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Objective: We aimed to develop a clinical test of 3D canal dysfunction by perceptual matching of motion stimuli as an alternative to vestibular ocular reflex assessment., Study Design: The study was a comparison with age-matched controls., Setting: The study was performed in a clinical neurophysiology laboratory., Patients: Ten patients with acute unilateral vestibular nerve section and 9 patients in the chronic stage of recovery, 2 acute-stage and 2 chronic-stage patients with posterior canal plugging, and 35 healthy individuals were studied., Interventions: Seated on a motorized rotating chair in darkness, subjects were exposed to discrete, raised cosine velocity (60 degrees/s peak) rotations, for random displacements < or = 180 degrees rightward and leftward. They responded by rotating themselves back to the starting position with a joystick control. Horizontal canals were tested with head upright, ipsilateral versus contralateral vertical canal pairs were tested with the head down, face horizontal and co-planar anterior-posterior canal pairs were tested with the head down and turned approximately 45 degrees to the left or right., Main Outcome Measures: These were accuracy and symmetry of responses., Results: Normal responses were approximately accurate returns to start. Nine patients with acute nerve section were hypometric (undershooting start) when displaced toward the lesion but normometric to the intact side. Eight chronic-stage nerve section patients with chronic dysfunction were hypometric to the lesion for vertical canal stimuli, but one third showed normal responses for horizontal canal testing. Patients with posterior canal plugging were hypometric specifically toward the plugged canal., Conclusions: The method reliably identifies acute and chronic dysfunction of vertical canals and acute dysfunction of horizontal canals. Dysfunction of a single canal can be specified.

Hypothesis: We have theorized that surgical occlusion of all three semicircular canals (TCO) may be an effective means to treat vestibular pathology limited to semicircular canal dysfunction while preserving hearing and otolithic function., Background: A procedure that would eliminate vertigo while preserving hearing and minimizing postoperative dysequilibrium would be desirable., Methods: Staged bilateral TCO was performed on four cats and compared to staged bilateral labyrinthectomy in four cats. Balance and gait analysis were performed for 3 weeks after each surgical procedure--a total of 6 weeks of testing., Results: Balance testing, gait analysis, and righting reflex were found to be better among the cats undergoing TCO compared to labyrinthectomy., Conclusions: Compared to labyrinthectomy in the cat, TCO appears to have advantages for vestibular compensation after unilateral and contralateral surgery.

To define better the benefits and risks of intratympanic gentamicin injection treatment of intractable vertigo or drop attacks due to Ménière's disease, we reviewed the charts of 18 patients whom we have now observed for > 1 year after having completed this mode of therapy. There were nine women and nine men aged 29-81 years; all had poor hearing in the affected ear. Of the 18 patients, 14 have had no further vertigo or drop attacks (11 patients after a single set of three to five injections, another three after a further set of one to five injections). The treatment could be effective even if it did not abolish caloric responses from the treated ear, even if it did not produce an acute vestibular deafferentation syndrome afterwards, and even after a failed vestibular nerve section. After treatment, five of the 18 patients developed oscillopsia and ataxia--symptoms and signs of (presumably permanent) chronic vestibular insufficiency; this proportion is not obviously lower than that after vestibular neurectomy or surgical labyrinthectomy. Of the 18 patients, 12 showed no change in the 1-kHz threshold and 13 showed no change in the 4-kHz threshold. When hearing did deteriorate, the threshold rose by more than 30 dB at 1 kHz in four patients and at 4 kHz in six patients. We conclude and confirm that intratympanic gentamicin injections are a convenient and, in most cases, effective and safe treatment for intractable vertigo or drop attacks due to Ménière's disease.

