The surgical treatment of vertigo.

These treatments destroy all or part of the labyrinth, or deconnect it from the vestibular centres. 1. Labyrinthectomy a) Total labyrinthectomy This procedure may be either chemical or surgical. The intratympanic application of Gentamycin is the gold standard for the treatment of intractable chronic vertigo of the kind found in Ménière's disease. 1-4 Ideally, the aminoglycosides are administered in the round window niche through a paracentesis, a transtympanic tube or sometimes through a pump (not available now). The easiest solution today is to administer it using the Spongostan of a Silverstein tube (Micromedics Inc. Minnesota 5510 USA). This treatment results in good control of the vertigo (>80%) but it may adversely affect hearing. Surgical labyrinthectomy should be avoided. Otologists should aim to preserve cochlear morphology so that cochlear implantation remains possible at a later stage. The destruction of the diseased end organ will eliminate vertigo symptoms but also destroys hearing. This procedure should be reserved for ears with significant hearing loss in old patients. b) Localised labyrinthectomy The plugging of a semi-circular canal is an effective treatment with >90% success in vertigo control in cases of intractable benign paroxysmal positional vertigo (BPPV). 5-7 It usually involves the posterior canal and sometimes the horizontal. Incomplete occlusion of the canal may result in recurrence of BPPV and in a catiogenic fistula. 8 2. Vestibular neurotomies and neurectomies a) Singular neurectomy This approach is proposed for chronic disabling refractory BPPV. The neurectomy is carried out in the ampullary recess of the posterior semi-circular canal. This technique provides complete relief from BPPV in 96% of subjects. 9 Sensorineural hearing loss is a complication in 3-4%. A positive fistula response may be present for a few months in some patients. b) Vestibular neurotomy A vestibular neurotomy in the pontocerebellar angle allows for the deconnection of the vestibular end organ from the vestibular nuclei and the cerebellum. It usually results in a central vestibular compensatory reorganisation, allowing for the recovery of functional equilibrium. This compensation can happen despite the persistent evolutive disease in the ear or the nerve. It is less efficient in the elderly and so this will not be the first-choice surgical option for them. A vestibular neurotomy results in improvements or the resolution of vertigo in >90%.