Intratympanic Contrast in the Evaluation of Menière Disease: Understanding the Limits

Studies describing endolymphatic hydrops in Menière disease after off-label intratympanic gadolinium-based contrast have been limited by long acquisition times. We aimed to demonstrate the feasibility of post-intratympanic imaging on a 3T MR imaging system within a clinically tolerable acquisition time and to address potential pitfalls in acquisition or interpretation.

FDA Investigational New Drug 115,342 and institutional review board approval were obtained for intratympanic injection of 8-fold diluted Gd-DTPA into the more symptomatic ear of 6 adults with Menière disease. 3T MR imaging was performed using a 3-inch surface coil before and up to 28 hours after injection using FLAIR to define the nonenhancing endolymphatic space within the enhancing perilymph. Variable FLAIR TI images were used to determine the impact of fluid-suppression on interpretation. Image quality was assessed for perilymphatic and extralabyrinthine contrast enhancement, definition of endolymphatic anatomy, and other anatomic variants or pathologic findings.

The surface coil afforded 0.375 × 0.375 mm in-plane FLAIR resolution in <4 minutes 30 seconds, sufficient to perceive the nonenhancing spiral lamina, interscalar septa, and endolymphatic structures. Coronal views highlighted a potential interpretation pitfall of vestibular endolymphatic distention overestimation due to partial volume averaging. Varying FLAIR TI resulted in visible changes in the perception of the cochlear endolymphatic space. CSF enhancement was detectable at the internal auditory canal fundus on the injected side in half of the patients, which may confound interpretation.

Using a surface coil preserves high resolution within a clinically acceptable acquisition time. Pitfalls remain regarding the interpretation of these images and optimizing protocols across platforms in the absence of a clear internal reference for standardization.