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

Treatment of Ménière's Disease

Start all patients with conservative management including a low-sodium diet (1500-2300 mg daily), avoidance of caffeine and alcohol, and consider a diuretic as first-line therapy, reserving more invasive interventions only for those who fail conservative measures after several months. 1, 2

Initial Conservative Management (First-Line)

All patients should begin with lifestyle and dietary modifications as the foundation of treatment 3:

• Sodium restriction to 1500-2300 mg daily to reduce endolymphatic fluid accumulation 1, 2, 4
• Eliminate or significantly reduce caffeine intake, as it can trigger attacks in susceptible patients 1, 2, 4
• Limit alcohol consumption, which may precipitate vertigo episodes 1, 2, 4
• Identify and manage allergies, as they contribute to symptoms in up to 30% of patients 2
• Stress management through relaxation techniques, regular exercise, and adequate sleep 2
• Maintain a symptom diary to identify personal triggers 2

Important caveat: While these dietary modifications are widely recommended, the evidence supporting them is very low certainty, with no placebo-controlled RCTs for salt or caffeine restriction 5. However, given their low risk and potential benefit, they remain the standard first approach 1, 2.

Pharmacotherapy for Maintenance

Diuretics

• Diuretics are recommended as first-line pharmacologic maintenance therapy to modify electrolyte balance in the endolymph and reduce its volume 1, 2
• This recommendation is based on moderate-quality evidence from observational studies and Cochrane reviews 2

Betahistine

• Betahistine cannot be definitively recommended due to questionable efficacy 2
• The BEMED trial found no significant difference between betahistine and placebo in reducing vertigo attacks 2
• Despite this, betahistine (a histamine analogue) may increase vasodilation to the inner ear and is used in some countries 2, 4, 6

Acute Attack Management

• Offer a limited course of vestibular suppressants ONLY during acute vertigo attacks, not for chronic use 1, 2
• Options include antihistamines (dimenhidrinato, meclizina) 2
• Benzodiazepines may be used for associated anxiety, but use with extreme caution due to dependence risk 2

Intratympanic Therapies (Second-Line)

When to Consider

Progress to intratympanic therapy only after several months of failed conservative management in patients with active, disabling disease 3, 1.

Intratympanic Steroids

• Offer intratympanic steroid injections to patients with active Ménière's disease not responsive to conservative measures 1, 2, 4
• 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

Intratympanic Gentamicin

• Reserve for patients with persistent vertigo who have failed conservative and steroid therapies 2, 7
• Achieves complete vertigo control in approximately 73.6% of patients 2
• Critical consideration: Risk of hearing loss varies by administration method—use low-dose protocols 2, 7
• Gentamicin reduces vestibular function in the treated ear without requiring complete ablation 7

Surgical Interventions (Third-Line)

Decision Algorithm Based on Hearing Status

The critical decision point is whether the patient has "usable hearing" 3:

Usable hearing is defined as:

• Class A: Discrimination 70-100%; PTA <30 dB
• Class B: Discrimination 50-69%; PTA 31-50 dB
• Class C: Discrimination 50-69%; PTA >50 dB
• Class D (non-usable): Discrimination <50%; any PTA 3, 1

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

• Consider non-ablative procedures to preserve auditory function 1, 4
• Options include endolymphatic sac decompression 4, 8
• Vestibular nerve section for vertigo control while preserving hearing 4

For Patients WITHOUT Usable Hearing (Class D)

• Offer labyrinthectomy to patients who have failed less definitive therapy 1, 2
• This ablative procedure sacrifices remaining hearing but provides vertigo control 4
• Converts the dynamic fluctuating inner ear lesion to a static state through destruction 3

Critical warning: 10-25% of cases eventually become bilateral 1, 2. Never perform ablative procedures on the only hearing ear 2.

Vestibular Rehabilitation

• Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy 2
• Benefits include improved symptom control and reduced fall risk 2
• Do NOT use for acute vertigo attack management 2

Hearing Rehabilitation Options

As hearing loss often worsens over time despite treatment 4:

• Conventional hearing aids for patients with usable hearing 1, 4
• CROS hearing aids when speech discrimination is severely compromised 1, 4
• Bone-anchored devices for severe to profound hearing loss in the affected ear with normal hearing in the better ear 4
• Cochlear implants for severe hearing loss where amplification provides limited benefit 1, 4

Treatments NOT Recommended

• Do NOT offer positive pressure therapy (Meniett device) based on systematic reviews showing no significant difference compared to placebo 1, 2

Essential Monitoring Requirements

• Obtain audiometry at diagnosis and regularly during follow-up to document characteristic low-to-mid-frequency sensorineural hearing loss and monitor progression 1, 2, 4
• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment 1, 2, 4
• Assess quality of life impact using validated instruments 1, 4

Critical Clinical Pitfalls to Avoid

• Recognize the high placebo response: Up to 60% of patients show improvement with placebo in clinical trials, making treatment efficacy difficult to assess 3, 1
• Watch for drop attacks (Tumarkin's otolithic crisis) in later disease stages—sudden falls without warning or loss of consciousness 3, 1, 2, 4
• Remember bilateral involvement: 10-25% of cases affect both ears over time, which critically impacts surgical decision-making 1, 2
• Set realistic expectations: Complete restoration of hearing is not currently possible; hearing loss often worsens despite treatment 1, 4
• Avoid prolonged benzodiazepine use due to dependence risk 2
• Consider comorbidities that may contraindicate certain medications (renal or cardiac disease, asthma) 2

Stepwise Treatment Algorithm Summary

1. Initial (all patients): Low-sodium diet + trigger avoidance + diuretic 1, 2
2. Acute attacks only: Short-course vestibular suppressants 1, 2
3. Persistent symptoms after months: Intratympanic steroids 1, 2
4. Refractory to above: Intratympanic gentamicin 2
5. Surgical consideration: Based on hearing status—non-ablative if usable hearing, ablative if non-usable 1, 2, 4