smaller dose protocols are of considerable interest.
Long-Term Disability of Class A Patients with Meniere’s Disease after treatment with intraympanic gentamicin.
Intratympanic treatment of intractable unilateral Meniere disease: gentamicin or dexamethasone?
Occasionally destructive treatments are advocated for tinnitus, but these are not discussed here.
Once it is clear that a destructive procedure is indicated, what remains is to choose among several possibilities outlined below. Compared to labyrinthectomy, the lowest risk surgical procedure, gentamicin injections are also lower in risk because there is no need for general anesthesia.
At this point, treatment is stopped and another method of eliminating vestibular function is used (such as labyrinthectomy). Unsteadiness usually resolves after several months, but in older individuals, some unsteadiness may be permanent (although vertigo spells are nearly always stopped). Gentamicin injection is associated with a higher rate of hearing loss than surgical nerve sectioning (Colletti, 2007; Hillman, 2004). Some patients get relief from Meniere’s disease symptoms in spite of a subtotal ablation of vestibular function. For example, its use might be considered when the remaining ear affected by Meniere’s disease is the only-hearing ear. Saccule derived nerve fibers may be purposefully spared because they tend to run close to the cochlear nerve (Silverstein et al, 1994).
Our view is that middle fossa nerve sections are rarely indicated, as gentamicin injection treatment has similar effectiveness with much less risk. Patients report a significant improvement in quality of life after labyrinthectomy despite hearing loss (Diaz, 2007). At the American Hearing Research Foundation (AHRF), we are interested in projects that might lead to improved treatments of vestibular disorders. In recent years, this process has become simpler as one procedure, Gentamicin injection, has become much better understood, popular, and generally preferable. Sometimes there is an attempt to cut these fibers at another site with a singular neurectomy. Labyrinthectomy results in greater improvement in dizziness than nerve sectioning (Badke, 2002). Click here if you would you would like more information about contributing to the AHRF’s efforts. Singular neurectomies, however, are somewhat difficult and unreliable even in very experienced hands. Several authors have reported that tinnitus or the sensation of fullness may improve substantially after TTG (for example, Herraiz et al., 2010).



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