Otolaryngological manifestations of HIV/Aids: A review

Abstract

Background: Ménière's therapy has been controversial for several generations of otolaryngologists. The major surgical inventions include intratympanic drug injections, as well as vestibular nerve sections and endolymphatic sac (ES) decompressions. Recently, an argument has been made to combine ES decompression with steroid injection; however, diffusion of steroids from the ES to the cochlea has not previously been demonstrated. Objective: To describe the diffusion of dexamethasone and gadolinium from the ES to the inner ear. Design: Prospective cohort study. Participants: 19 patients with Ménière's disease recruited during a 1-year period starting in January 2008. All patients had been diagnosed with definite Ménière's disease according to the American Academy of Otolaryngology criteria. All patients had also failed medical therapy including diuretic, betahistine, and a low-salt diet for at least 6 months. Methods: Before the procedure, the patients underwent audiometry, auditory brainstem response, electrocochleography, electronystagmography, and vestibular-evoked myogenic potentials. Sixteen patients had ES decompression with injection of dexamethasone alone. Three patients had dexamethasone with gadolinium. A total of 0.2 mL of dexamethasone 4 mg/mL was injected over 2 seconds. During the procedure, intraoperative electrocochleography was performed. Serial MRI was performed after injection in those who received gadolinium. Interventions: ES decompression with dexamethasone injection. Results: One patient required a vestibular nerve section 2 months after surgery, but the others completed follow-up visits out to 1 year. In all but 2 patients, the electrocochleography changed about 10 minutes after injection. These changes reverted to normal within 60 minutes. In the patients who received gadolinium, the initial distribution was from the ES to the vestibule and semicircular canals within 24 hours. After 48 hours, the gadolinium was also seen in the cochlea in 2 of the 3 patients. Pure tone hearing significantly improved from 48 dB to 33 dB after 12 months. The tinnitus handicap inventory also improved significantly, from 35 at baseline to 22. The authors pointed out that vertigo spells were controlled in 95% of the patients. Conclusions: This approach "might reveal new prospects for treating viral, metabolic, autoimmune, and genetic disorders of the cochlea." Reviewer's Comments: In many centers, intratympanic dexamethasone would have been attempted before this procedure, which is a less invasive method to deliver steroids to the inner ear. Many of these patients may have been able to achieve a similar result with intratympanic steroids. I believe it would have been more interesting if ES injection were studied only on patients who failed intratympanic steroids since it would answer the question of whether these patients were insensitive to steroids or whether it was just a failure of the steroids to diffuse into the inner ear. I also would have liked to see a better description of the vertigo symptoms before and after this procedure. (Reviewer-Benjamin T. Crane, MD).