Dizziness: Surgical Treatment
Guest: Dr. Ted Meyer – Otolaryngology/Head & Neck Surgery, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Ted Meyer, who is Assistant Professor of Otolaryngology, Ear, Nose, and Throat, here at the Medical University of South Carolina. Dr. Meyer, in other podcasts, you and Dr. Lambert discussed dizziness. Let’s talk, now, about the surgical treatment of dizziness. What are some of the causes of dizziness for which surgery might be an option?
Dr. Ted Meyer: One of the most common causes of dizziness for which surgery is a reasonable treatment option is Meniere’s disease. Meniere’s disease, which we’ve talked about before, is thought to be due to too much fluid in the inner ear. And, if salt restriction, plus a diuretic, does not help the patient, there are options, including a simple injection of an ototoxic antibiotic into the middle ear. The antibiotic will destroy some of the function of the inner ear in hope of controlling spells of vertigo.
Other surgeries for Meniere’s disease involve otologic surgery, or ear surgery. One is an endolymphatic sac decompression, or endolymphatic sac decompression with a shunt. That follows a standard mastoidectomy, and then opening up what’s called the endolymphatic sac to decompress this area. The thought is that it helps regulate fluid flow in the inner ear, and stops patients having spells of vertigo.
If a patient with Meniere’s disease does not have usable hearing, they can undergo a labyrinthectomy to actually destroy the balance function of the ear totally. You can also have a vestibular nerve section, which can be done in one of several different ways to actually cut the vestibular nerves. That’s a little more invasive of a surgery, but results are excellent.
Dr. Linda Austin: Wow. So, there are a number of different options. All of those sound like they must be incredibly delicate procedures though. I mean, you’re talking about tiny structures, right?
Dr. Ted Meyer: Yes; talking about tiny structures. And these are not, generally, done by a general otolaryngologist. They’re done by neurotologists, who have fellowship training to do these sorts of things.
Dr. Linda Austin: Such as yourself?
Dr. Ted Meyer: Such as myself, and Dr. Lambert.
Dr. Linda Austin: Right. Anybody else in our center?
Dr. Ted Meyer: Nobody else in our center is trained to do these sorts of things.
Dr. Linda Austin: Now, I’m just curious, if one does remove the labyrinth, which is responsible for balance, what is the adjustment like?
Dr. Ted Meyer: Usually, the labyrinth is in fairly bad repair before surgery; otherwise, you wouldn’t need a labyrinthectomy, but it still does function. Destroying the labyrinth, then, leaves the balance center of the brain input from only one ear, or the good side. There’s a complicated process that occurs, but patients are extremely vertiginous?
Dr. Linda Austin: Meaning, dizzy?
Dr. Ted Meyer: Meaning dizzy.
Dr. Linda Austin: Yeah.
Dr. Ted Meyer: Their eyes have nystagmus, which means their eyeballs move side to side, indicating that they’re dizzy, or vertiginous. And, over time, the brain, then, compensates by clamping down on function, and then allowing for compensation of just having one balance organ feeding the brain.
Dr. Linda Austin: How long does that adjustment period last? I would imagine that’s quite uncomfortable while that’s going on.
Dr. Ted Meyer: It is. It’s extremely uncomfortable for several days upfront. But patients are encouraged to get up and walk around even the day of surgery. Some of these can even be done on an outpatient basis, as long as you give the patient some medication to get by with the dizziness at home. And, after three to four days, patients are doing fairly well. Then, after a month or so, they’re feeling pretty darned good, in most cases.
Dr. Linda Austin: Boy, that’s remarkable, that the human body can adapt in that way.
Dr. Ted Meyer: It is. We don’t expect them to function normally at all times. But if somebody has vertigo from Meniere’s disease to the point of requiring a labyrinthectomy, they’re usually in very bad shape to begin with, so they’re happy that they’re not having spells. And then they work very hard to compensate from the surgery.
Dr. Linda Austin: So, this is for fairly advanced, or severe, cases?
Dr. Ted Meyer: Fairly advanced cases, yes.
Dr. Linda Austin: And, is that the same with the removal of the vestibular nerve; that’s for pretty advanced cases?
Dr. Ted Meyer: Yes. If you do a vestibular nerve section, instead of a labyrinthectomy, you’re doing this to cut the nerve, but preserve hearing. With a labyrinthectomy, you lose hearing completely.
Dr. Linda Austin: I see. But, cutting the vestibular nerve really amounts to the same thing from a balance/dizziness point of view, is that right?
Dr. Ted Meyer: Yes.
Dr. Linda Austin: So, you have that same period of adaptation, then, following that. Tell us, again, the first of the operations that you talked about.
Dr. Ted Meyer: The endolymphatic sac decompression?
Dr. Linda Austin: Exactly. Explain that a little bit more, if you would.
Dr. Ted Meyer: The inner ear is a very complicated structure for hearing and balance. It’s basically a fluid-filled sac inside a fluid-filled cavity, inside the temporal bone. Part of that fluid-filled sac is the cochlea that we use for hearing. And then the complicated vestibular system is the remaining part of the sac. One of the outpouchings from this sac is called the endolymphatic sac. And there’s an endolymphatic duct that helps to control the flow endolymph, which is the fluid in the sac, in the inner ear.
Because Meniere’s disease is thought to be due to either an overproduction or under-absorption of this fluid, performing the endolymphatic sac operation in the vast majority of patients who undergo the procedure helps with their spells of vertigo. Whether it’s through fluid dynamics or pressure dynamics, we don’t really understand that fully, but it does seem to work in a lot of patients. The procedure is not used as much as it was in the past, with the advent of injecting ototoxic antibiotics into the middle ear, which is a very simple procedure to do, and, again, gives the vast majority of patients relief from their spells of vertigo.
Dr. Linda Austin: How about other causes of dizziness? What other causes of dizziness might be appropriately treated with surgery?
Dr. Ted Meyer: That’s a very good question. Most causes of dizziness do not require surgery. But certainly, some can. A common cause of vertigo, or BPPV; benign paroxysmal positional vertigo, causes patients to be dizzy when they role over in bed, lay back in bed, or bend down to pick something up. A lot of times, this gets better with time. But for patients that it doesn’t, they can be treated with an Epley maneuver, which is a positioning of the head in a certain way to get the little crystals in the inner ear back to a place where they won’t cause dizziness. In a small percentage of patients with BPPV, this just doesn’t work, and a surgery can be done for them, which is actually plugging one of the balance canals responsible for dizziness. And in patients that have gotten to this point, the procedure is very helpful. That’s just in a small percentage of patients, however.
One of the things we see fairly commonly as a cause of dizziness is an acoustic neuroma. I think you’ve talked to Dr. Patel about this, and possibly Dr. Lambert, in other podcasts. Acoustic neuromas are benign growths on the balance nerve, and cause hearing loss tendinous, but they also cause dizziness. And it’s usually more of a vague dizziness without true vertigo or spells of spinning.
Dr. Linda Austin: Is there a surgical procedure, then, for acoustic neuroma?
Dr. Ted Meyer: Yes. Acoustic neuromas can be just observed with scans periodically to assess for growth. They can be radiated, or they can be removed surgically. And there are at least three different approaches that can be used surgically to try to remove these tumors. In two of the approaches, you can attempt to preserve hearing, if that’s possible. In the other, you will lose hearing. But the idea with the surgery is to remove as much of the tumor as you can, as safely as possible.
Dr. Linda Austin: Thank you very much, Dr. Meyer.
Dr. Ted Meyer: Thank you.
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