What are the management options for Meniere's disease?

Management of Meniere's Disease

Stepwise Treatment Algorithm

Start with dietary modifications and lifestyle changes, progress to maintenance pharmacotherapy with diuretics, then consider intratympanic therapies for refractory cases, and reserve surgery only when all medical management fails. 1, 2

First-Line: 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 certain patients 1, 2
• Restrict alcohol intake since it may precipitate vertigo episodes 1, 2
• Address allergy management, as allergies contribute to symptoms in up to 30% of patients 1, 2
• Implement stress reduction through relaxation techniques, regular exercise, and adequate sleep 1, 2
• Maintain a symptom diary to identify personal triggers 1

Important caveat: The evidence quality for dietary modifications is limited (Grade C), but these interventions carry minimal risk and should still be implemented first 2, 3

Acute Attack Management (20 minutes to 12 hours)

• Prescribe vestibular suppressants only during acute attacks—never for maintenance therapy as they impair central vestibular compensation 1, 2
• Use antihistamines (dimenhidrinato or meclizina) for acute vertigo control 1, 2
• Consider benzodiazepines cautiously for associated anxiety, but avoid prolonged use due to dependence risk and impaired vestibular compensation 1, 2

Maintenance Pharmacotherapy

• Prescribe diuretics as the primary maintenance therapy to modify electrolyte balance in the endolymph and reduce its volume 1, 2
• Betahistine (histamine analogue) may be offered to increase inner ear vasodilation, though recent evidence including the BEMED trial showed no significant difference versus placebo 1, 2

Critical distinction: The American Academy of Otolaryngology-Head and Neck Surgery cannot make a definitive recommendation for betahistine due to questionable efficacy, making diuretics the more evidence-supported maintenance option 1

Intratympanic Therapies for Refractory Disease

When non-invasive treatments fail after adequate trial:

• Offer intratympanic steroids first for patients with active disease not responsive to conservative management, providing 85-90% improvement in vertigo symptoms versus 57-80% with conventional therapy 1, 2

  • Benefits include better vertigo control, improved quality of life, and faster return to work 1
  • Risks include hearing loss, tympanic membrane perforation, and persistent imbalance 1

• Reserve intratympanic gentamicin for persistent vertigo after failed conservative therapies, achieving complete vertigo control in approximately 73.6% of patients 1, 2

  • This is an ablative therapy with variable hearing loss risk depending on administration method 1

Vestibular Rehabilitation (Grade A Evidence)

• Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy to promote central vestibular compensation 2
• Benefits include improved balance, gait stability, symptom control, reduced fall risk, and enhanced quality of life 1, 2
• Do not use vestibular rehabilitation for acute vertigo attacks—it is only beneficial for chronic imbalance 1

Surgical Options for Refractory Cases

Reserve surgery only after all medical management has failed:

• Endolymphatic sac decompression for hearing-preserving surgery, though the Danish Sham Surgery Study showed both active surgery and placebo resulted in approximately 70% vertigo reduction 2, 4
• Vestibular nerve section for hearing-sparing vertigo control 5
• Labyrinthectomy for patients with non-usable hearing and failed less definitive therapy—this sacrifices remaining hearing but controls vertigo 1, 5
• Cochlear implantation can restore substantial hearing function even after ablative procedures 5

Treatments NOT Recommended

• Do not prescribe positive pressure therapy (Meniett device) as systematic reviews and RCTs show no significant difference compared to placebo (Grade B evidence against) 1, 2

Monitoring Requirements

• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment intervention 1, 2
• Obtain serial audiograms when assessing patients to monitor hearing progression 2, 5
• Regularly evaluate impact on quality of life 1, 2
• Adjust treatment based on symptom evolution 1

Critical Pitfalls to Avoid

• Never use vestibular suppressants for maintenance therapy—only during acute attacks—as they impair central compensation 2
• Avoid prolonged benzodiazepine use due to dependence risk 1
• Consider comorbidities (renal disease, cardiac disease, asthma) that may contraindicate certain medications 1
• Recognize that no definitive cure exists for Meniere's disease—treatment is symptomatic and preventive 1, 6
• Distinguish between temporary hearing fluctuations and permanent progression, as this guides treatment decisions particularly for surgical interventions 5
• Hearing loss often worsens over time despite treatment interventions 5