The objective of this study was to describe the light microscopic pathology of labyrinthine fistulae in chronic otitis media (COM) in seven temporal bones and to discuss clinical and surgical implications. In COM, labyrinthine fistulae are usually caused by cholesteatoma, with the lateral semicircular canal being the most commonly affected site. Some fistulae are asymptomatic, whereas, others affect the auditory and vestibular systems to varying degrees. Surgical removal of cholesteatoma matrix over a fistula carries a risk of sensorineural hearing loss. Knowledge of the pathology of fistulae may provide a better understanding of their clinical manifestations and may allow a more rational approach to surgical management. The Massachusetts Eye and Ear Infirmary temporal bone collection contains 115 specimens with COM, of which seven specimens show pathologic fistulization of the bony labyrinth. Histologic sections from these seven bones were evaluated with respect to type of COM, location and size of fistula, changes in the inner ear adjacent to the fistula, middle ear and mastoid disease, and pathology in the vestibular and cochlear sense organs. The following conclusions are presented (a) Labyrinthine fistulae can be caused not only by cholesteatoma, but also by granulomatous COM without cholesteatoma and even by localized infection within a canal-down mastoid cavity. (b) Cholesteatoma matrix or inflammatory tissue usually becomes apposed to the endosteum or membranous labyrinth within the fistula. In most cases, reactive inner ear changes do not occur at the fistula site. Occasionally, there is thickening of the endosteum or chronic localized labyrinthitis. (c) Most bones do not show any alterations of the vestibular and cochlear sense organs. Occasionally, there is serous labyrinthitis, which might lead to partial sensorineural hearing loss. (d) A protective "walling-off" phenomenon in the labyrinth is not common. Therefore, if overwhelming infection or surgical trauma breaches the natural barriers of the endosteum/membranous labyrinth, then the fistula may allow rapid dissemination of infection throughout the inner ear.

To characterize otologic causes for vertigo, data on 564 patients with the six most common diseases involving vertigo were retrieved from the database of a computer-aided diagnostic system for neurotologic diseases. The diseases were Meniere's disease, vestibular schwannoma, benign paroxysmal positional vertigo, vestibular neuritis, sudden deafness, and traumatic vertigo. The prevalence of tinnitus in the study population was 76%. The most severe forms of vertigo and nausea were found in vestibular neuritis, whereas the most severe case of tinnitus appeared in Meniere's disease. Of the patients with vestibular schwannoma, 49% had had vertigo. A linear discrimination analysis using case history classified 90% of the patients into correct groups. The key questions discriminating between the diseases concerned the frequency and duration of vertigo attacks, the duration of hearing loss and vertigo, and the occurrence of head injury. Making a correct diagnosis during the first office visit can be difficult, especially for sudden deafness, vestibular schwannoma, and Meniere's disease. Neurotologic and audiometric information was of minor value in distinguishing between these six diseases. Vestibular schwannoma had significantly greater asymmetry in electronystagmography and smaller gains in smooth pursuit in comparison with the other disease. Factorial analysis did not aid the clustering of these diseases.

Twelve patients with auditory and/or vestibular symptoms were examined with a gadolinium magnetic resonance imaging (Gd-MRI) study. They all were found to have enhancement of only the endolymphatic duct/sac structures of the inner ear. Most of these findings were unilateral, but a few were bilateral. The patients underwent auditory, vestibular, and blood tests in an attempt to clarify the reason for this abnormal enhancement. Several specific etiologies were identified, but several cases had unknown causes. In this article we review the concept of inflammation of the inner ear structures with particular attention to the role of the endolymphatic duct/sac in the immune response of the inner ear. The idea of an inflammatory response of the inner ear leading to endolymphatic hydrops (Meniere's disease) is discussed, but these patients did not follow a clear path from inflammation of the endolymphatic duct/sac to endolymphatic hydrops. However, the longest follow-up was only 4 years, and our observations remain preliminary. Finally, the authors have found that Gd-MRI study of the inner ear provides valuable information in the investigation of patients with new auditory and/or vestibular symptoms.

Improvements in diagnosis and management of chronic ear disease in general and cholesteatoma in particular have led to a decreased incidence of serious labyrinthine complications. Unfortunately, significant disease still does occur and, if unrecognized, may result in significant morbidity. Labyrinthine fistulae secondary to cholesteatoma cause potentially irreversible symptoms such as hearing loss and vertigo. This study reviews 17 patients who developed labyrinthine fistula secondary to cholesteatoma. Sixteen involved the horizontal semicircular canal and one involved the oval window. The cholesteatoma matrix was removed in all cases and the underlying fistula repaired primarily. Cochlear function was preserved in all patients. Sixteen of 17 patients have had no further difficulty with vertigo beyond the immediate postoperative period. The evaluation and contemporary management of this difficult problem are discussed.

Tumor types other than acoustic neuromas are uncommonly encountered in the cerebellopontine angle, and unusual lesions limited to the internal auditory canal (IAC) are given more rare. We present five patients with unusual tumors of the IAC including two meningiomas, two arachnoid cysts, and a hemangioma. These unusual tumors, and lipomas, are discussed. Particular attention is paid to the pathophysiology of the lesions and treatment recommendations. The differential diagnosis of intracanalicular lesions using magnetic resonance imaging is also presented.

