Middle ear exploration in patients with Ménière's disease who have failed outpatient intratympanic gentamicin therapy

OBJECTIVE: Treatment of medically refractory Ménière's disease (MD) with intratympanic (IT) gentamicin has now become a standard therapy. This procedure is effective in controlling vertigo attacks, but approximately 10% of patients do not have an adequate response. The objective of the current study was to evaluate the option of middle ear exploration with direct application of gentamicin to the round window (MEE-G) in patients with persistent MD after transtympanic injection of gentamicin. STUDY DESIGN: A retrospective chart review of 191 patients with MD treated with IT gentamicin revealed 16 who failed to have symptomatic relief after transtympanic injection. Options discussed with these patients included labyrinthectomy, vestibular nerve section, and MEE-G. SETTING: Tertiary referral center. PATIENTS: Eight patients opted for MEE-G. INTERVENTION: Patients were taken to the operating room for MEE-G. After removal of the round window obstruction, gentamicin-soaked pledgets were placed for at least 30 minutes. MAIN OUTCOME MEASURES: Control of MD-related vertigo and need for additional therapy. RESULTS: At the time of MEE-G, all 8 patients were found to have adhesions, bone dust blocking the round window, or a thickened round window membrane. In 6 of these patients, vertigo symptoms due to MD either resolved with no further therapy (4 patients) or with subsequent IT gentamicin injections in clinic (2 patients). The remaining 2 patients underwent a vestibular nerve section, which resolved MD symptoms in each case. CONCLUSION: Anatomic barriers to the round window membrane may be a significant cause of IT gentamicin failure, and MEE-G can be considered before ablative therapy in this subset of patients with Ménière's disease.