What are the treatment options for Meniere's disease?

Treatment Options for Ménière's Disease

There is no cure for Ménière's disease, but treatment options range from dietary modifications and medications to more invasive procedures, with management typically following a stepwise approach from least to most aggressive interventions based on symptom severity. 1

Understanding Ménière's Disease

Ménière's disease is characterized by:

• Spontaneous vertigo attacks lasting 20 minutes to 12 hours
• Fluctuating low- to mid-frequency sensorineural hearing loss
• Tinnitus and aural fullness in the affected ear
• Association with endolymphatic hydrops (excess fluid in the inner ear)

Treatment Algorithm

First-Line: Lifestyle and Dietary Modifications

• Low-sodium diet (1500-2300 mg daily) 1

  • Helps reduce fluid retention in the inner ear
  • Reading food labels is essential for monitoring sodium intake

• Additional dietary restrictions:

  • Limit alcohol consumption
  • Limit caffeine intake
  • Maintain well-balanced meals throughout the day
  • Stay hydrated with water (avoid high-sugar beverages)

• Other lifestyle modifications:

  • Stress management techniques
  • Regular exercise
  • Adequate sleep
  • Identify and manage allergies (may contribute to symptoms in up to 30% of patients) 1

Second-Line: Pharmacologic Management

For Acute Vertigo Attacks:

• Vestibular suppressants (limited course only during attacks) 1
  • Antivertigo medications
  • Antihistamines
  • Benzodiazepines (caution: significant risk for drug dependence) 1
  • Anticholinergics like scopolamine (limited use due to side effects)

For Maintenance Therapy:

• Diuretics 1

  • Remove excess body fluid
  • May improve vertigo control in 79% of patients 2
  • Less convincing evidence for hearing improvement
  • Caution: Some research suggests potential adverse effects on inner ear function due to blood pressure changes 3

• Betahistine 1

  • Histamine analog that increases vasodilation to inner ear
  • Commonly used in Europe 4
  • May be offered as maintenance therapy to reduce symptoms or prevent attacks 1

• Corticosteroids 1, 4

  • Particularly useful in bilateral forms of Ménière's disease
  • Especially if autoimmune basis is suspected

Third-Line: Minimally Invasive Procedures

• Intratympanic steroid injections 1

  • For patients not responsive to noninvasive treatments
  • Injected through the eardrum into the middle ear
  • Grade B evidence based on RCTs showing efficacy for vertigo control 1
  • Benefits: Improved vertigo control, better quality of life, faster return to work
  • Risks: Hearing loss, eardrum perforation, persistent imbalance

• Intratympanic gentamicin injections 1

  • Selectively damages vestibular cells to control vertigo
  • Effective for vertigo control but carries risk of hearing loss
  • Reserved for patients with significant vertigo despite other treatments

Fourth-Line: Surgical Options

• Endolymphatic sac decompression 1

  • Hearing-sparing procedure
  • Aims to reduce endolymphatic pressure
  • Success reported in majority of patients with low morbidity 5

• Vestibular nerve section 1, 5

  • Hearing-sparing procedure
  • For patients with severe, refractory vertigo
  • Preserves hearing but permanently eliminates vestibular function

• Labyrinthectomy 1

  • Hearing-ablative procedure (destroys remaining hearing)
  • Only considered when hearing is already severely compromised
  • Provides definitive vertigo control

Important Considerations

What NOT to Do

• Do not prescribe positive pressure therapy (e.g., Meniett device) 1

  • Recommendation against based on systematic reviews showing ineffectiveness

• Do not recommend vestibular rehabilitation for acute vertigo attacks 1

  • Not effective during acute episodes
  • However, vestibular therapy may be beneficial for chronic imbalance after the acute phase

Quality of Life Considerations

• Ménière's disease can significantly impact quality of life through:

  • Unpredictable vertigo attacks
  • Progressive hearing loss
  • Constant tinnitus and fullness
  • Anxiety about future attacks

• Patient support groups can provide valuable resources and emotional support 1

Follow-up and Monitoring

• Regular follow-up is essential to:
  • Assess treatment response
  • Monitor hearing function
  • Adjust treatment as needed
  • Address psychological aspects of the disease 4

Common Pitfalls to Avoid

1. Overuse of vestibular suppressants - can lead to dependency and may delay central compensation
2. Inadequate sodium restriction - patients need specific guidance on dietary sodium reduction
3. Delayed escalation of therapy - patients with severe, frequent attacks may need more aggressive intervention sooner
4. Neglecting psychological impact - anxiety and depression are common and require attention
5. Excessive cooling of extremities during episodes - can lead to tissue damage 1

Remember that Ménière's disease is often characterized by spontaneous remissions and exacerbations, making assessment of treatment efficacy challenging. The goal of treatment is to reduce the frequency and severity of vertigo attacks while preserving hearing as much as possible.