Intratympanic gentamicin in monolateral Meniere's disease: our experience

The aim of this study was to verify the efficacy of a modified Odkvist titration protocol of intratympanic gentamicin application in the control of vertigo attacks and the effects on the auditory and vestibular function in a group of 71 patients affected by monolateral MD resistant to medical therapy. All the patients underwent an intratympanic administration of a 1-ml solution containing 26.6 mg of gentamicin sulfate. The treatment protocol provided one to three injections for a total amount of gentamicin varying from 26.6 to 80 mg. Five days after the first gentamicin administration, cochlear and vestibular function tests were performed. The worsening of the PTA greater than 15 dB, the appearance of clinical signs of vestibulotoxicity such as imbalance or persistent spontaneous nystagmus beating away from the injected ear or of a "curative vertigo" were the criteria taken into consideration to stop the treatment. In the absence of any sign, a second and third injection were performed. The presence of an unchanged frequency of the attacks at least 3 months after the previous cycle was the parameter considered to perform a second or third cycle. Seventeen (24%) patients were submitted to a second cycle of therapy and two (3%) to a third cycle. After a mean follow-up period of 20.3 months (range: 3 to 48) all 71 patients experienced good control of the vertigo attacks: grade A in 46 cases and grade B in 25 cases according to the AAO-HNS CoHE criteria. The pure tone average (PTA) hearing threshold (500-3,000 Hz) worsened in 19 patients, improved in 5 and was unchanged in 47. On the basis of the experience acquired during the treatment, we progressively decreased the number of injections from 3/cycle to a 1-2/cycle of therapy. Moreover, in the later phase of the study re-injections were administered 1 or 2 weeks after the previous application and avoided in the presence of signs of depression of the vestibular and/or cochlear function. A residual caloric excitability was found in 30% of the cases. Vertigo control doesn't seem to be linked to the achievement of vestibular inexcitability. The marker of successful gentamicin treatment at short-term is the appearance of signs of curative vertigo and/or vestibular imbalance, and at long-term the disappearance of vertigo attacks.