14 Surgery for Vertigo Surgical management of vertigo is very seldom indicated nowadays and is performed mainly for patients with Meniere’s disease who have failed management with office-administered intratympanic steroids and/or gentamicin. A recent survey of members of the American Otological Society and the American Neurotology Society indicates that the number of vestibular neurectomies, labyrinthectomies, and endolymphatic sac surgeries has decreased, whereas the use of office-administered intratympanic gentamicin therapy has become the most frequently used treatment for Meniere’s disease.1 Posterior and horizontal canal obliteration is very rarely indicated on patients with benign paroxysmal vertigo who have failed repositioning maneuver and vestibular exercises.2–4 Dizziness arising from other etiologies such as chronic vestibular neuronitis, following sensorineural hearing loss, and temporal bone fracture have also been treated surgically.5 Lastly, surgery may be considered for dizziness secondary to superior canal dehiscence, perilymph fistula, and eighth nerve vascular compression.6–11 The type of surgery for Meniere’s disease depends on several factors, the most important being the status of hearing. These procedures can be classified as either hearing destructive or hearing preservative. What constitutes serviceable hearing is debatable because even severe and profound hearing loss currently can be rehabilitated with cochlear implantation as long as the cochlea remains intact. In general the rule of 50/50 (pure tone average more than 50 dB and discrimination less than 50%) is used. The hearing-destructive procedures include the transmastoid and transcanal labyrinthectomies, which both provide excellent control of vertigo. The transmastoid labyrinthectomy accomplishes complete ablation of the vestibular neuroepithelia of the three semicircular canals and achieves vertigo control in up to 97% of patients.12–16 Patient questionnaires have demonstrated a significant incidence of mild to moderate persisting postoperative disequilibrium in these patients.15 To avoid destruction of the only balanced ear and the ensuing ataxia following this procedure, it is mandatory to evaluate the vestibular function of the opposite ear prior to surgery. Hamid and I have seen cases with vestibular function in the involved side and absent vestibular function on the contralateral side. This is more important for older individuals with other associated disorders such as visual problems, diabetic neuropathy, and arthritis. Transcanal labyrinthectomy is a less extensive procedure and is performed via a tympanostomy. In patients at higher risk for general anesthesia, this procedure can be performed under local anesthesia. After the stapedial footplate is removed, the vestibular neuroepithelia (utricle, saccule) are extirpated. Postoperative imbalance with this procedure, however, has been reported more often than with translabyrinthine labyrinthectomy in older patients.17 The hearing-preservative procedures include mainly the various types of endolymphatic sac surgery and vestibular nerve section. Endolymphatic sac surgery continues to be very controversial and is considered by many to be of doubtful effectiveness. In the early 1980s, Thomsen et al18
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