(14.3)--E2017+SFORL指南：梅尼埃病的诊断和治疗策略.pdf
Please cite this article in press as:Nevoux J,et al.Diagnostic and therapeutic strategy in Menires disease.Guidelines of the FrenchOtorhinolaryngology-Head and Neck Surgery Society(SFORL).European Annals of Otorhinolaryngology,Head and Neck diseases(2016),http:/dx.doi.org/10.1016/j.anorl.2016.12.003ARTICLE IN PRESSG ModelANORL-631;No.of Pages 4European Annals of Otorhinolaryngology,Head and Neck diseases xxx(2016)xxxxxxAvailable online atScienceDSFORL GuidelinesDiagnostic and therapeutic strategy in Menires disease.Guidelinesof the French Otorhinolaryngology-Head and Neck Surgery Society(SFORL)J.Nevouxa,V.Franco-Vidalb,D.Bouccarac,C.Parietti-Winklerd,A.Uziele,A.Chaysf,X.Dubernardf,V.Couloignerg,V.Darrouzetb,T.Momh,on behalf of Groupe de Travailde la SFORLaService ORL et chirurgie cervico-faciale,78,avenue du Gnral-Leclerc,94275 Le Kremlin-Bictre,FrancebService ORL,hpital Pellegrin,universit de Bordeaux,33076 Bordeaux,FrancecInserm UMRS 1159,service ORL,universit Pierre-et-Marie-Curie,CHU Piti-Salptrire,APHP,75013 Paris,FrancedService ORL,CHU de Nancy,EA 3450 DevAH,universit de Loraine,54035 Nancy,FranceeService ORL,hpital Gui-de-Chauliac,CHU de Montpellier,34090 Montpellier,FrancefService ORL et chirurgie de la face et du cou,CHU de Reims,Reims,FrancegService dORL pdiatrique et de chirurgie cervico-faciale,149,rue de Svres,75015 Paris,FrancehInserm UMR 1107,service ORL,laboratoire de biophysique neurosensorielle,universit dAuvergne,CHU Gabriel-Montpied,Clermont-Ferrand,Francea r t i c l e i n f oKeywords:Menires diseaseDiagnostic criteriaDiagnostic testsTreatmenta b s t r a c tObjectives:The authors present the guidelines of the French Otorhinolaryngology-Head and Neck SurgerySociety(Socit franc aise doto-rhino-laryngologie et de chirurgie de la face et du cou:SFORL)for diagnosticand therapeutic strategy in Menires disease.Methods:A work group was entrusted with a review of the scientific literature on the above topic.Guide-lines were drawn up,then read over by an editorial group independent of the work group.The guidelineswere graded according to the literature analysis and recommendations grading guide published by theFrench National Agency for Accreditation and Evaluation in Health(January 2000).Results:Menires disease is diagnosed in the presence of the association of four classical clinical items andafter eliminating differential diagnoses on MRI.In case of partial presentation,objective audiovestibulartests are recommended.Therapy comprises medical treatment and surgery,either conservative or sac-rificing vestibular function.Medical treatment is based on lifestyle improvement,betahistine,diureticsor transtympanic injection of corticosteroids or gentamicin.The main surgical treatments,in order ofincreasing aggressiveness,are endolymphatic sac surgery,vestibular neurotomy and labyrinthectomy.2016 Elsevier Masson SAS.All rights reserved.1.IntroductionThe etiology of Menires disease remains unknown and diag-nosis,which is basically clinical,tends to be over-inclusive,withoutrespecting established criteria.Criteria were first laid out more than20 years ago,by the AAO-HNS 1(level of evidence 4),and weremodified in 2015 by an extended consensus between internationalscientific societies 2(level of evidence 4).To help practitionersin this difficult diagnosis and in assessing severity,complementaryCorresponding author.Inserm UMR 1107,service ORL,universit dAuvergne,CHU Gabriel-Montpied,53,rue Montalembert,63003 Clermont-Ferrand cedex 1,France.E-mail address:tmomchu-clermontferrand.fr(T.Mom).examinations,mainly screening for underlying hydrops(which isfrequent),have been developed.Treatment is varied,and efficacyhard to assess.Treatment may be medical,or surgical,either con-servative or sacrificing vestibular function with risk,in some cases,for cochlear function.The present guidelines are intended for all ENT physicians liablefind themselves managing a patient with Menires disease.Theobjectives are three-fold:making the diagnosis,selecting appro-priate tests to confirm diagnosis and monitor treatment efficacy,and selecting the treatment option best suited to the patient.Weconsidered it particularly important:to clarify the diagnostic criteria for the disease so as to preventover-diagnosis in patients with heterogeneous and incompletehttp:/dx.doi.org/10.1016/j.anorl.2016.12.0031879-7296/2016 Elsevier Masson SAS.All rights reserved.Please cite this article in press as:Nevoux J,et al.Diagnostic and therapeutic strategy in Menires disease.Guidelines of the FrenchOtorhinolaryngology-Head and Neck Surgery Society(SFORL).European Annals of Otorhinolaryngology,Head and Neck diseases(2016),http:/dx.doi.org/10.1016/j.anorl.2016.12.003ARTICLE IN PRESSG ModelANORL-631;No.of Pages 42 J.Nevoux et al./European Annals of Otorhinolaryngology,Head and Neck diseases xxx(2016)xxxxxxpresentations(level of evidence 4),and also to rule out differentialdiagnoses(level of evidence 4);to inform practitioners in