The authors thank Isobel Bowring for proofreading the article, and Nele Ruysschaert for the help with information on the anesthesia.

This protocol is used for a randomized controlled trial that is currently being carried out in the Netherlands. The trial compares endolymphatic duct blockage (EDB) to endolymphatic sac decompression (ESD)9. The protocol was approved by the medical ethics committee METC Leiden-Den Haag-Delft (number P20.118) and the board of the hospital, as well as the hospital&#39;s research ethics committee (Haga Hospital Research Board, T20-108). All patients who participated in the trial where this protocol is followed have provided written informed consent.&#160;The results of this trial are expected in late 2024.
1. Preoperative procedures
<ol>
	<li>Patient selection
	<ol>
		<li>Verify that all the diagnostic criteria for definite Meniere&#39;s disease according to the AAO-HNS criteria are met1. To be included in this study, select patients who have suffered more than three attacks in the previous 6 months. The attacks must meet the diagnostic criteria of an attack1.</li>
		<li>Rule out all the criteria of vestibular migraine reported by the consensus of the B&#225;r&#225;ny Society and the International Headache Society10.</li>
		<li>Due to its invasive nature, only consider this treatment in patients who have failed conservative treatment. This includes at least two intratympanic injections with (any type of) steroid and at least 6 weeks apart.</li>
		<li>In case of deafness of the contralateral ear, carefully consider this treatment option, as the effect of this surgery on hearing is not clear. This was reported to concern 2% of the patients by Saliba et al.5</li>
	</ol>
	</li>
	<li>Informed consent
	<ol>
		<li>Inform the patient about: potential benefits: reduction of vertigo attacks; risks: general risks of surgery (bleeding, wound infection, risks of general anesthesia), damage to the inner ear (deafness, disequilibrium), facial nerve damage, cerebrospinal fluid (CSF) leakage, and meningitis; and unknowns: effect on hearing loss, tinnitus, and aural fullness are currently unknown. The procedure seems to spare hearing function5,11, but the literature is limited.</li>
	</ol>
	</li>
	<li>Preoperative testing
	<ol>
		<li>Perform an MRI scan to rule out a retro-cochlear lesion, a CT scan, a hearing test (PTA), and electrocochleography preoperatively. Consider performing vestibular tests if the patient has complaints of chronic vertigo related to head movement.</li>
		<li>Check the CT scan for anomalies in the area of surgery, such as a high-riding jugular bulb. If a high-riding jugular bulb is present, this should be taken into account when operating. Also, assess the course of the vestibular aqueduct.</li>
	</ol>
	</li>
	<li>Consider using an operation room that is equipped with a CT scan.</li>
</ol>
2. Operative procedures
<ol>
	<li>Setting up the operation room
	<ol>
		<li>Place the anesthesia unit at the foot end of the patient to avoid problems with the CT scan.</li>
		<li>Place the control panel of the intraoperative neuromonitoring system as far away from the head of the patient as possible to avoid problems with the CT scan.</li>
	</ol>
	</li>
	<li>Perform regular safety checks and induce general anesthesia.
	<ol>
		<li>Using target-controlled anesthesia (TGA), administer propofol (2.5-4 mcg/mL) and remifentanil (0.3-0.5 mg/kg).</li>
		<li>Administer a low dose of the muscle relaxant rocuronium (0.3-0.5 mg/kg), as the facial nerve monitor is used during surgery.</li>
		<li>Intraoperatively, administer 4 mg of ondansetron and 4 mg of dexamethasone to prevent nausea postoperatively.</li>
		<li>Monitor the depth of anesthesia based upon hemodynamics-pulse, blood pressure, and CO2.</li>
		<li>Prepare analgesics to be administered at the end of surgery: 1 g of metamizole or 75 mg of diclofenac.</li>
	</ol>
	</li>
	<li>Position the patient as for a mastoidectomy: rotate the head to the contralateral side (45&#176; maximum) with the neck slightly in flexion.</li>
	<li>Preparation for surgery
	<ol>
		<li>If necessary, shave any hair around the ear. Check to confirm if the tympanic membrane is intact.</li>
		<li>Sterilize the outer ear, the external ear canal, and the skin around the ear with chlorohexidine or povidone. Infiltrate the retro-auricular skin with 2% lidocaine/1:80,000 adrenaline.</li>
		<li>Cover the patient with sterile sheets, leaving the surgery area free.</li>
	</ol>
	</li>
	<li>Surgery
	<ol>
		<li>Make a retroauricular incision of 7-8 cm just behind the auricle using a scalpel. Spread the subcutaneous layers until the temporal muscle is visible at the cranial side.</li>
		<li>Make a Palva flap (anterior based) by making a U-shaped incision to the petrous bone. Be careful not to damage the temporal muscle.</li>
		<li>Using forceps and a raspatorium, peel the periosteum off the cortex until the external auditory canal is found.</li>
		<li>Position two spreaders in the tissue layers so that the petrous bone is exposed. Place the spreaders in a position such that their handles are away from the operation site.</li>
		<li>Perform a canal wall up mastoidectomy using the burrs. Form a triangle and burr through the cortex and identify the mastoid cells. Identify the sigmoid sinus (caudal) and dura (cranial) as landmarks.</li>
		<li>Identify the dura of the posterior fossa and the curvature of the horizontal vestibular canal. Identify the posterior semicircular canal (PSCC) and the dura mater of the posterior fossa.</li>
		<li>Identify the prominence of the horizontal semicircular canal (HSCC) to determine Donaldson&#39;s line, to approximate the position of the ES (see Figure 1).</li>
		<li>Thin the bone over the sac and the dura with diamond burrs and skeletonize the ES completely.</li>
		<li>Remove the remaining bone and expose the dura. Using an elevator, lift the dura toward the brain, exposing the medial side of the posterior canal. Identify the ES caudally as a flat, thick, white structure. The medialization of the dura exposes the ED somewhere in Donaldson&#39;s line, where it connects with the sacculus and utriculus. 
