Endolymphatic hydrops in patients with unilateral and bilateral Meniere's disease

A 3-hour time interval may not be sufficient for delayed enhancement magnetic resonance imaging with intravenous gadoteridol injection based on 3d-real IR sequence of the inner ear in Meniere's disease patient

BACKGROUND

Magnetic resonance imaging (MRI) can be applied to visualize endolymphatic hydrops (EH).

AIMS/OBJECTIVES

To explore whether a 3-h time interval was feasible for clinical practice.

MATERIALS AND METHODS

We prospectively enrolled 15 patients with unilateral Meniere's disease, each of whom underwent delayed enhancement MRI scan of the inner ear after intravenous gadoteridol injection at a 3-h interval. The ears of these patients were divided into two groups (group A: the affected ears; group B: the unaffected ears). Among the two groups, the signal intensity in perilymphatic area of the basal turn of cochlea, the results of visual evaluations in the vestibule, cochlea and semicircular canal and the detection results of EH were compared.

RESULTS

Regarding the signal intensity, a difference was found between group A and group B (p = .016). Besides, no difference was found between the visual evaluations in the vestibule, cochlea and semicircular canal of the two groups. Regarding the detection results of EH, group A (6 vestibules were undiagnosable; 8 cochleae were undiagnosable); group B (9 vestibules were undiagnosable; 10 cochleae were undiagnosable).

CONCLUSIONS AND SIGNIFICANCE

In the clinical application of gadoteridol for the inner ear, 3-h delayed MR imaging may not be sufficient.

Meniere's disease: Pathogenesis, treatments, and emerging approaches for an idiopathic bioenvironmental disorder

Meniere's disease (MD) is a severe inner ear condition known by debilitating symptoms, including spontaneous vertigo, fluctuating and progressive hearing loss, tinnitus, and aural fullness or pressure within the affected ear. Prosper Meniere first described the origins of MD in the 1860s, but its underlying mechanisms remain largely elusive today. Nevertheless, researchers have identified a key histopathological feature called Endolymphatic Hydrops (ELH), which refers to the excessive buildup of endolymph fluid in the membranous labyrinth of the inner ear. The exact root of ELH is not fully understood. Still, it is believed to involve several biological and bioenvironmental etiological factors such as genetics, autoimmunity, infection, trauma, allergy, and new theories, such as saccular otoconia blocking the endolymphatic duct and sac. Regarding treatment, there are no reliable and definitive cures for MD. Most therapies focus on managing symptoms and improving the overall quality of patients' life. To make significant advancements in addressing MD, it is crucial to gain a fundamental understanding of the disease process, laying the groundwork for more effective therapeutic approaches. This paper provides a comprehensive review of the pathophysiology of MD with a focus on old and recent theories. Current treatment strategies and future translational approaches (with low-level evidence but promising results) related to MD are also discussed, including patents, drug delivery, and nanotechnology, that may provide future benefits to patients suffering from MD.

Delayed post gadolinium MRI descriptors for Meniere's disease: a systematic review and meta-analysis

OBJECTIVES

Delayed post-gadolinium magnetic resonance imaging (MRI) detects changes of endolymphatic hydrops (EH) within the inner ear in Meniere's disease (MD). A systematic review with meta-analysis was conducted to summarise the diagnostic performance of MRI descriptors across the range of MD clinical classifications.

MATERIALS AND METHODS

Case-controlled studies documenting the diagnostic performance of MRI descriptors in distinguishing MD ears from asymptomatic ears or ears with other audio-vestibular conditions were identified (MEDLINE, EMBASE, Web of Science, Scopus databases: updated 17/2/2022). Methodological quality was evaluated with Quality Assessment of Diagnostic Accuracy Studies version 2. Results were pooled using a bivariate random-effects model for evaluation of sensitivity, specificity and diagnostic odds ratio (DOR). Meta-regression evaluated sources of heterogeneity, and subgroup analysis for individual clinical classifications was performed.

RESULTS

The meta-analysis included 66 unique studies and 3073 ears with MD (mean age 40.2-67.2 years), evaluating 11 MRI descriptors. The combination of increased perilymphatic enhancement (PLE) and EH (3 studies, 122 MD ears) achieved the highest sensitivity (87% (95% CI: 79.92%)) whilst maintaining high specificity (91% (95% CI: 85.95%)). The diagnostic performance of "high grade cochlear EH" and "any EH" descriptors did not significantly differ between monosymptomatic cochlear MD and the latest reference standard for definite MD (p = 0.3; p = 0.09). Potential sources of bias were case-controlled design, unblinded observers and variable reference standard, whilst differing MRI techniques introduced heterogeneity.

CONCLUSIONS

The combination of increased PLE and EH optimised sensitivity and specificity for MD, whilst some MRI descriptors also performed well in diagnosing monosymptomatic cochlear MD.

