Management of patients with Menière’s Disease (MD) has been challenging since the discovery of the disease. An endolymphatic hydrops is hypothesized as an epiphenomenon in MD [
1]. It has been reported that colorful variable presentation of symptoms leads to challenges in diagnosing MD, whereupon diagnostic criteria have been established in the 1970s and revised multiple times throughout the decades [
2‐
4]. The most current revision by an international joint effort of the
International Classification of Vestibular Disorders 2015 defines two categories: definitive MD and probable MD [
5]. However, not all MD patients seem to fit into the categories given by these criteria [
6], which might be a result of considering solely clinical characteristics for defining this disorder. In addition, providing an individualized treatment concept bears another challenge in the management of MD patients. Throughout the different continents, specialists follow different treatment concepts, e.g., involving the discussion about efficacy of betahistine and diuretics [
7,
8], debating when ablative or non-ablative options should be introduced, and the widely debated effect of the non-ablative endolymphatic sac surgery (ESS) [
9]. However, a current international consented recommendation provides a staged treatment concept considering non-ablative and ablative treatment options as the following [
10]: (1) conservative medical treatment with lifestyle and diet adjustments, vestibular rehabilitation, and betahistine orally [
11‐
15]; (2) intratympanic injections of corticosteroids [
16]; (3) ESS [
17]; (4) as the first ablative option intratympanic injections of the ototoxic antibiotic gentamicin [
18]; and (5) as
ultima ratio the labyrinthectomy [
19]. Since the 1920s the idea of manipulation on the inner ear such as decompressing the endolymphatic sac evolved when Portmann drew parallels to glaucoma [
20] which was later expanded by William House in the 1960s by inserting a permanent shunt into the subarachnoid space or mastoid [
21]. The history of establishing different techniques on surgical manipulation of the inner ear for treatment of MD is depicted in the review of Kersbergen and colleagues [
22]. Different methods have been evaluated to date, from performing a mere decompression of the endolymphatic sac, an endolymphatic sac incision, an endolymph-mastoid shunt surgery with insertion of a small silicone shunt, to the most invasive technique, the endolymph-subarachnoid space shunt [
17,
21,
23]. However, contradictory prevalence data on radiological temporal bone specifics exists suggesting a potential hypoplasia or degeneration of the vestibular duct and endolymphatic sac [
24‐
27]. Thus, efficacy of ESS with a hypoplastic or degenerated endolymphatic sac is called into question. In addition, clinical efficacy on this treatment option is widely debated as ESS holds a common perception of a placebo surgery as stated in the early work of Thomsen et al. [
9,
28‐
35]. Many other, solely retrospective studies, report of a high rate of vertigo control postinterventional [
17] and a non-ablative character of this treatment option. A recent meta-analysis of Szott and colleagues revealed a mean hearing impairment postoperatively of a pure tone average of around 9 dB and 25% speech discrimination [
36]. Thus, further assessment of ESS with regard to efficacy, quality of life and postoperative hearing is demanded. Volume and the complex regulation of its inner ear fluid compositions [
37] could be altered by manipulation on the endolymphatic sac by ESS. However, effect of opening the perilymphatic system has not been evaluated systematically in MD patients so far. In cochlear implantation (CI), the perilymphatic system is routinely opened by inserting the electrode via the round window. Due to the quality-of-life impairing effect of episodic vertigo attacks, all treatment concepts focus on the reduction of these attacks and less so on hearing rehabilitation. Moreover, fitting acoustic hearing aids in those patients who might intermittently experience fluctuating hearing levels is challenging and often demotivating, especially when the contralateral ear is healthy with normacusis. Therefore, in the present study, we (1) investigated the potential effect on reduction of vertigo by alternating the pressure within the endo- and in addition perilymphatic system by comparing patients with ESS and/or CI surgery and (2) evaluated hearing rehabilitation results in these patient groups.