		NOTE: Be careful not to damage the duct. If the duct is damaged or ruptured, use fascia or donor pericardium to plug the leak.</li>
		<li>Using the elevator, create a site to insert the tip of the instrument to clip the duct. At this level, in order to prevent any CSF leak, take care not to traumatize the dura, which is often thin.</li>
		<li>Using an elevator, try different clip sizes to determine which clip fits best. 
		NOTE: Thinning of the bone over the sigmoid sinus may be necessary to allow introduction of the clip instrument.</li>
		<li>If a CT scan is available in the operation room, follow the subsequent steps.
		<ol>
			<li>Without closing the clip, perform a CT scan. Cover the patient with a sterile cover. Position the scan so that the complete skull is scanned.</li>
			<li>Choose the protocol 20sDCT Head Micro under 3D head and follow the activate stand movements.</li>
			<li>Choose skull base and set up in the caudal-cranial direction. Follow the necessary 3D activate stand movement steps.</li>
			<li>After performing the scan, open Preset gallery and go to Head and neck. Select the preset DynaCTHead Petrosa.</li>
			<li>Assess the images to decide whether the clip is in the correct position. Do not forget to send the images to the patient file.</li>
			<li>If the clip is not placed correctly over the ED, replace the clip and/or consider using another size.</li>
			<li>Repeat step 2.5.12.2-2.5.12.6 of the CT-scan to assess the new clip position until satisfactory.</li>
		</ol>
		</li>
		<li>Remove the clip with an elevator and place the clip in the clip applier. Place the clip over the ED and close the clip. 
		NOTE: Clipping of the duct causes traction on the involved structures and may lead to tearing of the dura. If CSF leakage occurs, use fibrin sealant and fascia or donor pericardia to close the tear in the dura.</li>
		<li>Consider using a second clip to ensure the duct is tightly blocked. Ensure that the clips are positioned at the correct location and (completely) block the ED. If there is no CT scan available, check the clip position following the subsequent steps.
		<ol>
			<li>Make an incision along the inferior edge of the ES, starting from the posterior site of the newly positioned clip toward the sigmoid sinus using a knife.</li>
			<li>If the incision opens the sac, this confirms the correct placement of the clip. If a CSF leak is observed, continue the dissection medially in order to localize the sac.</li>
			<li>Repeat this procedure until correct placement of the clip is confirmed.</li>
		</ol>
		</li>
		<li>Completion of surgery
		<ol>
			<li>Close the tissue in layers, close the Palva flap and the subcutaneous layer using an absorbable polyfilament suture (70 cm), and close the skin with an absorbable monofilament suture by applying a subcutaneous continuous suture (70 cm).</li>
			<li>Cover the closed skin with plasters and a bandage. Wrap one bandage around the head to keep the plasters in place.</li>
			<li>Administer the analgesic that was prepared in step 2.2.5.</li>
		</ol>
		</li>
	</ol>
	</li>
</ol>
3. Postoperative care
<ol>
	<li>Examination of the patient after surgery
	<ol>
		<li>Determine if nystagmus is present. If spontaneous nystagmus is present, determine whether the fast phase is toward the operated ear or toward the contralateral side. If the fast phase is in the direction of the operated side, this indicates hyperexcitation of the operated ear and may be due to stimulation of the labyrinth from the surgery. This nystagmus is expected to fade out. If the fast phase is in the direction of the non-operated ear, this may indicate loss of function of the operated ear.</li>
		<li>Scratch the bandages to screen for loss of cochlear function. If the scratching on the operated side is not heard, and loss of hearing is suspected, consider administering steroids (1 mg/kg/day) for 7 days.</li>
		<li>Consider performing a bone conduction hearing on the day after surgery. If hearing loss is noticed, consider administering steroids (1 mg/kg/day) for 7 days.</li>
		<li>In case of pain, prescribe 1 g of acetaminophen (paracetamol) four times a day, and add 50 mg of diclofenac three times a day. In case of nausea, prescribe 4 mg of ondansetron.</li>
	</ol>
	</li>
	<li>Keep the patient under observation until they are mobile, can eat and drink, and can go to the toilet independently.</li>
	<li>Consider dismissal on the day of surgery if the patient feels confident and has assistance at home. If the patient does not feel well, or feels dizzy or unbalanced, keep the patient overnight for observation.
	<ol>
		<li>Upon dismissal, instruct the patient to keep the bandage around the head for 24 h, as well as the plasters underneath, keeping them dry until the next visit to the surgeon, 7 days after surgery.</li>
		<li>If bleeding or leakage of clear fluid occurs, ask the patient to contact the department immediately. In case of fever or excessive pain, ask the patient to contact the department.</li>
		<li>Explain what the patient can expect after the surgery-dizziness and vertigo attacks; dizziness and/or vertigo are common in the weeks after surgery. Inform the patient that having a vertigo attack does not mean that the surgery has failed. With regards to pain, most patients do not experience much pain after surgery, but acetaminophen (paracetamol) can be taken.</li>
	</ol>
	</li>
</ol>
4. Postoperative visits
<ol>
	<li>Ask the patient to visit the surgeon 1 week after surgery. During this visit, remove the bandages and assess the wound. In case of signs of infection, prescribe antibiotics. In case of motion-related, short-lasting vertigo, consider that it might be benign paroxysmal positional vertigo (BPPV). Perform the Dix-Hallpike test, and if positive, carry out the Epley maneuver.</li>
	<li>Plan a PTA 6 weeks after surgery. Plan a follow-up visit 6 months and 1 year after surgery. Perform a hearing test at each visit.</li>
</ol>