KEY POINTS

• A meta-analysis of delayed post-gadolinium magnetic resonance imaging (MRI) for the diagnosis of Meniere's disease is reported for the first time and comprised 66 studies (3073 ears). • Increased enhancement of the perilymphatic space of the inner ear is shown to be a key MRI feature for the diagnosis of Meniere's disease. • MRI diagnosis of Meniere's disease can be usefully applied across a range of clinical classifications including patients with cochlear symptoms alone.

Advanced Magnetic Resonance Imaging Sheds Light on the Distinct Pathophysiology of Various Types of Acute Sensorineural Hearing Loss

OBJECTIVE

To compare the findings of magnetic resonance imaging (MRI) with advanced protocols in patients with various types of acute sensorineural hearing loss (ASNHL).

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Two hundred eighty-seven patients with ASNHL.

INTERVENTIONS

All patients underwent MRI scanning, including heavily T2-weighted three-dimensional fluid-attenuated inversion recovery before and 4 hours after the intravenous administration of gadolinium contrast medium (delayed 3D-FLAIR). A hybrid of the reversed image of the positive endolymph signal and the native image of the perilymph signal image was constructed to visualize the endolymphatic space.

RESULTS

The detection rates of abnormal MRI findings vary significantly among different types of ASNHL. A hyperintense signal on delayed 3D-FLAIR was observed in all patients with intralabyrinthine schwannoma or vestibular schwannoma and 20.5% of patients with idiopathic sudden sensorineural hearing loss (ISSNHL) but was rarely observed in definite Ménière's disease (MD, 2.6%). In contrast, endolymphatic hydrops (EH) was frequently observed in patients with definite MD (79.5%) but was observed much less frequently in patients with ISSNHL (11.0%). In patients with cochlear MD and ALHL, detection rates of cochlear EH were similar to those with definite MD, whereas detection rates of vestibular EH were significantly lower than in patients with definite MD.

CONCLUSIONS

The significantly different detection rates of abnormal MRI findings among various types of ASNHL shed light on the distinct pathophysiology of each disorder. A diagnosis based on MRI findings with advanced protocols may help select treatment strategies and provide prognostic information for patients.

Endolymphatic Hydrops Magnet Resonance Imaging in Ménière's Disease Patients after Cochlea Implantation

INTRODUCTION

Cochlear implantation in patients with Ménière's disease (MD) is the treatment of choice in cases of functional deafness. Additional vertigo control is of central importance in this group of patients. Endolymphatic hydrops (ELH) is the pathophysiological correlate of MD and can be evaluated by magnet resonance imaging (MRI). Bilateral MD occurs in 10-33% and can be the reason for a postoperative persisting or newly occurring vertigo in this group. Recent developments in the field of implant magnets and experience in MRI sequences allow the diagnostic performance of MRI in cochlear implantees to be evaluated. The aim of the present study was to evaluate the possibility of MRI as a visual diagnostic tool for endolymphatic hydrops in cochlear implantees.

MATERIAL AND METHODS

This was a retrospective study including three cochlear implantees (age: 61-76 years, one female, two male) suffering from MD who, postoperatively, had a recurrence of vertigo with Ménière's-like symptoms. An MRI was performed for the evaluation of ELH (ELH-MRI). MRI observation was performed by a 4 h iv. delayed Gad 3 D Flair sequence.

RESULTS

In all cases, the ipsilateral implant magnet artifact covered the vestibulum, the semicircular canals and the cochlea. The contralateral vestibulum, the semicircular canal and the cochlea were fully observable, and a classification of the ELH-MRI could be performed.

CONCLUSION

ELH-MRI scanning allows for the detection of contralateral labyrinthine endolymphatic hydrops and is a tool for the postoperative evaluation of vertigo in cochlear implantees.

A Novel MR Imaging Sequence of 3D-ZOOMit Real Inversion-Recovery Imaging Improves Endolymphatic Hydrops Detection in Patients with Ménière Disease

BACKGROUND AND PURPOSE

The detection rate of premortem MR imaging endolymphatic hydrops is lower than that of postmortem endolymphatic hydrops in Ménière disease, indicating that current MR imaging techniques may underestimate endolymphatic hydrops. Therefore, we prospectively investigated whether a novel high-resolution MR imaging technique, the 3D zoomed imaging technique with parallel transmission real inversion-recovery (3D-ZOOMit real IR), would improve the detection of endolymphatic hydrops compared with conventional 3D TSE inversion-recovery with real reconstruction.

MATERIALS AND METHODS

Fifty patients with definite unilateral Ménière disease were enrolled and underwent 3D-ZOOMit real IR and 3D TSE inversion-recovery with real reconstruction 6 hours after IV gadolinium injection. The endo- and perilymph spaces were scored separately. The contrast-to-noise ratio, SNR, and signal intensity ratio of the 2 sequences were respectively calculated and compared. The presence of endolymphatic hydrops was evaluated.

