What are the treatment options for Meniere's disease and when should a patient be referred to a specialist, such as an otolaryngologist (ear, nose, and throat doctor) or neurologist?

Treatment Options for Meniere's Disease and Specialist Referral Guidelines

Patients with Meniere's disease should be managed with a stepwise approach starting with conservative measures and progressing to more invasive treatments only when symptoms remain uncontrolled, with referral to an otolaryngologist recommended at the time of diagnosis or when symptoms are not adequately controlled with initial management. 1

Diagnosis of Meniere's Disease

Definite Meniere's disease is characterized by:

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

Treatment Algorithm

First-Line Treatment (Conservative Management)

1. Dietary and Lifestyle Modifications

   • Low-sodium diet (1500-2300 mg daily)
   • Limit alcohol consumption
   • Limit caffeine intake
   • Identify and avoid individual triggers (stress, allergies, barometric pressure changes) 1

2. Oral Pharmacotherapy

   • Maintenance therapy:

     • Diuretics (to reduce endolymphatic fluid)
     • Betahistine (where available) 1

   • Acute attack management:

     • Antivertigo medications (vestibular suppressants)
     • Antiemetics
     • Antihistamines
     • Short-term anxiolytics (benzodiazepines) if needed 1, 2

Second-Line Treatment (When Conservative Measures Fail)

1. Intratympanic Steroid Therapy

   • May be offered to patients with active Meniere's disease not responsive to noninvasive treatment 1
   • Requires referral to otolaryngologist

2. Intratympanic Gentamicin

   • Chemical labyrinthectomy option
   • Effective for vertigo control but carries risk of hearing loss 1
   • Requires specialist administration

Third-Line Treatment (Surgical Options)

1. Endolymphatic Sac Decompression (hearing-sparing)
2. Vestibular Nerve Section (hearing-sparing)
3. Labyrinthectomy (hearing-ablative, only for non-functional hearing) 1

When to Refer to a Specialist

Immediate referral to otolaryngologist is recommended:

• At initial diagnosis for proper evaluation and treatment planning
• When symptoms are not adequately controlled with dietary and lifestyle modifications
• Before initiating any invasive treatments (intratympanic injections or surgical options)
• For patients with bilateral disease (requires special consideration)
• When drop attacks (Tumarkin's otolithic crisis) occur
• For patients with rapidly progressive hearing loss 1

Consider neurology referral when:

• Differential diagnosis includes central causes of vertigo
• Comorbid migraine is suspected (migraine can mimic or coexist with Meniere's disease)
• Neurological symptoms beyond typical Meniere's presentation are present 1

Treatment Effectiveness and Monitoring

• Diet and lifestyle modifications: May help 70-80% of patients with proper adherence
• Diuretics and oral medications: Provide symptomatic relief but don't alter disease course
• Intratympanic treatments: Can reduce vertigo attacks in 70-90% of patients
• Surgical options: Reserved for medication-refractory cases 1, 3

Important Considerations and Pitfalls

• Avoid positive pressure therapy as it has been shown to be ineffective 1
• Do not recommend vestibular rehabilitation for acute attacks, though it may help with chronic imbalance between episodes 1
• Monitor for bilateral disease development (occurs in 10-50% of cases), which limits ablative treatment options 1, 4
• Sodium restriction effectiveness may be related to increased aldosterone levels, which can help reduce endolymphatic hydrops 5
• Quality of life impact should be regularly assessed, as Meniere's disease significantly affects daily functioning and psychological wellbeing 1

Patient Education

Patients should be informed that:

• Meniere's disease is chronic but manageable
• Symptoms may fluctuate and eventually stabilize over time
• Treatment aims to reduce frequency and severity of attacks
• Support groups can provide valuable resources and emotional support 1

Connecting patients with resources such as the Vestibular Disorders Association or Meniere's Society can help them cope with this chronic condition 1.