<ol>
	<li>Lopez-Escamez, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+criteria+for+Meni&#232;re's+disease.">Diagnostic criteria for Meni&#232;re's disease.</a> Journal of Vestibular Research: Equilibrium &amp; Orientation. 25 (1), 1-7 (2015).</li><li>Perez-Garrigues, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Time+course+of+episodes+of+definitive+vertigo+in+Meniere's+disease.">Time course of episodes of definitive vertigo in Meniere's disease.</a> Archives of Otolaryngology-Head &amp; Neck Surgery. 134 (11), 1149-1154 (2008).</li><li>Alarc&#243;n, A. V., Hidalgo, L. O. V., Ar&#233;valo, R. J., Diaz, M. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Labyrinthectomy+and+vestibular+neurectomy+for+intractable+vertiginous+symptoms.">Labyrinthectomy and vestibular neurectomy for intractable vertiginous symptoms.</a> International Archives of Otorhinolaryngology. 21 (2), 184-190 (2017).</li><li>Pullens, B., Verschuur, H. P., van Benthem, P. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgery+for+M&#233;ni&#232;re's+disease.">Surgery for M&#233;ni&#232;re's disease.</a> Cochrane Database of Systematic Reviews. 2013 (2), (2013).</li><li>Saliba, I., Gabra, N., Alzahrani, M., Berbiche, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endolymphatic+duct+blockage:+a+randomized+controlled+trial+of+a+novel+surgical+technique+for+M&#233;ni&#232;re's+disease+treatment.">Endolymphatic duct blockage: a randomized controlled trial of a novel surgical technique for M&#233;ni&#232;re's disease treatment.</a> Otolaryngology-Head and Neck Surgery. 152 (1), 122-129 (2015).</li><li>M&#248;ller, M. N., Kirkeby, S., Vikes&#229;, J., Nielsen, F. C., Cay&#233;-Thomasen, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+human+endolymphatic+sac+expresses+natriuretic+peptides.">The human endolymphatic sac expresses natriuretic peptides.</a> Laryngoscope. 127 (6), E201-E208 (2017).</li><li>Takumida, M., Bagger-Sj&#246;b&#228;ck, D., Wers&#228;ll, J., Rask-Andersen, H., Harada, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-dimensional+ultrastructure+of+the+endolymphatic+sac.">Three-dimensional ultrastructure of the endolymphatic sac.</a> Archives of Oto-Rhino-Laryngology. 244 (2), 117-122 (1987).</li><li>Friis, M., Thomsen, A. R., Poulsen, S. S., Qvortrup, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Experimental+hyperactivity+of+the+endolymphatic+sac.">Experimental hyperactivity of the endolymphatic sac.</a> Audiology &amp; Neuro-Otology. 18 (2), 125-133 (2013).</li><li>Schenck, A. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effectiveness+of+endolymphatic+duct+blockage+versus+endolymphatic+sac+decompression+in+patients+with+intractable+M&#233;ni&#232;re's+disease:+study+protocol+for+a+double-blinded,+randomised+controlled+trial.">Effectiveness of endolymphatic duct blockage versus endolymphatic sac decompression in patients with intractable M&#233;ni&#232;re's disease: study protocol for a double-blinded, randomised controlled trial.</a> BMJ Open. 11 (8), e054514 (2021).</li><li>Lempert, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vestibular+migraine:+Diagnostic+criteria.">Vestibular migraine: Diagnostic criteria.</a> Journal of Vestibular Research: Equilibrium &amp; Orientation. 32 (1), 1-6 (2022).</li><li>Schenck, A. A., Bommelj&#233;, C. C., Kruyt, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcomes+of+endolymphatic+duct+blockage+for+M&#233;ni&#232;re's+disease:+an+observational+cohort+study.">Outcomes of endolymphatic duct blockage for M&#233;ni&#232;re's disease: an observational cohort study.</a> American Journal of Otolaryngology and Head. 4 (5), 1140 (2021).</li><li>Kato, B. M., LaRouere, M. J., Bojrab, D. I., Michaelides, E. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluating+quality+of+life+after+endolymphatic+sac+surgery:+The+M&#233;ni&#232;re's+Disease+Outcomes+Questionnaire.">Evaluating quality of life after endolymphatic sac surgery: The M&#233;ni&#232;re's Disease Outcomes Questionnaire.</a> Otology &amp; Neurotology. 25 (3), 339-344 (2004).</li><li>Kimura, R. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Experimental+blockage+of+the+endolymphatic+duct+and+sac+and+its+effect+on+the+inner+ear+of+the+guinea+pig.+A+study+on+endolymphatic+hydrops.">Experimental blockage of the endolymphatic duct and sac and its effect on the inner ear of the guinea pig. A study on endolymphatic hydrops.</a> The Annals of Otology, Rhinology, and Laryngology. 76 (3), 664-687 (1967).</li><li>Lundquist, P. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aspects+on+endolymphatic+sac+morphology+and+function.">Aspects on endolymphatic sac morphology and function.</a> Archives of Oto-Rhino-Laryngology. 212 (4), 231-240 (1976).</li><li>Lundquist, P. G., Kimura, R., Wersaell, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Experiments+in+endolymph+circulation.">Experiments in endolymph circulation.</a> Acta Oto-Laryngologica. Supplementum. 188, 198 (1964).</li><li>Wackym, P. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Human+endolymphatic+sac:+possible+mechanisms+of+pressure+regulation.">Human endolymphatic sac: possible mechanisms of pressure regulation.</a> The Journal of Laryngology and Otology. 101 (8), 768-779 (1987).</li><li>Linthicum, F. H., Santos, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endolymphatic+sac+amputation+without+hydrops.">Endolymphatic sac amputation without hydrops.</a> Otology &amp; Neurotology. 32 (2), e12-e13 (2011).</li><li>Niu, Y., Chen, W., Lin, M., Sha, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Progression+of+endolymphatic+hydrops+and+vertigo+during+treatment+in+Meniere's+disease.">Progression of endolymphatic hydrops and vertigo during treatment in Meniere's disease.</a> Acta Oto-Laryngologica. 142 (9-12), 653-657 (2022).</li><li>Merchant, S. N., Adams, J. C., Nadol, J. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pathophysiology+of+Meniere's+syndrome:+are+symptoms+caused+by+endolymphatic+hydrops.">Pathophysiology of Meniere's syndrome: are symptoms caused by endolymphatic hydrops.</a> Otology &amp; Neurotology. 26 (1), 74-81 (2005).</li><li>Basura, G. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+practice+guideline:+M&#233;ni&#232;re's+disease.">Clinical practice guideline: M&#233;ni&#232;re's disease.</a> Otolaryngology-Head and Neck Surgery. 162, S1-S55 (2020).</li><li>Hussain, K., Murdin, L., Schilder, A. G. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Restriction+of+salt,+caffeine+and+alcohol+intake+for+the+treatment+of+M&#233;ni&#232;re's+disease+or+syndrome.">Restriction of salt, caffeine and alcohol intake for the treatment of M&#233;ni&#232;re's disease or syndrome.</a> Cochrane Database of Systematic Reviews. 12, (2018).</li><li>Burgess, A., Kundu, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diuretics+for+M&#233;ni&#232;re's+disease+or+syndrome.">Diuretics for M&#233;ni&#232;re's disease or syndrome.</a> Cochrane Database of Systematic Reviews. 3, (2006).</li><li>van Esch, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Betahistine+for+Meni&#232;re's+disease+or+syndrome.">Betahistine for Meni&#232;re's disease or syndrome.</a> Cochrane Database of Systematic Reviews. 1, (2001).</li><li>Phillips, J. S., Westerberg, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intratympanic+steroids+for+M&#233;ni&#232;re's+disease+or+syndrome.">Intratympanic steroids for M&#233;ni&#232;re's disease or syndrome.</a> Cochrane Database of Systematic Reviews. 7, (2011).</li></ol>

