What are the treatment options for Meniere's disease?

Treatment of Ménière's Disease

Begin with patient education, dietary sodium restriction (1500-2300 mg daily), and lifestyle modifications; offer vestibular suppressants only during acute vertigo attacks; escalate to intratympanic gentamicin for refractory cases, reserving surgical ablation for patients with non-usable hearing who have failed all other therapies. 1, 2

Initial Conservative Management

Patient Education (Required First Step)

• Educate all patients about the natural history, symptom control measures, treatment options, and expected outcomes at the time of diagnosis. 1
• Explain that up to 60% of patients in placebo groups show vertigo control, reflecting the episodic fluctuating nature of the disease. 1
• Inform patients that there is no definitive cure, and treatment goals focus on reducing vertigo frequency/severity rather than eliminating all symptoms. 2

Dietary and Lifestyle Modifications

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation. 2
• Limit alcohol consumption, as it can trigger attacks in susceptible patients. 2
• Limit caffeine intake, which may act as a trigger. 2, 3
• Implement stress management through relaxation techniques, regular exercise, and adequate sleep. 2
• Maintain a symptom diary to identify personal triggers. 2
• Note that evidence for dietary modifications is limited, but these interventions carry minimal risk. 2

Pharmacotherapy for Acute Vertigo Attacks

Vestibular Suppressants (Acute Use Only)

• Offer a limited course of vestibular suppressants exclusively during acute vertigo episodes lasting 20 minutes to 12 hours. 1, 2
• Use antihistamines (dimenhidrinato, meclizine) as first-line agents. 2, 4
• Consider benzodiazepines for severe anxiety during attacks, but use cautiously due to dependence risk. 2, 4
• Do not prescribe vestibular suppressants for chronic maintenance therapy. 1

Maintenance Pharmacotherapy

Diuretics

• Prescribe diuretics to modify electrolyte balance in the endolymph and reduce its volume. 2, 4, 3
• This represents the primary maintenance therapy option with moderate evidence quality. 2

Betahistine (Controversial)

• Betahistine is widely used in Europe as a histaminergic agent that increases inner ear vasodilation. 2, 4, 5
• However, the 2020 AAO-HNS guideline cannot make a definitive recommendation for betahistine due to questionable efficacy, as the BEMED trial found no significant difference between betahistine and placebo in reducing vertigo attacks. 2

Intratympanic Therapies (Second-Line)

Intratympanic Steroids

• Offer intratympanic steroids to patients with active Ménière's disease not responsive to conservative measures. 1, 2
• Studies demonstrate 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy. 2
• Benefits include better vertigo control, improved quality of life, and faster return to work. 2
• Risks include hearing loss, tympanic membrane perforation, and persistent imbalance. 2

Intratympanic Gentamicin (Third-Line)

• Offer intratympanic gentamicin to patients with active disease who have failed non-ablative therapies. 1, 2
• Achieves complete vertigo control in approximately 73.6% of patients across studies. 2
• Low-dose protocols reduce vestibular function without requiring complete ablation. 6
• Risk of hearing loss varies by administration method; use titrated dosing protocols. 2, 6

Surgical Options (Fourth-Line)

Ablative Surgery

• Offer labyrinthectomy or vestibular nerve section only to patients with non-usable hearing (Class D: word discrimination <50%) who have failed all less definitive therapies. 1, 2
• Serviceable hearing is defined as AAO-HNSF Class A/B (discrimination ≥50%, PTA ≤50 dB). 1
• Surgical ablation converts the dynamic fluctuating lesion to a static state through inner ear destruction. 1

Vestibular Rehabilitation

• Offer vestibular rehabilitation/physical therapy for chronic imbalance between attacks or following ablative therapy, not for acute vertigo management. 1, 2
• Benefits include improved symptom control and reduced fall risk. 2
• This is particularly important after gentamicin therapy or surgical ablation to facilitate central compensation. 2

Treatments NOT Recommended

Positive Pressure Therapy

• Do not prescribe positive pressure therapy (Meniett device) for Ménière's disease patients. 1, 2
• Systematic reviews show no significant difference compared to placebo. 2

Routine Vestibular Testing

• Do not routinely order vestibular function testing or electrocochleography to establish the diagnosis. 1

Essential Monitoring Requirements

Audiometric Follow-Up

• Obtain an audiogram at initial assessment and document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss at each follow-up visit. 1, 2
• Regularly evaluate impact on quality of life. 1, 2
• Adjust treatment based on symptom evolution. 2

Imaging Considerations

• Consider MRI of the internal auditory canal and posterior fossa only in patients with non-fluctuating sensorineural hearing loss, tinnitus, or aural pressure to exclude vestibular schwannoma or other structural lesions. 1

Critical Pitfalls to Avoid

• Do not continue vestibular suppressants beyond acute attacks, as chronic use provides no benefit and may delay central compensation. 1
• Do not proceed directly to ablative therapy without exhausting conservative and intratympanic options, as the natural history shows spontaneous improvement in many patients. 1
• Screen for vestibular migraine, which can mimic Ménière's disease and requires different management. 1
• Consider comorbidities (renal disease, cardiac disease, asthma) that may contraindicate specific medications like diuretics or benzodiazepines. 2
• Recognize that bilateral involvement occurs in 25-40% of cases, requiring preservation of hearing in the better ear. 5