What is the recommended treatment approach for a patient with Meniere's disease, characterized by vertigo, tinnitus, and hearing loss?

Menière's Disease: Treatment Approach

For patients with Menière's disease presenting with vertigo, tinnitus, and hearing loss, begin with dietary sodium restriction (1500-2300 mg daily) and diuretics as first-line maintenance therapy, offer vestibular suppressants only during acute vertigo attacks, and reserve intratympanic gentamicin for patients who fail conservative management. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis requires: 1

• Two or more spontaneous vertigo episodes lasting 20 minutes to 12 hours (definite MD) or up to 24 hours (probable MD) 1
• Audiometrically documented low-to-mid-frequency sensorineural hearing loss in the affected ear 1, 3
• Fluctuating aural symptoms (tinnitus, ear fullness, or hearing loss) 1
• Obtain baseline audiogram—this is mandatory, not optional 1

Critical pitfall: Rule out vestibular migraine, which presents with vertigo lasting minutes to days and often has headache history. 3 Do NOT routinely order vestibular function testing or electrocochleography for diagnosis—these are not recommended. 1

Stepwise Treatment Algorithm

Step 1: Conservative Management (First-Line)

Initiate all patients on: 2, 3

• Sodium restriction: 1500-2300 mg daily to reduce endolymphatic fluid accumulation 2
• Diuretics to modify electrolyte balance and reduce endolymph volume 2
• Limit caffeine and alcohol—both can trigger attacks 2
• Consider betahistine (16-48 mg daily in divided doses) to increase inner ear vasodilation, though recent evidence questions its efficacy 2

Important caveat: The BEMED trial found no significant difference between betahistine and placebo for reducing vertigo attacks, making diuretics the more reliable maintenance option. 2 However, betahistine remains widely used in Europe. 4, 5

Step 2: Acute Attack Management

During active vertigo episodes: 1, 2

• Offer a limited course of vestibular suppressants ONLY during attacks—not for chronic use 1
• Options include antihistamines (meclizine, dimenhydrinate) 2
• Benzodiazepines may be added for severe anxiety, but use cautiously due to dependence risk 2

Critical warning: Do NOT use vestibular suppressants chronically—they delay central compensation and worsen long-term outcomes. 2

Step 3: Intratympanic Therapies (For Active Disease Refractory to Conservative Treatment)

If symptoms persist after several months of conservative management: 2, 3

Intratympanic steroids may be offered first: 1, 2

• Provides 85-90% improvement in vertigo symptoms versus 57-80% with conventional therapy 2
• Benefits: Better vertigo control, improved quality of life, faster return to work 2
• Risks: Hearing loss, tympanic membrane perforation, persistent imbalance 2

Intratympanic gentamicin for persistent vertigo despite above measures: 1, 2

• Achieves complete vertigo control in approximately 73.6% of patients 2
• This is chemical ablation—it destroys vestibular function 1
• Risk of hearing loss varies by administration protocol 2

Step 4: Surgical Options (For Refractory Cases)

For patients with usable hearing (Class A, B, or C): 3

• Consider endolymphatic sac decompression (hearing-preserving) 3, 6
• Vestibular nerve section (hearing-preserving, highly effective for vertigo) 6

For patients with non-usable hearing (Class D): 1, 3

• Labyrinthectomy—sacrifices remaining hearing but provides definitive vertigo control 1, 6
• Vestibular rehabilitation/physical therapy should be offered following ablative procedures 1

Critical consideration: 10-25% of cases eventually become bilateral—never perform ablative procedures if there's risk of bilateral disease, as this could leave the patient without any vestibular or hearing function. 1, 3

Treatments NOT Recommended

Do NOT prescribe positive pressure therapy (Meniett device)—multiple systematic reviews show no significant difference versus placebo and may actually worsen hearing. 1, 2

Monitoring Requirements

Document at every follow-up visit: 1

• Resolution, improvement, or worsening of vertigo frequency and severity 1
• Changes in tinnitus and hearing loss 1
• Quality of life impact using validated instruments 3
• Obtain serial audiograms to monitor hearing progression 1, 3, 6

Hearing Rehabilitation

As hearing deteriorates (which occurs in most patients despite treatment): 6

• Conventional hearing aids for usable hearing 3, 6
• CROS hearing aids when speech discrimination is severely compromised 3, 6
• Cochlear implants for severe bilateral hearing loss where amplification fails 3, 6

Reality check: Hearing loss often worsens over time despite all interventions—complete restoration is not currently possible. 3, 6 Set realistic expectations with patients. 1

Patient Education Essentials

Counsel all patients about: 1

• Natural history: Up to 60% show placebo response in trials; disease has fluctuating course 3
• No definitive cure exists—treatment is symptomatic and preventive 2
• Risk of bilateral involvement (10-25% over time) 1, 3
• Watch for drop attacks (Tumarkin's otolithic crisis) in later stages—sudden falls without warning or loss of consciousness 3
• Maintain symptom diary to identify personal triggers 1, 2

Common triggers to identify: Cold weather fronts, stress, allergies (contribute in up to 30% of patients). 2, 7