The authors have nothing to declare.

EDB is a potential new treatment modality, aiming to reduce vertigo attacks while sparing inner ear function in patients with intractable MD. In the current literature, the results seem promising, but little data is available.
Rationale of the technique 
Targeting the ES for relieving MD symptoms has been controversial for some decades. In the past, the general belief has been that the (ES) mainly has a role in the resorption of endolymph13,</...

M&#233;ni&#232;re&#39;s disease (MD) is an incapacitating disease characterized by vertigo bouts, aural symptoms, and hearing loss1. Endolymphatic hydrops in the inner ear is present in patients with MD, but the exact aetiology of the disease remains unclear. In most patients, the symptoms resolve over time2; despite this, the majority of patients seek active treatment because of the unpredictable pattern of attacks.
Treatment for MD aims to reduce vertigo attacks. In the past century, different treatment modalities have been proposed, both surgical and non-surgical. Destructive surgical interventions, such as labyrinthectomy or vestibular neurotomy, are effective in controlling vertigo but cause deafness and a loss of vestibular function on the operated ear3,4. Surgeries on the endolymphatic sac (ES) have been studied, such as decompression and shunting of the sac, but neither of the proposed interventions have been proven to be more effective than placebo surgery4.
In 2015, Saliba et al. published the results of a randomized controlled trial comparing a new technique, endolymphatic duct blockage (EDB), to endolymphatic sac decompression (ESD)5. The trial yielded promising results, with 96.5% of the patients in the EDB group being free of vertigo attacks after 2 years. The rationale behind this technique is that the ES is at least partially responsible for the disturbed homeostasis of endolymph and produces an overload of endolymph due to increased production. By blocking the endolymphatic duct (ED), the surplus of endolymph that is generated in the sac is hindered from flowing to the rest of the inner ear. This hypothesis is supported by histological studies6,7,8.
Whether EDB is the appropriate treatment for an individual patient depends on various factors. The patient&#39;s preference and the surgeon&#39;s preference play a role, but local health care regulations may also influence treatment choice. In our center, EDB is only considered in patients who suffer vertigo attacks despite treatment with intratympanic (IT) injections with corticosteroids, and if vestibular migraine has been ruled out. EDB is especially suitable for patients with good hearing function who reject ablative treatment. This article describes the surgical steps of this new technique and discusses the literature that is currently available.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Adson Forceps, Delicate, Smooth, 1 x 2 teeth, 12 0mm</td>
			<td>Aesculap BV</td>
			<td>BD511R</td>
			<td></td>
		</tr>
		<tr>
			<td>Adson-Brown Tissue Forceps, 7 x 8 teeth, 120 mm</td>
			<td>Aesculap BV</td>
			<td>BD700R</td>
			<td></td>
		</tr>
		<tr>
			<td>Baby Adson Retractor, hinged, semi-S tip, 3 x 4 prongs blade end, 140 mm</td>
			<td>Aesculap BV</td>
			<td>BV085R</td>
			<td></td>
		</tr>
		<tr>
			<td>Baby Senn-Miller RetractorFlat Handle, SHARP tip, 3 PRONGS blade end, blade size 8 x 7/22 x 7, 165 mm</td>
			<td>Aesculap BV</td>
			<td>BT006R</td>
			<td></td>
		</tr>
		<tr>
			<td>Bien Air Nano Micromotor OsseoDUO + NANOmicromotor</td>
			<td>Bien air</td>
			<td>1700524-001</td>
			<td>Electronic motor used for mastoidectomy</td>
		</tr>
		<tr>
			<td>Bien air tubing set for peristaltic pump</td>
			<td>Bien air</td>
			<td>1100037</td>
			<td></td>
		</tr>
		<tr>
			<td>Coagulation Forceps</td>
			<td>Aesculap BV</td>
			<td>E700246</td>
			<td>Used for hemostasis</td>
		</tr>
		<tr>
			<td>Cord, bipolar, 4.5 m</td>
			<td>Valleylab BV</td>
			<td>E360150L</td>
			<td></td>
		</tr>
		<tr>
			<td>Diamond burrs 0.8x 70 to 7.0x70</td>
			<td>Bien air</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ear Curette, Pointed, Double Ended, cup size LARGE, 170 mm</td>
			<td>Aseculap BV</td>
			<td>OG189R</td>
			<td></td>
		</tr>
		<tr>
			<td>Ethicon hechtdraad 3/0 sh-1 vicryl 70 cm</td>
			<td>Ethicon</td>
			<td>3006273</td>
			<td>Suture for deeper tissue layers</td>
		</tr>
		<tr>
			<td>Fibrin Sealant</td>
			<td>Baxter BV</td>
			<td>BE-90-01-040</td>
			<td>Tissue glue used in case of liquor leakage</td>
		</tr>
		<tr>
			<td>Gillies Skin Hook, Tip 0.5/6mm, jaw STR, SERR</td>
			<td>Aesculap BV</td>
			<td>OL611R</td>
			<td></td>
		</tr>
		<tr>
			<td>Gillies Tissue Forceps, Delicate, X-SERR tip, 1 x 2 teeth, 155 mm</td>
			<td>Aesculap BV</td>
			<td>BD660R</td>
			<td></td>
		</tr>
		<tr>
			<td>Halsted Mosquito Forceps, Delicate, CVD jaw, 125 mm</td>
			<td>Aesculap BV</td>
			<td>BH111R</td>
