Treatments for Meniere’s disease: Fact, Fiction or Biological Plausibility? Part VI

Endolymphatic Sac Decompression

When conservative management approaches such as diuretics and a salt restricted diet do not satisfactorily control Meniere’s symptoms, more aggressive approaches may be considered. Surgical procedures for Meniere’s disease fall into two categories: Reparative and Ablative. Endolymphatic Sac Decompression (ESD) is considered reparative. An article from Emedicine.com describes the purpose of the procedure:

Endolymphatic Sac Decompression or Shunt Placement

In theory, the endolymphatic sac procedure decreases the buildup of endolymphatic pressure by removing petrous bone that encases the endolymph reservoir. This allows the reservoir sac to expand more freely than before and allows the pressure to dissipate. In addition, some surgeons insert a drain or valve from the endolymphatic space to the mastoid or subarachnoid space to reduce pressure further. Exposure of the endolymphatic sac is essentially extended mastoidectomy.

A review of the literature regarding ESD is less than inspiring. Portman {{1}}[[1]]Portman, G. (1927). The saccus endolymphaticus and an operation for draining the same for the relief of vertigo. J Laryngol Otol, 42, 809.[[1]] introduced endolymphatic sac decompression, with noted resolution of Meniere’s-type symptoms. Thomsen et al {{2}}[[2]]Thomsen, J., Bretlau, P., Tos, M., & Johnson, N. J. (1981). Placebo effect for surgery for Meniere’s disease. Arch Otolaryngol, 107, 271–277[[2]].  reported their “sham study” in which they performed simple mastoidectomy with sac decompression in one group and mastoidectomy without sac decompression in a second group. Group 1 noted improvement in 73%, whereas group 2 had an improvement rate of 80%. Silverstein et al (1989) followed up on two groups of patients for more than 8 years. Group 1 had endolymphatic sac surgery; group 2 had no surgery. They noted no significant difference in reported relief of vertigo.

The same article from Emedicine.com nicely sums up the prevailing sentiment regarding ESD surgery:

The endolymphatic sac procedure is perhaps one of the most controversial issues in neuro-otology. Critics state that the procedure is completely worthless. Authors of the famous Danish study argue that endolymphatic surgery is as useless as sham surgery and that any benefit is a placebo effect.

Proponents of sac surgery argue that patients really do improve. Compared with destructive procedures, endolymphatic sac procedures have low risk and morbidity and can provide relief to patients in whom medical therapy fails.

 

There are many anecdotal reports of complete resolution of symptoms following endolymphatic sac surgery. On a personal note, the mother of one of our staff audiologists underwent ESD after years of debilitating Meniere’s attacks, and improved dramatically. Like most treatments for Meniere’s disease, what works great for one person, may have no effect on another.

 

 

 

 

 

 

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.