Vittorio Colletti, Francesco G.

Fiorino,
Marco Carner, and Sergio Turazzi

Vestibular Neurectomy and

Microvascular Decompression
of the Coch lear Nerve
in Men iere's Disease

Meniere's disease is typically characterized by the vertigo was proposed by McCabe and Harker9 and by
classic symptomatological triad consisting of vertigo as- M0ller, based on the frequent presence of a vascular loop
10

sociated with nausea and vomiting, fluctuating but pro-
gressive hearing loss, and tinnitus. Aural fullness is also a
frequent symptom. The main pathophysiological sub-
strate of Meniere's disease is certainly endolymphatic
hydrops, the etiology of which is probably multifactorial,
but still not completely understood. Poor knowledge of the
causes of Meniere's disease has given rise to a number of
medical and surgical treatments that almost invariably
treat symptoms.
Vestibular neurectomy (VN) is to date the surgical
treatment of choice in Meniere's disease, with success
rates for vertigo ranging from 85 to 100%. 1-8 Postopera-
tive auditory results, however, are somewhat unpredict-
able. Improvement in hearing, tinnitus, and aural fullness
have been reported by some authors, without any convinc-
ing explanation regarding the causes of this phenomenon.
Microvascular decompression (MVD) of cranial
nerve VIII in Meniere's disease and disabling positional
in contact with the VIIth nerve in these patients. We have
personally observed and reported contact between the
anterior or posterior inferior cerebellar arteries (AICA,
PICA) and the VIIIth nerve in seven consecutive VNs
performed in subjects with Meniere's disease."I The ultra-
structural evaluation of the removed portion of the ves-
tibular nerve always showed severe alterations in the cen-
tral portion of the nerve (ie, degeneration of the axons with
altered myelin sheaths, proliferation of the astrocyte pro-
cesses, and numerous spherical bodies), which were prob-
ably the consequence of the vascular cross-compression.
In the series reported on by McCabe and Harker9 and
M0ller'0 vertigo improved in 72 to 100% of subjects with
Meniere's disease who had undergone MVD. Improve-
ment in hearing was found in 0 to 22%.
The findings in the literature and our own personal
data prompted us to perform an accurate exploration of the
cerebellopontine angle (CPA) in each subject with Me-

Skull Base Surgery, Volume 4, Number 2, April 1994 ENT Department and Neurosurgery Department (ST.), University of Verona, Verona, Italy
Reprint requests: Dr. Fiorino, Clinica ORL, Ospedale Policlinico, Via delle Menegone 10, I-37134 Verona, Italy Copyright X 1994 by Thieme
Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved. 65
 SKULL BASE SURGERYNOLUME 4, NUMBER 2 APRIL 1994