			<td></td>
		</tr>
		<tr>
			<td>Handpiece for burr</td>
			<td>Bien air</td>
			<td>1600830-001</td>
			<td></td>
		</tr>
		<tr>
			<td>Hartmann Ear Forceps , Tip 4 mm, jaw STR</td>
			<td>Aesculap BV</td>
			<td>OG329R</td>
			<td></td>
		</tr>
		<tr>
			<td>Hartmann-Wullstein Ear Forceps</td>
			<td>Aesculap BV</td>
			<td>OF410R</td>
			<td></td>
		</tr>
		<tr>
			<td>Hejek Mallet, &#216;27 220 mm</td>
			<td>Aesculap BV</td>
			<td>FL044R</td>
			<td></td>
		</tr>
		<tr>
			<td>Horizon Metal Ligation System - Clips size MICRO, SMALL, MEDIUM</td>
			<td>Teleflex Medical</td>
			<td>1201, 2200, 5200</td>
			<td>Titanium clip used for blockage of endolymphatic duct</td>
		</tr>
		<tr>
			<td>House Ear Curette</td>
			<td>Aesculap BV</td>
			<td>OG182R</td>
			<td>Double Ended, cup size (mm) 1.5/1.8, tip ANG</td>
		</tr>
		<tr>
			<td>Lucae Bayonet Forceps</td>
			<td>Aesculap BV</td>
			<td>BD878R</td>
			<td>SERR tip, 140mm</td>
		</tr>
		<tr>
			<td>Lucae Bayonet Forceps</td>
			<td>Aesculap</td>
			<td>BD878R</td>
			<td>SERR tip, 140mm</td>
		</tr>
		<tr>
			<td>Lucae Ear Hook Button</td>
			<td>Aesculap BV</td>
			<td>OF278R</td>
			<td>Hook end SMALL, tip SHARP, 130mm</td>
		</tr>
		<tr>
			<td>Mayo Dissecting Scissors</td>
			<td>Aesculap BV</td>
			<td>BC587R</td>
			<td>Round Blade, B/B tip, CVD blade, 165mm</td>
		</tr>
		<tr>
			<td>Mayo Dissecting Scissors, Round Blade, B/B tip, CVD blade, 165 mm</td>
			<td>Aesculap BV</td>
			<td>BC587R</td>
			<td></td>
		</tr>
		<tr>
			<td>McIndoe Thumb Forceps, Delicate</td>
			<td>Aesculap BV</td>
			<td>BD236R</td>
			<td>SERR tip, 150 mm</td>
		</tr>
		<tr>
			<td>Micro Adson Forceps, Delicate, SERR with platform tip Tip, 12 cm</td>
			<td>Aesculap BV</td>
			<td>BD220R/425.112</td>
			<td></td>
		</tr>
		<tr>
			<td>Monocryl 4-0 FS-2. 70 cm</td>
			<td>Ethicon</td>
			<td>Y422H</td>
			<td>Suture for skin</td>
		</tr>
		<tr>
			<td>NIM response 3.0</td>
			<td>Medtronic</td>
			<td>NIM4CM01</td>
			<td>Nerve monitoring system</td>
		</tr>
		<tr>
			<td>OSSEODUO control unit</td>
			<td>Bien air</td>
			<td>1600513-001</td>
			<td></td>
		</tr>
		<tr>
			<td>Paired Subdermal electrodes with subdermal ground electrode and subdermal stim return, 2 channel</td>
			<td>Medtronic Xomed</td>
			<td>8227410</td>
			<td></td>
		</tr>
		<tr>
			<td>Scalpel Handle #3&#160; F/ Blades</td>
			<td>Aesculap BV</td>
			<td>BB070R</td>
			<td></td>
		</tr>
		<tr>
			<td>Steel burrs 0.8x 70 to 7.0x 70</td>
			<td>Bien air</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Volkmann Curette, tip size 3.6 mm, 170 mm</td>
			<td>Aesculap BV</td>
			<td>FK631R</td>
			<td></td>
		</tr>
		<tr>
			<td>Watertight, 2-button multifunction pedal</td>
			<td>Bien air</td>
			<td>1600517-001</td>
			<td></td>
		</tr>
		<tr>
			<td>Williger Bone Elevator, blade 6, 160 mm</td>
			<td>Aesculap BV</td>
			<td>FK300R</td>
			<td></td>
		</tr>
		<tr>
			<td>Wire bending forceps, curved downards, 80 mm, jaw length 3.50 mm, with tubular shaft</td>
			<td>McGee</td>
			<td>OG359R</td>
			<td>Used to close clip</td>
		</tr>
		<tr>
			<td>Wullstein Retractor, sharp tip, 3 x 3 prongs blade end, 130 mm</td>
			<td>Aesculap BV</td>
			<td>BV076R</td>
			<td></td>
		</tr>
	</tbody>
</table>

endolymphatic duct blockage as a surgical treatment option for m&#233;ni&#232;re's disease

Endolymphatic duct blockage is a relatively new treatment option for M&#233;ni&#232;re's disease, aiming to reduce vertigo attacks while sparing hearing and equilibrium. After a regular mastoidectomy, the posterior semicircular canal is identified, and Donaldson's line is determined. This is a line through the horizontal semicircular canal, crossing the posterior semicircular canal. The endolymphatic sac is usually found at this site under the posterior semicircular canal. The bone of the endolymphatic sac and the dura are thinned until the sac is skeletonized, after which the endolymphatic duct is identified. The duct is then blocked with a titanium clip. Using a computerized tomography (CT) scan, the position is confirmed. Follow-up visits take place 1 week, 6 weeks and 1 year after surgery. To this day, only one prospective trial assessing this method has been conducted, comparing this new method to endolymphatic sac decompression. Results of the duct blockage are promising, with 96.5% of the patients free of vertigo after 2 years. However, further research is required.

Surgical factors 
This procedure was performed by one of the authors (HB) in both the Haga Hospital and the Antwerp University Hospital. Data from the Antwerp University Hospital could not be retrieved, but approximately 100 patients underwent EDB at that location. In the Haga Hospital, EBD is only allowed in the context of the aforementioned trial. In this trial, surgery was performed on 38 patients. Due to the blinded character of the trial, it is unknown how many and which of these patients under...

