耳鼻咽喉头颈外科学：梅尼埃眩晕

1、Menieres Disease and VertigoMenieres diseaseIn 1861, Prosper Meniere described a condition which now bears his name. It is a disorder of the inner ear It causes episodes of vertigo, ringing (tinnitus), a feeling of fullness or pressure in the ear, and fluctuating hearing loss.It affect the entire la

2、byrinth, includes both the semicircular canals and the cochlea.Clinical featuresepisodic vertigofluctuating deafnessfluctuating tinnitusaural fullnessIncidenceGreat Britain：1/636/yearSweden：46/100 000/yearJapan：increased dramaticallyAfrica：uncommonracial variation? (Caucasians and Blacks)Peak Onset:

3、 4th and 5th decade PathophysiologyLabyrinth is divided into two parts (bony , membranous). Including cochlear, vestibuli, three semicircular canals (Reissners membrane, basilar membrane, organ of Corti , scala vestibuli, scala medial, scala tympanic,utricle and saccule ).Endolymph and perilymphpath

4、ophysiologyPathophysiologyEndolymphatic hydropsnormalhydropspathophysiologyTraditional thinking on the origin of Menieres disease : The most prevalent opinion is that an acute attack of Menieres disease results from fluctuating pressure of the fluid within the inner ear. A system of membranes, calle

5、d the membranous labyrinth, contains a fluid called endolymph. The membranes can become dilated like a balloon when pressure increases. This is called hydrops. One way for this to happen is when the drainage system, called the endolymphatic duct or sac is blocked. pathophysiologycochlear hydrops and

6、 saccular hydrops,was seen in most, but utricular hydrops was uncommonpathophysiologyMechanical distortion and increased tension sensorineural hearing lossvestibular organ vestibule dysfunctionPossible MechanismsAuto-immunevirusischemicEtiologyUnknownallergy: 81% of patients with MD had a history of

7、 childhood allergy,and 87% had significant symptoms of a systemic disorder suggesting allergyautoimmunity: immunological abnormalities immunoglobulins lymphocytes in endolymphatic sacEtiologyGenetic:14-20% familial tendencyAnatomical: small vestibular aqueduct (congenital abnormity、infection、genetic

8、)Traumatic:biochemical dysfunction in the membranous labyrinth cells ,debris into endolymph obstruct the endolym-phatic duct and sacEtiologyViral infection: higher antibody reactivity to herpes simplex virus type Idysfunction of autonomic nervous system abnormal metabolic and endocrine states Clinic

9、al manifestationsTypical presenting history: episodic attacks of rotatory vertigo (96.2%) tinnitus(91.1%) hearing loss (87.7) aural pressure (74.1%) Clinical manifestations1.Vertigo Vertigo begins suddenly Asssociated with vegetative signs：pallor、nausea、diarrhoea、vomiting、 Accompanied by tinnitus、he

10、aring loss and fullness Clinical manifestations Head movement exacerbates the symptoms Length of attacks is variable, most episodes lasting 2-3 hrs During attack ,patient has a normal level of consciousness Horizontal nystagmus Clinical manifestations2.Tinnitus continuous or intermittent usually mor

11、e marked before and during an attack 3.Deafness sensorineural hearing loss fluctuant and progressive low frequency hearing loss to high frequency hearing loss Clinical manifestationsClinical manifestations4.FullnessDiagnosisHistoryPhysical ExamAudiogramVEMPsECoGVNGBlood testsMRIinvestigations1.horiz

12、ontal rotatory nystagmus2.Tympanic membrane、 midle ear and eustachian tube functions Investigations (assessment of cochlear function) 3.pure tone audiometry 4050% most often demonstrate a flat audiograminvestigations (assessment of vestibular function )Static Vestibular Balance Nystagmus: Check dire

13、ction Check for torsional component Check for gaze suppressionFrenzel眼镜检查investigations (assessment of vestibular function )94% patients abnormal reactions to the caloric test Evaluation of the reaction is based on the maximum speed of the slow phase of the generated nystagmus investigations An ENG

14、(electronystagmogram) may be performed to evaluate balance function. In a darkened room, eye movements are recorded as warm and cool water or air are gently introduced into each ear canal. Since the eyes and ears work in coordination through the nervous system, measurement of eye movements can be us

