内淋巴管阻塞作为梅尼埃病的手术治疗选择
1Department of Otorhinolaryngology,Haga Hospital, 2Department of Otorhinolaryngology,Leiden University Medical Centre, 3Division of Otolaryngology-Head and Neck Surgery, Montreal University Hospital Center (CHUM),University of Montreal, 4Department of Otorhinolaryngology,Bergman Clinics, 5Department of Otorhinolaryngology,Antwerp University Hospital
Summary
内淋巴管阻塞对于梅尼埃病患者来说是一种相对较新的手术方法。在常规乳突切除术后，使用常规钛血夹识别和结扎内淋巴管。目前正在一项随机试验中评估该程序的有效性。
Abstract
内淋巴管阻塞是梅尼埃病的一种相对较新的治疗选择，旨在减少眩晕发作，同时保留听力和平衡。常规乳突切除术后，确定后半规管，并确定唐纳森线。这是一条穿过水平半规管的线，穿过后半规管。内淋巴囊通常位于后半规管下方的该部位。内淋巴囊和硬脑膜的骨头变薄，直到囊骨架化，然后识别内淋巴管。然后用钛夹堵住管道。使用计算机断层扫描 （CT） 扫描，确认位置。手术后 1 周、6 周和 1 年进行随访。迄今为止，只进行了一项评估这种方法的前瞻性试验，将这种新方法与内淋巴囊减压术进行了比较。导管阻塞的结果很有希望，96.5% 的患者在 2 年后没有眩晕。然而，还需要进一步的研究。
Introduction
梅尼埃病 （MD） 是一种以眩晕发作、听觉症状和听力损失为特征的失能性疾病1。MD 患者存在内耳内淋巴积水，但该病的确切病因尚不清楚。在大多数患者中，症状会随着时间的推移而消退2;尽管如此，由于不可预测的发作模式，大多数患者仍寻求积极治疗。
MD的治疗旨在减少眩晕发作。在过去的一个世纪里，人们提出了不同的治疗方式，包括手术和非手术。破坏性手术干预，如迷路切除术或前庭神经切断术，可有效控制眩晕，但会导致耳聋和手术耳前庭功能丧失 3,4。已经研究了内淋巴囊 （ES） 的手术，例如囊的减压和分流，但所提出的干预措施均未被证明比安慰剂手术更有效4.
2015 年，Saliba 等人发表了一项随机对照试验的结果，该试验比较了一种新技术，即内淋巴管阻塞 （EDB） 与内淋巴囊减压 （ESD）5。该试验取得了可喜的结果，EDB组96.5%的患者在2年后没有眩晕发作。这种技术背后的基本原理是，ES至少部分负责内淋巴的稳态紊乱，并且由于产量增加而产生内淋巴过载。通过阻塞内淋巴管 （ED），囊中产生的多余内淋巴液被阻止流向内耳的其余部分。这一假设得到了组织学研究的支持6,7,8。
EDB 是否适合个体患者取决于多种因素。患者的偏好和外科医生的偏好起着一定的作用，但当地的医疗保健法规也可能影响治疗选择。在我们中心，EDB 仅适用于尽管接受了鼓室内 （IT） 皮质类固醇注射治疗后仍出现眩晕发作的患者，并且已经排除了前庭性偏头痛。EDB特别适合听力功能良好但拒绝消融治疗的患者。本文介绍了这项新技术的手术步骤，并讨论了目前可用的文献。
Protocol
该协议用于目前正在荷兰进行的一项随机对照试验。该试验比较了内淋巴管阻塞 （EDB） 与内淋巴囊减压 （ESD）9。该协议得到了医学伦理委员会 METC Leiden-Den Haag-Delft（编号 P20.118）和医院董事会以及医院研究伦理委员会（Haga 医院研究委员会，T20-108）的批准。所有参与遵循该方案的试验的患者都提供了书面知情同意书。该试验的结果预计将于 2024 年底公布。 <…
Representative Results
手术因素该手术由Haga医院和安特卫普大学医院的作者之一（HB）进行。无法检索到安特卫普大学医院的数据，但大约有 100 名患者在该地点接受了 EDB。在Haga医院，只有在上述试验的背景下才允许EBD。在这项试验中，对 38 名患者进行了手术。由于该试验的盲法性质，尚不清楚这些患者中有多少人和哪些人接受了EDB，以及有多少人接受了内淋巴囊减压术（ESD）。但是，这些程序非常?…
Discussion
EDB 是一种潜在的新治疗方式，旨在减少眩晕发作，同时保留顽固性 MD 患者的内耳功能。在目前的文献中，结果似乎很有希望，但可用的数据很少。
技术的基本原理
几十年来，靶向 ES 缓解 MD 症状一直存在争议。过去，人们普遍认为（ES）主要在内淋巴13,14,15,16的吸收中起作用。<sup c…
Divulgaciones
The authors have nothing to disclose.
