What is the best management of Meniere's disease?

Management of Ménière's Disease

The best management of Ménière's disease involves a stepwise approach starting with dietary and lifestyle modifications, followed by pharmacotherapy, and progressing to more invasive interventions only when conservative measures fail to control symptoms. 1

Diagnosis and Initial Assessment

Definite Ménière's disease is characterized by:

• Two or more spontaneous vertigo attacks lasting 20 minutes to 12 hours
• Audiometrically documented low-to-midfrequency sensorineural hearing loss in the affected ear
• Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear 1

First-Line Management: Lifestyle and Dietary Modifications

Dietary Modifications:

• Sodium restriction (1500-2300 mg daily) based on American Heart Association recommendations 1
• Limit caffeine consumption as it may trigger attacks in some patients
• Limit alcohol consumption
• Maintain adequate hydration throughout the day

Lifestyle Modifications:

• Stress management techniques (as stress hormones like vasopressin may worsen symptoms)
• Regular exercise
• Adequate sleep (preferably in a dark room to maintain hormonal circadian rhythm)
• Allergy identification and management (allergies contribute to symptoms in up to 30% of patients) 1

Second-Line Management: Pharmacotherapy

For Acute Vertigo Attacks:

• Vestibular suppressants (limited course only during attacks) 1
  • Antihistamines (e.g., meclizine, dimenhydrinate)
  • Benzodiazepines (e.g., diazepam) - use cautiously due to risk of dependence
  • Anticholinergics (e.g., scopolamine) - limited use due to side effects

For Maintenance Therapy:

• Diuretics to reduce endolymphatic hydrops 1, 2
• Betahistine (a histamine analog that increases vasodilation to the inner ear) 1
• Corticosteroids particularly if autoimmune basis is suspected or in bilateral disease 2

Third-Line Management: Minimally Invasive Procedures

When medical therapy fails to control symptoms:

• Intratympanic injections through the eardrum 1
  • Steroids (hearing-preserving)
  • Gentamicin (chemical labyrinthectomy - may affect hearing)

Fourth-Line Management: Surgical Interventions

For intractable cases with severe symptoms despite medical therapy:

• Hearing-preserving procedures:
  • Endolymphatic sac decompression/shunt 3, 4
  • Vestibular nerve section
• Ablative procedures (for non-serviceable hearing):
  • Labyrinthectomy 1

Important Considerations and Pitfalls

• Avoid long-term use of vestibular suppressants as they can impair central vestibular compensation 1
• Regular follow-up is essential to monitor disease progression and treatment response
• Consider vestibular rehabilitation for patients with persistent imbalance
• Screen for comorbid conditions that may exacerbate symptoms:
  • Sleep apnea in patients with increased vertigo episodes
  • Migraine (vestibular migraine can mimic or coexist with Ménière's)
  • Anxiety/depression related to chronic disease

Patient Education and Support

• Educate patients about the natural history of the disease
• Provide information about symptom triggers and management strategies
• Encourage participation in support groups 1
• Explain that while there is no cure, symptoms can be effectively managed in most patients

Treatment Algorithm

1. Start with lifestyle and dietary modifications for all patients
2. Add maintenance pharmacotherapy if symptoms persist
3. Use acute medications only during attacks
4. Consider intratympanic injections if vertigo control is inadequate
5. Consider surgical options only after failure of less invasive approaches

The evidence for lifestyle and dietary interventions, while commonly recommended, is of low to very low certainty according to recent systematic reviews 5. Nevertheless, these conservative approaches are recommended as first-line due to their low risk profile and potential benefits in symptom control.