RESULTS

The endolymphatic space in the cochlea and vestibule was better visualized with 3D-ZOOMit real IR than with conventional 3D TSE inversion-recovery with real reconstruction (P < .001). There were differences between the 2 sequences in the evaluation of no cochlear hydrops and cochlear hydrops (both, P < .017). All contrast-to-noise ratio, SNR, and signal intensity ratio values of 3D-ZOOMit real IR images were statistically higher than those of conventional 3D TSE inversion-recovery with real reconstruction (all, P < .001).

CONCLUSIONS

The 3D-ZOOMit real IR sequences are superior to conventional 3D TSE inversion-recovery with real reconstruction sequences in visualizing the endolymphatic space, detecting endolymphatic hydrops, and discovering contrast permeability.

Confrontation of endolymphatic hydrops diagnosis on 3-Tesla MRI to clinical and audiovestibular findings in Meniere's disease

Objective

The aim of this study was to compare different MRI diagnostic criteria for endolymphatic hydrops (EH) and to investigate the relation between audiovestibular and MRI findings in Meniere's disease (MD).

Materials and methods

Prospective cross-sectional cohort study in 2 referral centers included 76 patients with unilateral (n = 62) or bilateral (n = 14) MD. All patients underwent inner ear 3T-MRI 4 h (n = 52) or >24H (n = 24) following audiovestibular tests. T2-CISS and 3D-FLAIR images 4H after gadolinium were obtained. EH diagnosis was based on saccular morphology on coronal views (T2 and 3D-FLAIR), semi quantitative estimation of endolymphatic space enlargement, and saccule utricle ratio inversion (SURI) on 3D-FLAIR axial views.

Results

SURI was the best criterion related to the disease side (43 SURI+ on symptomatic ears, n = 77, vs. 6 SURI+ on asymptomatic ears, n = 53, p < 0.0001, Chi-2). Same-day MRI revealed relation between EH, hearing loss and caloric weakness which could not be detected on delayed MRI: SURI was associated with a higher pure-tone average (43 ± 4.1 dB in SURI+ ears, n = 42 vs. 23 ± 2.6 SURI-, n = 62, p < 0.0001, unpaired t-test,), and a higher proportion of vestibular caloric weakness (23/46 SURI+ ears vs. 4/62 SURI-, p < 0.001, Chi-2). Among all criteria, SURI combined to caloric weakness was the best predictor of the affected side in a logistic regression model.

Conclusion

SURI had the strongest relation to the side the disease and audio vestibular findings for unilateral, probable and definite meniere disease. A short delay between MRI and audio vestibular tests improved the coherence between the findings.

Characteristics of clinical details and endolymphatic hydrops in unilateral and bilateral Ménière's disease in a single Asian group

Objectives

To elucidate the characteristics of the clinical details and endolymphatic hydrops (EH) in bilateral Ménière's disease (BMD).

Methods

A total of 545 patients with definite MD were enrolled. Demographic variables; the age of onset; disease course; inner ear function; the coexistence of related disorders such as migraine, delayed MD, drop attacks, and autoimmune diseases; familial history; and characteristics of EH were analyzed.

Results

In the study population, the prevalence of BMD was 15.4%. The disease duration of BMD (84.0 ± 89.6 months) was significantly longer than that of unilateral MD (UMD, 60.1 ± 94.0 months) (P = 0.001). As evaluated by hearing thresholds and cervical and ocular vestibular evoked myogenic potentials, inner ear functions were more deteriorated in BMD (P &lt; 0.05) than in UMD. The proportions of delayed MD and a family history of vertigo were significantly larger in BMD (P &lt; 0.05). EH was observed in 100% of cases on the clinically affected side and 6.1% of cases on the unaffected side.

Conclusion

A low prevalence of BMD, longer disease duration, higher frequencies of delayed MD, and family history of vertigo in patients with BMD were significant findings observed in the present study. All affected ears presented with EH, and a low percentage of unaffected sides presented with EH.

Correlation of clinical parameters with endolymphatic hydrops on MRI in Meniere's disease

A clinical diagnosis of Ménière's disease (MD) is made based on medical history and audiometry findings. The 1995 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines requires histopathological confirmation of endolymphatic hydrops (EH) for a diagnosis of “certain” MD. Symptoms such as dizziness and ear fullness are important diagnostic features; however, the descriptions provided by patients are frequently vague and non-specific. A recently developed magnetic resonance imaging (MRI) protocol to document EH is, therefore, useful for the evaluation of inner ear status in patients with MD. In this study, patients with MD were assessed using MRI and the HYDROPS (HYbriD of Reversed image Of Positive endolymph signal and native image of positive perilymph Signal) protocol to investigate the effectiveness of MRI for visualization of the endolymphatic space in the diagnosis of MD by correlating clinical laboratory parameters with the grade of EH. Of the 123 patients with MD recruited in this study, 80 had definite MD, 11 had probable MD, and 32 had possible MD based on the 1995 AAO-HNS guidelines. The EH grade based on HYDROPS MRI was determined independently by two otorhinolaryngologists and compared with several clinical parameters, including the diagnostic scale of MD (1995 AAO-HNS guidelines), pure tone average (PTA), low tone average (LTA), canal paresis (CP) on the caloric test, and disease duration. Cochlear hydrops and vestibular hydrops were detected in 58 and 80% of 80 definite MD ears, in 33 and 58% of 12 probable MD ears, and in 5 and 27% of 37 possible MD ears, respectively. The proportion of higher hydrops grades increased significantly with grade according to the MD diagnostic scale (p < 0.0001). Both PTA and LTA were significantly higher in patients with hydrops grade 2 than hydrops grade 0 in both the cochlea and the vestibule. CP was significantly higher in patients with grade 2 than grade 0 vestibular hydrops. Disease duration was not associated with hydrops grade. Radiological evaluation of MD using the HYDROPS protocol is useful for evaluation of the extent and severity of EH in the diagnosis of MD based on its pathophysiological mechanism.

