What are the management options for Meniere's disease?

Management of Meniere's Disease

The management of Meniere's disease should follow a stepwise approach, beginning with lifestyle modifications and medical therapy, progressing to intratympanic interventions, and finally surgical options for refractory cases. 1

Diagnosis and Clinical Features

Meniere's disease is characterized by:

• Two or more spontaneous vertigo attacks (each lasting 20 minutes to 12 hours)
• Audiometrically documented fluctuating low- to mid-frequency sensorineural hearing loss
• Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear 2

First-Line Management: Lifestyle Modifications

Lifestyle modifications are essential initial interventions:

• Dietary changes:

  • Limit sodium intake to 1500-2300 mg daily 1
  • Avoid excessive caffeine, alcohol, and nicotine 2
  • Eat well-balanced meals throughout the day 2
  • Drink plenty of water, avoiding high-sugar beverages 2

• Other lifestyle modifications:

  • Manage stress appropriately 2
  • Get adequate exercise and sleep 2
  • Identify and manage any allergies (may contribute to symptoms in up to 30% of patients) 2
  • Consider joining a support group 2

Medical Therapy

When lifestyle modifications are insufficient:

1. Symptomatic management during attacks:

   • Vestibular suppressants should be offered during acute Meniere's attacks only 2
   • Options include:
     • Benzodiazepines (caution: risk for dependence) 2
     • Anticholinergics (scopolamine, atropine) 2
     • Antiemetics 1

2. Preventive medications:

   • Diuretics (thiazides, potassium-sparing, loop diuretics, carbonic anhydrase inhibitors) 1
   • Betahistine (16-48 mg daily in divided doses) - though recent high-quality trials like BEMED found no significant difference from placebo 1

Second-Line Treatment

For patients who fail to respond to lifestyle modifications and medical therapy:

• Intratympanic steroids:
  • Indicated for active Meniere's disease not responsive to noninvasive treatments 1
  • Benefits include improved vertigo control and quality of life 1
  • Risks include eardrum perforation and persistent imbalance 1

Third-Line Treatment

Based on hearing function:

• For patients with serviceable hearing:

  • Endolymphatic sac decompression surgery 1, 3

• For patients with poor hearing:

  • Intratympanic gentamicin injections 1, 3
  • Reduces vestibular function in the treated ear 1
  • Risk of hearing loss must be considered 3

Last Resort Options

For intractable cases:

• With non-serviceable hearing:

  • Labyrinthectomy (controls vertigo but sacrifices remaining hearing) 1, 3
  • May be combined with cochlear implantation 3

• With serviceable hearing:

  • Vestibular nerve section 1, 3

Adjunctive Therapies

• Vestibular rehabilitation:

  • Beneficial for chronic imbalance between attacks 1
  • Not recommended during acute vertigo attacks 1

• Hearing aids:

  • Beneficial for patients with hearing loss 1

Monitoring and Follow-up

• Regular audiologic and vestibular assessment to monitor disease progression 1
• Consider tapering or stopping medication once symptoms subside 1

Important Considerations

• Up to 60% vertigo control has been documented in placebo groups, making treatment efficacy difficult to determine 1
• Meniere's disease affects both ears in 10-25% of cases over time, requiring caution with ablative procedures 1
• Patient education is crucial for shared decision-making 2, 1
• The psychological impact (anxiety, depression, social isolation) should be addressed 1

Treatment Pitfalls to Avoid

• Prolonged use of vestibular suppressants can delay central compensation and should be limited to acute attacks only 2
• Benzodiazepines carry significant risk for drug dependence 2
• Positive pressure therapy (Meniett device) is not recommended due to lack of efficacy compared to placebo 1
• Bilateral disease requires special consideration before destructive procedures to avoid total vestibular loss 1