Anatomy of the transmastoid endolymphatic sac decompression in the management of Ménière’s disease.

Ménière’s disease affects 1 in 1000 people and produces vertigo and hearing loss (Morrison, 1981). Endolymphatic sac decompression has been advocated on the basis that endolymphatic hydrops is the underlying pathology. The endolymphatic sac is said to be the terminal dilatation of the membranous labyrinth. It has been proposed that endolymph flows from the semicircular canals and cochlea to the endolymphatic sac. Portman (1927) devised a procedure for ‘decompressing’ the endolymphatic sac by removal of the bone from the posterior cranial fossa to relieve the symptoms of Ménière’s disease. Surgery on the endolymphatic sac remains controversial. Shea (1979) and Bagger-Sjöbäck et al (1990, 1993) have studied the endolymphatic sac using different techniques. There are discrepancies in the results between the two studies. The hypothesis that the endolymphatic sac can be safely approached and decompressed by a transmastoid route was tested. A total of thirteen cadaver heads and ten isolated temporal bones were used. A series of dissections were performed to examine the endolymphatic sac, perform measurements and analyse surgical approaches to the sac. Histological and electron microscopic study were performed. The lumen of the endolymphatic sac was not always identifiable in the dura of the posterior cranial fossa or it frequently lay over the sigmoid sinus. In the dura of the posterior cranial fossa where the endolymphatic sac is located was a thickening of the dura. This thickening was present even in the absence of the endolymphatic sac. The endolymphatic sac can be safely approached by a transmastoid approach, if there is an extraosseous component to the endolymphatic sac. The proximal endolymphatic sac can be approached by posterior cranial fossa route