Consensus on MR Imaging of Endolymphatic Hydrops in Patients With Suspected Hydropic Ear Disease (Meniere)

Endolymphatic hydrops (EH) is considered the histological hallmark of Meniere's disease. Visualization of EH has been achieved by special sequences of inner ear magnetic resonance imaging (MRI) with a gadolinium-based contrast agent via intravenous or intratympanic administration. Although it has been applied for more than 10 years since 2007, a unified view on this technique has not yet been achieved. This paper presents an expert consensus on MRI of endolymphatic hydrops in the following aspects: indications and contra-indications for patient selection, methods of contrast-agent administration (intravenous or intratympanic), MRI sequence selection, the specific scanning parameter settings, and standard image evaluation methods and their advantages and disadvantages. For each part of this consensus, a comment is attached to elucidate the reasons for the recommendation.

Endolymphatic Hydrops Magnetic Resonance Imaging in Menire's Disease Patients on a Vertigo Attack

OBJECTIVE

To investigate the characteristics of endolymphatic hydrops (EH) in Menire's disease (MD) patient on a vertigo attack.

STUDY DESIGN

Prospective study.

SETTING

Tertiary referral center.

PATIENTS

Thirty-six MD patients underwent the enhanced magnetic resonance imaging (MRI) examinations of the inner ear on a vertigo attack were enrolled.

MAIN OUTCOME MEASURES

All patients met the diagnostic criteria for MD and underwent intravenous gadolinium injection 4 hours before the MRI examinations. The MRI examinations were performed in MD patients on a vertigo attack.

RESULTS

Various degrees of vestibular EH appeared in almost all affected ears (2 ears had no EH, 11 ears had mild EH, 26 ears had significant EH). The positive rate of vestibular EH was 37/39 (94.9%). Cochlear EH occurred in 29 ears among 39 affected ears (17 ears had mild EH, 12 ears had significant EH).

CONCLUSION

MRI with intravenous gadolinium injection can provide a better assessment of EH in MD patient on a vertigo attack. Vestibular EH seems to be closely related with the vertigo attacks in MD patients, which needs further study.

Dilatation of the Endolymphatic Space in the Ampulla of the Posterior Semicircular Canal: A New Clinical Finding Detected on Magnetic Resonance Imaging

OBJECTIVES

To investigate the clinical features of ears with dilatation of the endolymphatic space in the ampulla of the posterior semicircular canal on magnetic resonance imaging.

STUDY DESIGN

Retrospective study.

SETTING

A university hospital.

METHODS

This study included 1,842 ears from 934 patients who underwent 3-T magnetic resonance imaging with gadolinium to investigate the presence of endolymphatic hydrops. Age, sex distribution, hearing thresholds on pure-tone audiometry, and vestibular symptoms were compared between cases of unilateral and bilateral dilatation of the endolymphatic space in the ampulla of the posterior semicircular canal.

RESULTS

Forty-eight ears (17 men and 14 women; mean age 49.9 yrs) showed dilatation of the endolymphatic space in the ampulla of the posterior semicircular canal. Age and the rate of chronic sensorineural hearing loss were significantly higher in the unilateral group (14 ears) than in the bilateral group (34 ears). The average hearing thresholds and rates of vestibular symptoms reported did not differ between unilateral and bilateral cases, but some patients showed positional nystagmus.

CONCLUSIONS

Dilatation of the endolymphatic space in the ampulla was observed selectively in the posterior semicircular canal, though its pathogenesis was not clear. Such dilatation is not usually accompanied by vestibular endolymphatic hydrops, and it may be a cause of vertigo and dizziness.

Novel Magnetic Resonance Imaging-Based Method for Accurate Diagnosis of Meniere's Disease

Background: Pathologically, Meniere's disease symptoms are considered to be associated with endolymphatic hydrops. Examinations revealing endolymphatic hydrops can be useful for accurate Meniere's disease diagnosis. We previously reported a quantitative method for evaluating endolymphatic hydrops, i.e., by measuring the volume of the endolymphatic space using three-dimensional magnetic resonance imaging (MRI) of the inner ear. This study aimed to confirm the usefulness of our methods for diagnosing Meniere's disease. Here, we extracted new explanatory factors for diagnosing Meniere's disease by comparing the volume of the endolymphatic space between healthy volunteers and patients with Meniere's disease. Additionally, we validated our method by comparing its diagnostic accuracy with that of the conventional method.

