Intratympanic Therapies in Ménière Disease: Evaluation of Outcomes and Early Vertigo Control

Abstract

Objective To evaluate outcomes of intratympanic (IT) dexamethasone and gentamicin in Ménière Disease (MD). Methods Charts of adult patients with unilateral definite MD receiving IT gentamicin or dexamethasone from 2005 to 2017 were retrospectively reviewed. All patients had at least 6 months follow‐up. Failure in each group was defined as the need for more aggressive therapy. Prior to 2011, all patient received IT gentamicin, administered as primary therapy after failure of conservative treatment measures. Gentamicin was administered every 2 weeks, up to three injections, until vertigo control was achieved. Beginning in 2011, the treatment protocol shifted to IT dexamethasone as initial treatment, with gentamicin used for dexamethasone failures. Dexamethasone was administered weekly for up to three injections. Treatments could be repeated if symptoms recurred. Results Thirty‐three patients received IT dexamethasone, and 70 patients received IT gentamicin. Dexamethasone patients received a mean of 3.3 injections compared to 2.7 in the gentamicin group (P = 0.011). There were 12 (38%) failures in the dexamethasone group and only seven (10%) gentamicin failures (P = 0.025). No patients failed both treatments. The mean time to failure in the dexamethasone group was 5 months, whereas in the gentamicin group it was 27 months. Change in pure tone audiometry from baseline was not different between treatment groups (P = 0.30). Conclusion Subjects receiving IT gentamicin required fewer injections and had a significantly longer time to failure than IT dexamethasone. Audiometric outcomes were similar between the groups. The use of IT gentamicin as initial therapy for early and long‐term control of MD is safe and effective. Level of Evidence 3 Laryngoscope, 129:216–221, 2019

Long-Term Follow-Up of Intratympanic Methylprednisolone Versus Gentamicin in Patients With Unilateral Menière's Disease

“…Although not reaching statistical significance, there was a trend for a higher frequency of repeat injections required in the methylprednisolone than in the gentamicin group as perhaps expected, and recently reported in a retrospective series (n=33) using dexamethasone. 13 We acknowledge that there are several limitations with this follow-up study, including the absence of a placebo arm. It was felt that it would have been unethical to leave patients in the severely symptomatic stage of Menière's Disease untreated for up to 2 years, particularly in view of the 2014 gentamicin Vs placebo RCT which was stopped early and the 2011 Cochrane review.…”

“…[26][27][28][29] Dose-dependent hearing loss has been discussed, however, in recent studies with IT gentamicin, which have revealed that hearing outcomes can be comparable to IT steroids. 13,14 A literature review of ITS for Menière's disease was undertaken by one of our co-authors in 2017. 30 12 studies (6 prospective) meeting AAOHNS reporting guidelines were identified, of which 8 have been published since the 2011 ITS Cochrane paper.…”

“…7 A recent international consensus document has supported intratympanic steroids (ITS) as appropriate second-line management when non-invasive treatments have failed, but despite this there remains scepticism in the literature regarding steroid treatment. 6,[8][9][10][11][12][13] Between 2009 and 2015 we carried out a prospective double-blind randomized comparative effectiveness trial of intratympanic injections of methylprednisolone versus gentamicin for unilateral refractory Menière's disease with two year follow-up of vertigo control and audiovestibular function. 14 The trial concluded that the primary outcome, vertigo control, was equal in both treatment arms, thus providing the first high level evidence in support of the use of intratympanic methylprednisolone.…”

Effects of an Intratympanic Injection of Dexamethasone Combined with Gentamicin on the Expression Level of Serum P0 Protein Antibodies in Patients with Meniere's Disease

“…Even though gentamicin as an antibiotic reduces vertigo in patients, it might also damage their vestibular function and worsen their hearing ( 10 ). Therefore, this drug is usually used for patients with MD who fail to receive conservative treatment ( 11 ). Dexamethasone is a synthetic corticosteroid with anti-inflammatory, anti-allergic, and immunosuppressive effects ( 12 ).…”

Pharmacological, surgical and diagnostic innovations in Meniere’s disease: a review

“…First-line treatment includes dietary restrictions for salt, caffeine, and alcohol associated to drugs both for acute attacks (dimenhydrinate, benzodiazepines) 12 , and as prophylactic therapy (betahistine, β-blockers, diuretics) 13 . When first-line treatment does not offer satisfactory symptom control, intratympanic (IT) administration of gentamicin or corticosteroids can be performed 14 ; however, many studies showed that IT gentamicin may expose the patients to a risk of hearing loss, depending on dosage and intervals between administrations 15 . Labyrinthectomy or other surgical procedures can be suggested for intractable MD 16 .…”