What is the diagnosis and management approach for Mineires disease?

Ménière's Disease: Diagnosis and Management

Ménière's disease is diagnosed clinically based on recurrent vertigo attacks, documented low-to-midfrequency sensorineural hearing loss, and fluctuating aural symptoms, with management focusing on lifestyle modifications, medications for symptom control, and surgical interventions for refractory cases. 1

Diagnostic Criteria

Definite Ménière's Disease

• Two or more spontaneous attacks of vertigo, each lasting 20 minutes to 12 hours
• Audiometrically documented fluctuating low-to-midfrequency sensorineural hearing loss in the affected ear on at least one occasion before, during, or after vertigo episodes
• Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear 1

Key Diagnostic Steps

1. Audiometric testing - Essential for diagnosis of definite Ménière's disease 1

   • Pure tone thresholds and speech recognition measures
   • Rule out conductive components
   • Document low-to-midfrequency sensorineural hearing loss

2. Rule out vestibular migraine - Critical differential diagnosis 1

   • Assess for history of migraine
   • VM may present with short (<15 minutes) or prolonged (>24 hours) vertigo
   • Visual auras may occur before, during, or after attacks
   • Hearing loss in VM is mild/absent and stable over time

3. Imaging considerations

   • MRI of internal auditory canal and posterior fossa may be offered for patients with asymmetric sensorineural hearing loss 1
   • Not routinely required for all patients with suspected Ménière's disease

4. Avoid routine vestibular function testing or electrocochleography

   • Not recommended for establishing diagnosis 1
   • May have role in individualized cases but not routinely needed

Management Approach

First-Line Interventions

1. Lifestyle modifications 2

   • Low-sodium diet (1500-2300 mg daily)
   • Limit alcohol and caffeine intake
   • Stress management
   • Improve sleep hygiene
   • Consider food diary to identify personal triggers

2. Acute attack management

   • Vestibular suppressants - Offer limited course during attacks only 1, 2
     • Benzodiazepines (use with caution due to dependency risk)
     • Antiemetics for symptom control
     • Avoid long-term use as they can impair vestibular compensation

Second-Line Interventions

1. Maintenance therapy 2, 3

   • Diuretics - May be offered to reduce endolymph volume
     • Thiazides (e.g., hydrochlorothiazide)
     • Potassium-sparing diuretics
     • Loop diuretics
   • Betahistine - Consider at 16-48 mg daily
     • Use with caution in patients with asthma or peptic ulcer disease
     • Limited high-quality evidence for efficacy

2. Intratympanic therapies for persistent symptoms 2

   • Steroid injections
   • Gentamicin for refractory vertigo (note: risk to hearing)

Surgical Options for Refractory Cases

1. Hearing-preserving procedures 2

   • Vestibular nerve section
   • Endolymphatic sac surgery (controversial efficacy)

2. Ablative procedures (for severe cases with profound hearing loss) 2

   • Labyrinthectomy

Rehabilitation and Support

1. Vestibular rehabilitation for chronic imbalance between attacks 2
2. Hearing aids for patients with hearing loss 2
3. Patient education about disease course and management expectations 1, 2

Important Considerations

• About 10-25% of patients develop bilateral Ménière's disease over time, impacting treatment decisions, especially regarding ablative therapies 2
• The emotional impact of this condition should not be underestimated; patients often struggle with ongoing vertigo attacks, incapacitating tinnitus, and hearing loss 1
• There is no cure for Ménière's disease, only symptom management 2
• Regular follow-up with serial audiograms is necessary to monitor disease progression 2
• Vestibular migraine and Ménière's disease can coexist in up to 35% of patients 1

Treatment Algorithm

1. Initial diagnosis: Confirm with audiogram and rule out vestibular migraine
2. First-line treatment: Lifestyle modifications + acute attack management
3. If symptoms persist: Add maintenance therapy (diuretics and/or betahistine)
4. For refractory symptoms: Consider intratympanic therapies
5. Last resort: Surgical interventions based on hearing status and symptom severity