What are the symptoms and treatment options for a patient with Ménière’s disease?

Ménière's Disease: Symptoms and Treatment

Core Symptoms

Ménière's disease is diagnosed by recurrent vertigo episodes lasting 20 minutes to 12 hours, accompanied by fluctuating low-to-mid-frequency sensorineural hearing loss, tinnitus, and aural fullness. 1

The cardinal symptoms include:

• Vertigo attacks: Spontaneous spinning sensation lasting 20 minutes to 12 hours (not seconds or days) 2, 1
• Fluctuating hearing loss: Initially affects low-to-mid frequencies, documented by audiometry, with hearing that alternates between worsening and improving early in disease 2, 3
• Tinnitus: Ringing, buzzing, or other phantom noises in the affected ear that fluctuate with attacks 2, 3
• Aural fullness: Sensation of ear pressure or plugging in the affected ear 2, 3

Disease Progression Patterns

• Hearing loss initially fluctuates but eventually may involve all frequencies and worsen over time despite treatment 1, 3
• Drop attacks (Tumarkin's otolithic crisis) can occur in later stages, causing sudden falls without warning 1
• Bilateral involvement develops in 10-25% of cases over time, which critically impacts surgical decision-making 1
• Most commonly affects adults between 40-70 years of age 2

Diagnostic Workup

Audiometry is essential to document the characteristic low-to-mid-frequency sensorineural hearing loss. 1

Required testing includes:

• Audiogram: Measures hearing levels across frequencies, takes approximately 30 minutes with no significant risks 2, 1
• MRI of brain with contrast: Excludes cerebellopontine angle tumors and other structural causes 2, 4
• Video/electronystagmography: Evaluates vestibular function, takes about 1 hour, may cause temporary vertigo and nausea 2
• Electrocochleography: Measures cochlear electrical responses, may cause ear discomfort 2

Keep a symptom journal documenting attack frequency, duration, associated symptoms, and triggers—this aids accurate diagnosis which may require multiple visits 2

Treatment Algorithm: Stepwise Approach

The American Academy of Otolaryngology-Head and Neck Surgery recommends starting with conservative measures and progressing to more invasive interventions only after failure of less aggressive options. 1

First-Line: Conservative Management

Start all patients here before considering any invasive therapy:

• Low-sodium diet: 1500-2300 mg daily to reduce fluid retention 2, 3
• Dietary trigger avoidance: Limit caffeine and alcohol consumption 2, 3
• Diuretics: Remove excess body fluid to stabilize inner ear fluid dynamics 2, 3
• Betahistine: Histamine analogue that increases vasodilation to inner ear (commonly used in Europe) 2, 3
• Antihistamines: If allergies are suspected as contributing factors 2, 3

Acute Attack Management

For symptomatic control during vertigo episodes:

• Antivertigo medications: Vestibular suppressants with anticholinergic and anti-emetic effects 2, 4
• Benzodiazepines: Alleviate anxiety and provide vestibular sedation during acute attacks 4, 5

Second-Line: Minimally Invasive Interventions

For patients failing conservative measures after several months: 1

• Intratympanic steroid injections: Through the eardrum into the middle ear for active disease not responsive to conservative therapy 1, 3
• Vestibular rehabilitation/physical therapy: For patients with residual vestibular dysfunction 2, 1

Third-Line: Ablative Therapy

For patients with severe, refractory vertigo despite above measures:

• Intratympanic gentamicin: Reduces vestibular function in the treated ear without requiring complete ablation to control vertigo 2, 4, 6

Fourth-Line: Surgical Options

Surgery is reserved for patients failing all medical management, with procedure selection based on hearing status: 1

For patients with usable hearing (Class A, B, or C):

• Endolymphatic sac decompression: Hearing-sparing procedure that may stabilize hearing 1, 3
• Vestibular nerve section: Hearing-sparing procedure for vertigo control 2, 3

For patients with non-usable hearing (Class D):

• Labyrinthectomy: Ablative procedure that sacrifices remaining hearing but effectively controls vertigo 2, 3

Hearing Rehabilitation Options

Hearing aids should be offered based on the degree of hearing loss and speech discrimination: 1

• Conventional hearing aids: For patients with usable hearing 2, 1, 3
• CROS hearing aids: When speech discrimination is severely compromised in the affected ear 1, 3
• Bone-anchored devices: For severe-to-profound unilateral hearing loss with normal contralateral hearing 3
• Cochlear implants: For severe bilateral hearing loss where amplification provides limited benefit, can restore substantial function even after labyrinthectomy 1, 3

Critical Pitfalls and Considerations

Before considering ablative procedures like labyrinthectomy, patients must understand that 10-25% of cases eventually affect the contralateral ear, potentially leaving them without meaningful hearing or vestibular function bilaterally. 2, 1

Additional important considerations:

• Placebo effect is substantial: Up to 60% of patients show improvement with placebo in clinical trials, making treatment efficacy difficult to assess 1
• Complete hearing restoration is not possible: While symptoms can be managed, patients should understand that hearing loss often worsens despite treatment 1, 3
• Positive pressure therapy is not recommended for Ménière's disease 1
• Regular monitoring is essential: Serial audiometry to track hearing progression and quality of life assessments should be part of ongoing management 1, 3
• Psychological impact is significant: Patients often experience anxiety between attacks, fearing recurrence, requiring regular follow-up and support 2, 5

Differential Diagnosis to Exclude

Rule out these conditions that mimic Ménière's disease:

• Vestibular migraine: Vertigo lasting minutes to days with headache history 1
• BPPV: Brief vertigo provoked by head position changes 1
• Vestibular neuritis: Acute prolonged vertigo without hearing loss 1
• Labyrinthitis: Sudden severe vertigo with prolonged symptoms >24 hours 1
• Cerebellopontine angle tumors: Progressive unilateral hearing loss with imbalance 1
• Otosyphilis, autoimmune inner ear disease, Lyme disease, multiple sclerosis: Require specific testing to exclude 4