Watch this Scientific Journal Video about Endolymphatic Duct Blockage as a Surgical Treatment Option for MÃƒÂ©niÃƒÂ¨re's Disease at JoVE.com

Endolymphatic Duct Blockage as a Surgical Treatment Option for M&#233;ni&#232;re's Disease

Endolymphatic duct blockage is a relatively new surgical method for patients suffering from M&#233;ni&#232;re's disease. Following a regular mastoidectomy, the endolymphatic duct is identified and ligated using a regular titanium hemoclip. The effectiveness of this procedure is currently being assessed in a randomized trial.

Endolymphatic duct blockage is a relatively new treatment option for M&#233;ni&#232;re's disease, aiming to reduce vertigo attacks while sparing hearing ...

endolymphatic-duct-blockage-as-surgical-treatment-option-for-mnire-s

Research

JoVE Journal

Medicine

877 Views.  Haga Hospital. Endolymphatic duct blockage is a relatively new surgical method for patients suffering from Ménière's disease. Following a regular mastoidectomy, the endolymphatic duct is identified and ligated using a regular titanium hemoclip. The effectiveness of this procedure is currently being assessed in a randomized trial. 

Video: Endolymphatic Duct Blockage as a Surgical Treatment Option for Ménière's Disease

Osteopathic Manipulative Treatment as a Useful Adjunctive Tool for Pneumonia

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in the hospitalization of 1.1 million patients2. With an average length of in-patient hospital stay of five days2, pneumonia and influenza comprise significant financial burden costing the United States $40.2 billion in 20053. Under the current Infectious Disease Society of America/American Thoracic Society guidelines, standard-of-care recommendations include the rapid administration of an appropriate antibiotic regiment, fluid replacement, and ventilation (if necessary). Non-standard therapies include the use of corticosteroids and statins; however, these therapies lack conclusive supporting evidence4. (Figure 1)

Osteopathic Manipulative Treatment (OMT) is a cost-effective adjunctive treatment of pneumonia that has been shown to reduce patients&#8217; length of hospital stay, duration of intravenous antibiotics, and incidence of respiratory failure or death when compared to subjects who received conventional care alone5. The use of manual manipulation techniques for pneumonia was first recorded as early as the Spanish influenza pandemic of 1918, when patients treated with standard medical care had an estimated mortality rate of 33%, compared to a 10% mortality rate in patients treated by osteopathic physicians6. When applied to the management of pneumonia, manual manipulation techniques bolster lymphatic flow, respiratory function, and immunological defense by targeting anatomical structures involved in the these systems7,8, 9, 10.

The objective of this review video-article is three-fold: a) summarize the findings of randomized controlled studies on the efficacy of OMT in adult patients with diagnosed pneumonia, b) demonstrate established protocols utilized by osteopathic physicians treating pneumonia, c) elucidate the physiological mechanisms behind manual manipulation of the respiratory and lymphatic systems. Specifically, we will discuss and demonstrate four routine techniques that address autonomics, lymph drainage, and rib cage mobility: 1) Rib Raising, 2) Thoracic Pump, 3) Doming of the Thoracic Diaphragm, and 4) Muscle Energy for Rib 1.5,11

Pneumonia is one of the top ten leading causes of death in the U.S. Osteopathic manipulative techniques (OMT) may be utilized as an adjunctive therapy in the treatment of pneumonia to enhance biomechanical and immune function; and ultimately, to reduce hospital stay, duration of antibiotics, incidence of respiratory failure, and mortality. In this video-article, we will review randomized controlled studies on the use of OMT in pneumonia patients, as well as demonstrate specific hands-on techniques that are routinely practiced by osteopathic physicians when treating pulmonary infections.

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in ...

Isolated Hepatic Perfusion as a Treatment for Liver Metastases of Uveal Melanoma

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic agent melphalan. Briefly, the procedure starts with the setup of a percutaneous veno-venous bypass from the femoral vein to the external jugular vein. Via a laparotomy, catheters are then inserted into the proper hepatic artery and the caval vein. The portal vein and the caval vein, both supra- and infrahepatically, are then clamped. The arterial and venous catheters are connected to a heart lung machine and the liver is perfused with melphalan (1 mg/kg body weight) for 60 min. This way it is possible to locally perfuse the liver with a high dose of a chemotherapeutic agent, without leakage to the systemic circulation.
In previous studies including patients with isolated liver metastases of uveal melanoma, an overall response rate of 33-100% and a median survival between 9 and 13 months, have been reported. The aim of this protocol is to give a clear description of how to perform the procedure and to discuss IHP as a treatment option for liver metastases of uveal melanoma.

Here, we present a protocol how to perform an isolated liver perfusion (IHP) with melphalan and we also discuss IHP as a treatment option for liver metastases of uveal melanoma.

Isolated hepatic perfusion (IHP) is a procedure where the liver is surgically isolated and perfused with a high concentration of the chemotherapeutic ...

Surgical Injury to the Mouse Pancreas through Ligation of the Pancreatic Duct as a Model for Endocrine and Exocrine Reprogramming and Proliferation

Expansion of pancreatic beta cells in vivo or ex vivo, or generation of beta cells by differentiation from an embryonic or adult stem cell, can provide new expandable sources of beta cells to alleviate the donor scarcity in human islet transplantation as therapy for diabetes. Although recent advances have been made towards this aim, mechanisms that regulate beta cell expansion and differentiation from a stem/progenitor cell remain to be characterized. Here, we describe a protocol for an injury model in the adult mouse pancreas that can function as a tool to study mechanisms of tissue remodeling and beta cell proliferation and differentiation. Partial duct ligation (PDL) is an experimentally induced injury of the rodent pancreas involving surgical ligation of the main pancreatic duct resulting in an obstruction of drainage of exocrine products out of the tail region of the pancreas. The inflicted damage induces acinar atrophy, immune cell infiltration and severe tissue remodeling. We have previously reported the activation of Neurogenin (Ngn) 3 expressing endogenous progenitor-like cells and an increase in beta cell proliferation after PDL. Therefore, PDL provides a basis to study signals involved in beta cell dynamics and the properties of an endocrine progenitor in adult pancreas. Since, it still remains largely unclear, which factors and pathways contribute to beta cell neogenesis and proliferation in PDL, a standardized protocol for PDL will allow for comparison across laboratories.

