For patients with refractory Meniere's disease, selective vestibular neurotomy is a surgical alternative to traditional and conservative procedures, such as endolymphatic subdecompression or intratympanic gentamicin injection. The aim of vestibular neurotomy is to control vertigo while preserving hearing function and facial nerve. Thanks to the endoscope magnification and advanced intraoperative neuromonitoring, it is possible to maximize the complete section of vestibular nerve fibers. We present a series of 28 patients who underwent a combined microscopic selective vestibular neurotomy. All patients were previously treated with endolymphatic duct and sac drainage, with no improvements of the symptoms. The results are enlisted as follows. Vertigo disappeared in 26 of 28 patients and improved in one patient. Only one patient remained unchanged, probably because of the incomplete vestibular nerve section. Two complications occurred, CSF leakage, solved by a surgical revision, and skin infection. Walter Dendy first recognized the possibility to perform a selective vestibular nerve section via the posterior fossa. Nonetheless, because of the associated morbidity and mortality, this procedure could not gain a widespread acceptance. In recent years, endoscopy and intraoperative neuromonitoring paved the way for this surgical treatment. The aim of surgery is to reach a complete section of vestibular nerve while sparing cochlear and fascial nerves. Indeed, an incomplete vestibular deafferentation results in a failure to control vertigo after surgery. Simulation of the vestibular nerve after resection is useful to demonstrate deafferentation. Presigmoid retrolabyrinthine approach provides a direct access to the CPA with minimal cerebellar retraction. Furthermore, it is possible to obtain a better working angle for vestibular nerve section toward the fifth nerve and to identify early and better the fascial nerve. Since all of our patients were previously submitted to DASD, part of the approach path was already created. The presigmoid retrolabyrinthine approach may offer a surgical corridor with a direct view on the vestibular nerve section area with a clearer visualization of anatomic landmarks. These images show in the same patient the most anterior and posterior surgical routes as if to simulate a pre- and retrosigmoid approach respectively. The success of the vestibular neurotomy depends on the identification of the cleavage plane between the cochlear and vestibular components of the eighth nerve, marked by the presence of a small vessel and by a chromatic difference of the two nervous components. The key point of vestibular nerve section is to perform it as close as possible to the brain stem, where the two eighth nerve components are disjointed and the vestibular fibers are directed toward the fifth nerve. An intraparative video is illustrated. Thanks to the endoscopic magnification, it's possible to see the dendivane and the mixed nerve complex. Here, the dissection is shown, also performed thanks to a water-jack dissection. And the final results. The selective vestibular neurotomy via presigmoid retrolabyrinthine approach is a safe procedure for intractable menial disease with a serviceable ERM function. This procedure is characterized by a low rate of complications and about 90% vertigo control after surgery. The use of endoscope technique and intraparative neuromonitoring may guarantee a complete selective vestibular neurotomy. For a successful procedure, a complete defermentation of all vestibular nerve fibers is mandatory.

selective vestibular neurotomy

Meniere's disease

surgical option

vertigo control

hearing preservation