Ménière's Disease and Its Treatment
Ménière's disease is an inner ear disorder characterized by episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness, with no cure but multiple treatment options ranging from dietary modifications to surgical interventions. 1, 2
Definition and Diagnostic Criteria
Ménière's disease is defined by the following criteria:
- 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 on at least one occasion before, during, or after a vertigo episode
- Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear 1
The underlying pathology is endolymphatic hydrops, an excessive accumulation of endolymph fluid in the inner ear 2, 3.
Clinical Presentation
Cardinal Symptoms
- Vertigo: Rotational sensation of self-motion or environment motion lasting 20 minutes to 12 hours
- Hearing loss: Fluctuating, initially affecting low to mid-frequencies
- Tinnitus: Ringing, buzzing, or other noises that may fluctuate in intensity
- Aural fullness: Sensation of pressure or plugging in the affected ear 1, 2
Additional Features
- Typically affects adults in their 40s-70s
- Can be unilateral or bilateral (25-40% of cases)
- May include drop attacks (Tumarkin's Otolithic Crisis) in later stages
- Symptoms are episodic and unpredictable 1, 2, 4
Differential Diagnosis
| Condition | Distinguishing Features |
|---|---|
| Vestibular migraine | Attacks may be shorter or longer; less likely to have hearing loss; often has migraine history; photophobia common |
| BPPV | Brief vertigo (seconds) triggered by position changes; no hearing loss |
| Vestibular neuritis | Prolonged vertigo (days); no hearing loss |
| Labyrinthitis | Prolonged vertigo with sudden non-fluctuating hearing loss |
| Vestibular schwannoma | Chronic imbalance rather than episodic vertigo; progressive non-fluctuating hearing loss |
| Stroke/ischemia | May have other neurological symptoms; usually no associated hearing loss [1,2] |
Diagnostic Workup
- Detailed history: Focus on vertigo characteristics, duration, associated symptoms
- Audiometric testing: Document fluctuating low- to mid-frequency sensorineural hearing loss
- Video/electronystagmography: Evaluate vestibular function
- Electrocochleography: Measure electrical responses of cochlea and auditory nerve
- MRI of brain: Rule out other causes and potentially visualize endolymphatic hydrops 1
Treatment Approach
First-Line: Lifestyle and Dietary Modifications
- Low-sodium diet (1500-2300 mg daily)
- Limit alcohol consumption
- Limit caffeine intake
- Identify and manage triggers (stress, allergies, etc.) 1, 2
Second-Line: Medications
- Diuretics: To reduce fluid volume
- Betahistine: Histamine analog that increases inner ear blood flow
- Antivertigo medications: For acute vertigo symptoms
- Antihistamines: If allergies are a contributing factor 1, 2, 4
Third-Line: Noninvasive Therapies
- Vestibular rehabilitation: Physical therapy to improve balance
- Hearing aids: For hearing loss management 1, 2
Fourth-Line: Middle Ear Injections
- Intratympanic steroids: Anti-inflammatory effect
- Intratympanic gentamicin: Chemical labyrinthectomy (can affect hearing) 1, 2, 4
Fifth-Line: Surgical Options
- Endolymphatic sac decompression: Hearing-sparing procedure
- Vestibular nerve section: Hearing-sparing procedure
- Labyrinthectomy: Ablative procedure (sacrifices remaining hearing) 1, 2
Important Considerations
Patient Education
- Explain the chronic, fluctuating nature of the disease
- Encourage symptom journaling to identify triggers
- Discuss quality of life impact and psychological effects 1, 2
Monitoring
- Regular audiometric testing to track hearing loss progression
- Document changes in vertigo frequency and severity
- Assess impact on quality of life 1, 2
Bilateral Disease Caution
- Consider bilateral potential (25-40% of cases) before destructive procedures
- Ablative procedures like labyrinthectomy should be approached with caution as they sacrifice remaining hearing 1, 4