niere's disease and undergoing VN using the retrosigmoid The SISI test, Bekesy audiometry, and the stapedius
approach. The purpose of the present study was to verify reflex indicated the presence ofcochlear involvement in all
whether VN combined with MVD of the cochlear nerve patients. Peristimulatory adaptation (STAT and reflex de-
yields better auditory results than VN alone. cay test) was absent in all subjects. However, the acoustic
reflex was elicited from the affected ear at thresholds
greater than 95 dB in nine subjects. Poor growth function
MATERIALS AND METHODS was observed in an additional six patients. Transtympanic
ECoG was performed in eight subjects in the VN group
Subjects and in 10 in the VN-MVD group, using alternating po-
larity clicks. An abnormal SP/AP ratio (ie, greater than
Thirty subjects with classic symptoms of unilateral 0.45) was observed in four and six subjects, respectively.
Meniere's disease presented with a vascular contact be- ABRs displayed latency values that were within the
tween the AICA or the PICA and the VIIIth nerve intra- tolerance limits (mean ± 2.5 SD) of our normal popula-
operatively. The first 15 patients underwent VN. The tion in 17 subjects, that is, 2.3 msec for the I-III interpeak
frequent presence of a vascular contact with the VIlIth latency, 2.0 msec for the Ill-V interpeak latency, and 0.2
cranial nerve induced us to perform MVD of the cochlear msec for the I-III interaural interval. Minor signs of retro-
nerve in combination with the VN in the next 15 subjects cochlear involvement, such as a wave II of low amplitude
who presented with vascular cross-compression. or absent or a slight increase in I-III interpeak latency or
Subjects were informed preoperatively about the sur- interaural interval (not greater than 0.2 msec compared to
gical procedures, the expected postoperative relief from tolerance limits), were seen in seven subjects in the VN
vertigo, and the unpredictability of auditory results. group and in six subjects in the VN-MVD group.
The subjects' ages ranged from 24 to 59 years (mean, The frequency of vertigo, evaluated over the 6-month
42.5) in the first group and from 27 to 58 years (mean, period prior to surgery, ranged from one episode a month
45.2) in the second. Male to female ratios were 1.6 and to two a week: duration of crises ranged from 30 minutes
1.4, respectively, in the two groups. The right ear was to 4 hours.
involved in 14 subjects and the left ear in 16. The duration A decrease in vestibular responsiveness, as evaluated
of the disease ranged from 2 to 15 years, with a mean by the Veits method (10 ml of 20°C water irrigated for 10
duration of 5.6 years in the first group and 5.3 years in the seconds), consistently indicated unilateral impairment of
second. vestibular function.
Gadolinium-enhanced magnetic resonance imaging
(MRI) with angiography revealed the presence of a vascu-
lar contact with the cochleovestibular nerve in the CPA
Diagnostic Protocol in 18 subjects (60%). The dominant vessel was either the
AICA, the PICA, or branches of these. No vascular contact
The diagnosis of Meniere' disease was reached on the with the contralateral VIIlth nerve was revealed with
basis of clinical and audiological data. In particular, the MRI.
symptoms matched the 1985 criteria reported by the Com-
Medical treatment (diuretics, low-sodium diets, anti-
mittee on Hearing and Equilibrium of the American Acad- histamine derivatives, vasodilators) had failed to limit
emy of Otolaryngology-Head and Neck Surgery (AAO).12
vertigo and tinnitus in all cases, with the result that the
The preoperative audiological protocol comprised working and social activities of all subjects were severely
pure-tone, speech, Bekesy and immittance audiometry, disturbed.
the Short Increment Sensitivity Index (SISI), the Supra
Threshold Adaptive Test (STAT), auditory brainstem re-
sponse (ABR) and electrocochleography (ECoG). The
SISI measures the ear's ability to detect small intensity Su rgery
changes, a feature that is particularly enhanced in cochlear
disorders. The STAT is able to detect the presence of The patients were operated on by the first author
abnormal decay in sound perception in retrocochlear dis- (V.C.) using a retrosigmoid approach. Briefly, subjects lay
orders. in the supine position with the head rotated contralaterally
The affected ears showed a pure-tone average (PTA) to the operated ear. After performing a roughly 8 cm long
(0.5-3 kHz) of 54.8 dB (+18.5) in the subjects undergo- linear incision (3 cm behind the retroauricular sulcus), a
ing VN plus MVD and 51.5 (+ 15.4) dB in subjects in the retrosignoid craniectomy with a diameter of 4 cm was
VN group. The differences between the two groups were carried out. Its anterior and rostral limits were the sigmoid
not statistically significant on the basis of the t test for and transverse sinuses, respectively. Bone wax was uti-
unpaired data. The speech discrimination score was al- lized to obliterate mastoid cells, which were opened in
ways equal to or greater than 80%. The PTA (0.5 to 3 kHz) pneumatized mastoids. The dura was opened in a "Y"
in the contralateral ear was always better than 25 dB fashion. The cerebellum was gently depressed, utilizing a
66 hearing level. self-retaining retractor that was secured to the operating
 TREATMENT OF MENIERE'S DISEASE-COLLETTI ET AL

