Zoran Becvarovski FRACS,  Dennis I Bojrab MD,  John Zappia MD

Michigan Ear Institute, Farmington Hills, Michigan USA; and

St George Public Hospital and St George Private Medical Complex,  Kogarah  N.S.W.   AUSTRALIA

ABSTRACT

Objective

The objectives of this study were to investigate the short term effect of this mastoid oscillation on true rotary vertigo, imbalance, tinnitus, aural fullness and hearing in Meniere’s disease patients.

Study Design and Setting

Twenty minutes of mastoid oscillation using the ZB Mastoid Oscillation Protocol (ZBMOP) was performed in thirteen patients.

Results and Conclusions

The immediate post vibration effect in all 10 classic Meniere’s disease patients was a decrease in fullness and a subjective improvement hearing, while only 66 % reported decreased tinnitus.  Follow up at a mean of 3 months, showed no further vertigo in 80% and continued benefit in the fullness and subjective hearing in 50% of patients. 

(Full paper submitted to American Academy of Otolaryngology for publication: December 2001)

 INTRODUCTION

Meniere’s disease was first described by Prosper Meniere[1] in 1861 and is defined as a symptom complex consisting of true rotary vertigo associated with fluctuating hearing loss, fullness and tinnitus. Oscillation can be described as the periodic motion of a medium in opposite directions from the position of equilibrium.

Mastoid oscillation in humans has been used for therapeutic purposes (during particle repositioning maneuvers for benign paroxysmal positional vertigo[2]) and more recently as a diagnostic tool in the evaluation of vestibular disorders[3]. A variety of medical and surgical treatments for Meniere’s disease have been reported all of which have a 60-90% control of the vertigo. We report preliminary results of the ZB mastoid oscillation protocol (ZBMOP) in ten patients with classic Meniere’s disease that presented during an acute exacerbation of their symptoms.

METHODS AND RESULTS

ZB Mastoid Oscillation Protocol (ZBMOP)

Patients with Meniere’s disease that have failed maximal medical therapy and where surgical intervention is being considered, underwent the ZBMOP. Prerequisites included a normal contrast enhanced MRI and a negative Hallpike test.  If there was any history of cerebral or retinal pathology, these patients were excluded. Following a detailed discussion of the protocol, and it’s possible advantages and disadvantages, informed consent was obtained. An audiogram was performed immediately prior and 30 minutes after the ZBMOP.

The patient was placed in the operative otologic position (supine with the head turned 60 degrees to the contralateral side). The mastoid oscillation was performed for 20 minutes using a handheld Brookstone massager (Brookstone, Nashua, New Hampshire, USA) which consists of an “off-center” rotating motor rotating at approximately 5000 revolutions per minute, resulting in vibration. The oscillator was fixed to a head band and applied to the mastoid cortex of the pathological ear. Following oscillation, the patient continued to lie in the same position for another 30 minutes. Following discharge, the patient was instructed to rest, avoid bending over and avoid strenuous activity for 24 hours.  A questionnaire was used to grade the vertigo severity, vertigo frequency, tinnitus severity, fullness severity, nausea, and hearing prior to, and after oscillation.

Thirteen patients with Meniere’s disease underwent oscillation. Ten patients had classic Meniere’s disease with true rotary vertigo, fullness, fluctuating hearing loss and tinnitus. Three patients had cochlear hydrops with fluctuating hearing loss and tinnitus (no balance symptoms).

Patients with classic Meniere’s disease (n= 10)

All ten patients reported decreased fullness in the affected ear immediately after oscillation. A subjective hearing improvement was noted in all patients immediately after oscillation, both 1 hour and 1 month after oscillation. Eight of ten (80%) patients had no further rotary vertigo at a mean follow up of 3 months (range 1-6 months). Three patients reported persistent problems with mild unsteadiness  at 3 months. Tinnitus was present before oscillation in six of the ten (60%) patients and improved in four of these six (66%) patients one hour after oscillation.  At 1 month only three of the six patients (50%) had improved tinnitus. At 3 months 50% of all 10 patients had continued subjective hearing and tinnitus improvement. Five of the 10 (50%) patients had true rotary vertigo at the beginning of the procedure and all five had significant improvement in their vertigo 1 hour after oscillation.

Patients with Hearing Loss and Tinnitus (cochlear hydrops: n=3)

No change was noted in hearing, fullness, and tinnitus in these patients immediately following the ZBMOP and at 3 months follow-up. No other adverse effects were seen in these patients. 

DISCUSSION

Microscopic particles within the endolymphatic system have been demonstrated previously by Lundquist. [4]   Some authors have postulated that obstruction of the endolymphatic duct leads to hydrops.[5] This obstruction may be secondary to a build up of silt or debris within the endolymphatic duct. We have termed this build of silt or debris as ductolithiasis. The endolymphatic hydrops subsequently produces a sensation of pressure, fullness, and tinnitus due to stretching of the membranous labyrinth. In response, the ELS secretes the hormone saccin which increases endolymph production (hydrops) and thus “pushes” the duct open. Simultaneously, the ELS produces an increase in osmotically active glycoproteins which help draw endolymph into the sac.

The controversies surrounding the treatment can be well illustrated by the Danish sham study of Thomsen[6]  in 1981. The original results showed that there was no statistically significant difference between cortical mastoidectomy and endolymphatic shunting in controlling the vertigo in Meniere’s patients. A re-analysis of the same data by numerous authors including most recently Welling and Nagaraja[7], have shown that there was a statistically significant benefit from endolymphatic shunting compared to placebo mastoidectomy. Thus, we also realize that the ZBMOP may simply be a placebo, but a non-invasive one. Further, long term, randomized controlled studies may help answer this.

We postulate that mastoid oscillation (and the drilling during mastoidectomy) helps to mobilize the ductolithiasis and thus promote flow of endolymph relieving the hydrops. By placing the patients in the surgical position we are aiming to place the ELS in a dependant position. By oscillating the mastoid we postulate that we are loosening the debris (ductoliths) and promoting flow within the endolymphatic duct. We use the analogy of tapping on an upside down ketchup bottle to aid the exit of its contents. This results in relief of the fullness, tinnitus and vertigo. An improvement in hearing may occur to ability of Reissner's membrane to vibrate more effectively following resolution of the hydrops.

CONCLUSIONS

The short term effect of mastoid oscillation has resulted in control of vertigo and fullness in all patients with classic Meniere’s disease that had vertigo at the initiation of oscillation. The effect of the ZBMOP has resulted in control of vertigo and fullness in 80% of patients with classic Meniere’s disease at a mean follow up of 3 months. The control of tinnitus and hearing loss (50%) were not as dramatic. A better understanding these interesting observations, may provide more insight into the pathophysiology and treatment of Meniere’s disease in the future.

At present we view the success of the ZBMOP as an interesting finding. It may serve as an intermediate treatment step in patients that are refractory to medical treatment and who are being considered for more aggressive treatment.

REFERENCES

Disclaimer

 Please note: The above is intended as a general guideline only for Dr. Becvarovski’s patients.

This material should not be used for purposes of diagnosis or treatment without consulting a physician.

 Each patient is an individual and should be treated accordingly.

Please contact our rooms if you are concerned or require any further information.

Dr Zoran Becvarovski  MBBS, FRACS

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Copyright © 2001. Dr Zoran Becvarovski. All rights reserved.
Revised: 20-12-2002.