What are the treatment options for Meniere's disease?

Treatment of Ménière's Disease

Start with dietary modifications (low sodium 1500-2300 mg/day, limit caffeine and alcohol) combined with patient education, then escalate to diuretics and/or betahistine for maintenance therapy, followed by intratympanic steroids if symptoms persist, and reserve intratympanic gentamicin or surgery for refractory cases. 1

Initial Conservative Management

Patient Education (Essential First Step)

• Educate all patients about the natural history showing episodic vertigo attacks lasting 20 minutes to 12 hours, progressive hearing loss despite treatment, and fluctuating aural symptoms including tinnitus and ear fullness 1, 2
• Discuss realistic expectations: symptoms can be managed but complete hearing restoration is not currently possible 2
• Encourage symptom diaries to identify personal triggers for attacks 3

Dietary and Lifestyle Modifications

• Restrict sodium intake to 1500-2300 mg daily to reduce fluid retention and stabilize inner ear fluid dynamics 1, 2, 3
• Limit caffeine consumption as it can trigger attacks in susceptible patients 1, 3
• Restrict alcohol intake as it may precipitate vertigo episodes 1, 3
• Manage allergies if present, as they contribute to symptoms in up to 30% of patients 3
• Implement stress reduction through relaxation techniques, regular exercise, and adequate sleep 3

Important caveat: The evidence for dietary modifications is limited (Grade C), based primarily on observational studies rather than robust RCTs, though individual patients may benefit from identifying personal triggers 1, 4

Pharmacotherapy for Acute Vertigo Attacks

• Prescribe vestibular suppressants (antihistamines like meclizine or dimenhidrinato) only during acute attacks, not for continuous use 1, 3
• Consider short-term benzodiazepines for severe anxiety during attacks, but use cautiously due to dependence risk 1, 3
• Critical pitfall: Avoid prolonged use of vestibular suppressants as they impair vestibular compensation and worsen chronic imbalance 1

Maintenance Therapy (Second-Line)

Diuretics

• Offer diuretics to modify electrolyte balance in the endolymph and reduce its volume 1, 3
• This represents a primary maintenance option with Grade C evidence from observational studies 1
• Monitor for contraindications including renal or cardiac disease 1

Betahistine

• Consider betahistine (histamine analogue) to increase inner ear vasodilation and improve circulation 1, 2, 3
• Evidence conflict: Recent BEMED trial showed no significant difference versus placebo, making the evidence for betahistine questionable despite widespread use 3
• The 2020 AAO-HNS guideline rates this as Grade C evidence with an "option" recommendation 1

Intratympanic Therapies (Third-Line for Non-Responders)

Intratympanic Steroids

• Offer intratympanic steroids to patients with active disease not responding to conservative measures 1, 2, 3
• Expect 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy 3
• Benefits include improved vertigo control, better quality of life, and faster return to work 1
• Risks include hearing loss, tympanic membrane perforation, and persistent imbalance 1, 3
• This has Grade B evidence from RCTs and systematic reviews 1

Intratympanic Gentamicin

• Reserve for patients who have failed conservative and steroid therapies 3, 5
• Achieves complete vertigo control in approximately 73.6% of cases 3
• Major risk: Hearing loss varies by administration method and dosing protocol 3, 6
• Use low-dose protocols to minimize vestibular ablation while controlling vertigo 6

Surgical Options (Fourth-Line for Refractory Cases)

Hearing-Preserving Procedures

• Endolymphatic sac decompression may stabilize hearing in select patients 2, 5
• Vestibular nerve section controls vertigo while preserving hearing 2, 5

Ablative Procedures

• Labyrinthectomy for patients with non-usable hearing and failed medical therapy 2, 3, 5
• Consider cochlear implantation after labyrinthectomy to restore hearing function 2, 5

Vestibular Rehabilitation

• Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy 3
• Do not use for acute vertigo attacks 1
• Benefits include improved symptom control and reduced fall risk 3

Treatments NOT Recommended

• Do not prescribe positive pressure therapy (Meniett device) - systematic reviews show no significant difference versus placebo 1, 3

Monitoring Requirements

• Obtain serial audiograms to document progression of low- to mid-frequency sensorineural hearing loss 1, 2, 3
• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment intervention 1, 3
• Assess quality of life impact as part of ongoing management 1, 2
• Monitor for bilateral involvement, which occurs in 25-40% of cases 7

Critical Clinical Pitfalls

• Distinguish temporary hearing fluctuations from permanent progression - this guides treatment intensity 2
• Avoid continuous vestibular suppressants which impair compensation 1
• Screen for contraindications before prescribing diuretics (renal/cardiac disease) or betahistine (asthma) 1
• Recognize that hearing often worsens over time despite interventions, eventually involving all frequencies 2
• Rule out vestibular schwannoma or cerebrovascular events in patients presenting with vertigo and hearing loss 8