table. Cerebellar retraction and CPA exposure were facili- RESULTS

tated by cerebrospinal fluid (CSF) egress. Sharp dissec-
tion of the arachnoid permitted access to the VIlIth nerve.
The vascular compression identified intraoperatively was
often characterized by a vascular loop in contact with the
vestibular-cochlear bundle. A number of vessels impinged
on the nerve, whereas some passed between the VIIth and
VIlIth cranial nerves. Vessels were often located under the
flocculus, which had to be dissected from the VlIIth nerve
in order to move the compressing vessel off the nerve. In
most cases, the offending vessels were arteries, but veins
were found compressing the nerve in six patients. Multiple
vessels were often found compressing the intracranial por-
tion of the VIlIth nerve. The vessels were mobilized and
moved away from the nerve by blunt dissection. Thereaf-
ter, the cleavage plane between the cochlear and the ves-
tibular nerve was identified at the distal portion of the
VIlIth nerve and enlarged with a sharp instrument. The
proximal end of the vestibular nerve close to the brainstem
was cut and separated from the cochlear nerve in a medial
to lateral fashion, up to the porus acusticus. The CPA was
further explored in order to detect other vessels compress-
ing the root entry zone of the cochlear nerve.
When complete microvascular decompression was
obtained, the cochlear nerves of 15 subjects were envel-
oped completely or partially at the root entry zone by
small pieces of autogenous muscle (Fig. 1). The aims of
this surgical step were twofold: to avoid recurrence of the
neurovascular contact and to furnish a vascular supply to
the cochlear nerve.
All operations were performed with the aid of direct
monitoring of auditory evoked potentials. Continuous
monopolar and repeated bipolar recording of cochlear
nerve action potentials and ABR recordings were per-
formed simultaneously. These techniques have been de-
scribed elsewhere'3 and will not be reported here.
The operative results are evaluated according to the
1985 criteria of the AA0.12
Intense vertigo was experienced by most subjects in
the days following surgery. A 2nd- or 3rd-degree horizon-
tal rotatory nystagmus with a quick component toward the
untreated ear was present in all patients. The severity of
these symptoms diminished over the following days, thus
permitting all except two patients with a CSF leak to be
discharged 12 to 15 days after surgery. At discharge, only
slight disturbance of balance function and a 1st degree
nystagmus with a quick component toward the untreated ear
were present in all subjects when Bartels glasses were worn.
During the postoperative observation period, no defi-
nite vertigo (ie, rotatory vertigo with nausea or vomiting,
or both) was observed in any of these patients. Thus, the
numerical vertigo score was zero in all subjects in both
groups, indicating complete control of definite vertigo
(Tables 1 and 2). Slight unsteadiness and lack of balance
were always present immediately after discharge and
gradually improved in the subsequent weeks. Disability,
evaluated according to the AAO criteria,12 was severe in
all subjects before surgery. It improved in all patients,
although a mild disability persisted in two patients in each
group and a moderate disability in two subjects undergo-
ing MVD and VN and in one operated on by VN alone.
Patients were able to resume work and social activity,
which had been severely impaired before surgery, within 4
weeks of discharge in 13 subjects, within 4 to 6 weeks in
10, and within 6 to 8 weeks in 7.
The ice water test (10 ml irrigated for 10 seconds),
performed every 3 months, invariably demonstrated ab-
sence of the response in the treated ear at electronystag-
mography examination.

Table 1. Surgical Outcomes in Patients

with Meniere's Disease: VN-MVD Group
as Evaluated by the AAO (1985) Criteria
Symptoms Result No.
Vertigo (n = 15) Score 0 15 100
Score 1-40
Score 41-80
Score 81-120
Score >120
Disability (n = 15) Improved 15 100
Unchanged
Worse
Hearing (n = 15) Improved 7 46.7
Unchanged 8 53.3
Worse
Tinnitus (n = 11) Improved 7 62.6
Unchanged 4 37.4
Worse
Figure 1. Microvascular decompression with muscle Fullness (n = 9) Improved 6 66.7
interposition aftervestibular neurectomy in a patients with Unchanged 3 33.4
Meniere's disease. Worse
67
 SKULL BASE SURGERYNOLUME 4, NUMBER 2 APRIL 1994