15、ed to test the balance system. In about 50 percent of patients, the balance function is reduced in the affected ear.investigations electronystagmogram检查(investigations)Rotatory Chair检查(Dynamic Posturography) Sense of balance is maintained Dizziness, vertigo, and motion sickness all relate to the sen

16、se of balance and equilibrium. Your sense of balance is maintained by a complex interaction of the following parts of the nervous system:The inner ear (also called the labyrinth), which monitors the directions of motion, such as turning, rolling, forward-backward, side-to-side, and up-and-down motio

17、ns.The eyes, which monitor where the body is in space (i.e., upside down, right side up, etc.) and also directions of motion.The pressure receptors in the joints of the lower extremities and the spine, which tell what part of the body is down and touching the ground.The muscle and joint sensory rece

18、ptors (also called proprioception) tell what parts of the body are moving.The central nervous system (the brain and spinal cord), which processes all the information from the four other systems to maintain balance and equilibrium.The symptoms of motion sickness and dizziness appear when the central

19、nervous system receives conflicting messages from the other four systems.Differential diagnosis of Menieres syndromeTrauma acoustic trauma, temporal bone fracture, surgical trauma to the inner earAutoimmune autoimmune inner ear disease, Cogans disease, LupusInfectious chronic otitis media, syphilis,

20、 labyrinthitis (viral or bacterial)Metabolic otosclerosis, Pagets disease, hyperlipidemiaCogans SyndromeInterstitial keratitisvertigo, tinnitus, SNHLpositive LTT to corneal antigenDifferential diagnosis of Menieres syndromeNeoplastic acoustic neuroma, leukemia,Congenital/Developmental Mondinis dyspl

21、asia large vestibular aqueduct syndrome, congenital deafness, jugular bulb diverticulumEndocrine thyroid disease, diabetesIdiopathic perilymphatic fistula, Menieres diseaseacoustic neuromaMeningioma FeaturesClassificationTreatmentsPrecise etiology of MD remains obscure, it is therefore not surprisin

22、g that no cure for the disorder exists Most paper on therapy for MD have poor or absent controls between the therapy and placeboA good dorctor-patient relationship be established Management Principle 1、adjust autonomic nervous function2、reduce hydrops3、improve the hypoxemia of inner ear4、psychothera

23、pyManagementfour step approach 1、dietary changes： elimination of caffeine and reduction of sodium intake. 2、medical therapy： control of any identified underlying medical problems (such as hypothyroidism or diabetes), maintenance diuretic therapy and use of vestibular suppressant medication during ac

24、ute spells 3、conservative surgical therapy 4、ablative surgical therapyManagement1、medical therapy: 1)vestibular sedatives ；vertigo is due to a sudden asymmetry in vestibular input to the central nervous system chlorpromazine、diphenhydramine 2) Diuretics:reduce endolymphatic accumulation hydrochlorth

25、iazide 3)vasodilators：MD is the result of strial ischaemia or endolymphatic sac hypoperfusion ：nicotinic acid、 betahistine Endolymphatic Sac SurgeryTreatment with AminoglycosidesAminoglycosides are a family of antibiotics that are toxic to sensory hair cells in the inner earStreptomycin and gentamyc

26、in are predominantly toxic to the vestibular labyrinth (as opposed to cochlea), hence are most suitable to be used in the the treatment of MDVarious techniques have been used to administer aminoglycosides to the inner ear :systemic administration, transtympanic injection,and the placement of gelfoam

27、 soaked in aminoglycosides into the round window niche Medical TherapySteroids90%Perfusion via round window microcatheters placement 圆窗龛Perfusion via round window microcatheters placementIntratympanic Gentamicin Vestibular Nerve SectionLabyrinthectomy Other causes of labyrinthine vertigo Vestibular

28、neuronitis is occasionally seen in adults, more commonly in the winter months.It is usually regarded as transient infection (viral) of the ganglion of Scarpa Sudden deafness with vertigoBenign positional vertigo(BPV) is considered to be due to a degenerative condition of the utricular and saccular m

29、aculae.The attackslast a few seconds only and are brought on by head movement,particularly lying back in bed. BPVBPVBPVVertebro-basilar insufficiency may br the cause of major but momentary attacks of vertigo. The symptome of sudden vertigo may be caused by rotation of the neck or hyperextension, for example when the patient looks up to admire an architectural feature immediately overhead. Ototoxic drugs, streptomycin and its analogues,in certain cases,dest