What are the treatment options and diagnostic tests for Meniere's Disease?

Treatment and Diagnostic Tests for Meniere's Disease

For Meniere's Disease, a stepwise approach beginning with conservative measures and progressing to more invasive interventions is recommended, with treatment decisions guided by symptom severity and response to therapy. 1, 2

Diagnostic Tests

Required Tests

• Audiogram: Essential for diagnosis and monitoring progression 1, 2
• Patient symptom history: Document episodes of vertigo (duration, frequency), hearing loss patterns, tinnitus, and aural fullness 1
• MRI of the brain/internal auditory canals: To rule out other causes such as acoustic neuroma 1, 3

Additional Tests When Indicated

• Video- or electronystagmogram: Evaluates vestibular function (may cause vertigo and nausea during testing) 1
• Electrocochleography: Measures electrical responses of the cochlea and auditory nerve 1

Treatment Algorithm

First-Line Treatment

1. Lifestyle and Dietary Modifications:

   • Low-sodium diet (1500-2300 mg daily) 1, 2
   • Limit alcohol consumption 1, 2
   • Limit caffeine intake 1, 2
   • Stress management 2
   • Consider keeping a food diary to identify personal triggers 2

2. Medications for Acute Attacks:

   • Vestibular suppressants: Benzodiazepines and antiemetics for acute vertigo attacks (short-term use only) 2
   • Antivertigo medications for symptomatic relief 1

Second-Line Treatment

If symptoms persist despite lifestyle modifications:

1. Diuretics: Thiazides, potassium-sparing, or loop diuretics to reduce endolymph volume 1, 2

   • Hydrochlorothiazide is commonly used 2

2. Betahistine: 16-48 mg daily (use with caution in patients with asthma or peptic ulcer disease) 2

3. Noninvasive Therapies:

   • Vestibular rehabilitation (physical therapy): Particularly beneficial for chronic imbalance between attacks 1, 2, 4
   • Hearing aids for patients with hearing loss 1, 2

Third-Line Treatment

For patients with persistent symptoms despite above measures:

1. Middle Ear Injections:
   • Intratympanic steroids: Improves vertigo symptoms in 85-90% of patients compared to 57-80% with conventional therapy 2
   • Intratympanic gentamicin: Achieves complete vertigo control in approximately 73.6% of patients but carries a 25.1% risk of hearing loss 1, 2, 5

Fourth-Line Treatment (Surgical Options)

For severe, refractory cases:

1. Hearing-Preserving Procedures:

   • Endolymphatic sac decompression 1, 6
   • Vestibular nerve section 1, 2

2. Ablative Procedures (for profound hearing loss):

   • Labyrinthectomy 1, 2

Important Considerations and Caveats

• Disease Progression: Meniere's disease is characterized by fluctuating symptoms that may eventually "burn out" after causing significant damage 7, 6

• Bilateral Disease Risk: 10-25% of patients develop bilateral Meniere's disease over time, which impacts treatment decisions, especially regarding ablative therapies 2

• Monitoring: Regular follow-up with serial audiograms is essential to track disease progression and treatment response 1, 2

• Treatment Expectations: There is no cure for Meniere's disease, only symptom management. This should be clearly discussed with patients 2

• Avoid: Positive pressure therapy (Meniett device) is not recommended due to lack of evidence showing effectiveness 2

• Quality of Life Assessment: Regular evaluation of how symptoms impact daily functioning and psychological wellbeing is recommended 1, 2

Special Considerations

• Comorbid Conditions: Evaluate for migraine, which has a high rate of co-occurrence with Meniere's disease 3

• Differential Diagnosis: Rule out other conditions that can mimic Meniere's disease, including otosyphilis, autoimmune inner ear disease, perilymphatic fistula, superior semicircular canal syndrome, Lyme disease, multiple sclerosis, vestibular paroxysmia, and temporal bone tumors 3