selecting instrumental tests that willbe useful and contributive or essential to paraclinical work-up.Such tests should meet two objectives:screen for hydrops 36(level of evidence 2),which is usuallyassociated and requires specific treatment,assess cochlear and vestibular involvement at a given time-point in disease progression,bearing in mind the widefluctuations that are characteristic 2(level of evidence 4);to specify the respective roles of the various treatment modal-ities,both destructive and conservative 7,8(level of evidence2),medical and surgical,according to disease stage and possiblebilateral involvement;this should include possible physiother-apy or psychotherapy 9(level of evidence 1).A national work group was entrusted with drawing upguidelines for Diagnostic and Therapeutic Strategy in MeniresDisease.The French Health Authority(HAS)formalized expertconsensus methodology for good practice guidelines was used(http:/www.has-sante.fr).A pilot group organized the logisticsof the consensus conference,and choice of members of the edi-torial group performing the literature analysis by means of thePubMed database.Each retrieved article was graded A,B,C or“expert opinion”according to decreasing level of evidence,in linewith the guide to literature analysis and recommendations gradingof the French National Health Evaluation and Accreditation Agency(ANAES).Based on a written rationale,an initial series of guide-lines was drawn up and then assessed by the editorial group andmodified in line with the results and comments received.2.Results2.1.1 Diagnosis of Menires diseaseDiagnosis of Menires disease is clinical,based on simple crite-ria associated to presumed presence of endolymphatic hydrops.Itis first of all essential to distinguish between“definite”and“proba-ble”Menires disease.In the opinion of the experts,vertigo crisesassociated with hearing loss are preconditions for any diagnosis ofMenires disease.“Definite”Menires disease is to be diagnosed in the absence ofother identified cause and presence of an association of the follow-ing 4 clinical signs(Expert opinion):vestibular signs:at least 2 rotational vertigo episodes last-ing between more than 2 minutes and 12 hours,or Tumarkinsotolithic crises(drop attacks without initial loss of conscious-ness);auditory signs:low frequency(2 kHz)hearing loss on twocontiguous frequencies,of at least 30 dB in case of normal con-tralateral hearing or at least 35 dB in case of bilateral hearing loss,on an audiogram performed during or after a crisis;these signsmay occur several months or years before onset of vertigo;other otologic signs:tinnitus or aural fullness;fluctuating otologic signs.It is important to bear in mind that endolymphatic hydropsmay be primary,in which case the term Menires disease is fullyappropriate,or may be secondary to a potentially severe pathologyrequiring specific treatment.Menires disease should be diagnosed only after ruling outdifferential diagnoses of tumor(cerebellopontine ngle or endolym-phatic sac tumor),deformity(Chiari malformation)or degenerativeinflammatory pathology(multiple sclerosis)on MRI of the posteriorfossa and cervico-occipital hinge on axial and sagittal slices withand without contrast enhancement,and including high-resolutionT2-weighted 3D acquisitions(Expert opinion).In“probable”Menires disease,incomplete symptomatologyleaves diagnosis uncertain,and certain objective paraclinicalexaminations that have shown specificity in definite forms are con-tributive.In case of suggestive but incomplete clinical presentation(“probable”or merely hypothetical Menires disease),beforescreening for hydrops or intralabyrinthine pressure or volumedefect,some or all of the following objective audiovestibularexplorations should be performed(Grade B):multifrequencyadmittancemetry,and/or acoustic phase-shift test using transientotoacoustic emissions(TOAEs)and/or distortion product OAEs(DPOAEs),and/or electrocochleography to assess the summatingpotential/action potential ratio(SP/AP).Positive findings demon-strate intralabyrinthine pressure regulation disorder.Before informing the patient of the diagnosis and setting upadapted treatment,it is essential to check progression status andespecially the size of any lesions already present in the vestibuleor cochlea,even if measured deficits are fluctuating.Instrumentalassessment should be backed up by functional and quality-of-lifeassessment,going beyond simply counting the number of crises.The 1995 AAO-HNS Functional Level Scale(Appendix 1)assessesseverity in 6 levels 1(Expert opinion),and a French version hasbeen validated 2(Expert opinion).When definite Menires disease is diagnosed,pre-treatmentinstrumental assessment should be performed,including at leastcomplete pure-tone and speech audiometry and videonystagmog-raphy with calibrated caloric test(Expert opinion);preferably,vestibular evoked myogenic potentials(VEMP)and a video headimpulse test(VHIT)should be associated,if available.Disabilityshould be assessed