What are the treatment options and investigations for Meniere's disease?

Treatment and Investigations for Meniere's Disease

For patients with Meniere's disease, first-line treatment should include lifestyle modifications (low-sodium diet, limiting alcohol and caffeine), diuretics, and/or betahistine, with progression to intratympanic steroids for those not responsive to conservative treatment. 1, 2

Diagnostic Evaluation

Required Investigations

• Detailed history focusing on:

  • Vertigo characteristics (spontaneous attacks lasting 20 minutes to 12 hours)
  • Fluctuating hearing symptoms
  • Tinnitus and aural fullness 1

• Audiometric testing to document fluctuating low- to mid-frequency sensorineural hearing loss 1

• Vestibular function tests:

  • Video/electronystagmography
  • Electrocochleography (measures electrical responses of cochlea)
  • Vestibular-evoked myogenic potential testing 1, 3

• MRI of brain to:

  • Rule out other causes (e.g., vestibular schwannoma)
  • Potentially visualize endolymphatic hydrops 1

Treatment Algorithm

1. First-Line Treatment (Conservative Management)

• Dietary and Lifestyle Modifications:

  • Low-sodium diet (1500-2300 mg daily)
  • Limit alcohol consumption
  • Limit caffeine intake
  • Identify and manage triggers (stress, allergies) 1, 2, 4

• Pharmacological Options:

  • Diuretics to reduce fluid volume
  • Betahistine to increase inner ear blood flow 2, 1
  • Antivertigo medications for acute attacks 1
  • Antihistamines if allergies are contributing 1

2. Second-Line Treatment

• Intratympanic steroids for patients with active Meniere's disease not responsive to noninvasive treatment 2, 1
  • Benefits: Improved vertigo control, improved quality of life, faster return to work 2
  • Risks: Hearing loss, eardrum perforation, persistent imbalance 2

3. Third-Line Treatment (Based on Hearing Status)

• For patients with usable hearing:

  • Endolymphatic sac decompression 1, 5
  • Vestibular nerve section 1

• For patients with non-usable hearing:

  • Intratympanic gentamicin (chemical labyrinthectomy) 1, 6, 5
  • Surgical labyrinthectomy (with or without cochlear implantation) 1, 5

Important Clinical Considerations

Effectiveness of Treatments

• Positive pressure therapy should NOT be prescribed as it has been shown to be ineffective 2

• Vestibular rehabilitation/physical therapy should NOT be recommended for managing acute vertigo attacks but may be beneficial during the intercritic period 2, 5

• Betahistine and diuretics have shown benefit in observational studies, though evidence quality is moderate 2

Treatment Monitoring

• Regular audiometric testing to track hearing loss progression
• Document changes in vertigo frequency and severity
• Assess impact on quality of life 1

Cautions and Pitfalls

1. Diagnostic challenges: Meniere's disease can be confused with vestibular migraine, BPPV, or vestibular neuritis - careful attention to symptom patterns is essential 1

2. Bilateral disease: Consider more conservative approaches as 10-25% of cases may become bilateral over time 2

3. Sodium restriction risks: While recommended, monitor for hyponatremia, especially in elderly patients or those with comorbidities 2

4. Intratympanic gentamicin risks: Can cause hearing loss; low-dose protocols are now preferred to balance vertigo control with hearing preservation 6

5. Patient expectations: The disease course can be unpredictable with symptoms that may naturally fluctuate, making treatment efficacy assessment challenging 2, 1

The treatment approach should follow a stepwise progression, starting with conservative measures and advancing to more invasive options only when symptoms remain uncontrolled. Quality of life should be a primary consideration in treatment decisions, as the unpredictable nature of attacks can cause significant anxiety and social isolation 1.