Vestibular Neurectomy

Complete ablation of the peripheral vestibular apparatus or de-afferentation by sectioning of the vestibular nerve leads to total loss of function on one side, which can then be effectively compensated by central mechanisms. This aims to bring about a constant and long-lasting state of equilibrium that would not be possible if the vestibular input were fluctuating.

Indications for vestibular neurectomy are as follows:

• Intractable Meniere disease

• Recurrent vestibular neuronitis

• Traumatic labyrinthitis

The most common indication for vestibular neurectomy is Meniere disease not responding to medical treatment for over 6 months and causing incapacitating attacks of vertigo.

In unilateral Meniere disease, patients with functional hearing are treated by vestibular neurectomy via the middle fossa ^[1] or posterior approaches, whereas those with profound hearing loss may be offered translabyrinthine cochleovestibular neurectomy.

In bilateral Meniere disease, the surgery is done on the worse side, while some centers may also perform the surgery bilaterally.

Contraindications  for vestibular neurectomy are as follows:

• Only hearing ear

• Central vestibular dysfunction

• Poor medical condition

• Age more than 70 years is a relative contraindication.

Outcomes

Although vestibular neurectomy has the highest success rate among all the different surgical procedures performed for the treatment of Meniere disease (the others being sac decompression with shunting, cochleosacculotomy, and labyrinthectomy), recurrent vertigo may occur due to various causes such as incomplete nerve section, neuroma formation, unsatisfactory compensation processes, vestibular dysfunction in the contralateral ear, nerve regeneration, and failure to diagnose nonotologic vertigo. ^[2] Also, vestibular neurectomy, and also the other surgical procedures, produce better results in correctly diagnosed Meniere disease than in other vestibular causes of vertigo. ^[2]

Counseling plays a major role in both the preoperative and postoperative phases because patients more or less exchange spontaneous vertigo for a constant sense of disequilibrium, overall reducing the quality of life. In cases of TLVNS, any residual hearing, however poor, is sacrificed, and the patient must accept this outcome as well. ^[2]

Other factors, such as advanced age (which may hinder central compensatory mechanisms), contralateral tinnitus, the onset of vertigo as the first symptom in Meniere disease, and the presence of eye disease, are also associated with poorer results following surgery. ^[2]