Intratympanic Steroid Perfusion for Meniere's Disease

A diagnosis of Menière's disease will present symptoms that include recurrent, spontaneous episodic vertigo, hearing loss, tinnitus, and aural fullness. Disease course is often fluctuating, and thus efforts to study the outcomes of therapy are often difficult. An initial treatment with diuretics and a low salt diet are frequently helpful to those with this disorder.

Systemic corticosteroids (steroids produced by the adrenal cortex delivered intravenously) have long been used in treating Menière's disease, theoretically down-regulating the immunologic dysfunction thought to be a factor in some patients with this disorder. Corticosteroids are well known for both their anti-inflammatory and electrolyte altering effects. Inner ear steroid receptors have been demonstrated in animal models as well as human temporal bones. Increased cochlear blood flow has also been proposed as a mechanism by which corticosteroids act upon the inner ear.

However, oral or intravenous corticosteroids can cause high blood pressure, osteoporosis, and increased susceptibility to infection. Some suggest that inserting the steroids directly into the tympanic cavity (known as intratympanic steroid perfusion) has the advantage of avoiding the systemic side effects associated with oral corticosteroids, as well as delivering high concentrations to the inner ear end organ. Steroids delivered by the intratympanic route demonstrate higher concentrations in the perilymph that those administered intravenously; the best profile has been reported for methylprednisolone. No ototoxicity has been found in animal models.

A team of ear, nose, and throat specialists has set out to study the efficacy of intratympanic steroid perfusions in patients with Menière's disease with respect to the variables of vertigo and hearing. The authors of "Intratympanic Steroid Perfusion For Menière's Disease" are Kelley M. Dodson, MD, Erika Woodson, and Aristides Sismanis, MD, FACS, all from the from the Virginia Commonwealth University School of Medicine and Health Sciences, Medical College of Virginia Campus, Richmond, VA. Their findings are to be presented at the annual meeting of the American Neurotology Society http://itsa.ucsf.edu/~ajo/ANS/ANS.html being held May 3, 2003, at the Opryland Hotel, Nashville, TN.

Methodology: Twenty-two Menière's disease patients underwent intratympanic steroid perfusion at the Medical College of Virginia Hospitals/ Virginia Commonwealth University between November 1998 and March 2003. All patients had follow-up of 12 to 47 months (mean of 24.5 months). There were 12 women and 10 men in the study, with a mean age of 52 (range, 24 -- 78). All patients had failed previous medical treatment with low salt diet and diuretics. The mean number of perfusions per patient was three (range one to five).

Perfusion of 0.3 to 0.4 cc of steroid was performed in the office, using a tuberculin syringe attached to a 1.5-inch, 30-gauge needle. Perfusions were performed under the surgical microscope by inserting the needle in the posterior-inferior aspect of the tympanic membrane. No local anesthesia was used. Patients remained in the supine position with their head turned to the opposite direction for twenty minutes. While in this position, they were asked to refrain from swallowing and spit their saliva into a kidney basin. Reassessment occurred within several weeks.

Nine patients (41 percent) received perfusions of methylprednisolone 80mg/ml, 3 patients (14 percent) received perfusions of dexamethasone 24mg/ml; 3 patients (14 percent) received dexamethasone 10mg/ml and 7 patients (31 percent) received combinations of the three previous medications. Medication selection was based on the availability at the time of perfusion.

Successful control of vertigo was defined as complete elimination of vertigo spells. Audiograms were obtained just prior to the perfusion, at the first post perfusion visit (mean 3 weeks, range, 1-10 weeks), and at the most recent visit. Significant hearing change was considered as a 10-dB alteration in pure tone average (PTA) at 0.5, 1, 2, and 4 KHz and/or 15 percent or more change in speech discrimination score (SDS). Hearing deterioration was defined as mild (<40dB PTA), moderate (41-60dB), severe (61-80dB), and profound (>80dB). Assessment of the low frequencies PTA at 0.25, 0.5, and one KHz, often affected in Menière's disease, was also performed in the same manner.

Results: Control of vertigo was reported by 12 of 22 patients (55 percent) at the first visit following the initial perfusion. Four patients (18 percent) reported long-term vertigo control. Two of these patients received perfusions of both dexamethasone 24mg/ml and methylprednisolone 80mg/ml on different occasions; one patient received dexamethasone 10mg/ml, the other methylprednisolone 80mg/ml.

Four patients (19 percent) demonstrated more than 10dB gains in PTA. One patient (five percent) demonstrated a short-term increase in SDS. Two patients (nine percent) had improvement of more than 10dB in PTA, and one patient (four percent) had SDS improvement of more than 15 percent. Hearing ultimately decreased in nine patients (41 percent). No tympanic membrane or middle ear complications were identified in this group of patients.

Conclusions: Intratympanic steroid perfusion is considered a minimally invasive, nondestructive treatment for Menière's disease, which has been reported to have a low rate of complications. However, the results of intratympanic steroid perfusion reported in the literature are mixed. The results of this study are similar to those that have reported vertigo control in the immediate post-perfusion period in many patients. Short-term improvement in hearing was not identified in either study. Furthermore, the present study did not find any long-term benefits in neither hearing nor vertigo control. In fact, almost half of patients experienced a decline in hearing; whether this reflects the disease history or a manifestation of this or additional treatments is unknown. The one patient in the study who progressed to profound hearing loss had received intratympanic gentamicin following steroid perfusion.

This study suggests that steroid perfusion does not alter disease course in patients with Menière's disease, although it may improve vertigo in the immediate post-perfusion period. Therefore, this modality of treatment may be useful for treating acute exacerbations of Menière's disease with prominent vertiginous symptoms, especially in those patients who cannot tolerate oral corticosteroids, such as diabetics. Furthermore, it may also be useful as a diagnostic test to determine which patients may respond to immunologic treatment.