What are the treatment options for Meniere's disease?

Treatment Options for Meniere's Disease

The first-line treatment for Meniere's disease should include vestibular suppressants for acute attacks, lifestyle modifications (particularly low-sodium diet), and maintenance therapy with diuretics and/or betahistine. 1

Diagnosis and Assessment

• Meniere's disease is diagnosed clinically based on characteristic symptoms: vertigo attacks, fluctuating hearing loss, tinnitus, and aural fullness
• An audiogram should be obtained for baseline assessment and regular follow-up to monitor disease progression 1
• Vestibular migraine should be ruled out as it can coexist with or be confused for Meniere's disease 1

Acute Attack Management

• Vestibular suppressants should be offered during acute Meniere's attacks only 2
  • Options include benzodiazepines and antiemetics
  • Caution: Use should be limited due to risks of dependence, sedation, and impaired vestibular compensation 1

First-Line Maintenance Therapy

1. Lifestyle Modifications:

   • Low-sodium diet (1500-2300 mg daily) 1
   • Limit alcohol and caffeine intake 1
   • Manage stress through relaxation techniques 1
   • Consider keeping a food diary to identify personal triggers 1
   • Carbohydrate management may help prevent sodium retention 3

2. Medication Options:

   • Diuretics: May be offered to reduce endolymph volume 1
     • Options include thiazides (e.g., hydrochlorothiazide), potassium-sparing diuretics, and loop diuretics
   • Betahistine: May be considered at 16-48 mg daily 1
     • Caution: Use with care in patients with asthma or peptic ulcer disease

Patient Education

• Clinicians should educate patients about the natural history of Meniere's disease, symptom control measures, treatment options, and outcomes 2
• Education should include both verbal and written information about the disease and its impact on quality of life 1
• Patients should understand that Meniere's disease has no cure, only symptom management 1

Second-Line Interventions

When first-line treatments fail to control symptoms:

1. Intratympanic Therapies:

   • Steroid injections: May be considered for persistent symptoms 1
   • Gentamicin injections: May be considered for vertigo control in refractory cases 1
     • Caution: Risk of hearing loss with gentamicin

2. Surgical Options:

   • Vestibular nerve section: A hearing-sparing procedure 1
   • Labyrinthectomy: May be considered for severe cases with profound hearing loss 1
   • Endolymphatic sac decompression: May be considered when medical treatment fails 4

Rehabilitation and Support

• Vestibular rehabilitation: Recommended for chronic imbalance between attacks 1
• Hearing aids: Beneficial for patients with hearing loss 1
• Support groups: Provide valuable resources and emotional support 1

Important Considerations

• About 10-25% of patients develop bilateral Meniere's disease over time, which impacts treatment decisions, especially regarding ablative therapies 1
• The pathophysiology involves endolymphatic hydrops (excessive endolymph accumulation in the inner ear) 5
• Regular follow-up is essential to monitor disease progression and treatment effectiveness 1
• Avoid: Positive pressure therapy (Meniett device) is not recommended due to lack of evidence showing effectiveness 1

Treatment Algorithm

1. Start with: Vestibular suppressants for acute attacks + lifestyle modifications (especially low-sodium diet)
2. If symptoms persist: Add diuretics and/or betahistine
3. If still inadequate control: Consider intratympanic steroid injections
4. For refractory cases: Consider intratympanic gentamicin or surgical options based on hearing status