The operations
The procedures
Eight operations, organised by one question — what is there to lose? Use the comparator to weigh vertigo control against hearing for each, then read the detail below.
Compare the options
Filter by hearing status to see which procedures fit, and compare their vertigo control, hearing outcome, surgical approach and risks.
Procedure explorer
8 of 8- Endolymphatic sac surgeryHearing preserved
Refractory Ménière's disease
- Vertigo control
- 60–80%
- Approach
- Transmastoid (decompression or shunt)
Decompresses or drains the endolymphatic sac to relieve hydrops — the least destructive option.
Risks: CSF leak, sensorineural hearing loss (rare), wound issues. Efficacy debated (sham-controlled data).
- Vestibular neurectomyHearing preserved
Refractory Ménière's with serviceable hearing
- Vertigo control
- >90%
- Approach
- Middle fossa or retrosigmoid
Selectively divides the vestibular nerve, abolishing pathological input while sparing the cochlear nerve.
Risks: Facial-nerve injury, CSF leak, intracranial complications; more invasive than ESS.
- LabyrinthectomyHearing sacrificed
Refractory peripheral vertigo, non-serviceable hearing
- Vertigo control
- >95%
- Approach
- Transmastoid
Ablates the vestibular end-organs entirely — the most reliable vertigo control, but sacrifices all hearing on that side.
Risks: Irreversible deafness; temporary post-ablative imbalance/oscillopsia needing rehabilitation.
- Canal plugging / resurfacing (SSCD)Hearing variable
Superior semicircular canal dehiscence
- Vertigo control
- ~85%
- Approach
- Middle fossa or transmastoid
Closes the 'third window' by plugging the canal lumen or resurfacing the bony roof; plugging outlasts resurfacing.
Risks: Sensorineural hearing loss, CSF leak (esp. middle fossa); resurfacing has higher recurrence.
- Posterior semicircular canal occlusionHearing preserved
Intractable posterior-canal BPPV
- Vertigo control
- >90%
- Approach
- Transmastoid
Occludes the affected canal to stop pathological cupular deflection — for BPPV that fails repositioning.
Risks: Sensorineural hearing loss, facial-nerve injury, perilymph fistula (all uncommon).
- Perilymph fistula repairHearing variable
Perilymph fistula (oval/round window)
- Vertigo control
- 70–80%
- Approach
- Transcanal exploratory tympanotomy
Seals the abnormal window leak with soft-tissue graft (fat, fascia) ± reinforcement.
Risks: Diagnosis is contested (no reliable marker); hearing recovery inconsistent, especially if delayed.
- Translabyrinthine resectionHearing already lost
Vestibular schwannoma, non-serviceable hearing
- Vertigo control
- High (ablative)
- Approach
- Translabyrinthine
Removes the tumour with direct IAC access and minimal cerebellar retraction; sacrifices the labyrinth (hearing already lost).
Risks: Permanent hearing/vestibular loss on that side; facial-nerve risk (preservation >90% in expert hands); post-op imbalance.
- Cochlear implantation (VS / NF2)Hearing variable
Vestibular schwannoma / NF2 with intact cochlear nerve
- Vertigo control
- n/a (auditory rehabilitation)
- Approach
- Round window / cochleostomy (± simultaneous resection)
Restores hearing when the cochlear nerve is anatomically and functionally intact; not a vertigo operation.
Risks: Requires intact cochlear nerve and patent cochlea; ABI needed if nerve non-functional.
Hearing-sparing procedures
Endolymphatic sac surgeryis the least destructive option for refractory Ménière’s — decompressing or shunting the sac to relieve hydrops, with ~60–80% vertigo control and preserved hearing, though its efficacy is debated.1,2 Vestibular neurectomydivides the vestibular nerve while sparing the cochlear nerve, giving definitive vertigo control (>90%) with preserved hearing via a middle-fossa or retrosigmoid approach — more invasive, with facial-nerve and CSF-leak risks.3,4
Posterior semicircular canal occlusiontreats the rare intractable posterior-canal BPPV that fails repositioning, occluding the canal with >90% control and preserved hearing.8 Perilymph-fistula repair seals an oval- or round-window leak with a soft-tissue graft (70–80% symptomatic benefit), though the diagnosis remains contested after decades of debate.9,10
Ablative procedures (non-serviceable hearing)
Labyrinthectomyremoves the vestibular end-organs entirely — the most reliable vertigo control (>95%) but sacrificing all hearing on that side, so it is reserved for ears that have already lost serviceable hearing.5 Translabyrinthine resection removes a vestibular schwannoma through the labyrinth, giving direct access with minimal cerebellar retraction and facial-nerve preservation above 90% in expert hands — at the cost of hearing and vestibular function on that side.11
Cochlear implantation is the exception that restores rather than removes: in selected schwannoma/NF2 patients with an intact cochlear nerve, it rehabilitates hearing (it is not a vertigo operation) — a consideration especially in NF2, where schwannomas are bilateral.12,13
SSCD: plugging or resurfacing
Superior canal dehiscence creates a third window causing sound- and pressure-induced vertigo. Surgery closes it by plugging the canal lumen or resurfacing the bony roof, via a middle-fossa or transmastoid approach, with ~80–90% symptom resolution. Plugging generally outlasts resurfacing, which has a higher recurrence; the approach choice remains debated.6,7
Key points
- Hearing-sparing: endolymphatic sac surgery, vestibular neurectomy, canal occlusion, fistula repair.
- Ablative (non-serviceable hearing): labyrinthectomy and translabyrinthine resection — highest, most reliable control.
- Vertigo control rises with destructiveness; the trade-off is hearing.
- SSCD is treated by plugging or resurfacing; plugging lasts longer.
- Cochlear implantation restores hearing in selected schwannoma/NF2 cases — not a vertigo operation.