This protocol describes an injury model involving the surgical ligation of the pancreatic duct in the adult mouse pancreas, resulting in severe injury that establishes an environment that allows beta cell neogenesis and proliferation. This model can be used as a tool to study mechanisms involved in beta cell formation.

Expansion of pancreatic beta cells in vivo or ex vivo, or generation of beta cells by differentiation from an embryonic or adult stem cell, can provide ...

MRI-guided dmPFC-rTMS as a Treatment for Treatment-resistant Major Depressive Disorder

Here we outline the protocol for magnetic resonance imaging (MRI) guided repetitive transcranial magnetic stimulation (rTMS) to the dorsal medial prefrontal cortex (dmPFC) in patients with major depressive disorder (MDD). Technicians used a neuronavigation system to process patient MRIs to generate a 3-dimensional head model. The head model was subsequently used to identify patient-specific stimulatory targets. The dmPFC was stimulated daily for 20 sessions. Stimulation intensity was titrated to address scalp pain associated with rTMS. Weekly assessments were conducted on the patients using the Hamilton Rating Scale for Depression (HamD17) and Beck Depression Index II (BDI-II). Treatment-resistant MDD patients achieved significant improvements on both HAMD and BDI-II. Of note, angled, double-cone coil rTMS at 120% resting motor threshold allows for optimal stimulation of deeper midline prefrontal regions, which results in a possible therapeutic application for MDD. One major limitation of the rTMS field is the heterogeneity of treatment parameters across studies, including duty cycle, number of pulses per session and intensity. Further work should be done to clarify the effect of stimulation parameters on outcome. Future dmPFC-rTMS work should include sham-controlled studies to confirm its clinical efficacy in MDD.

Here we outline the procedure for MRI-guided repetitive transcranial magnetic stimulation to the dorsomedial prefrontal cortex as an experimental treatment for major depressive disorder.

Here we outline the protocol for magnetic resonance imaging (MRI) guided repetitive transcranial magnetic stimulation (rTMS) to the dorsal medial ...

Transcanalicular Diode Laser-assisted Dacryocystorhinostomy for the Treatment of Primary Acquired Nasolacrimal Duct Obstruction

Today&#39;s gold standard in the treatment of infrasaccal primary acquired nasolacrimal duct obstruction (PANDO) is external dacryocystorhinostomy (DCR), a relatively invasive procedure that can be performed after failure of recanalizing treatments. However, with progress in the field of diode laser technology, new approaches have emerged. Laser-assisted transcanalicular DCR with subsequent bicanalicular silicon intubation is a new option showing great promise as a viable minimally invasive procedure. Under permanent endoscopic visual control from the nasal cavity, a diode laser fiber is inserted into the lacrimal sac and laser energy is applied to create a bony ostium between the lacrimal sac and the nasal cavity. Since no skin incision needs to be made, advantages of this method comprise the sparing of the skin as well as the medial palpebral structures and the physiological palpebral-canalicular pump mechanism. The duration of surgery as well as reconvalescence is generally shorter than with external DCR. Complications include silicon tube prolapse, mild swelling and, rarely, canalicular infection and thermal injury. One-year functional success rates, defined as complete resolution of symptoms and ostium patency, are high, yet still range behind those of external DCR. However, secondary external DCR after failure of laser-assisted DCR can be performed without difficulty. Thus, laser-assisted transcanalicular DCR is a valid option that should be considered as a second-step procedure after failure of recanalization procedures and before external DCR.

The goal of this protocol is to present transcanalicular laser-assisted dacryocystorhinostomy as a minimally invasive approach in the treatment of primary acquired nasolacrimal duct obstruction.

Today&#39;s gold standard in the treatment of infrasaccal primary acquired nasolacrimal duct obstruction (PANDO) is external dacryocystorhinostomy (DCR), ...

A Mouse Model for Chronic Pancreatitis via Bile Duct TNBS Infusion

Chronic pancreatitis (CP) is a complex disease involving pancreatic inflammation and fibrosis, glandular atrophy, abdominal pain and other symptoms. Several rodent models have been developed to study CP, of which the bile duct 2,4,6 -trinitrobenzene sulfonic acid (TNBS) infusion model replicates the features of neuropathic pain seen in CP. However, bile duct drug infusion in mice is technically challenging. This protocol demonstrates the procedure of bile duct TNBS infusion for generation of a CP mouse model. TNBS was infused into the pancreas through the ampulla of Vater in the duodenum. This protocol optimized drug volume, surgical techniques, and drug handling during the procedure. TNBS-treated mice showed features of CP as reflected by bodyweight and pancreas weight reductions, changes in pain-associated behaviors, and abnormal pancreatic morphology. With these improvements, mortality associated with TNBS injection was minimal. This procedure is not only critical in generating pancreatic disease models but is also useful in local pancreatic drug delivery.

Chronic pancreatitis (CP) is a disease characterized by inflammation and fibrosis of the pancreas, often associated with intractable abdominal pain. This article focuses on refining the technique to generate a mouse model of CP via bile duct infusion with 2,4,6 -trinitrobenzene sulfonic acid (TNBS).

Chronic pancreatitis (CP) is a complex disease involving pancreatic inflammation and fibrosis, glandular atrophy, abdominal pain and other symptoms. ...

