Background & Clinical Context
The vestibular nerve section, also known as vestibular neurectomy, is a surgical procedure reserved for patients with intractable peripheral vertigo who have failed conservative medical therapy. This intervention involves selective transection of the vestibular portion of the eighth cranial nerve while preserving hearing (cochlear function) whenever possible. Common underlying diagnoses include Meniere's disease, recurrent vestibulopathy, and delayed endolymphatic hydrops.
Case Presentation
A 52-year-old female presented with a five-year history of episodic vertigo, fluctuating hearing loss, and aural fullness in the right ear. Despite optimized medical management — including diuretics, betahistine, and intratympanic corticosteroid injections — she continued to experience debilitating attacks (3–4 per month) that severely impaired her quality of life. Preoperative audiometry showed moderate sensorineural hearing loss in the affected ear with speech discrimination of 72%. Vestibular testing (caloric and video head impulse test) confirmed a significant peripheral vestibular deficit on the right side.
Key Preoperative Findings: Unilateral peripheral vestibular hypofunction, preserved but diminished hearing, refractory vertigo despite maximal medical therapy. The patient was deemed an appropriate candidate for vestibular nerve section via a retrosigmoid approach.
Surgical Procedure
The procedure was performed under general anesthesia with intraoperative neuromonitoring. A retrosigmoid craniotomy provided access to the cerebellopontine angle. The cochlear and facial nerves were identified and carefully preserved. The vestibular nerve fibers were selectively sectioned using microsurgical techniques. Total resection of the superior and inferior vestibular nerve branches was achieved. The surgery was uneventful, with an estimated blood loss of 150 mL and an operative time of 2 hours 45 minutes.
Postoperative Recovery & Outcomes
Immediately after surgery, the patient experienced expected acute vestibular imbalance (oscillopsia and disequilibrium), which was managed with vestibular suppressants and early physical therapy. By the third postoperative day, she was ambulating with assistance. At the six-week follow-up, the patient reported complete cessation of vertigo spells. She described mild residual imbalance only when walking in the dark, but no falls. Audiometry confirmed hearing preservation (within 10 dB of preoperative levels, speech discrimination 68%). The postoperative dizziness gradually resolved over three months with vestibular rehabilitation.
Discussion & Key Takeaways
This case underscores the efficacy of vestibular nerve section in eliminating debilitating vertigo when medical therapy fails. The procedure offers several advantages over labyrinthectomy, primarily the potential for hearing preservation. However, patient selection is critical. Ideal candidates have unilateral peripheral vestibular dysfunction with serviceable hearing in the affected ear. Complications, though infrequent, include facial nerve injury, CSF leak, meningitis, and incomplete symptom relief due to residual vestibular fibers.
In this case, the patient achieved a Class A outcome (complete vertigo control with preserved hearing) according to the 1995 AAO-HNS criteria for Meniere's disease. Long-term follow-up at 18 months showed stable hearing and no recurrence of vertigo.
Conclusion
The vestibular nerve section remains a powerful tool in the neurotologist's armamentarium for refractory vertigo. With meticulous surgical technique and appropriate patient selection, the procedure can provide complete, durable relief while safeguarding cochlear function. Multidisciplinary collaboration between otology, neurosurgery, and vestibular rehabilitation optimizes outcomes.