Table 2. Surgical Outcomes in Patients this parameter remained unchanged. In addition, a slight
with Meniere's Disease: VN Group improvement, inferior to the 10 dB required by the AAO,
as Evaluated by the AAO (1985) Criteria was detected in five subjects (Table 3). Mean PTA (0.5 to 3
Symptoms Result No. % kHz) significantly improved (P <0.05) from 54.8 dB pre-
Vertigo (n = 15) Score 0 15 100 operatively to 46 dB postoperatively. The mean pure-tone
Score 1-40 threshold at 4 to 8 kHz also improved from 63.1 to 59.3
Score 41-80 dB, but the difference was not significant.
Score 81-120 The auditory results obtained in the control group
Score >120
Disability (n = 15) Improved 15 100 (VN alone) are displayed in Figure 3. Two patients in this
Unchanged group (13.3%) improved their hearing significantly (PTA,
Worse 0.5 to 3 kHz), and one presented with a significant worsen-
Hearing (n = 15) Improved 2 13.3 ing, whereas the remaining 12 were unchanged (Table 2).
Unchanged 12 80
Average thresholds at 0.5 to 3 kHz and 4 to 8 kHz were
Worse 1 6.7
Tinnitus (n = 11) Improved 3 27.3 unchanged postoperatively in this group (Table 4).
Unchanged 7 63.6 Eleven subjects from each group presented with con-
Worse 1 9.1 tinuous tinnitus preoperatively. This symptom was un-
Fullness (n = 9) Improved 4 40 changed in four subjects in the VN-MVD group and
Unchanged 6 60
improved in seven. Tinnitus was worse in one subject in
Worse
the VN group, unchanged in seven and improved in three.
The difference was statistically significant according to
the Fisher test.
Of the nine VN-MVD patients complaining of aural
fullness before surgery, six (66.7%) reported postopera-
tive improvement. An improvement was also observed in
4 of 10 patients in the VN group. No subjects complained
Figure 2 compares preoperative and postoperative of a worsening of this symptom.
hearing levels (mean + 1 SD) in the group of subjects ABR did not change significantly in the 17 patients
operated on by VN plus MVD. An improvement in aver- who presented with preoperative normal findings. One of
age hearing level ranging from 5 dB at 4 kHz to 14 dB at 1 the seven patients in the VN group with preoperative
and 2 kHz was obtained postoperatively. The difference abnormal ABR presented with a decrease in the 1-111
was significant (P <0.01), as assessed by ANOVA for interpeak latency to normal values. This outcome was
paired data. achieved in three of the six patients with abnormal ABR in
Seven subjects in this group (46.7%) presented a the VN-MVD group; one of them also reported an in-
significant increase in PTA (0.5 to 3 kHz) according to the crease in wave II amplitude. Surgical complications were
AAO criteria (more than 10 dB), whereas in eight (53.3%) limited to a temporary CSF leak in two subjects.

0
VN-MVD
group |p < 0.01|
20

dB HL
60

80 A

x preoperative * postoperative
.4tl% Il
250 500 1000 2000 3000 4000 8000 Figure 2. Preoperative and
postoperative mean (± 1 SD) pure-
68 Frequency (Hz) tone threshold in the VN-MVD group.
 TREATMENT OF MEN I ERE'S DISEASE-COLLETTI ET AL

Table 3. Pure-Tone Average at 0.5 to 3 kHz and Jannetta et a120 described a pathologic condition that
at 4 to 8 kHz in Subjects Undergoing VN-MVD they called disabling positional vertigo, often charac-
Pure-Tone Threshold terized by a sudden onset followed by persistent unsteadi-
Preoperative Postoperative ness, lack of balance, and motion intolerance. Hearing
Patient Average Average Average Average I
loss with different audiometric shapes was often present.
No. 0.5-3 kHz 4-8 kHz 0.5-3 kHz 4-8 kHzr Patients recovered from vertigo after MVD of the VHIlth
53.6 62.5 33.7 55
nerve. Similar findings were described by McCabe and
2 33.7 37.5 18.7 25 Harker9 and Wiet et al,18 who reported on patients with
3 21.2 50 18.7 37.5 vascular compression, some with vestibular Meniere's
4 60 40 46.2 40 disease.
5 45 85 40 85 Isolated cochlear symptoms (hearing loss or tinnitus)
6 25 70 22.5 65
7 81.2 70 70 57.5 occurring as a consequence of neurovascular conflict have
8 67.5 70 67.5 70 also been reported.'6"17
9 60 65 61.2 72.5 M0ller'0 showed evidence that the typical symp-
10 63.75 72.5 53.7 65 tomatological triad of Meniere's disease may have neuro-
11 55 40 31.2 37.5 vascular cross-compression as the anatomic and patho-
12 45 55 47.5 60
13 70 85 68.7 95 logic substrate. MVD of the cochleovestibular bundle has
14 68.5 55 48.7 40 been advocated both by M0ller'0 and by Schwaber and
15 72.5 80 73.7 85 HallN9 as a valuable alternative to VN in patients with
Mean 54.8 63.1 46 59.3 disabling positional vertigo due to CNCS. M0ller'0 exam-
SD 17 16.4 18.3 19.1 ined 10 patients with the classic triad of symptoms of
Meniere's disease, who recovered from vertigo after
MVD surgery. In Schwaber and Hall's series'9 of patients
with disabling vertigo, recovery was achieved in three of
four subjects after MVD of the VIIlth nerve, and in only
DISCUSSION two of nine patients undergoing VN. On the basis of these
findings, these investigators no longer recommend VN for
Vascular cross-compression of cranial nerves has disabling vertigo due to CNCS.
been accepted as a cause of trigeminal neuralgia, glos- The prerequisite for MVD is that the VIlIth nerve has
sopharyngeal neuralgia, and hemifacial spasm. 14,15 More not undergone irreversible pathologic changes due to vas-
recently, it has also been shown that vertigo, hearing loss, cular compression. However, we have recently observed
and tinnitus can be the result of a vascular loop impinging that vestibular nerve removed from patients with Meniere's
on the VIlIth nerve9-11,16-18 and giving rise to the symp- disease associated with vascular cross-compression pre-
tomatological complex that has been defined as the co- sented severe and irreversible ultrastructural alterations.'1
chleovestibular nerve compression syndrome (CNCS).19 The proximal portion of the vestibular nerve specimens
The symptoms can occur in isolation or in various combi- presented a highly abnormal morphology: degeneration of
nations and can mimic other disorders, such as Meniere's the axons with altered myelin sheaths, severe proliferation
disease or acoustic tumor. of the astrocyte processes, and numerous spherical bodies.

209
40
dB HL
60

80

Figure 3. Preoperative and 100

postoperative mean (+ 1 SD) pure-
tone threshold in the VN group. Frequency (Hz) 69
 SKULL BASE SURGERYNOLUME 4, NUMBER 2 APRIL 1994

Table 4. Pure-Tone Average at 0.5 to 3 kHz and compared with control subjects. This confirms our belief
at 4 to 8 kHz in Subjects Undergoing VN Alone that Meniere's disease can be sustained by a vascular
Pure-Tone Threshold cross-compression and implies that the consequent patho-
Preoperative Postoperative logic changes are, at least partly, reversible.
Patient Average Average Average Average It is likely that short-lasting Meniere's disease due to
No. 0.5-3 kHz 4-8 kHz 0.5-3 kHz 4-8 kHz cochleovestibular compression, in which no or only minor
1 43.7 52.5 45 57.5 changes in the vestibular nerve have occurred, can be
2 43.7 47.5 48.7 52.5 treated by MVD alone. A two-tier surgical strategy could
3 21.2 50 21.2 50 probably be applied in the near future in disabling Me-
4 51.2 32.5 50 32.5 niere's syndrome associated with vascular cross-compres-
5 42.5 85 50 95 sion: (1) MVD alone, when the disease is short-lasting, or
6 42.5 75 41.7 75 (2) VN with MVD of the cochlear nerve in long-lasting
7 81.2 70 81.2 70
8 67.5 70 53.7 60 stabilized forms of the disease. This must be verified in
9 45 52.5 47.5 52.5 further studies investigating the anatomic status of the
10 63.7 72.5 62.5 72.5 vestibular nerve as a function of the duration of the dis-
11 53.7 40 53.7 40 ease. Unfortunately, it is not known how preoperative
12 45 55 60.5 62.5 clinical tests can predict the extent of alterations of the
13 51.2 55 33.7 47.5
14 52.2 80 50 80 vestibular nerve and their reversibility.
15 68.7 55 66.2 57.5 In conclusion, neurovascular cross-compression of
Mean 51.5 59.5 51 60.3 the VIlIth nerve at its root entry zone is a fairly common
SD 13.84 14.6 13.47 15.7 finding in subjects with a clinical diagnosis of disabling
Meniere's disease. This finding suggests the advisability
of thorough exploration of the root entry zone of the VIlIth
cranial nerve, which proves to be an easy task using the
It is interesting that slight alterations were found in control retrosigmoid approach. VN associated with MVD of the
subjects (acoustic neuroma). Schwaber and Whetsell,21 cochlear nerve in patients with Meniere's disease in-
however, detected only mild alterations in the vestibular creases the success rate in terms of hearing function,
nerves of patients with Meniere's disease. The discrep- tinnitus, and aural fullness.
ancy in these reports could be attributed to the different
investigative techniques, that is, electron microscopy in
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