What is the recommended evaluation and treatment for Meniere's disease?

Meniere's Disease: Evaluation and Treatment

Diagnosis

Diagnose definite Meniere's disease when patients present with ≥2 episodes of vertigo lasting 20 minutes to 12 hours, plus audiometrically documented low-to-mid frequency sensorineural hearing loss, plus fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear, when other causes are excluded. 1

Diagnostic Criteria Breakdown

Definite Meniere's Disease requires: 1

• Two or more spontaneous vertigo attacks lasting 20 minutes to 12 hours
• Audiometrically documented low-to-mid frequency sensorineural hearing loss on at least one occasion
• Fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in affected ear
• Other causes excluded

Probable Meniere's Disease requires: 1

• At least 2 episodes of vertigo/dizziness lasting 20 minutes to 24 hours
• Fluctuating aural symptoms in affected ear
• Other causes excluded

Critical History Elements

Confirm true vertigo (spinning/rotational sensation), not vague dizziness or lightheadedness, as this is the hallmark symptom. 1 Ask specifically about:

• Spontaneous versus provoked onset 1
• Exact duration of active vertigo (seconds suggest BPPV, not Meniere's) 1
• Concurrent otologic symptoms during attacks 1

Screen for vestibular migraine, which closely mimics Meniere's disease and may coexist. 1 Vestibular migraine differs by:

• Attack duration may be <15 minutes or >24 hours 1
• Hearing loss typically mild, absent, or stable 1
• Photophobia and motion intolerance more prominent 1
• Visual auras common 1

Required Diagnostic Testing

Obtain an audiogram in all patients being evaluated for Meniere's disease—this is essential and non-negotiable. 1 The audiogram documents the characteristic low-to-mid frequency sensorineural hearing loss required for definite diagnosis. 1

Do NOT routinely order vestibular function testing or electrocochleography to establish the diagnosis. 1 These tests are not necessary for diagnosis and add unnecessary cost.

Consider MRI of the internal auditory canal and posterior fossa only in patients with nonfluctuating sensorineural hearing loss, when symptoms suggest alternative diagnoses like vestibular schwannoma. 1 The key differentiator: Meniere's causes fluctuating hearing loss, while tumors cause progressive, nonfluctuating loss. 1

Treatment Algorithm

Step 1: Initial Conservative Management

Start all patients with dietary sodium restriction (1500-2300 mg daily) and lifestyle modifications. 2 This reduces endolymphatic fluid accumulation. 2

Counsel patients to limit: 2

• Alcohol (triggers attacks) 2
• Caffeine (triggers attacks in some patients) 2
• Identify and manage allergies (contribute to symptoms in 30% of patients) 2

Educate patients about the natural history: Meniere's has a fluctuating course with up to 60% placebo response in trials, and 10-25% eventually develop bilateral disease. 1, 2 This education is mandatory, not optional. 1

Step 2: Acute Attack Management

Offer a limited course of vestibular suppressants ONLY during acute vertigo attacks, not for chronic use. 1, 2 Options include:

• Antihistamines (meclizine, dimenhydrinate) 2
• Benzodiazepines for severe anxiety (use cautiously due to dependence risk) 2

Step 3: Maintenance Pharmacotherapy

Prescribe diuretics as first-line maintenance therapy to modify endolymphatic electrolyte balance and reduce volume. 2 Diuretics are the most reliable maintenance option based on current evidence. 2

Betahistine cannot be definitively recommended due to questionable efficacy—the BEMED trial showed no significant difference versus placebo. 2 While some international guidelines mention betahistine, recent high-quality evidence does not support its use. 2

Step 4: Intratympanic Therapies for Refractory Disease

Offer intratympanic steroids to patients with active Meniere's disease not responding to conservative measures. 1, 2 Studies show 85-90% improvement in vertigo symptoms versus 57-80% with conventional therapy. 2 Risks include hearing loss, tympanic membrane perforation, and persistent imbalance. 2

Offer intratympanic gentamicin to patients with persistent vertigo despite non-ablative therapy. 1, 2 Complete vertigo control occurs in approximately 73.6% of patients. 2 Gentamicin reduces vestibular function without requiring complete ablation. 3 Risk of hearing loss varies by administration protocol. 2

Step 5: Surgical Options for Severe Refractory Cases

Consider labyrinthectomy only for patients who have failed all other therapies AND have non-usable hearing in the affected ear. 2 This is critical: never perform ablative procedures on the only hearing ear, as 10-25% of cases become bilateral. 2

Treatments NOT Recommended

Do NOT prescribe positive pressure therapy (Meniett device)—multiple systematic reviews show no benefit versus placebo and may worsen hearing. 1, 2 This recommendation is definitive. 2

Vestibular Rehabilitation

Offer vestibular rehabilitation/physical therapy for chronic imbalance between attacks or following ablative therapy, NOT for acute vertigo management. 1, 2 Benefits include improved symptom control and reduced fall risk. 2

Monitoring Requirements

Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each intervention, and assess quality of life impact. 1, 2 Obtain serial audiograms to monitor progression. 2

Watch for Tumarkin's otolithic crises (drop attacks) in later disease stages—these occur suddenly without warning or loss of consciousness. 2

Critical Pitfalls to Avoid

• Do not miss vestibular migraine: It mimics Meniere's closely and requires different treatment. 1
• Do not perform ablative surgery without considering bilaterality risk: 10-25% develop bilateral disease. 2
• Do not use vestibular suppressants chronically: They are only for acute attacks. 1, 2
• Do not diagnose Meniere's without audiometric documentation: Clinical suspicion alone is insufficient. 1