What are the management options for an adult patient with Meniere's disease, a history of tinnitus, and recurrent vertigo episodes?

Management of Ménière's Disease

Start with conservative management including a low-sodium diet (1500-2300 mg daily) and a diuretic, then escalate to intratympanic therapies if vertigo persists after several months of medical management. 1

Initial Conservative Management

The first-line approach focuses on lifestyle modifications and medical therapy:

• Implement sodium restriction to 1500-2300 mg daily to reduce endolymphatic fluid accumulation 2
• Prescribe a diuretic (such as hydrochlorothiazide or acetazolamide) to alter electrolyte balance in the endolymph and reduce its volume 2, 3
• Eliminate caffeine and alcohol, as both can trigger vertigo attacks in susceptible patients 2
• Encourage patients to maintain a symptom diary to identify personal triggers and monitor treatment response 2

This conservative approach should be maintained for several months before considering escalation, as the disease has a naturally fluctuating course with up to 60% placebo response in clinical trials. 4, 1

Acute Vertigo Attack Management

During active vertigo episodes lasting 20 minutes to 12 hours:

• Offer vestibular suppressants only during acute attacks, not for chronic use 2
• Use antihistamines (meclizine 25-50 mg or dimenhydrinate 50 mg) for symptomatic relief 2
• Consider short-term benzodiazepines for severe anxiety associated with attacks, but avoid prolonged use due to dependence risk 2

Do not use vestibular suppressants chronically, as they can interfere with central compensation mechanisms. 2

Betahistine Consideration

The evidence for betahistine is mixed and controversial:

• Betahistine cannot be definitively recommended based on the BEMED trial, which showed no significant difference from placebo in reducing vertigo attacks 2
• However, one retrospective study showed statistically significant reduction in frequency and duration of vertigo episodes with betahistine (mean dose 87.5 mg daily), though not in attack intensity 5
• If betahistine is used, the dose should be titrated individually, as no dose-response relationship has been established 5

Given the conflicting evidence and the AAO-HNS guideline's inability to make a definitive recommendation, prioritize diuretics over betahistine for maintenance therapy. 2

Escalation to Intratympanic Therapies

For patients with persistent vertigo despite 3-6 months of conservative management:

Intratympanic Steroids (First Invasive Option)

• Offer intratympanic steroids for active disease not responsive to conservative measures 1, 2
• This provides 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy alone 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 (For Refractory Cases)

• Reserve gentamicin for patients who have failed conservative and steroid therapies 2, 6
• Achieves complete vertigo control in approximately 73.6% of patients 2
• The goal is partial vestibular ablation, not complete destruction, as complete ablation is not required for vertigo control 7
• Administer via transtympanic injection as an outpatient procedure 6
• Hearing loss risk varies by protocol: use low-dose, titrated protocols to minimize cochlear damage 6, 7

Surgical Options for Refractory Disease

For Patients with Usable Hearing (Class A, B, or C)

• Consider endolymphatic sac decompression as a non-ablative procedure to preserve auditory function 1
• Usable hearing is defined as: Class A (discrimination 70-100%, PTA <30 dB), Class B (discrimination 50-69%, PTA 31-50 dB), or Class C (discrimination 50-69%, PTA >50 dB) 4, 1

For Patients with Non-Usable Hearing (Class D)

• Labyrinthectomy may be offered to patients who have failed less definitive therapy and have non-usable hearing (discrimination <50%) 1, 2

Vestibular Rehabilitation

• Offer vestibular rehabilitation for chronic imbalance between attacks, not for acute vertigo episodes 2
• This is particularly beneficial following ablative therapy to facilitate central compensation 2
• Benefits include improved symptom control and reduced fall risk 2

Hearing Rehabilitation

As hearing loss often progresses despite treatment:

• Conventional hearing aids for patients with usable hearing 1
• CROS hearing aids for severely compromised speech discrimination 1
• Cochlear implants for severe bilateral hearing loss where amplification provides limited benefit 1

Monitoring Requirements

• Obtain audiometry at diagnosis and regularly during follow-up to document the characteristic low-to-mid-frequency sensorineural hearing loss and monitor progression 4, 1, 2
• Document changes in vertigo frequency/severity, tinnitus, and hearing loss after each intervention 1, 2
• Assess quality of life impact using validated instruments 1

Critical Pitfalls to Avoid

• Do not recommend positive pressure therapy (Meniett device), as systematic reviews show no significant difference compared to placebo 1, 2
• Recognize that 10-25% of cases eventually become bilateral, which impacts surgical decision-making—avoid ablative procedures in the only hearing ear 1
• Watch for drop attacks (Tumarkin's otolithic crisis) in later disease stages, which occur suddenly without warning and without loss of consciousness 4, 1
• Do not expect complete hearing restoration, as current treatments cannot reverse established hearing loss 1
• Screen for comorbidities (renal disease, cardiac disease, asthma) that may contraindicate diuretics or other medications 2