What are the management options for Meniere's (Inner Ear) disease?

From the Guidelines

Management of Meniere's disease should focus on controlling vertigo attacks and improving quality of life, with initial treatment including lifestyle modifications and medications such as diuretics and vestibular suppressants, as recommended by the 2020 clinical practice guideline 1. The goals of treatment are to prevent or reduce vertigo severity and frequency, relieve or prevent hearing loss, tinnitus, and aural fullness, and improve quality of life. Some key lifestyle modifications include:

• Reducing salt intake to less than 2 grams daily
• Avoiding caffeine, alcohol, and tobacco
• Managing stress Medications are the first-line therapy, with options including:
• Diuretics like hydrochlorothiazide (25-50 mg daily) or acetazolamide (250 mg twice daily) to reduce inner ear fluid pressure
• Vestibular suppressants such as diazepam (5-10 mg), meclizine (25-50 mg every 4-6 hours), or promethazine (25 mg) to provide relief during acute vertigo attacks
• Anti-nausea medications like ondansetron (4-8 mg) as needed For patients with frequent, severe attacks not responding to medication, more invasive options may be considered, including:
• Intratympanic steroid or gentamicin injections
• Endolymphatic sac decompression surgery
• Vestibular nerve section in refractory cases Vestibular rehabilitation therapy is also beneficial for improving balance between attacks, as recommended by the 2020 clinical practice guideline 1. These treatments aim to reduce endolymphatic hydrops (excess fluid in the inner ear), which is believed to cause the characteristic symptoms of vertigo, fluctuating hearing loss, tinnitus, and aural fullness by creating pressure on sensory cells in the inner ear. It is essential to document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss and any change in quality of life in patients with Meniere's disease, as recommended by the 2020 clinical practice guideline 1. Clinicians should also counsel patients about the natural history, measures for symptom control, treatment options, and outcomes, and may offer magnetic resonance imaging of the internal auditory canal and posterior fossa in patients with nonfluctuating sensorineural hearing loss, tinnitus, or pressure in the affected ear, when these symptoms are not better accounted for by another disorder, as recommended by the 2020 clinical practice guideline 1.

From the Research

Meniere's Disease Management

• The initial management of Meniere's disease can involve a low-salt diet and a diuretic 2, 3.
• Treatment with intratympanic injection of gentamicin can be beneficial when vertigo persists despite optimal medical management 2.
• Gentamicin reduces vestibular function in the treated ear, although complete ablation of this vestibular function is not typically required in order to achieve control of vertigo 2.
• Many treatment options exist for the management of vertigo, including intratympanic injection of gentamicin (low dose) for patients for whom vertigo has not been controlled by medical measures 2.
• The Furstenberg regimen, which consists of a low-sodium diet and diuretics, has been shown to be effective in relieving symptoms of Meniere's disease in the vast majority of cases 3.
• Strict adherence to a professionally prescribed, low-sodium diet is crucial for the success of conservative management programs 3.

Treatment Options

• Intratympanic injection of gentamicin is a treatment option for patients with persistent vertigo despite medical management 2.
• The Furstenberg regimen is a conservative management approach that has been shown to be effective in relieving symptoms of Meniere's disease 3.
• Diuretics and a low-salt diet are commonly used in the initial management of Meniere's disease 2, 3.

Disease Characteristics

• Meniere's disease is characterized by spontaneous attacks of vertigo, fluctuating sensorineural hearing loss, aural fullness, and tinnitus 2.
• The pathologic process involves distortion of the membranous labyrinth with the formation of endolymphatic hydrops 2.
• Vertigo is often the most debilitating symptom associated with Meniere's disease 2.

Note: The study 4 is not relevant to Meniere's disease management.