Labyrinthine fistula in chronic otitis media with cholesteatoma most commonly involves the horizontal semicircular canal. We report three cases of cochlear fistula in chronic otitis media with cholesteatoma. All of them had a long history of otorrhea. One patient had total hearing loss of the affected side. The other two patients had conductive hearing loss. Radical mastoidectomy had been done in all cases. Cholesteatoma in the tympanic cavity destroyed the basal turn of the cochlea. These fistulas were sealed with muscle or Gelfoam with streptomycin. We found no fistula in the semicircular canal in any of the three cases. We report three cases of cochlear fistula in chronic otitis media with cholesteatoma, and review the literature.

There are several hyperostosis diseases of the skull that are accompanied by hearing impairment. In this article a case of Engelmann disease is presented. Currently > 130 cases of Engelmann disease are reported in literature. About 18% of these cases reported hearing impairment, but it is possible that this figure may be higher, because many of the authors concentrated on other aspects of the disease and made no reference to hearing loss in their reports. The etiology of deafness is the narrowing of the internal auditory canals cause by bony encroachment on nerves and vessels. This lends to progressive perceptive hearing loss and narrowing of the tympanic cavities. The result is fixation or adhesion of ossicle to tympanic walls, and narrowing of the bony part of auditory tubes, which causes serous otitis media.

We report a case of hearing preservation after removal of the semicircular canals and discuss the possible explanations for the mechanisms of preservation of hearing after removal of the labyrinth. We hope to promote the perspectives and possibilities of functional surgery of the inner ear and for tumors of the cerebellopontine angle.

This study involved elderly patients with Meniere's disease with incapacitating vertigo. Several of these patients underwent surgery for relief of symptoms that was tailored to the individual's general health and degree of physical activity. Factors that might affect postoperative rehabilitation and recovery were considered, including vision, vertebrobasilar ischemia, proprioception (such as neuropathy resulting from diabetes), and basal ganglia disease. The postoperative results of this tailored approach have been completely satisfactory.

Endolymphatic hydrops (EH) associated with otosclerosis has been noted for many years. However, the causal relationship of these two entities remains controversial. Having reviewed the records of patients with otosclerosis describing fluctuant hearing loss and vertiginous symptoms, the authors found the EH may coexist with otosclerosis preoperatively; they may be two separate diseases that exist coincidentally; or EH may be caused by the otosclerotic process. Secondly, EH may occur with a fistula after surgery. Occurring after stapedectomy, EH may be caused by fistulization of the bony labyrinth, which is effectively treated by surgery to seal the fistula, which may cause EH to subside and hearing to improve. Thirdly, delayed EH may occur months or years after stapedectomy, possibly as a result of otosclerotic foci or surgical insult to the labyrinth. Dexamethasone, diuretics, and a room air rebreather can be used in the treatment of delayed EH. Hearing may be maintained or may deteriorate, but there usually is no dizziness. The clinical manifestations of EH associated with otosclerosis include a conductive or mixed type of hearing loss; the presence of fullness, tinnitus, fluctuation of hearing, episodic vertigo, an elevated negative summating potential (SP), and an increased summating potential:action potential (SP:AP) ratio shown by ECoG. This report presents five cases of EH associated with otosclerosis.

Atherosclerotic carotid artery disease (ACAD) as a cause of objective-pulsatile tinnitus has not been adequately addressed in the literature. This report presents the authors' experience in 12 patients with pulsatile tinnitus arising from ACAD. Ipsilateral carotid bruit was detected in all patients and objective tinnitus was present in eight cases. The intensity of the carotid bruit was louder than the objective tinnitus in all patients. Carotid artery stenosis was confirmed in all patients with noninvasive vascular flow mapping. Atherosclerotic carotid artery disease should be highly suspected in patients with pulsatile-objective tinnitus who are older than 50 years and have associated cardiovascular risk factors. Pulsatile tinnitus in these patients can be the first manifestation of ACAD. Duplex ultrasound study of the carotid arteries can confirm the diagnosis. Consultation with a vascular surgeon is essential in selected cases.

The diagnosis of perilymphatic fistula can be confusing and prone to error. The signs and symptoms can be extremely varied, and currently there is no clinical or laboratory test that accurately predicts the presence of this entity. The only reliable method of diagnosis, namely surgical exploration, is often frustrating as, commonly, no evidence of an active fistula is found. Four children initially believed to have a perilymphatic fistula were found on exploration instead to have an absent round window reflex with normal mobility of the ossicular chain. These children presented with a history of abrupt, step-wise decreases in their hearing thresholds that frequently progressed from a mixed to a purely sensorineural loss. No anatomic abnormalities were found on high-resolution computed tomography. The authors theorize that this finding may represent altered fluid dynamics within the inner ear. Whether it signifies a prior fistula that has spontaneously healed remains to be confirmed. A review of the literature along with possible pathophysiologic mechanisms is presented.

