What are the treatment options for Ménière's disease?

Treatment Options for Ménière's Disease

The treatment of Ménière's disease should follow a stepwise approach, beginning with lifestyle modifications and progressing to more invasive interventions only when conservative measures fail to control vertigo attacks and improve quality of life. 1

First-Line Treatments: Lifestyle and Dietary Modifications

Dietary Restrictions

• Low-sodium diet (1500-2300 mg daily) as recommended by the American Heart Association 1
• Limit alcohol consumption
• Limit caffeine intake

These dietary modifications aim to reduce endolymphatic fluid buildup in the inner ear, though the evidence supporting their efficacy is limited 2.

Trigger Management

• Identify and avoid personal triggers that may worsen symptoms, including:
  • Weather changes
  • Allergies
  • Stress
  • Sleep deprivation

Second-Line Treatments: Medications

When dietary and lifestyle modifications fail to adequately control symptoms, medication therapy should be considered:

Oral Medications

• Diuretics to reduce fluid retention and endolymphatic pressure
• Antivertigo medications (vestibular suppressants) for acute vertigo attacks
• Antihistamines particularly if allergies are suspected as contributing factors
• Betahistine (histamine analogue) to increase vasodilation to the inner ear 1

Non-Invasive Supportive Therapies

• Vestibular rehabilitation (physical therapy) to improve balance function
• Hearing aids to address hearing loss

Third-Line Treatments: Intratympanic Injections

For patients with persistent and disabling vertigo attacks despite conservative therapy:

• Intratympanic steroid injections (hearing-preserving)
• Intratympanic gentamicin (chemical labyrinthectomy - may affect hearing) 1

Fourth-Line Treatments: Surgical Interventions

Surgery should be considered only after failure of less invasive approaches. The choice of surgical procedure depends primarily on hearing status:

For Patients with Usable Hearing

• Endolymphatic sac decompression (with or without shunt placement) 1, 3
• Vestibular nerve section (hearing-preserving) 1

For Patients with Non-Serviceable Hearing

• Labyrinthectomy (hearing-ablative) 1

Treatment Algorithm Based on Disease Severity

1. Initial Presentation/Mild Disease:

   • Low-sodium diet (1500-2300 mg daily)
   • Limit alcohol and caffeine
   • Identify and manage triggers
   • Consider diuretics

2. Moderate Disease (Persistent Symptoms):

   • Continue dietary restrictions
   • Add oral medications (diuretics, antivertigo medications)
   • Consider vestibular rehabilitation
   • Address hearing loss with hearing aids if needed

3. Severe Disease (Refractory to Conservative Management):

   • Intratympanic injections (steroids first, then gentamicin if needed)
   • Consider surgical options based on hearing status

Important Considerations

• The natural history of Ménière's disease includes spontaneous remissions, making it difficult to assess treatment efficacy
• Up to 60% of patients in placebo groups of clinical trials show improvement in vertigo symptoms 1
• Hearing may stabilize over time, but residual balance problems may require long-term vestibular therapy 1
• Treatment decisions should consider the preservation of hearing whenever possible
• The disease may affect both ears in 10-25% of cases over time 1

Pitfalls and Caveats

• Avoid delaying appropriate treatment escalation when quality of life is significantly impacted
• Be aware that many studies on Ménière's disease are poorly designed with inadequate controls 1
• Recognize that most treatments primarily target vertigo control rather than other symptoms like hearing loss, tinnitus, and aural fullness 1
• Consider that bilateral Ménière's disease may require more conservative approaches to preserve function in both ears
• Ablative procedures should be reserved for patients who have failed more conservative approaches 3