Labyrinthectomy: Our Experience in a Tertiary Care Centre

Abstract

Labyrinthectomy is an effective surgical procedure for the management of poorly compensated unilateral peripheral vestibular dysfunction in the presence of a nonserviceable hearing. It involves removal of labyrinthine portion of the inner ear and exenteration of the neuroepithelium. In our institution, 8 cases underwent surgical labyrinthectomy from a period of 2013–2018 for various extensive disease manifestations, age ranges from 2 to 48 years. Includes, a child of 2 years age presented with bilateral foul smelling otorrhoea with external auditory canal cartilaginous stenosis, 5 cases of extensive cholesteatoma with labrynthitis and 2 cases of purulent labrynthitis among them 1 were suffering from Tuberculosis and was on Category 1 ATT and other one suffering from extensive granulation at the tympanomastoid area which was inconclusive of the diagnosis even after histopathological examination, so treated as tuberculosis and started on prophylactic antitubercular treatment in addition to surgery. All patients except the child gave past history of giddiness, but at the time of presentation they were not having giddiness or noticeable nystagmus and all had profound unilateral sensorineural hearing loss. Thus all the patients underwent a radical mastoidectomy with total labyrinthectomy and blind sac closure in 2 patients.

Introduction

Labyrinthectomy is a destructive process involving the complete removal of the labyrinthine portion of the inner ear and exenteration of the neuroepithelium in an attempt to eliminate vertigo and to allow the central compensation process to take over. It is performed unilaterally mainly for the management of poorly compensated vestibular dysfunction in the presence of a nonserviceable hearing. Jansen in 1895 was the first to describe ablation of labrynth during radical mastoidectomy for suppurative labrynthitis. In 1904 Lake described the use of the transmastoid labyrinthectomy for control of vertigo. Cawthorn reported a wall up mastoid approach for labyrinthine ablation [1].

Labyrinthectomy is done in cases of Purulent labyrinthitis, Extensive cholesteatoma involving petrous apex and labyrinth, Malignant lesions, Vestibular vertigo without serviceable hearing, First step of approach to the internal auditory canal (Fig. 1).

Fig. 1.

a Showing aural atresia; b showing purulent discharge from the ear

Most cholesteatomas are located in the aerated spaces of the middle ear and mastoid. A small percentage of Cholesteatomas may invade the petrous part of the temporal bone. These are either congenital or acquired lesions. Many Petrous bone lesions grow silently and erode important structures such as the inner ear, the internal carotid artery, the facial nerve or tegmen or sinus plates with intracranial complications. Once symptomatic, often present with severe clinical signs, such as deafness, facial nerve palsy, or central neurologic complications [2, 3].

Following cases will high light the importance of early detection and timely management and the importance of surgical decision of labyrinthectomy in those extensive disease conditions, resulting in a favourable outcome and lesser complications.

Clinical Data

In our institution, 8 cases underwent surgical labyrinthectomy from a period of 2013–2018 for various extensive disease manifestations, age ranges from 2 to 48 years. Includes, a child of 2 years age presented with bilateral foul smelling otorrhoea with external auditory canal cartilaginous stenosis, 5 cases of extensive cholesteatoma with labrynthitis and 2 cases of purulent labrynthitis among them 1 were suffering from Tuberculosis and was on Category 1 ATT and other one suffering from extensive granulation at the tympanomastoid area which was inconclusive of the diagnosis even after histopathological examination, so treated as Tuberculosis and started on prophylactic antitubercular treatment in addition to surgery. All patients except the child gave past history of giddiness, but at the time of presentation they were not having giddiness or noticeable nystagmus and all had profound unilateral sensorineural hearing loss (Fig. 2).

Fig. 2.

1 Showing presence of extensive cholesteatoma; 2 removal of the stapes; 3 removal of sequestra from the inner ear; 4 CSF leak repair by soft tissues; 5 plugging the cavity with soft tissues; 6 placement of temporalis fascia graft

Work Up

All patients underwent a detailed thorough clinical and radiological evaluation. Detailed history, otoscopic and microscopic examination of the ear was done. Aural toileting was also done. Audiometry, HRCT temporal bone and CT scan of the brain, routine blood investigations and serological tests were done.

All patients were put on broad spectrum parenteral antibiotics covering gram positive, negative and anaerobic infections before taken up for surgery.