Transiently evoked otoacoustic emissions (TEOAE) are generally present in ears with normal hearing, but absent in ears with cochlear hearing losses greater than 25-30 dB; they have been demonstrated previously in a few ears with retrocochlear hearing losses greater than 30 dB across the frequency range 0.25-8 kHz. To assess the potential of TEOAEs in the diagnosis of retrocochlear hearing losses, measurements were made in 45 patients with retrocochler disorder attributable to confirmed cerebellopontine angle (CPA) tumors. Transiently evoked OAEs elicited by click stimuli were recordable in 21 (47%) of the ears with tumor. Nine of these had normal hearing at two or more octave frequencies across the range 0.5-4 kHz and so might be expected to have TEOAEs regardless of the type of disorder. The other 12 ears had recordable TEOAEs despite hearing threshold levels greater than 25 dB between 0.5 and 4 kHz. The absence of TEOAEs in the remaining 24 ears (53%) indicated a significant outer hair cell component to the hearing loss. Neither age nor sex were significant factors in the occurrence of TEOAEs. The TEOAE test gives useful differential diagnostic information when emissions are recorded in ears having hearing threshold levels greater than 25 dB at all frequencies. In such ears there is relatively normal cochlear function at the level of the outer hair cells, at least at some frequencies, and hence, by inference, there must be a retrocochlear disorder.

Streptomycin perfusion of the labyrinth is the logical choice of treatment for the third stage of Meniere's disease with intractable vertigo. The results of streptomycin perfusion of the labyrinth are comparable to those of other treatments, including endolymphatic shunt and vestibular nerve section. Refinements must be made in the process of selecting candidates for the operation. To study the factors influencing the results of streptomycin perfusion of the labyrinth, 144 patients who had streptomycin perfusion of the labyrinth and were followed for 1 year were studied using the 1972 AAOO classification of results. The findings of this study indicate that only a low dosage of streptomycin and a small volume of perfusate are required to obtain good results. Patients who have long lasting severe endolymphatic hydrops with poor hearing preoperatively are less likely to achieve good results.

Controversy exists surrounding the diagnosis of spontaneous perilymphatic fistula. In an effort to help resolve this controversy the author conducted a review of the literature as well as a review of 212 of his patients who underwent surgical exploration for suspected perilymphatic fistula. Interpretation of the literature reviewed was hampered by the lack of a uniformly accepted definition for the word spontaneous. Dorland's Medical Dictionary defines spontaneous as that which occurs without external influence. Webster's Dictionary, on the other hand, provides a much more confining definition of the word by stating that a spontaneous event is one that occurs or is produced by its own energy. Only 58 percent of the author's 212 patients had an antecedent history of an external event that may have precipitated the suspected perilymphatic fistula (trauma, flying, diving) while almost 41 percent recalled an antecedent event of internal origin (lifting, straining, sneezing, nose blowing). If one were to support the definition of spontaneous provided by Dorland's Medical Dictionary, then the 41 percent of patients who had no antecedent history of external event would have to be considered as having spontaneous perilymphatic fistula. If, on the other hand, one were to endorse the definition of spontaneous provided by Webster's then less than 2 percent of the author's patients would have to be considered as having spontaneous perilymphatic fistula.

The disability resulting from uni-or bilateral loss of vestibular function was assessed by exposing subjects, in darkness, to random rotational displacements on a motorized chair away from a "center" position and requiring them to rotate themselves back to center using a "joystick" control. Normal subjects were accurate within 10 to 15 percent over 180-degree rotations. Alabyrinthine subjects failed to sense their rotation to any useful extent. Subjects with unilateral loss of function as a result of surgery produced hypometric responses to ipsilateral rotation and large amplitude, but inaccurate responses to contralateral rotation. This pattern became more symmetric and normometric with adaptation to loss of function. The procedure promises to be a more useful measure of adaptation than assessing vestibulo-ocular reflexes.

