Intratympanic Gentamicin Injection in Ménière’s Disease: Our Ten Years’ Experience and Outcomes

Objective: The aim of our study is to evaluate the effectiveness of intratympanic gentamicin injection (ITG) on vertigo control with reduced doses and its hearing effects. Materials and Method: The study was conducted at Otolaryngology Department of AORN “S.G. Moscati” between January 2005 and January 2015 on 72 patients with disabling unilateral Meniere’s disease. We use 0.2-0.3 mL of gentamicin sulfate at a concentration of 40mg/ml, injected into the affected ear through the posterior-inferior quadrant of the tympanic membrane. The procedure was carried out for three following days. Main outcome measures: vertigo control and hearing threshold changes after ITG treatment. Results: In 98.6% of the patients(n=71) the ITG produced the full remission of the vertiginous symptoms. In 91.6% of cases(n=66) a single treatment (three consequent injections) was sufficient to control vertigo, in 5.5% of cases(n=4) two treatments were necessary to control vertigo and in 1.3% of patients(n=1) three treatments were necessary to control vertigo. In no case we have had hearing loss after ITG procedure. The pre-treatment pure tone average was 48db. The post-treatment pure tone average was 49.2db. This difference was no statistical difference. Conclusion: In this study we reported high vertigo control, long follow-up and no case of significant hearing worsening. We consider the three injections in the following three days with low doses of gentamicin a safe and valid treatment for Meniere’s disease.

Intratympanic Gentamicin for Intractable Ménière's Disease - A Review and Analysis of Audiovestibular Impact

Abstract Introduction Intratympanic gentamicin regulates the symptoms in most patients with incapacitating Ménière's disease. The treatment protocols have changed over the years from medical labyrinthectomy to preservation of vestibular function. Objectives This study aims to review the audiovestibular response related to the effect of the drug in controlling vertigo. Data Synthesis Articles were identified by means of a search in the PubMed database using the key words Meniere and intratympanic or transtympanic gentamicin. Total 144 articles were reviewed after excluding those that were technical reports, those based on experimental animal studies, those that focused on outcomes other than vertigo (tinnitus or aural fullness), those with delivery methods other than tympanic membrane injection, and those with bilateral cases. If there was more than one article by the same author(s) or institution, only the most recent one matching the aforementioned criteria and those that were not overlapping were included. Conclusion Titration methods or multiple injections on a daily basis can be preferred if the patients have profound or non-serviceable hearing, since these methods have significant incidence of hearing loss. Treatment protocols with a frequency of injection not shorter than once a week, or those with injections on a monthly basis as "needed" provide the same level of vertigo control with better preservation of hearing. Caloric testing is not an ideal tool to analyze the correlation between vertigo control and the effect of gentamicin as compared with gain asymmetry of the vestibulo-ocular reflex. Vestibular-evoked myogenic potentials and the head thrust test are more reliable than other vestibular tests for the follow-up of patients undergoing gentamicin treatment.

Refractory episodic vertigo: role of intratympanic gentamicin and vestibular evoked myogenic potentials / Vertigem refratária episódica: papel da gentamicina intratimpânica e potencial evocado miogênico vestibular

Abstract Introduction: Even today, the treatment of intractable vertigo remains a challenge. Vestibular ablation with intratympanic gentamicin stands as a good alternative in the management of refractory vertigo patients. Objective: To control intractable vertigo through complete saccular and horizontal canal vestibular ablation with intratympanic gentamicin treatment. Methods: Patients with refractory episodic vertigo were included. The inclusion criteria were: unilateral ear disease, moderate to profound sensorineural hearing loss, and failure to other treatments. Included patients underwent 0.5-0.8 mL of gentamicin intratympanic application at a 30 mg/mL concentration. Vestibular ablation was confirmed by the absence of response on cervical vestibular evoked myogenic potentials and no response on caloric tests. Audiometry, electronystagmography with iced water, and vestibular evoked myogenic potentials were performed in all patients. Results: Ten patients were included; nine patients with Meniere's disease and one patient with (late onset) delayed hydrops. Nine patients showed an absent response on vestibular evoked myogenic potentials and no response on caloric tests. The only patient with low amplitude on cervical vestibular evoked myogenic potentials had vertigo recurrence. Vertigo control was achieved in 90% of the patients. One patient developed hearing loss >30 dB. Conclusions: Cervical vestibular evoked myogenic potentials confirmed vestibular ablation in patients treated with intratympanic gentamicin. High-grade vertigo control was due to complete saccular and horizontal canal ablation (no response to iced water in electronystagmography and no response on cervical vestibular evoked myogenic potentials).

Resumo Introdução: Ainda hoje, o controle da vertigem intratável permanece um desafio. A ablação vestibular com gentamicina intratimpânica permanece como uma boa alternativa no tratamento de pacientes com vertigem refratária. Objetivo: Controlar a vertigem intratável por meio de ablação vestibular completa dos canais sacular e horizontal com gentamicina intratimpânica como tratamento. Método: Pacientes com vertigem refratária episódica foram incluídos. Os critérios de inclusão foram doença unilateral da orelha, perda auditiva neurossensorial de moderada a profunda e fracasso com outros tratamentos. Os pacientes incluídos receberam uma aplicação de 0,5-0,8 mL de gentamicina intratimpânica com concentração de 30 mg/mL. A ablação vestibular foi confirmada pela ausência de resposta no teste de potencial evocado miogênico vestibular cervical (PEMVc) e nenhuma resposta nas provas calóricas. Audiometria, eletronistagmografia com água gelada e potencial evocado miogênico vestibular foram realizados em todos os pacientes. Resultados: Ao todo, dez pacientes foram incluídos: nove com doença de Ménière e um com hidropisia tardia. Nove pacientes apresentaram ausência de resposta no teste de potencial evocado miogênico vestibular e nenhuma resposta na prova calórica. O único paciente com baixa amplitude no PEMVc apresentou recorrência da vertigem. O controle da vertigem foi obtido em 90% dos pacientes. Um paciente desenvolveu perda auditiva > 30 dB. Conclusões: O PEMVc confirmou ablação vestibular nos pacientes tratados com gentamicina intratimpânica. O alto grau de controle da vertigem foi devido à ablação completa do sáculo e canal horizontal (sem resposta à água gelada na eletronistagmografia e ausência de resposta no PEMVc).