on the validated Functional Level Scale to quan-tify disease impact on quality of life,before treatment and tomonitor efficacy 1.2.2.Treatments for Menires diseaseDrawing up therapeutic guidelines was hampered by the lowlevel of evidence of studies in the international literature.Theauthors therefore chose to detail pros and cons for each treat-ment,before recommending indications.No fixed decision-tree,however,could be drawn up.We can only recommend determin-ing the patients complaints as clearly as possible and assessingglobal health status so as to guide optimal treatment,which shouldinitially comprise the most functionally conservative interventions.2.3.Medical treatments for Menires diseaseThere are many kinds of maintenance therapy in Meniresdisease,and they can be classified into main families.Initialmanagement should include lifestyle counselling.Next come thevarious types of conservative therapy;here we shall discussbetahistine,diuretics,and general route or intratympanic cortico-steroids;then transtympanic gentamicin,a destructive treatment,will be dealt with.Adjuvant treatments,such as physiotherapy and psychotherapyare important and will be dealt with independently.Finally,it isessential to compensate hearing loss,but this is a challenge for allthose involved in managing a patient with Menires disease:ENTspecialist,hearing-aid specialist and speech therapist.It is important that the strategy should be adapted not only tosymptom severity but also to global health status(Expert opinion).It is essential that first-line treatment should conserve vestibularfunction,keeping destructive treatments as a last resort 7,8 Please cite this article in press as:Nevoux J,et al.Diagnostic and therapeutic strategy in Menires disease.Guidelines of the FrenchOtorhinolaryngology-Head and Neck Surgery Society(SFORL).European Annals of Otorhinolaryngology,Head and Neck diseases(2016),http:/dx.doi.org/10.1016/j.anorl.2016.12.003ARTICLE IN PRESSG ModelANORL-631;No.of Pages 4J.Nevoux et al./European Annals of Otorhinolaryngology,Head and Neck diseases xxx(2016)xxxxxx 3(Expert opinion).Finally,it is essential to identify the patientscomplaint precisely,so as to adapt treatment(Expert opinion).The first“treatment”to initiate is lifestyle counselling.A healthier lifestyle should be encouraged,while making sure,on a case-by-case basis,that the rules are not so strict as to jeop-ardize psychological well-being.Nutritionally,excess salt is to beavoided,and a low-salt diet should be adopted if possible(Expertopinion).It is recommended to limit stimulants,and especially caf-feine(Grade C).Sleep disorder,and notably sleep apnea syndrome,should be screened for;in case of obstructive sleep apnea syn-drome,nocturnal positive pressure ventilation can improve hearingand reduce vestibular disability(Grade B).To minimize the clini-cal impact of symptoms,patients should be advised to adhere to aregular sleep cycle with sufficient sleep time(Grade C).Betahistine is probably the most widely prescribed mainte-nance therapy for Menires disease in France.Its contraindicationsshould be borne in mind:pheochromocytoma,acute gastroduo-denal ulcer,and hypersensitivity to a component of betahistine10.Betahistine should be prescribed as first-line maintenance ther-apy,as it can act on the endolymphatic sac and shows fewcomplications(Grade C).The authorized dose in France is 48 mgper day,in two doses(official market authorization);however,thisdose has no proof of efficacy,and higher doses are presently beingtested.Diuretics are also widely used in Menires disease,to reducehydrops by inducing urine flow to help deflate the fluid com-partments.A recent review of the literature on their efficacy inMenires disease found only studies with low levels of evidence11(level of evidence 4),which did,however,indicate improve-ment in vertigo and,to a lesser degree,hearing.Diuretic therapy can be recommended to improve vertigo sym-ptomatology(Grade C).The minimal effective dose is to be adjustedaccording to body-weight and kalemia,fractioning the dose over24 hours(Expert opinion).It is essential to check for risk factors:notably,hypersensitivity to an active molecule or excipient,whichconstitutes a definitive contraindication.Likewise,acetazolamideshould not be prescribed in case of history of nephritic colic or sul-famide intolerance.Kalemia should be normal before prescription,and regularly monitored throughout treatment.Oral corticotherapy is often used,but there are few studiesdemonstrating efficacy,and their level of evidence is low 12(level of evidence 3).A recent Cochrane review of randomized com-parative studies showed efficacy for intratympanic corticosteroidinjection 13(level of evidence 2).According to the authors of themost significant study,injection should be once daily for 5 consec-utive days 14(level of evidence 2),which was also shown to benon-ototoxic 15(level of evidence 1).Transtympanic corticosteroid injection can be used when oralmedication proves i