The history of otosclerosis surgery has been marked by major advances in both surgical technique and instrumentation. Fenestration, stapes mobilization, total stapedectomy, and stapedotomy were important advances in technique. Loupes, binocular microscopy, speculum holders, and microdrills similarly advanced instrumentation. What about fiberoptic argon laser handpieces for use in laser stapedotomy? Do they represent a significant advance in instrumentation, or are they merely another gimmick? Are fiberoptic argon laser handpieces safe? Experimentally, the thermal effects of argon laser, delivered via fiberoptic handpieces to a cadaver stapes and model vestibule, were studied. No significant temperature elevations within a model vestibule were observed during stapedotomy. There were significant temperature elevations within the laser plume at the level of the facial nerve. These findings are consistent with our experience in over 2200 primary and revision stapedotomies. To date, there have been no cases of significant hearing loss or permanent facial paralysis related to the use of these fiberoptic handpieces. We believe fiberoptic argon laser handpieces are as safe as conventional microsurgical instruments in stapes surgery.

Transtympanic electrocochleography (ECoG), using clicks and tone-bursts at 500, 1000, and 2000 Hz, was employed to study 80 patients with Meniere's disease and 25 non-Meniere's patients. The magnitude of the negative summating potential and the summating potential:action potential ratio (SP:AP) were examined in both groups. Groups were further divided based upon degree of hearing loss and audiometric configuration. An elevated SP:AP ratio was found in 83.7 percent of the Meniere's ears and 12 percent of the non-Meniere's. The likelihood of obtaining a positive ECoG in Meniere's patients was strongly related to degree of hearing loss but not audiometric configuration.

To create a rational treatment system for Meniere's disease, it is helpful to divide Meniere's disease into five stages according to the signs, symptoms, pathology, and natural history by recalling what is known for certain and what is probably true about Meniere's disease. It is known that Meniere's disease is attributable to endolymphatic hydrops, caused by a small, malfunctioning endolymphatic sac, abnormally placed since birth, and Meniere's disease is therefore a congenital disorder of the endolymphatic sac. It is probably true that there is often an immune, viral, metabolic, or other insult to the inner ear, that disturbs the balance between the cochlea, where endolymph is produced, and the endolymphatic sac, where most of it is absorbed. Using this five-stage classification, it is possible to separate Meniere's disease into the first three stages, for which different but reasonable treatments are possible, and the last two stages, for which no treatments are effective.

The existence of vestibular Menière's disease, once considered a variant of classic Menière's disease, but without hearing loss, has been questioned because of lack of objective evidence that endolymphatic hydrops is involved with the disease process. Transtympanic electrocochleography (TT ECoG) has emerged as a useful tool for electrophysiologic monitoring of the inner ear, and is especially valuable in assessing endolymphatic hydrops. A retrospective chart review was performed to identify those patients with a diagnosis consistent with vestibular Menière's disease in order to determine the presence or absence of endolymphatic hydrops using TT ECoG. A total of 15 patients were identified. Using established norms for the summating to action potential ratio (SP:AP) with click stimulus, 73 percent demonstrated values consistent with endolymphatic hydrops. The most commonly associated symptom was aural fullness (60%), followed by tinnitus (33%), and the disease was bilateral 53 percent of the time. The similarities between this clinical entity and classic Menière's disease are noted, and theoretic considerations are made.

Obliteration of the endolymphatic sac reliably results in endolymphatic hydrops in some animal species. While this procedure is frequently utilized in the study of experimental Meniere's disease, additional information regarding inner ear fluid hydrodynamics can be obtained by obstructing the cochlear aqueduct to eliminate the influence of the cerebrospinal fluid on the perilymphatic compartment of the inner ear. This report describes a modified extradural occipital approach for surgical obliteration of the endolymphatic sac and obstruction of the cochlear aqueduct in the guinea pig. The extradural approach allows direct visualization of the cochlear aqueduct without manipulation or retraction of the dura, sigmoid sinus, or cerebellum. For experimental studies, which require obliteration of both the endolymphatic sac and cochlear aqueduct, this approach provides improved reliability with reduced morbidity and mortality.

The retrosigmoid approach is utilized in a variety of cerebellopontine angle and internal auditory canal procedures. Drill curettage of the posterior internal auditory canal enhances lateral exposure, however, this step may also increase the patient's risk for postoperative cerebrospinal fluid (CSF) otorrhea. Obliteration of perilabyrinthine air cells is technically difficult and muscle graft displacement frequently occurs. A technique for posterior petrous dural flap stabilization of a temporalis muscle plug has proved successful in decreasing the risk of postoperative CSF fistula following retrosigmoid surgery. Temporal bone air-cell anatomy, as it relates to retrosigmoid, posterior internal auditory canal surgery is reviewed. Our technique for internal auditory canal closure, with bone wax, bone paté, muscle grafts, and petrous ridge dural flaps is outlined.

