What are the treatment options for Meniere's disease?

Treatment Options for Meniere's Disease

The management of Meniere's disease should follow a stepwise approach, beginning with lifestyle modifications and medications, progressing to intratympanic therapies, and considering surgical interventions only for refractory cases. 1

First-Line Management

Lifestyle Modifications

• Low-sodium diet (1500-2300 mg daily) - Recommended by the American Academy of Otolaryngology-Head and Neck Surgery to reduce endolymph volume 1
• Dietary restrictions:
  • Limit alcohol consumption
  • Reduce caffeine intake
  • Consider keeping a food diary to identify personal triggers 1
• Other lifestyle changes:
  • Stress management techniques
  • Ensuring adequate sleep in darkness
  • Elevating extremities and limiting ice/water immersion may provide relief 1

Pharmacological Management for Acute Attacks

• Vestibular suppressants - First-line therapy for acute vertigo attacks 1
  • Benzodiazepines (e.g., alprazolam)
  • Antiemetics
  • Caution: Use for limited duration only due to risk of dependence, sedation, and impaired vestibular compensation

Maintenance Pharmacotherapy

• Diuretics - Second-line therapy when vestibular suppressants fail 1
  • Thiazides (e.g., hydrochlorothiazide)
  • Potassium-sparing diuretics
  • Loop diuretics
• Betahistine - May be considered at dosages of 16-48 mg daily 1
  • Caution: Use with care in patients with asthma or peptic ulcer disease
  • Evidence for efficacy is limited but widely used in Europe 2

Second-Line Interventions

Intratympanic Therapies

• Intratympanic steroid injections 1

  • Improves vertigo symptoms in 85-90% of patients compared to 57-80% with conventional therapy
  • May be combined with betahistine for enhanced efficacy
  • Consider for persistent symptoms despite first-line measures

• Intratympanic gentamicin 1

  • Achieves complete vertigo control in approximately 73.6% of patients
  • Important caveat: Risk of hearing loss (25.1% overall)
  • Contraindicated in patients with:
    • Contralateral Meniere's disease
    • Known hypersensitivity to aminoglycosides

Rehabilitation and Support

• Vestibular rehabilitation (physical therapy) for chronic imbalance between attacks 1
• Hearing aids for patients with hearing loss 1
• Psychological support to address anxiety, depression, and social isolation that commonly accompany the disease 1

Surgical Options for Refractory Cases

• Vestibular nerve section - Hearing-sparing procedure 1
• Labyrinthectomy - May be considered for severe cases with profound hearing loss 1
• Endolymphatic sac decompression surgery - An extension of conservative treatment 3

Treatment Monitoring and Follow-up

• Obtain baseline audiogram and document severity of vertigo, tinnitus, and hearing loss 1
• Schedule regular follow-up to assess symptom improvement or worsening
• Perform serial audiograms to monitor hearing function
• Assess impact on quality of life 1

Important Considerations

• About 10-25% of patients develop bilateral Meniere's disease over time, which impacts treatment decisions, especially regarding ablative therapies 1
• There is no cure for Meniere's disease, only symptom management 1
• Treatment expectations should be discussed with patients, informing them of potential long-term effects 1
• If untreated for 10+ years, hearing may deteriorate as vertiginous episodes gradually subside 4

Treatments to Avoid

• Positive pressure therapy (Meniett device) should not be prescribed due to lack of evidence showing effectiveness 1

Special Considerations

• Bilateral disease: Consider corticosteroids, particularly if an autoimmune basis is suspected 2
• Diagnostic delays should be avoided, and treatment should not be delayed while awaiting additional testing, as Meniere's disease is primarily a clinical diagnosis 1