Acknowledgements
作者感谢 Isobel Bowring 校对本文，感谢 Nele Ruysschaert 帮助提供有关麻醉的信息。
Materials
| Adson Forceps, Delicate, Smooth, 1 x 2 teeth, 12 0mm | Aesculap BV | BD511R | |
| Adson-Brown Tissue Forceps, 7 x 8 teeth, 120 mm | Aesculap BV | BD700R | |
| Baby Adson Retractor, hinged, semi-S tip, 3 x 4 prongs blade end, 140 mm | Aesculap BV | BV085R | |
| Baby Senn-Miller RetractorFlat Handle, SHARP tip, 3 PRONGS blade end, blade size 8 x 7/22 x 7, 165 mm | Aesculap BV | BT006R | |
| Bien Air Nano Micromotor OsseoDUO + NANOmicromotor | Bien air | 1700524-001 | Electronic motor used for mastoidectomy |
| Bien air tubing set for peristaltic pump | Bien air | 1100037 | |
| Coagulation Forceps | Aesculap BV | E700246 | Used for hemostasis |
| Cord, bipolar, 4.5 m | Valleylab BV | E360150L | |
| Diamond burrs 0.8x 70 to 7.0×70 | Bien air | ||
| Ear Curette, Pointed, Double Ended, cup size LARGE, 170 mm | Aseculap BV | OG189R | |
| Ethicon hechtdraad 3/0 sh-1 vicryl 70 cm | Ethicon | 3006273 | Suture for deeper tissue layers |
| Fibrin Sealant | Baxter BV | BE-90-01-040 | Tissue glue used in case of liquor leakage |
| Gillies Skin Hook, Tip 0.5/6mm, jaw STR, SERR | Aesculap BV | OL611R | |
| Gillies Tissue Forceps, Delicate, X-SERR tip, 1 x 2 teeth, 155 mm | Aesculap BV | BD660R | |
| Halsted Mosquito Forceps, Delicate, CVD jaw, 125 mm | Aesculap BV | BH111R | |
| Handpiece for burr | Bien air | 1600830-001 | |
| Hartmann Ear Forceps , Tip 4 mm, jaw STR | Aesculap BV | OG329R | |
| Hartmann-Wullstein Ear Forceps | Aesculap BV | OF410R | |
| Hejek Mallet, Ø27 220 mm | Aesculap BV | FL044R | |
| Horizon Metal Ligation System – Clips size MICRO, SMALL, MEDIUM | Teleflex Medical | 1201, 2200, 5200 | Titanium clip used for blockage of endolymphatic duct |
| House Ear Curette | Aesculap BV | OG182R | Double Ended, cup size (mm) 1.5/1.8, tip ANG |
| Lucae Bayonet Forceps | Aesculap BV | BD878R | SERR tip, 140mm |
| Lucae Bayonet Forceps | Aesculap | BD878R | SERR tip, 140mm |
| Lucae Ear Hook Button | Aesculap BV | OF278R | Hook end SMALL, tip SHARP, 130mm |
| Mayo Dissecting Scissors | Aesculap BV | BC587R | Round Blade, B/B tip, CVD blade, 165mm |
| Mayo Dissecting Scissors, Round Blade, B/B tip, CVD blade, 165 mm | Aesculap BV | BC587R | |
| McIndoe Thumb Forceps, Delicate | Aesculap BV | BD236R | SERR tip, 150 mm |
| Micro Adson Forceps, Delicate, SERR with platform tip Tip, 12 cm | Aesculap BV | BD220R/425.112 | |
| Monocryl 4-0 FS-2. 70 cm | Ethicon | Y422H | Suture for skin |
| NIM response 3.0 | Medtronic | NIM4CM01 | Nerve monitoring system |
| OSSEODUO control unit | Bien air | 1600513-001 | |
| Paired Subdermal electrodes with subdermal ground electrode and subdermal stim return, 2 channel | Medtronic Xomed | 8227410 | |
| Scalpel Handle #3 F/ Blades | Aesculap BV | BB070R | |
| Steel burrs 0.8x 70 to 7.0x 70 | Bien air | ||
| Volkmann Curette, tip size 3.6 mm, 170 mm | Aesculap BV | FK631R | |
| Watertight, 2-button multifunction pedal | Bien air | 1600517-001 | |
| Williger Bone Elevator, blade 6, 160 mm | Aesculap BV | FK300R | |
| Wire bending forceps, curved downards, 80 mm, jaw length 3.50 mm, with tubular shaft | McGee | OG359R | Used to close clip |
| Wullstein Retractor, sharp tip, 3 x 3 prongs blade end, 130 mm | Aesculap BV | BV076R |
Referencias
- Lopez-Escamez, J. A., et al. Diagnostic criteria for Menière’s disease. Journal of Vestibular Research: Equilibrium & Orientation. 25 (1), 1-7 (2015).
- Perez-Garrigues, H., et al. Time course of episodes of definitive vertigo in Meniere’s disease. Archives of Otolaryngology-Head & Neck Surgery. 134 (11), 1149-1154 (2008).