Orbital spaceflight exposes astronauts to an environment in which gravity is reduced to negligible magnitudes of 10(-3) to 10(-6) G. Upon insertion into earth orbit, the abrupt loss of the constant linear acceleration provided by gravity removes the otolith stimulus for vestibular sensation of vertical orientation constantly present on Earth. Since the central nervous system (CNS) assesses spatial orientation by simultaneously interpreting sensory inputs from the vestibular, visual, and proprioceptive systems, loss of the otolith-mediated vertical reference input results in an incorrect estimation of spatial orientation, which, in turn, causes a degradation in movement control. Over time, however, the CNS adapts to the loss of gravitational signals. Upon return to Earth, the vertical reference provided by gravitational stimulation of the otolith organ reappears. As a result, a period of CNS readaptation must occur upon return to terrestrial environment. Among the physiological changes observed during the postflight CNS readaptation period is a disruption of postural equilibrium control. Using a dynamic posturography system (modified NeuroCom EquiTest), 16 astronauts were tested at 60, 30, and 10 days preflight and retested at 1 to 5 hours, and 8 days postflight. All astronauts tested demonstrated decreased postural stability immediately upon return to Earth. The most dramatic increases in postural sway occurred during those sensory conditions in which both the visual and proprioceptive feedback information used for postural control were altered by the dynamic posturography system, requiring reliance primarily upon vestibular function for control of upright stance. Less marked but statistically significant increases in sway were observed under those conditions in which visual and foot support surface inputs alone were altered.(ABSTRACT TRUNCATED AT 250 WORDS)

Luetic endolymphatic hydrops (LEH) is an effectively treatable disorder that requires astute clinical judgment to suspect, confirm, and treat. We provide a review of the literature as well as recommendations regarding the clinical management of LEH with discussion of several illustrative cases. We also give an overview of laboratory testing for the diagnosis and monitoring of the infectious process. Ultimately, the control of the otologic symptoms in LEH requires acumen on the part of the clinician.

As a new method of testing the righting reflex, which has been considered to be closely related to the otolith function, we used the Auto-Tilt Test (ATT) on 24 patients with positional vertigo, on 5 patients with Meniere's disease before and after cochlearendolymphatic shunt, and on 10 normal subjects. The subject is required to stand on an electrically driven tilt board with an autoregulating switch in hand, and to perform bilateral tilt swings of 5 degrees and 10 degrees wearing a helmet with a Head Inclinometer or tilt sensor. The result of this test in patients with positional vertigo revealed the patients had an abnormal labyrinthine reflex and significantly excessive tilt in the return swing from the side of the lesion. In addition, we consistently observed an inaccurate righting reflex, coupled with a diminished sensation of tilt, on the side of the lesion. The results in Meniere's disease patients, followed up before and after surgery, showed that the depressed righting reflex toward the affected side and the tendency to list to the healthy side before surgery, improved after surgery.

The essential features of the posturing and positional mechanisms in man are defined and the causes of their dysfunction categorized to provide a scheme of surgical management appropriate for each. The authors' long-term results (two to twelve years) with (1) twenty-seven operations designed to decompress the endolymphatic system, (2) twenty-eight selective eighth nerve sections are documented and compared, by means of statistical analysis, with those reported by others during the past fifteen years. Although the latter procedure provided better control of vertigo, there was no difference between the two groups in regard to preservation of hearing. Nor was there any evidence from this study that either operation did anything to alter the progressive hearing loss that characterizes Meniere's disease. Nevertheless, because of failure of noninvasive therapy to control vertiginous symptoms in some patients, it would appear that there is still a definite place for surgical treatment. Saccus decompression is recommended as the initial procedure because it is technically less difficult. In patients whose vertigo persists in conjunction with useful auditory function vestibular nerve section should be considered before resorting to total labyrinthectomy.

Over 250 reports concerning or related to Meniere's disease, published in English from 1978 through 1982, are summarized. Reports have been classified into the categories of incidence of occurrence, analysis and reporting results, pathophysiology, etiologic theories, diagnostic methods, medical management, and surgical procedures. Major emphases in reporting from 1978 though 1982 have been in the areas of pathophysiologic studies, expansion of diagnostic procedures, and the use of sac decompression and neurectomy procedures. This literature review reveals the continuing disagreement regarding the pathophysiology of Meniere's disease and the resultant continued controversies in its management.