Methods and Findings: This is a prospective diagnostic accuracy study performed at vertigo/dizziness centre of our university hospital, a tertiary hospital. Eighty-six patients with definite unilateral Meniere's disease and 47 healthy volunteers (25 and 33 males, and 22 and 53 females in the control and patient groups, respectively) were enrolled. All participants underwent 3-Tesla MRI 4 h after intravenous injection of gadolinium to reveal the endolymphatic space. The volume of the endolymphatic space was measured and a model for Meniere's disease diagnosis was constructed and compared with models using conventional criteria to confirm the effectiveness of the methods used. The area under the receiver operating characteristic curve of the method proposed in this study was excellent (0.924), and significantly higher than that derived using the conventional criteria (0.877). The four indices, sensitivity, specificity, positive predictive value, and negative predictive value, were given at the threshold; all of these indices achieved higher scores for the 3D model compared to the 2D model. Cross-validation of the models revealed that the improvement was due to the incorporation of the semi-circular canals.

Conclusions: Our method showed high diagnostic accuracy for Meniere's disease. Additionally, we revealed the importance of observing the semi-circular canals for Meniere's disease diagnosis. The proposed method can contribute toward providing effective symptomatic relief in Meniere's disease.

The Importance of the Temporal Bone 3T MR Imaging in the Diagnosis of Menière's Disease

BACKGROUND

The aim of this study was to evaluate endolymphatic hydrops using the 3T temporal bone magnetic resonance imaging (MRI), performed according to the chosen protocol, and determine whether it could be applied as an objective diagnostic tool for Menière's disease.

METHODS

105 participants diagnosed with probable (n = 50) and definite (n = 55) Menière's disease were included in this prospective study at Vilnius University Hospital, Santaros Clinics. Audiometry, vestibular function tests, videonystagmography, and computer posturography were performed before MRI. The 3T MRI with gadolinium contrast was performed to evaluate the endolymphatic hydrops. Imaging protocol consisted of 3D-FLAIR and 3D T2DRIVE sequences. Vestibular endolymphatic sac was interpreted as enlarged if occupied more than 50% of the vestibular area.

RESULTS

78.1% of subjects had abnormal MRI findings other than hydrops, and it was more than 90% (50/55) of patients in the definite MD group (p < 0.001). Changes in caloric test were observed in 63.8% of subjects in general, and in 76.4% of patients with a definite Menière's disease. The side of the endolymphatic hydrops observed on MR imaging corresponded to the clinical diagnosis of the Menière's disease based on the results of audiometry (p < 0.001) and unilateral weakness (p < 0.001). Endolymphatic hydrops on MRI and directional preponderance in caloric test were two independent predictors of the definite Menière's disease.

CONCLUSIONS

Temporal bone 3T MRI with gadolinium contrast is clinically superior to confirm the diagnosis of Menière's disease. Grade II endolymphatic hydrops on MRI, directional preponderance, and unilateral weakness on caloric test were independent predictors for the definite Menière's disease.

The relationship between clinical characteristics and magnetic resonance imaging results of Ménière disease: a prospective study

Ménière disease (MD) is an idiopathic inner ear disorder, and endolymphatic hydrops (EH) being considered to be its pathological basis. Currently, there is no gold standard for diagnosing MD. Previous study has reported visualized EH using MRI by intratympanic gadolinium-based contrast media (GBCM) administration (IT-Gd) in patients with MD, and this technique was gradually established for MD diagnosis. However, few studies reported their diagnostic sensitivity and specificity in clinical application. This prospective study aimed at investigating the clinical characteristics and magnetic resonance imaging (MRI) results of patients with MD, and analyzing the relationship between clinical results and MRI findings in MD patients. Our study shows that the diagnostic sensitivity and specificity of MRI were 79.2% and 80.7% respectively. Moreover, there was no significant correlation between hearing levels and cochlear grading scores, nor vestibular grading scores. The duration of disease was not significantly associated with cochlear or vestibular grading scores. These findings suggest that IT-Gd MRI offers reliable radiological diagnostic criteria for MD.

Interpreting pendred syndrome as a foetal hydrops: Clinical and animal model evidence

BACKGROUND

Menière disease (MD) and SLC26A4 related deafness (Pendred syndrome (PS) or DFNB4) are two different inner ear disorders which present with fluctuating and progressive hearing loss, which could be a direct consequence of endolymphatic hydrops.

OBJECTIVE

To present similarities between both pathologies and explore how the concept of hydrops may be applied to PS/DFNB4.

METHODS

Review of the literature on MD, PS/DFNB4 and mouse model of PS/DFNB4.

