What is the recommended management approach for a patient with Meniere's disease?

Management of Ménière's Disease

Manage Ménière's disease with a stepwise approach starting with dietary sodium restriction (1500-2300 mg daily) and patient education, progressing to diuretics or betahistine for maintenance, vestibular suppressants only during acute attacks, and reserving intratympanic gentamicin for patients failing conservative therapy. 1, 2

Diagnosis and Initial Assessment

Diagnose definite Ménière's disease when patients present with ≥2 episodes of vertigo lasting 20 minutes to 12 hours, plus fluctuating sensorineural hearing loss, tinnitus, or aural pressure not better explained by another disorder. 1

• Obtain an audiogram at diagnosis showing characteristic low-to-mid-frequency sensorineural hearing loss 1, 2
• Consider MRI of the internal auditory canal and posterior fossa only if hearing loss is nonfluctuating, as this may indicate retrocochlear pathology 1
• Do NOT routinely order vestibular function testing or electrocochleography, as these are unnecessary for diagnosis 1
• Screen for vestibular migraine, which can coexist or mimic Ménière's disease 3

First-Line Treatment: Lifestyle and Dietary Modifications

Implement sodium restriction to 1500-2300 mg daily as the cornerstone of initial management. 2

• Limit caffeine intake, as it can trigger attacks in susceptible patients 2, 4
• Restrict alcohol consumption, which may precipitate vertigo episodes 2, 4
• Identify and manage allergies, which contribute to symptoms in up to 30% of patients 2
• Implement stress management through relaxation techniques, regular exercise, and adequate sleep 2
• Have patients maintain a symptom diary to identify personal triggers 2

Educate patients about the natural history: up to 60% show placebo response in trials, and 10-25% eventually develop bilateral disease. 2

Acute Attack Management

Offer a limited course of vestibular suppressants ONLY during acute vertigo attacks, not for long-term use. 1

• Use antihistamines (meclizine, dimenhydrinate) for acute vertigo control 2
• Consider benzodiazepines for severe anxiety during attacks, but use cautiously due to dependence risk 2
• Prescribe antiemetics as needed for nausea and vomiting 1
• Critical pitfall: Do NOT use vestibular suppressants chronically, as they impair central vestibular compensation 5

Maintenance Pharmacotherapy

Prescribe diuretics as first-line maintenance therapy to modify endolymph volume and electrolyte balance. 2, 6

• Betahistine (a histamine analogue) increases inner ear vasodilation and may reduce attack frequency, though recent evidence (BEMED trial) questions its efficacy over placebo 2
• Important caveat: The 2020 AAO-HNS guideline cannot make a definitive recommendation for betahistine due to questionable efficacy 2

Second-Line Treatment: Intratympanic Steroids

Offer intratympanic steroids to patients with active disease not responding to conservative measures and oral medications. 1, 2

• Provides 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

Third-Line Treatment: Intratympanic Gentamicin

Offer intratympanic gentamicin to patients with active disease failing non-ablative therapies, achieving complete vertigo control in approximately 73.6% of cases. 1, 2

• This is a chemical ablation of vestibular function 6
• Risk of hearing loss varies by administration protocol (no standardized protocol exists) 1
• Critical consideration: Avoid in patients at risk for bilateral disease, as this permanently damages vestibular function 2

Surgical Options for Refractory Cases

Reserve surgical ablative therapy (labyrinthectomy or vestibular nerve section) for patients with non-usable hearing who have failed all other therapies. 1, 2

• Endolymphatic sac decompression may be considered for hearing preservation, though evidence is limited 1, 6
• Labyrinthectomy is appropriate only when hearing is already severely compromised 6
• Watch for drop attacks (Tumarkin's otolithic crisis) in later disease stages, which occur suddenly without warning 2

Vestibular Rehabilitation

Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative procedures, NOT during acute attacks. 1, 5

• Improves postural balance, reduces fall risk, and enhances quality of life 5, 7
• Promotes adaptation to decreased vestibular input after unilateral loss 7
• Critical pitfall: Do NOT use during acute vertigo episodes, as it may worsen symptoms 5

Treatments NOT Recommended

Do NOT prescribe positive pressure therapy (Meniett device), as systematic reviews show no significant difference compared to placebo. 1, 2

Monitoring and Follow-Up

Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss at each visit, along with quality of life assessment. 1, 2

• Obtain serial audiograms to monitor hearing progression 2
• Adjust treatment based on symptom evolution 2
• Remember: There is no definitive cure for Ménière's disease; management focuses on symptom control and quality of life 2