From the Guidelines
Management of Meniere's disease should focus on controlling vertigo attacks and improving quality of life through a combination of lifestyle modifications, medications, and sometimes surgical interventions, as recommended by the 2020 clinical practice guideline: Ménière's disease 1. The initial treatment approach includes:
- A low-salt diet (less than 2g sodium daily) to reduce inner ear fluid pressure
- Avoidance of caffeine, alcohol, and tobacco which can trigger symptoms
- Diuretics like hydrochlorothiazide (25-50mg daily) or acetazolamide (250mg twice daily) to reduce inner ear fluid pressure During acute vertigo attacks, vestibular suppressants such as:
- Diazepam (5-10mg)
- Meclizine (25-50mg every 4-6 hours)
- Promethazine (25mg) can provide relief For persistent symptoms, intratympanic steroid injections (dexamethasone 4mg/ml) may be administered. In severe cases unresponsive to medical therapy, more invasive options include:
- Endolymphatic sac decompression
- Vestibular nerve section
- Gentamicin injections (40mg/ml) for chemical labyrinthectomy These treatments work by either reducing endolymphatic hydrops (excess fluid in the inner ear) or decreasing vestibular input. Patients should also consider vestibular rehabilitation therapy to improve balance and reduce fall risk, particularly between episodes. It is essential to note that the goals of Meniere's disease treatment are to prevent or reduce vertigo severity and frequency, relieve or prevent hearing loss, tinnitus, and aural fullness, and improve quality of life, as stated in the 2020 clinical practice guideline: Ménière's disease 1.
From the Research
Management of Meniere's Disease
Meniere's disease is a chronic condition of the inner ear characterized by vertigo attacks, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. The management of Meniere's disease includes medical and surgical treatments.
- Medical management:
- Diuretics: A systematic review of diuretics in the medical management of Meniere's disease found that oral diuretic therapy may be beneficial in improving vertigo episode frequency, with less convincing evidence for improvement in hearing outcomes 2.
- Betahistine: A systematic review and network meta-analysis found that oral high-dose betahistine was associated with hearing improvement compared to placebo, although the 95% credible intervals failed to rule out the possibility of no difference 3.
- Intratympanic steroids: A systematic review and network meta-analysis found that intratympanic steroid plus high-dose betahistine was associated with the largest difference in hearing improvement compared to placebo, and may be the best treatment option for achieving both hearing preservation and vertigo control 3.
- Surgical management:
- Endolymphatic sac surgery: A systematic review found that endolymphatic sac surgery may reduce symptoms in Meniere's disease when compared with placebo, although the evidence is generally of low certainty 4.
- Intratympanic gentamicin: A systematic review and network meta-analysis found that intratympanic gentamicin was associated with the highest probability of achieving complete vertigo control, although it may be detrimental to hearing preservation with high cumulative dosage and short interval between injections 3.
- Lifestyle modifications:
Treatment Protocols
The goal of treatment is to control vertigo symptoms and preserve hearing. A suggested protocol for medical management includes:
- Initiating medical therapy with diuretics, betahistine, or both, while awaiting consultation with otolaryngology-head and neck surgery 5.
- Considering nonablative therapies, such as intratympanic steroids, for symptoms refractory to medical therapy 6.
- Considering ablative therapies, such as intratympanic gentamicin, for symptoms refractory to nonablative therapies 6.
Future Research
There is a need for further research to establish the comparative effectiveness of different treatments for Meniere's disease, particularly for achieving both hearing preservation and vertigo control 3, 4. Additionally, information on the natural course of the disease is one of the biggest flaws in current research, and further studies are needed to address this knowledge gap 4.