What are the treatment options for a patient with Meniere's disease?

Treatment of Ménière's Disease

Stepwise Treatment Algorithm

Begin with dietary modifications and lifestyle changes, progress to maintenance pharmacotherapy with diuretics, then intratympanic therapies for refractory cases, and reserve surgery only when all medical options have failed. 1

First-Line: Dietary and Lifestyle Modifications

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation 1, 2
• Limit caffeine consumption, as observational data shows benefit from restricting intake 1, 2
• Reduce or eliminate alcohol, which can trigger attacks in susceptible patients 2, 3
• Address allergies if present, as they may contribute to symptoms in up to 30% of patients 1, 2
• Implement stress reduction through relaxation techniques and cognitive-behavioral strategies, which showed benefit in one RCT 1, 2
• Have patients maintain a symptom diary to identify personal triggers 2

Critical caveat: While dietary modifications are recommended as first-line therapy, the evidence quality is limited (Grade C), based primarily on observational studies rather than high-quality RCTs 1, 3

Acute Attack Management (20 Minutes to 12 Hours)

• Offer a limited course of vestibular suppressants ONLY during acute attacks 1, 2
• Use antihistamines (dimenhydrinate, meclizine) for acute vertigo control 1, 2
• Consider benzodiazepines cautiously for associated anxiety, but be aware of dependence risk and impaired vestibular compensation 1, 2

Important pitfall: Do NOT use vestibular suppressants for maintenance therapy, as they impair central vestibular compensation 1

Maintenance Pharmacotherapy (Second-Line)

• Offer diuretics to modify electrolyte balance in endolymph and reduce its volume 1, 2
• Consider betahistine (histamine analogue) to increase inner ear vasodilation, though evidence is mixed 1, 2
• Titrate down or stop medication once symptoms subside 4

Evidence nuance: The 2020 AAO-HNS guideline provides only an "Option" statement (Grade C evidence) for diuretics and betahistine, reflecting moderate quality evidence from observational studies and Cochrane reviews 1. The BEMED trial found no significant difference between betahistine and placebo in reducing vertigo attacks 2

Intratympanic Therapies (Third-Line for Refractory Disease)

When non-invasive treatments fail after adequate trial, offer or refer for intratympanic therapies 1, 2

Intratympanic Steroids

• Offer to patients with active disease not responsive to conservative measures 4, 1, 2
• Provides 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy 2
• Benefits include improved quality of life, faster return to work, and avoidance of hearing loss risk associated with gentamicin 1, 2
• Risks include hearing loss (paradoxically), tympanic membrane perforation, and persistent imbalance 2

Intratympanic Gentamicin

• Reserve for patients with persistent vertigo who have failed conservative therapies 1, 2
• Achieves approximately 73.6% complete vertigo control across studies 1, 2
• Risk of hearing loss varies by administration method (low-dose protocols preferred) 5
• Does not require complete vestibular ablation to achieve vertigo control 5

Vestibular Rehabilitation (Grade A Evidence)

Offer vestibular rehabilitation/physical therapy for chronic imbalance between attacks or following ablative therapy 1, 2

• Promotes central vestibular compensation and improves balance, gait, and gaze stability 1
• Benefits include improved symptom control, reduced fall risk, enhanced safety, and better quality of life 1, 2
• Do NOT use for acute attack management 2

Surgical Options (Last Resort for Refractory Cases)

Surgery is reserved exclusively for cases failing all medical management 1, 2

Hearing-Preserving Procedures

• Endolymphatic sac decompression when hearing is worth preserving 1, 6
  • Note: The Danish Sham Surgery Study showed both active surgery and placebo resulted in ~70% vertigo reduction, questioning efficacy 1
• Vestibular nerve section for vertigo control while preserving hearing 6

Ablative Procedures

• Labyrinthectomy for patients with non-usable hearing who have failed less definitive therapy 2, 6
• Sacrifices remaining hearing but controls vertigo 6
• Cochlear implantation can restore substantial hearing function even after labyrinthectomy 6

Critical consideration: 10-25% of cases eventually become bilateral—avoid ablative procedures in the only hearing ear 2

Treatment NOT Recommended

Do NOT prescribe positive pressure therapy (Meniett device) 1, 2

• Systematic reviews and RCTs show no significant difference compared to placebo for vertigo control 4, 1, 7
• Moderate quality evidence from two studies shows hearing levels are actually WORSE in patients using this therapy 4, 7
• Requires tympanostomy tube insertion with associated surgical risks 4, 7
• Grade B evidence recommendation AGAINST use 1

Essential Monitoring Requirements

• Obtain audiometry at diagnosis and regularly during follow-up to document characteristic low-to-mid-frequency sensorineural hearing loss 2, 6
• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment intervention 1, 2, 6
• Assess quality of life impact using validated instruments 2, 6
• Watch for drop attacks (Tumarkin's otolithic crisis) in later disease stages, which occur suddenly without warning 2

Patient Education Points

• Educate about natural history: the disease has a naturally fluctuating course with up to 60% placebo response in clinical trials 2
• Explain that there is no definitive cure for Ménière's disease 2
• Clarify that while symptoms can be managed, complete restoration of hearing is not currently possible 6
• Discuss that hearing often worsens over time despite treatment interventions 6