- Alarcón, A. V., Hidalgo, L. O. V., Arévalo, R. J., Diaz, M. P. Labyrinthectomy and vestibular neurectomy for intractable vertiginous symptoms. International Archives of Otorhinolaryngology. 21 (2), 184-190 (2017).
- Pullens, B., Verschuur, H. P., van Benthem, P. P. Surgery for Ménière’s disease. Cochrane Database of Systematic Reviews. 2013 (2), (2013).
- Saliba, I., Gabra, N., Alzahrani, M., Berbiche, D. Endolymphatic duct blockage: a randomized controlled trial of a novel surgical technique for Ménière’s disease treatment. Otolaryngology-Head and Neck Surgery. 152 (1), 122-129 (2015).
- Møller, M. N., Kirkeby, S., Vikeså, J., Nielsen, F. C., Cayé-Thomasen, P. The human endolymphatic sac expresses natriuretic peptides. Laryngoscope. 127 (6), E201-E208 (2017).
- Takumida, M., Bagger-Sjöbäck, D., Wersäll, J., Rask-Andersen, H., Harada, Y. Three-dimensional ultrastructure of the endolymphatic sac. Archives of Oto-Rhino-Laryngology. 244 (2), 117-122 (1987).
- Friis, M., Thomsen, A. R., Poulsen, S. S., Qvortrup, K. Experimental hyperactivity of the endolymphatic sac. Audiology & Neuro-Otology. 18 (2), 125-133 (2013).
- Schenck, A. A., et al. Effectiveness of endolymphatic duct blockage versus endolymphatic sac decompression in patients with intractable Ménière’s disease: study protocol for a double-blinded, randomised controlled trial. BMJ Open. 11 (8), e054514 (2021).
- Lempert, T., et al. Vestibular migraine: Diagnostic criteria. Journal of Vestibular Research: Equilibrium & Orientation. 32 (1), 1-6 (2022).
- Schenck, A. A., Bommeljé, C. C., Kruyt, J. M. Outcomes of endolymphatic duct blockage for Ménière’s disease: an observational cohort study. American Journal of Otolaryngology and Head. 4 (5), 1140 (2021).
- Kato, B. M., LaRouere, M. J., Bojrab, D. I., Michaelides, E. M. Evaluating quality of life after endolymphatic sac surgery: The Ménière’s Disease Outcomes Questionnaire. Otology & Neurotology. 25 (3), 339-344 (2004).
- Kimura, R. S. Experimental blockage of the endolymphatic duct and sac and its effect on the inner ear of the guinea pig. A study on endolymphatic hydrops. The Annals of Otology, Rhinology, and Laryngology. 76 (3), 664-687 (1967).
- Lundquist, P. G. Aspects on endolymphatic sac morphology and function. Archives of Oto-Rhino-Laryngology. 212 (4), 231-240 (1976).
- Lundquist, P. G., Kimura, R., Wersaell, J. Experiments in endolymph circulation. Acta Oto-Laryngologica. Supplementum. 188, 198 (1964).
- Wackym, P. A., et al. Human endolymphatic sac: possible mechanisms of pressure regulation. The Journal of Laryngology and Otology. 101 (8), 768-779 (1987).
- Linthicum, F. H., Santos, F. Endolymphatic sac amputation without hydrops. Otology & Neurotology. 32 (2), e12-e13 (2011).
- Niu, Y., Chen, W., Lin, M., Sha, Y. Progression of endolymphatic hydrops and vertigo during treatment in Meniere’s disease. Acta Oto-Laryngologica. 142 (9-12), 653-657 (2022).
- Merchant, S. N., Adams, J. C., Nadol, J. B. Pathophysiology of Meniere’s syndrome: are symptoms caused by endolymphatic hydrops. Otology & Neurotology. 26 (1), 74-81 (2005).
- Basura, G. J., et al. Clinical practice guideline: Ménière’s disease. Otolaryngology-Head and Neck Surgery. 162, S1-S55 (2020).
- Hussain, K., Murdin, L., Schilder, A. G. M. Restriction of salt, caffeine and alcohol intake for the treatment of Ménière’s disease or syndrome. Cochrane Database of Systematic Reviews. 12, (2018).
- Burgess, A., Kundu, S. Diuretics for Ménière’s disease or syndrome. Cochrane Database of Systematic Reviews. 3, (2006).
- van Esch, B., et al. Betahistine for Menière’s disease or syndrome. Cochrane Database of Systematic Reviews. 1, (2001).
- Phillips, J. S., Westerberg, B. Intratympanic steroids for Ménière’s disease or syndrome. Cochrane Database of Systematic Reviews. 7, (2011).
Citar este artículo
Schenck, A. A., Saliba, I., Kruyt, J. M., van Benthem, P. P., Blom, H. M. Endolymphatic Duct Blockage as a Surgical Treatment Option for Ménière’s Disease. J. Vis. Exp. (194), e65061, doi:10.3791/65061 (2023).