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 medical therapy, progressing to intratympanic treatments, and finally to surgical options for refractory cases. 1

First-Line Treatments: Lifestyle Modifications

Lifestyle modifications are recommended as initial management:

• Low-sodium diet (1500-2300 mg daily) 1
• Limiting alcohol and caffeine intake 1
• Stress management techniques 1
• Allergy management for patients with allergies 1
• Regular sleep patterns in darkness to maintain hormonal circadian rhythm 1

While evidence for dietary modifications is limited, the American Academy of Otolaryngology-Head and Neck Surgery recommends these as first-line approaches due to their favorable risk-benefit profile 2, 1.

Second-Line Treatments: Pharmacotherapy

For patients who don't respond adequately to lifestyle modifications:

• Diuretics (thiazides) to reduce endolymph volume 1
• Betahistine may be offered to reduce symptoms or prevent attacks 2, 1
• Antivertigo medications for symptomatic relief during acute attacks 1
• Antiemetics to control nausea and vomiting during attacks 1

The 2020 clinical practice guideline states: "Clinicians may offer diuretics and/or betahistine for maintenance therapy to reduce symptoms or prevent Ménière's disease attacks" 2.

Third-Line Treatments: Intratympanic Therapy

For patients with persistent symptoms despite medical management:

• Intratympanic steroids may be offered to patients with active Ménière's disease not responsive to noninvasive treatments 2
• Intratympanic gentamicin can be considered for vertigo control in patients with refractory symptoms 3

The guideline specifically recommends: "Clinicians may offer, or refer to a clinician who can offer, intratympanic steroids to patients with active Ménière's disease not responsive to noninvasive treatment" 2.

Fourth-Line Treatments: Surgical Options

For patients with disabling, persistent vertigo despite other treatments:

• Endolymphatic sac decompression - less invasive option that preserves hearing but has ~40% recurrence rate 1, 4
• Vestibular nerve section - for patients with useful hearing who have intractable vertigo 1, 4
• Labyrinthectomy - definitive treatment for vertigo control in patients without serviceable hearing 1, 4

Important Considerations

• Vestibular rehabilitation should NOT be recommended for acute vertigo attacks but may help with chronic imbalance between attacks 2, 1
• Positive pressure therapy should NOT be prescribed as it has been shown to be ineffective 2
• Bilateral disease (10-25% of cases) requires caution with ablative procedures to avoid total vestibular loss 2, 1
• Patient education is crucial for shared decision-making and should include verbal and written information about the disease, treatment options, and potential long-term effects 2

Treatment Algorithm

1. Start with lifestyle modifications (low-sodium diet, caffeine/alcohol reduction, stress management)
2. If inadequate control, add pharmacotherapy (diuretics and/or betahistine)
3. For persistent symptoms, consider intratympanic steroids
4. For refractory cases, consider surgical options based on hearing status:
   • With useful hearing: endolymphatic sac decompression or vestibular nerve section
   • Without useful hearing: labyrinthectomy

The treatment approach should be guided by symptom severity, hearing status, and the presence of bilateral disease, with the primary goals being vertigo control and preservation of hearing when possible 2, 1.