What are the treatment options for Meniere's disease?

Treatment Options for Meniere's Disease

Meniere's disease management requires a stepwise approach, starting with conservative measures like lifestyle modifications and medications, and progressing to more invasive interventions only when symptoms remain uncontrolled. 1

Diagnosis and Monitoring

• Audiogram is essential for diagnosis and monitoring disease progression
• Document symptom history: vertigo episodes, hearing loss patterns, tinnitus, and aural fullness
• Additional tests may include video/electronystagmogram and electrocochleography
• Regular follow-up with serial audiograms to track disease progression

First-Line Treatment: Lifestyle Modifications

• Low-sodium diet (1500-2300 mg daily) 1
• Limit alcohol and caffeine intake
• Stress management techniques
• Sleep in darkness (6-7 hours per night)
• Identify personal triggers through food diary 1
• Cooling measures (limiting ice/water immersion, elevating extremities)

Medication Options

1. Acute Attack Management:

   • Vestibular suppressants (benzodiazepines, antiemetics) for symptomatic relief
   • Use for limited duration to avoid dependence, sedation, and impaired vestibular compensation 1

2. Preventive Medications:

   • Diuretics (thiazides, potassium-sparing, loop diuretics) to reduce endolymph volume
   • Betahistine (16-48 mg daily) - use with caution in patients with asthma or peptic ulcer disease 1

Second-Line Interventions

• Intratympanic steroid injections: 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy 1
• Vestibular rehabilitation (physical therapy) for chronic imbalance between attacks
• Hearing aids for patients with significant hearing loss 1

Advanced Interventions for Refractory Cases

1. Intratympanic gentamicin:

   • Achieves complete vertigo control in ~73.6% of patients
   • Risk of hearing loss (25.1%)
   • Contraindicated in contralateral disease or aminoglycoside hypersensitivity 1

2. Surgical Options (for severe, refractory cases):

   • Endolymphatic sac decompression (hearing-preserving)
   • Vestibular nerve section (hearing-sparing)
   • Labyrinthectomy (for profound hearing loss) 1

Treatment Considerations and Pitfalls

• No cure exists - focus is on symptom management
• About 10-25% of patients develop bilateral disease over time, impacting treatment decisions 1
• Avoid ablative therapies in patients at risk for bilateral disease
• Evidence for dietary interventions like salt restriction is empirical rather than from high-quality RCTs 2
• Cochrane review found very low certainty evidence for lifestyle and dietary interventions 2

Quality of Life Management

• Regular evaluation of symptoms' impact on daily functioning and psychological wellbeing
• Patient education about disease course, treatment options, and expected outcomes
• Address psychological aspects (anxiety, depression, social isolation) 1

The management of Meniere's disease requires patience and a systematic approach, with careful monitoring of symptoms and treatment response over time. While there is no cure, most patients can achieve significant symptom control through appropriate interventions.