Plasma Polishing as a New Polishing Option to Reduce the Surface Roughness of Porous Titanium Alloy for 3D Printing

Porous titanium alloy implants with simulated trabecular bone fabricated by 3D printing technology have broad prospects. However, due to the fact that some powder adheres to the surface of the workpiece during the manufacturing process, the surface roughness in direct printing pieces is relatively high. At the same time, since the internal pores of the porous structure cannot be polished by conventional mechanical polishing, an alternative method needs to be found. As a surface technology, plasma polishing technology is especially suitable for parts with complex shapes that are difficult to polish mechanically. It can effectively remove particles and fine splash residues attached to the surface of 3D printed porous titanium alloy workpieces. Therefore, it can reduce surface roughness. Firstly, titanium alloy powder is used to print the porous structure of the simulated trabecular bone with a metal 3D printer. After printing, heat treatment, removal of the supporting structure, and ultrasonic cleaning is carried out. Then, plasma polishing is performed, consisting of adding a polishing electrolyte with the pH set to 5.7, preheating the machine to 101.6 &#176;C, fixing the workpiece on the polishing fixture, and setting the voltage (313 V), current (59 A), and polishing time (3 min). After polishing, the surface of the porous titanium alloy workpiece is analyzed by a confocal microscope, and the surface roughness is measured. Scanning electron microscopy is used to characterize the surface condition of porous titanium. The results show that the surface roughness of the whole porous titanium alloy workpiece changed from Ra (average roughness) = 126.9 &#181;m to Ra = 56.28 &#181;m, and the surface roughness of the trabecular structure changed from Ra = 42.61 &#181;m to Ra = 26.25 &#181;m. Meanwhile, semi-molten powders and ablative oxide layers are removed, and surface quality is improved.

Plasma polishing is a promising surface processing technology, especially suitable for 3D printing of porous titanium alloy workpieces. It can remove semi-molten powders and ablative oxide layers, thereby effectively reducing surface roughness and improving surface quality.

Porous titanium alloy implants with simulated trabecular bone fabricated by 3D printing technology have broad prospects. However, due to the fact that ...

Managing Gestational Vomiting with Ear Plaster Therapy

Ear Plaster Therapy as a Safe and Effective Treatment for Gestational Vomiting

Nausea and vomiting in pregnancy (NVP) are common symptoms that often complicate early pregnancy for many women. While clinical treatments such as fasting, fluid infusion, and nutritional support are conventionally applied to manage NVP, their effectiveness varies. However, traditional ear plaster therapy offers a promising alternative that effectively relieves symptoms and poses no known risk to the development of embryos or fetuses. This therapy is known for its ease of application, cost-effectiveness, and favorable outcomes. Previous studies have demonstrated the efficacy of combining ear plaster therapy with conventional treatments in alleviating symptoms of nausea and vomiting in pregnant women, surpassing the results achieved with conventional treatment alone. The protocol presented herein describes a method to relieve NVP using round, smooth, and hard cowherb seeds applied to specific ear points. These seeds are gently rubbed onto the surface of the ear, utilizing the principles of acupressure. By stimulating the designated ear points, this procedure aims to regulate the body's energy flow and restore balance, thereby reducing the severity and frequency of NVP. The application of cowherb seeds on specific ear points is a straightforward technique that healthcare professionals can easily implement or self-administered by pregnant women under appropriate guidance. Overall, ear plaster therapy presents a safe, effective, and economical approach for managing gestational vomiting, offering women a potential solution to alleviate their discomfort during pregnancy.

Author Spotlight: Alleviating Nausea and Vomiting in Pregnancy with Safe and Effective Auricular Acupuncture 

The presented protocol describes a traditional Chinese medicine treatment procedure known for its safety and effectiveness in managing gestational vomiting.

Nausea and vomiting in pregnancy (NVP) are common symptoms that often complicate early pregnancy for many women. While clinical treatments such as ...

Surgical Treatment of an Endolymphatic Sac Tumor

Endolymphatic sac tumors (ELST) are low-grade papillary adenocarcinoma originating from the endolymphatic sac. Usually slow-growing, with local aggressiveness and a low risk of distant metastases, ELST can be sporadic but also frequently associated with von Hippel Lindau disease. The current treatment of ELST is primarily surgical resection. A 55-year-old woman accessed our otologic tertiary level referral center for a sudden worsening of hearing loss in her left ear and vertigo. A magnetic resonance (MRI) and computer tomography scan study subsequently showed a mass in the petrous bone; hence, the presence of an ELST was hypothesized. After embolization of the mass, the patient underwent surgical removal of the lesion. The resection of the mass was done through a translabirinthine approach, with an uneventful procedure. No residual disease remained after surgery. After 24 months of radiologic follow up with MRI, there are no signs of recurrence disease. This paper reports the management of this sporadic ELST, as well as the follow up results, providing clinicians this protocol for the handling of such a challenging otologic skull base surgery and rare disease.

Here, we discuss clinical and radiological features of endolymphatic sac tumors and report the methodology and results of a surgical removal in a case in care at our otologic referral center.

Endolymphatic sac tumors (ELST) are low-grade papillary adenocarcinoma originating from the endolymphatic sac. Usually slow-growing, with local ...

Seminal Vesiculoscope Laser-Assisted Surgery to Treat Ejaculatory Duct Blockage

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory duct cyst. Intraoperative excision of the verumontanum is usually required to expose the ejaculatory ducts. However, preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. Maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume. Therefore, we attempted a novel technique that preserves the verumontanum, which is relatively easier and safer compared to TURED. The following were the procedural steps: 1. A 6F seminal vesiculoscope was introduced through the external urethral orifice to the vicinity of the verumontanum, locating the opening of the affected-side ejaculatory duct and introducing a guidewire into the cyst. This successful step preserved the verumontanum, maximizing the retention of the anti-reflux mechanism in the distal ejaculatory duct. 2. The holmium laser enlarged the affected-side ejaculatory duct opening to 5 mm, decreasing the likelihood of postoperative closure of the ejaculatory duct opening and simplifying the procedure. 3. A window was created within the cyst to access the contralateral seminal vesicle, and then a holmium laser was used to burn and dilate the opening to 5 mm, redirecting the contralateral ejaculatory duct into the cystic cavity. This modification preserved the opening of the healthy-side ejaculatory duct and provided a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively. The patients experienced no complications postoperatively, had shorter hospital stays, and showed improvement in semen volume. Hence, this surgical approach is simple yet effective.

Author Spotlight: Advanced Treatment of Seminal Duct Blockage Employing Endoscopy-Mediated Semen Channel Refluviation 

This protocol introduces the clinical application of seminal vesicle endoscopy combined with holmium laser in the treatment of ejaculatory duct obstruction caused by ejaculatory duct cyst.

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory ...