What are the treatment options for Meniere's disease?

Treatment Options for Ménière's Disease

Start with dietary modifications (sodium restriction to 1500-2300 mg/day, limiting caffeine and alcohol) combined with patient education, then escalate to diuretics or betahistine for maintenance therapy, followed by intratympanic steroids for refractory cases, and reserve intratympanic gentamicin or surgery for severe, treatment-resistant vertigo. 1, 2

Initial Conservative Management

Dietary and Lifestyle Modifications

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation in the inner ear 1, 2
• Limit caffeine consumption, as it can trigger attacks in susceptible patients 1, 2
• Restrict alcohol intake, which may precipitate vertigo episodes 2
• Have patients maintain a symptom diary to identify personal triggers 2
• Address allergies if present, as they contribute to symptoms in up to 30% of patients 2
• Implement stress management through relaxation techniques, regular exercise, and adequate sleep 2

Important caveat: The evidence for dietary modifications is limited (Grade C), based primarily on observational studies rather than robust RCTs. A 2023 Cochrane review found very low certainty evidence for these interventions. 1, 3 However, these modifications carry minimal risk and may benefit individual patients who identify specific triggers.

Patient Education (Essential First Step)

• Educate all patients about the natural history of Ménière's disease, including the episodic nature of attacks and progressive hearing loss 1
• Discuss all treatment options and realistic outcomes, emphasizing that no cure exists 2
• Explain that symptoms can be managed but complete hearing restoration is not currently possible 4

Acute Vertigo Attack Management

• Prescribe a limited course of vestibular suppressants only during active attacks 1
• Use antihistamines (meclizine, dimenhydrinate) as first-line agents 2
• Consider benzodiazepines for severe anxiety during attacks, but use cautiously due to dependence risk 2

Critical warning: Do not use vestibular suppressants continuously, as they impair vestibular compensation. Reserve them strictly for acute episodes. 1

Maintenance Pharmacotherapy

First-Line Maintenance Options

• Offer diuretics to modify endolymphatic fluid balance and reduce attack frequency 1, 2
• Consider betahistine (histamine analogue) to increase inner ear vasodilation, though recent evidence questions its efficacy 1, 2

Evidence nuance: The 2020 AAO-HNS guideline gives these an "option" recommendation (Grade C evidence) based on observational studies. The BEMED trial found no significant difference between betahistine and placebo, creating uncertainty about its true benefit. 2 However, given the favorable safety profile and potential benefit in some patients, a trial remains reasonable.

Contraindications to consider: Avoid diuretics in patients with renal or cardiac disease; monitor for hyponatremia risk. 1

Intratympanic Therapies (Second-Line)

Intratympanic Steroids

• Offer intratympanic steroids to patients with active disease not responding to conservative measures 1, 2
• Studies show 85-90% improvement in vertigo symptoms versus 57-80% with conventional therapy 2
• Benefits include improved vertigo control, better quality of life, and avoidance of general anesthesia 1
• Risks include hearing loss, tympanic membrane perforation, and persistent imbalance 1

Intratympanic Gentamicin

• Reserve for patients with persistent vertigo who have failed conservative therapies 2, 5
• Achieves complete vertigo control in approximately 73.6% of patients 2
• Use low-dose protocols to minimize hearing loss risk while maintaining efficacy 5
• Contraindicated in patients with contralateral disease or known aminoglycoside hypersensitivity 1

Surgical Options (Third-Line)

For Patients with Usable Hearing

• Endolymphatic sac decompression (hearing-sparing procedure) 4
• Vestibular nerve section (hearing-sparing, controls vertigo) 4

For Patients with Non-Usable Hearing

• Labyrinthectomy may be offered to patients who have failed less definitive therapy and have non-usable hearing 2, 4
• This ablative procedure sacrifices remaining hearing but provides definitive vertigo control 4
• Cochlear implantation can restore hearing function even after labyrinthectomy 4

Hearing Rehabilitation

• Conventional hearing aids for patients with usable hearing 4
• CROS hearing aids when speech discrimination is severely compromised 4
• Bone-anchored devices for severe unilateral loss with normal contralateral hearing 4
• Cochlear implants for bilateral severe hearing loss where amplification provides limited benefit 4

Treatments NOT Recommended

• Do not prescribe positive pressure therapy (Meniett device) - systematic reviews show no significant benefit over placebo 1, 2
• Vestibular rehabilitation is not effective for acute vertigo attacks (though it may help chronic imbalance between attacks) 2

Monitoring and Follow-Up

• Perform regular audiometric testing to monitor hearing progression 4, 6
• Document changes in vertigo frequency/severity, tinnitus, and hearing loss after each intervention 2, 4
• Assess quality of life impact as part of ongoing management 4
• Adjust treatment based on symptom evolution 2

Common Pitfalls to Avoid

• Do not delay escalation of therapy in patients with frequent, disabling vertigo attacks that significantly impair quality of life 1
• Distinguish between temporary hearing fluctuations and permanent progression when making treatment decisions 4
• Avoid continuous vestibular suppressant use, which impairs central compensation 1
• Monitor for hyponatremia with aggressive sodium restriction, though this has not been reported in studies 1
• Consider bilateral disease (occurs in 25-40% of cases) when planning ablative procedures 7