What are the treatment options for Meniere's disease?

Treatment Options for Meniere's Disease

Treatment for Meniere's disease should follow a stepwise approach, starting with lifestyle modifications and oral medications, progressing to intratympanic treatments, and finally considering surgical interventions for cases unresponsive to conservative management. 1

First-Line Treatment: Lifestyle Modifications and Oral Medications

Dietary and Lifestyle Changes

• Low-sodium diet (1500-2300 mg daily) is recommended as a primary intervention 1
• Limit alcohol consumption and caffeine intake 1
• Stress management techniques 1
• Allergy management when applicable 1
• Sleeping in darkness (6-7 hours in an unlit room) 1

Oral Medications

• Diuretics (thiazides) to reduce endolymph volume 1
• Betahistine may be offered to reduce symptoms or prevent attacks, though benefits may be limited based on high-quality evidence 1
• During acute attacks:
  • Antivertigo medications
  • Antiemetics
  • Antihistamines for symptomatic relief 1

Second-Line Treatment: Intratympanic Treatments

When patients don't respond to noninvasive treatments:

• Intratympanic steroids may be offered with benefits including:
  • Improved vertigo control
  • Enhanced quality of life
  • Faster return to work
  • Risks include hearing loss, eardrum perforation, and persistent imbalance 1
• Intratympanic gentamicin can be used for vertigo control, though it works by reducing vestibular function in the treated ear 2

Third-Line Treatment: Surgical Interventions

For patients with disabling, persistent vertigo despite other treatments:

Hearing-Preserving Options (for patients with usable hearing)

• Endolymphatic sac decompression to reduce endolymphatic pressure 1, 3
  • High vertigo control rate with low risk of audiovestibular loss
  • Wider decompression of the sac may impact outcomes

Ablative Procedures (for patients with poor hearing)

• Vestibular nerve section to sever the vestibular portion of cranial nerve VIII 1
• Labyrinthectomy to remove the labyrinth, controlling vertigo but sacrificing remaining hearing 1, 3
• Triple Semicircular Canal Occlusion (TSCO) - emerging partially ablative procedure with high vertigo control rate 3

Additional Considerations

Hearing Rehabilitation

• Hearing aids for patients with hearing loss 1
• Cochlear implants may be placed in active Meniere's disease patients or during ablative surgery 3

Supportive Care

• Vestibular rehabilitation/physical therapy beneficial for chronic imbalance between attacks (not during acute vertigo) 1
• Patient education is crucial for shared decision-making 1

Special Considerations

• Bilateral disease (10-25% of cases) requires caution with ablative procedures to avoid total vestibular loss 1
• Not recommended: Positive pressure therapy (Meniett device) due to lack of efficacy compared to placebo 1

Treatment Algorithm

1. Initial Management:

   • Low-sodium diet + lifestyle modifications
   • Diuretics and/or betahistine
   • Symptomatic treatment for acute attacks

2. If inadequate response after 3-6 months:

   • Progress to intratympanic steroids or gentamicin

3. If continued disabling symptoms:

   • For patients with usable hearing: Consider endolymphatic sac surgery
   • For patients with poor hearing: Consider ablative procedures (labyrinthectomy or vestibular nerve section)

4. Throughout treatment:

   • Address quality of life impacts including psychological aspects
   • Consider hearing rehabilitation as needed

The evidence for many Meniere's disease treatments remains limited, with few high-quality randomized controlled trials available 4, 5. Treatment decisions should consider the impact on vertigo control, hearing preservation, and overall quality of life.