Endolymphatic duct blockage is a relatively new surgical method for patients suffering from Ménière’s disease. Following a regular mastoidectomy, the endolymphatic duct is identified and ligated using a regular titanium hemoclip. The effectiveness of this procedure is currently being assessed in a randomized trial.
Endolymphatic duct blockage is a relatively new treatment option for Ménière’s disease, aiming to reduce vertigo attacks while sparing hearing and equilibrium. After a regular mastoidectomy, the posterior semicircular canal is identified, and Donaldson’s line is determined. This is a line through the horizontal semicircular canal, crossing the posterior semicircular canal. The endolymphatic sac is usually found at this site under the posterior semicircular canal. The bone of the endolymphatic sac and the dura are thinned until the sac is skeletonized, after which the endolymphatic duct is identified. The duct is then blocked with a titanium clip. Using a computerized tomography (CT) scan, the position is confirmed. Follow-up visits take place 1 week, 6 weeks and 1 year after surgery. To this day, only one prospective trial assessing this method has been conducted, comparing this new method to endolymphatic sac decompression. Results of the duct blockage are promising, with 96.5% of the patients free of vertigo after 2 years. However, further research is required.
Ménière's disease (MD) is an incapacitating disease characterized by vertigo bouts, aural symptoms, and hearing loss1. Endolymphatic hydrops in the inner ear is present in patients with MD, but the exact aetiology of the disease remains unclear. In most patients, the symptoms resolve over time2; despite this, the majority of patients seek active treatment because of the unpredictable pattern of attacks.
Treatment for MD aims to reduce vertigo attacks. In the past century, different treatment modalities have been proposed, both surgical and non-surgical. Destructive surgical interventions, such as labyrinthectomy or vestibular neurotomy, are effective in controlling vertigo but cause deafness and a loss of vestibular function on the operated ear3,4. Surgeries on the endolymphatic sac (ES) have been studied, such as decompression and shunting of the sac, but neither of the proposed interventions have been proven to be more effective than placebo surgery4.
In 2015, Saliba et al. published the results of a randomized controlled trial comparing a new technique, endolymphatic duct blockage (EDB), to endolymphatic sac decompression (ESD)5. The trial yielded promising results, with 96.5% of the patients in the EDB group being free of vertigo attacks after 2 years. The rationale behind this technique is that the ES is at least partially responsible for the disturbed homeostasis of endolymph and produces an overload of endolymph due to increased production. By blocking the endolymphatic duct (ED), the surplus of endolymph that is generated in the sac is hindered from flowing to the rest of the inner ear. This hypothesis is supported by histological studies6,7,8.
Whether EDB is the appropriate treatment for an individual patient depends on various factors. The patient's preference and the surgeon's preference play a role, but local health care regulations may also influence treatment choice. In our center, EDB is only considered in patients who suffer vertigo attacks despite treatment with intratympanic (IT) injections with corticosteroids, and if vestibular migraine has been ruled out. EDB is especially suitable for patients with good hearing function who reject ablative treatment. This article describes the surgical steps of this new technique and discusses the literature that is currently available.
EDB is a potential new treatment modality, aiming to reduce vertigo attacks while sparing inner ear function in patients with intractable MD. In the current literature, the results seem promising, but little data is available.
Rationale of the technique
Targeting the ES for relieving MD symptoms has been controversial for some decades. In the past, the general belief has been that the (ES) mainly has a role in the resorption of endolymph13,</…
The authors have nothing to disclose.
The authors thank Isobel Bowring for proofreading the article, and Nele Ruysschaert for the help with information on the anesthesia.
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 |