Deciding

Indications & patient selection

Good surgery starts with good selection. The work-up has to confirm the diagnosis, prove that conservative care has failed, and define what there is to lose.

When to consider surgery

Surgery is reserved for clear vestibular pathology causing disabling, chronic symptoms unresponsive to aggressive conservative therapy.1 Three broad situations qualify:

  • Intractable vertigo despite optimal therapy. Disabling attacks persisting after appropriate drugs, lifestyle change and vestibular rehabilitation — especially with an irreversible structural lesion (refractory Ménière's, SSCD, perilymph fistula).
  • Progressive disease with functional decline. Conditions that deteriorate or threaten complications if untreated — Tumarkin drop attacks, or a growing vestibular schwannoma with brainstem compression.
  • Severe quality-of-life impairment. A high symptom burden (e.g. a high Dizziness Handicap Inventory score) with a confirmed structural cause and failed conservative care.

Symptom burden is best quantified — the Dizziness Handicap Inventory turns a subjective complaint into a measurable score that helps justify surgery and track its outcome.2

The preoperative work-up

Because most procedures are irreversible, the assessment is thorough and multidisciplinary — otolaryngology, neurology, audiology and rehabilitation.

  • History & bedside examination — characterise the attacks, lateralise the lesion, and look for red flags (Dix–Hallpike, head impulse, Romberg).
  • Audiometry — pure-tone and speech discrimination define serviceable hearing, the pivotal choice between hearing-sparing and ablative surgery.
  • Vestibular testing — caloric, video head impulse and VEMPs localise the deficit, assess the opposite ear, and estimate compensation potential. VEMPs and HRCT confirm SSCD.3
  • Imaging — high-resolution CT for bony dehiscence; MRI to exclude retrocochlear and central lesions (schwannoma, infarct, MS).
  • Documented failure of conservative care — an adequate trial of drugs, rehabilitation and, for Ménière’s, intratympanic therapy.4

Two themes run through every decision. First, the contralateral labyrinth: ablative surgery only succeeds if a healthy opposite ear can drive central compensation, so its function must be confirmed before sacrificing the diseased side. Second, informed consent: patients must understand the diagnosis, the rationale, the alternatives, and the specific vestibular and auditory risks — including permanent imbalance, deafness and the need for rehabilitation — given how many of these operations cannot be undone.

Key points

  • Operate only for disabling, structurally-defined disease with documented failure of conservative care.
  • Quantify the burden (e.g. DHI) and confirm the diagnosis with audiometry, vestibular tests and imaging.
  • Serviceable hearing is the pivotal variable in choosing the procedure.
  • Confirm the opposite ear can compensate before any ablative operation.
  • Informed consent must cover the irreversible auditory and vestibular consequences.