RESULTS

MD and PS/DFNB4 share a number of similarities such as fluctuating and progressive hearing loss, acute episodes with vertigo and tinnitus, MRI and histological evidence of endolymphatic hydrops (although with different underlying mechanisms). MD is usually diagnosed during the fourth decade of life whereas PS/DFNB4 is congenital. The PS/DFNB4 mouse models have shown that biallelic slc26a4 mutations lead to Na+ and water retention in the endolymph during the perinatal period, which in turn induces degeneration of the stria vascularis and hearing loss. Crossing clinical/imagery characteristics and animal models, evidence seems to support the hypothesis of PS being a foetal hydrops.

CONCLUSIONS

When understanding PS/DFNB4 as a developmental hydrops, treatments used in MD could be repositioned to PS.

The value of 3D-real IR MRI with intravenous gadolinium injection in the diagnosis of suspected Meniere's disease in children

BACKGROUND

Intravenous gadolinium injection (IV-method) can be used to visualize endolymphatic hydrops.

AIMS/OBJECTIVES

This study was designed to use a three-dimensional inversion-recovery sequence with real reconstruction (3 D-real IR) sequence 4 h after the IV-method, images of the perilymph space were scored for endolymphatic hydrops in cases of suspected Meniere's disease (MD) in children to investigate its diagnostic value of MD in children.

MATERIALS AND METHODS

We collected 28 suspected MD children aged ≤17 years old, all of whom underwent the IV-method. After 4 h, inner ear 3 D-real IR magnetic resonance imaging (MRI) was performed and results were analyzed.

RESULTS

Gadolinium contrast agent was seen distributed in the perilymphatic space with perilymphatic enhancement on 3 D-real IR MRI, allowing differentiation between the perilymphatic and endolymphatic spaces. Based on perilymph MRI diagnostic scoring, 64.3% (18/28) of the patients were categorized as having endolymphatic hydrops, who were followed and eventually diagnosed with confirmed MDs.

CONCLUSIONS AND SIGNIFICANCE

Suspected MD children should undergo gadolinium-enhanced examinations of the inner ear while taking dynamic audiology examinations for the confirmed diagnosis.

The "hype" of hydrops in classifying vestibular disorders: a narrative review

Background

Classifying and diagnosing peripheral vestibular disorders based on their symptoms is challenging due to possible symptom overlap or atypical clinical presentation. To improve the diagnostic trajectory, gadolinium-based contrast-enhanced magnetic resonance imaging of the inner ear is nowadays frequently used for the in vivo confirmation of endolymphatic hydrops in humans. However, hydrops is visualized in both healthy subjects and patients with vestibular disorders, which might make the clinical value of hydrops detection on MRI questionable.

Objective

To investigate the diagnostic value of clinical and radiological features, including the in vivo visualization of endolymphatic hydrops, for the classification and diagnosis of vestibular disorders.

Methods

A literature search was performed in February and March 2019 to estimate the prevalence of various features in healthy subjects and in common vestibular disorders to make a graphical comparison between healthy and abnormal.

Results

Of the features studied, hydrops was found to be a highly prevalent feature in Menière’s disease (99.4%). Though, hydrops has also a relatively high prevalence in patients with vestibular schwannoma (48.2%) and in healthy temporal bones (12.5%) as well. In patients diagnosed with (definite or probable) Menière’s disease, hydrops is less frequently diagnosed by magnetic resonance imaging compared to the histological confirmation (82.3% versus 99.4%). The mean prevalence of radiologically diagnosed hydrops was 31% in healthy subjects, 28.1% in patients with vestibular migraine, and 25.9% in patients with vestibular schwannoma. An interesting finding was an absolute difference in hydrops prevalence between the two diagnostic techniques (histology and radiology) of 25.2% in patients with Menière’s disease and 29% in patients with vestibular schwannoma.

Conclusions

Although the visualization of hydrops has a high diagnostic value in patients with definite Menière’s disease, it is important to appreciate the relatively high prevalence of hydrops in healthy populations and other vestibular disorders. Endolymphatic hydrops is not a pathognomic phenomenon, and detecting hydrops should not directly indicate a diagnosis of Menière’s disease. Both symptom-driven and hydrops-based classification systems have disadvantages. Therefore, it might be worth to explore features “beyond” hydrops. New analysis techniques, such as Radiomics, might play an essential role in (re)classifying vestibular disorders in the future.

Electronic supplementary material

The online version of this article (10.1007/s00415-020-10278-8) contains supplementary material, which is available to authorized users.

Significance of high signal intensity in the endolymphatic duct on magnetic resonance imaging in ears with otological disorders

BACKGROUND

High signal intensity in the endolymphatic duct (ED) is occasionally observed on magnetic resonance imaging (MRI) in ears that have otological disorders.

OBJECTIVE

The signal intensity (SI) in the ED on post-contrast MRI was investigated in subjects with various otological disorders, and the meaning of high SI in the ED was evaluated.

MATERIAL AND METHODS

392 patients with otological disorders and 21 controls without otological symptoms underwent 3 T MRI. The SIs of the ED and the cerebellum were measured, the SI ratio (SIR) was calculated, and ears with SIR ≥4 were identified.

RESULTS

A high SIR was identified in the ED of 3.7% of ears affected by definite Meniere's disease (dMD), 100% of ears affected by large vestibular aqueduct syndrome (LVAS), and 7.1% of ears with no otological symptoms. On the whole, a significant relationship was found between the existence of vestibular or cochlear EH and the SIR in the ED.

CONCLUSION

The MRI finding of high SI in the ED may indicate the mechanism of inner ear disturbances in ears with otological disorders, especially in those with LVAS, and it may suggest an underlying disorder in some ears in which otological symptoms are not apparent.

Endolymphatic volume in patients with meniere's disease and healthy controls: Three-dimensional analysis with magnetic resonance imaging

Objective

Recently, 3-Tesla magnetic resonance imaging (MRI) with intravenous gadolinium injection has been used to reveal endolymphatic hydrops (EH). In the present study, we aimed to evaluate EH in patients with Meniere's disease (MD) objectively and quantitatively, and compared the endolymphatic space (ELS) in individuals with MD and healthy controls, to gain understanding of the characteristics of MD.

Methods

Eighty-two patients with unilateral MD (uMD), 16 patients with bilateral MD (bMD), and 47 healthy volunteers were enrolled. All participants underwent 3-T MRI at 4 hours after intravenous gadolinium injection. The volumes of the total fluid space (TFS) and ELS were measured semiautomatically using our workstation, and the percentage of ELS to TFS (ELS percentage) was calculated.

Results

The ELS percentage was 13.9 in the ears of controls, 18.2 in the contralateral ear of individuals with uMD, 26.1 in the affected ears of these individuals, and 23.0 in both ears of individuals with bMD. The ELS percentages in the affected ear of uMD and the ears of bMD individuals were significantly higher than that in the ears of control individuals (P < .01, one-way analysis of variance (ANOVA), Tukey's test).

Conclusion

The ELS is significantly larger in the affected ears of uMD and in both ears of bMD individuals. Accurate diagnosis of MD can be facilitated by using 3-T MRI 4 hours after intravenous gadolinium injection and performing volumetric measurements of the ELS.

Level of Evidence

2b.

Significance of Endolymphatic Hydrops Herniation Into the Semicircular Canals Detected on MRI

OBJECTIVE

The objective of this study was to investigate the relationship between endolymphatic hydrops (EH) and hearing level or vestibular symptoms by focusing on EH herniation into the semicircular canal (SCC).

STUDY DESIGN

Retrospective study.

SETTING

University hospital.

METHODS

The study included 1,548 ears of 775 patients who underwent magnetic resonance imaging (MRI) examination in our university hospital to investigate possible EH. MRI was performed 4 hours after intravenous injection of a standard dose of gadodiamide hydrate and/or 24 hours after intratympanic injection of gadopentetate dimeglumine diluted eightfold. The hearing threshold and vestibular symptoms were compared between ears with unilateral and bilateral EH herniation into the SCC and between ears having vestibular EH adjacent to the stapes footplate with or without EH herniation.

RESULTS

Forty-four ears (19 men and 25 women, mean age 53.6 yr) showed EH herniation into the SCC. The average hearing thresholds at 500 to 4000 Hz and presence of vestibular EH adjacent to the stapes footplate were significantly higher in ears with unilateral herniation than in those with bilateral herniation. The average hearing thresholds at 500 and 1000 Hz were significantly higher in the group of ears having adjacency with herniation than in those without herniation. Vestibular symptoms did not differ significantly between groups.

CONCLUSION

Unilateral herniation occurs with EH progression. Bilateral herniation may occur regardless of EH progression and might be influenced by other factors that alter the membranous labyrinth.

A possible mechanism of the formation of endolymphatic hydrops and its associated inner ear disorders

The pathology of Meniere's disease (MD) is well established to be endolymphatic hydrops. However, the mechanism underlying deafness and vertigo of MD or idiopathic endolymphatic hydrops is still unknown. In order to evaluate the pathogenesis of deafness and vertigo in MD, it seems to be rational to investigate the interrelationship between hydrops and inner ear disorders using animals with experimentally-induced endolymphatic hydrops. In spite of intense efforts by many researchers, the mechanism of vertiginous attack has been unexplained, because animals with experimental hydrops usually did not show vertiginous attack. Recently, there are two reports to succeed to evoke vertiginous attack in animals with experimental hydrops. In the present paper were first surveyed past proposals about underlying mechanism of the development of hydrops and inner ear disorders associated with hydrops, and were discussed the pathogenetic mechanism of vertiginous attack in hydrops. In conclusion, abrupt development of hydrops was thought to play a pivotal role in the onset of vertiginous seizure.

Prediction of Unilateral Meniere's Disease Attack Using Inner Ear Test Battery

OBJECTIVES

In the clinical setting, a variety of inner ear test results are obtained from patients with unilateral Meniere's disease (MD). In this study, the authors use inner ear test results as parameters to illustrate the relationship between inner ear function and vertigo attack frequency.

DESIGN

We retrospectively enrolled 50 unilateral MD patients. In addition to clinical symptoms, the results of pure-tone audiometry and caloric, acoustic cervical vestibular-evoked myogenic potential (cVEMP), galvanic cVEMP, vibratory ocular VEMP (oVEMP), and galvanic oVEMP tests were collected via chart review. The multiple linear regression method was used to examine which independent variables have a statistically significant influence on vertigo attacks.

RESULTS

In affected ears, the abnormal rate of the caloric, acoustic cVEMP, galvanic cVEMP, vibratory oVEMP, and galvanic oVEMP tests was 74%, 76%, 48%, 34%, and 30%, respectively. According to the regression model, the abnormal galvanic cVEMP response and abnormal galvanic oVEMP response had significantly negative correlations with the frequency of vertigo attacks after logarithmic transformation. A predictive model for disease attack frequency using significant parameters and their regression coefficients was proposed: (Equation is included in full-text article.) CONCLUSIONS:: Using the proposed model with galvanic VEMP, clinicians could develop better strategies to manage vertigo attacks in patients with MD.

Gadolinium-enhanced MRI reveals dynamic development of endolymphatic hydrops in Ménière's disease

INTRODUCTION

Meniere's disease is associated with impaired hearing, tinnitus, vertigo, and aural fullness. Many anatomical studies have suggested idiopathic endolymphatic hydrops as the pathological basis of Meniere's disease, which now can be visualized by using gadolinium -enhanced magnetic resonance imaging of the inner ear.

OBJECTIVE

To investigate the development of endolymphatic hydrops in Meniere's disease by monitoring the vestibules and cochleae of affected patients.

METHODS

Inner ears of 178 patients with definite unilateral Meniere's disease diagnosis were visualized by 3-dimensional fluid-attenuated inversion recovery and three-dimensional real inversion recovery magnetic resonance imaging following bilateral gadolinium intratympanic injection. The scans were used to evaluate the presence and degree of endolymphatic hydrops in the vestibules and cochlear structures, including the cochlear apical turn, the cochlear middle turn, and the cochlear basal turn. The correlation of endolymphatic hydrops occurrence between the various parts of the inner ear was determined.

RESULTS

Symptomatic endolymphatic hydrops was detected on the affected side in all patients, whereas asymptomatic endolymphatic hydrops was detected on the unaffected contra-lateral side in 32 patients (18.0%). On the affected side, the cochlear apical turn and the cochlear middle turn demonstrated significantly higher rates of endolymphatic hydrops than the cochlear basal turn and the vestibule. The severity of endolymphatic hydrops gradually decreased from the cochlear apical turn to the cochlear basal turn. On the contra lateral side, the incidence and degree of the detected asymptomatic endolymphatic hydrops were significantly greater in the cochleae than in the vestibules (p<0.05), with no significant difference detected between the cochlear turns.

CONCLUSION

Progression of endolymphatic hydrops appears to be directional, initiated in the cochlea. The order of endolymphatic hydrops severity gradually decreases from the cochlear apical turn to the cochlear basal turn and then to the vestibule. Endolymphatic hydrops in the vestibule is associated with symptomatic Meniere's disease.

Significance of Endolymphatic Hydrops in Ears With Unilateral Sensorineural Hearing Loss

OBJECTIVE

The purpose of this study was to investigate the existence of endolymphatic hydrops (EH) in affected and unaffected ears in patients with unilateral sensorineural hearing loss (SNHL) using contrast-enhanced magnetic resonance imaging (MRI), and to evaluate the significance of EH in various otological diseases.

STUDY DESIGN

Retrospective study.

SETTING

University hospital.

METHODS

One hundred eighty-two ears from 91 patients with unilateral SNHL were studied. The endolymphatic space was evaluated using 3-Tesla MRI with gadodiamide hydrate. Imaging data about the degree of EH in the cochlea and vestibule were analyzed and compared between ears with various otological diseases.

RESULTS

All affected ears with delayed endolymphatic hydrops had EH. In affected ears with definite Menière's disease, cochlear EH was observed in all ears and vestibular EH in 93% of ears, and these rates were significantly higher in the affected than in the unaffected ears. EH was also observed in the cochlea and vestibule in 66% and 41%, respectively, of the affected ears with idiopathic sudden SNHL; however, these percentages did not differ significantly from those in the unaffected ears (52% and 38%, respectively).

CONCLUSION

MRI showed that a high percentage of ears affected by Menière's disease or delayed endolymphatic hydrops had EH. Further studies should evaluate the implications of EH in ears, especially in those with sudden SNHL, in terms of secondary or pre-existing EH.