Surgery

All 8 patients with extensive diseases underwent radical mastoidectomy in which canal wall down mastoidectomy and complete obliteration of the Eustachian tube opening and total surgical labyrinthectomy (removal of all the 3 semicircular canals, vestibule and cochlea), followed by obliteration of the cavity and temporalis fascia grafting. The obliteration of the cavity was done with free soft tissue and post auricular pedicled graft as done in routine canal wall down mastoidectomy to reduce the overall size of the cavity. Sequestrae were noted in the vestibule in 3 cases and were removed completely (Fig. 3).

Fig. 3.

Showing postoperative picture

Extensive granulation tissue and soft tissue was seen involving all the 3 semicircular canal, vestibule and cochlea was present, no well differentiation of scala vestibule, scala media and scala tympani were noticed, as everything is converted into a soft tissue mass. In 5 cases necrosed malleus and incus were seen and in 3 cases noticed necrosed, displaced stapes within the vestibule on removal of these soft tissues. The cavity was drilled superiorly from the level of tegmen tympani and tegmen mastoid up to the Jugular bulb inferiorly, anteriorly from the level of internal carotid artery up to the sigmoid sinus. At the end of the procedure in the cavity the facial bony canal seen as a bridge across the whole cavity, from the geniculate ganglion area up to the stylomastoid foramen (pic). While drilling cochlear area, CSF leak was noticed in 2 patients which was plugged with fibrofatty tissue followed by blindsac closure of the external auditory canal. Child underwent surgery bilaterally.

Postoperatively patient was put on higher antibiotics, canal pack was removed on the 14th day and no evidence of any meningitis or meningism. Patient was followed up the next 6 months, weekly for the first 1 month then biweekly and then monthly. All patients presented with a well healed cavity at the end of 6 months and no patients complained of any giddiness.

Discussion

Labyrinthectomy is the destructive surgical procedure which is done when there is a poor peripheral vestibular dysfunction with a nonservicable hearing. Knowing the anatomy and physiology of the inner ear is crucial in labyrinthectomy. Removal of vestibular function is a highly efficacious option in the treatment of disabling vertigo arising from unilateral labyrinthine dysfunction. Regardless of the method used to ablate vestibular function, permanent post treatment impairment of the balance function will develop in a number of patients. Many surgeons are reluctant to recommend or perform a vestibular procedure, because this treatment may result in permanent disequilibrium, which may be more detrimental especially to the older patient than the episodic vertigo.

Two of the surgical options that exist for the treatment of disabling vertigo arising from an ear with nonserviceable hearing are a transmastoid labyrinthectomy and a translabrynthine vestibular nerve section [4, 5].

Literature explains posterior labyrinthectomy as removal of all the 3 semicircular canals along with the vestibule. We are performing a cochleotomy, that is, there is removal of the cochlea through transcanal approach and joining the 2 windows. In our study we also did total labyrinthectomy or subtotal petrosectomy in which all the 3 semicircular canals, vestibule and cochlea is done, along with this radical mastoidectomy is performed which involves canal wall down mastoidectomy with complete obliteration of the Eustachian tube opening and blind sac closure, that is complete obliteration of the external auditory canal was done.

Labyrinthectomy can be performed through either transcanal or transmastoid approach. It is the systematic removal of the labrynth preventing injury to the facial nerve. On drilling anatomical landmarks like the dome of the superior semicircular canal, superior aspect of the lateral semicircular canal and ampulla of the posterior semicircular canal, is kept as check points to prevent injury to the labyrinthine segment, Genu and vertical portion of the facial nerve respectively. Care must be taken while drilling and it should be done below to the facial canal.

Labyrinthectomy is performed commonly for the control of the vestibular disorders with a nonserviceable hearing. Cholesteatomas are the diseases which most commonly involves the middle ear cleft. The presence of extensive granulations in this time of antibiotic era is not that common. Most of the surgeons need not have witnessed such an extensive disease extending into the inner ear.

In our institutional study, we have experienced an extensive granulation tissue, soft tissue and purulent labrynthitis which are extending up to the inner ear. The child presented with bilateral disease and stenosis of the cartilaginous external auditory canal. Thus all the patients underwent a radical mastoidectomy with total labyrinthectomy and blind sac closure in 2 patients.

Author Contributions

IVG: Contributed to the design of study, collected samples, did data analysis and drafted the manuscript. Corresponding author for the manuscript. KCP: Contributed to the design of study, data analysis, helped frame and edited the manuscript. TRH: Contributed to the design of study, data analysis, helped frame and edited the manuscript; BAK: Contributed to the design of study, data analysis, helped frame and edited the manuscript. PK: Contributed to the design of study, data analysis, helped frame and edited the manuscript. VP: Contributed to the design of study, data analysis, helped frame and edited the manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors declare no conflict of interest or commercial affiliation related to this study.