Surgical Treatment of Vertigo

Timothy C. Hain, MD

Last edited: 2/17/99. Please read our disclaimer.

Overview Corrective treatments Destructive treatmentsContraindications Index

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Overview:

There are relatively few times when surgery is appropriate for dizziness. Most dizziness either can be treated effectively medically, or there is no treatment at all. Surgical treatments that are available can be broken down innto corrective and destructive types.

Corrective surgical treatments for vertigo:

Unfortunately, there are relatively few instances where surgery can be viewed as a corrective procedure for vertigo. Interestingly, in all cases where there is a proposed corrective surgery, either the process of diagnosis is controversial, or the treatment itself is controversial.  This suggests that caution is appropriate when a corrective procedure is proposed.

In perilymph fistula, surgery may be used to plug a leak in the inner ear. Both the diagnostic process and the treatment is somewhat controversial. Recently a new type of fistula has been described involving dehiscence of the superior canal. Whether or not surgery will be effective for this syndrome is presently uncertain.

In the microvascular compression syndrome, surgery may be used to move a blood vessel off of the vestibular nerve. Again, there is considerable controversy about diagnosis and treatment and we would advise caution and judicious second opinions before proceeding with such surgery.

In Meniere's disease, shunt surgery is intended to improve inner ear plumbing.  There is controversy primarily in regard to whether this procedure is effective. The consensus at this writing (4/1999), is that shunt surgery is modestly effective for several years. It compares unfavorably with transtympanic gentamicin (see destructive procedures).

All treatments for Meniere's must be compared with the natural history of Meniere's, where 60% of patients are in remission by 6 months. The most common type of shunt surgery consists of putting in a small tube or plastic sheet into the endolymphatic sac. Another procedure is termed "endolymphatic sac enhancement", a procedure which includes "lateral sinus decompression" (Sajjadi, Paparella and Williams, 1998). Shunt surgery is generally felt to be ineffective when viewed over 5 years although it may improve the situation for 2 years. The most disturbing report came out of the "Danish Sham Study", where individuals treated with placebo fared better than those with shunts. There is also good evidence that tubes placed in the sac close up by 4 years. Nevertheless, it is possible that procedures that either destroy the sac or remove surrounding bone through which lymphocytes migrate into the sac might alter its immune function enough to cause a remission of Meniere's disease. To summarize, at this writing, shunt surgery may have some short term benefit, and the mechanism of the benefit may relate to immune modulation.

In nearly all other instances, surgery is destructive, and is intended to disconnect an abberently functioning ear from the brain.

Destructive Surgical Procedures For Control of VertigoGentamicin treatment

These are designed to eliminate vertigo, possibly sacrificing hearing. These procedures are appropriate for consideration when medical treatment and vestibular rehabilitation has failed to control vertigo symptoms. Indications are generally much clearer for destructive treatment than for corrective treatments, and results are better.

For Meniere's disease, destructive procedures are associated with better control of vertigo than shunt surgery, showing good control in over 90% of patients followed for 5 or more years. The vestibular nerve may be sectioned via the middle fossa, retrolabyrinthine, and retrosigmoid approaches, with similar efficacy.  Transtympanic gentamicin treatment is a rapidly growing outpatient procedure that offers similar results to vestibular nerve section but with much less risk. Labyrinthectomy is appropriate for patients in whom there is no hearing in the ear which is causing vertigo and offers excellent control of vertigo, with less complications than nerve section.

Removal of the acoustic tumor in acoustic neuroma surgery generally results in elimination of vertigo, as the nerve is usually sectioned. 

In individuals who fail fistula surgery (for perilymph fistula), a destructive treatment also seems reasonable when symptoms are disabling.

For Benign Paroxysmal Positional Vertigo, selective posterior canal plugging offers a reasonable surgical approach to intractable symptoms. Singular neurectomy, an older procedure, is less popular because it produces hearing loss in 7-17% of patients and fails in 8-12%.

 

Contraindications

We generally do not think that destructive treatments are appropriate for vestibular neuritis, but there are occasional exceptions, when medical treatment fails and symptoms are severe. We also do not feel that destructive treatments are indicated when the diagnosis is unclear.  Destructive treatments are risky for continued vertigo when there is impairment of central adaptation, such as seniors and in people with pre-existing cerebellar problems.

Vestibular Rehabilitation therapy is appropriate in all patients who have had destructive treatment.

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References:

Sajjadi H, Paparella MM, Williams W. Endolymphatic sac enhancement surgery in elderly patients with Meniere's disease. ENT Journal, 975-981, 1998