What is the recommended treatment algorithm for Meniere's disease, including first‑line lifestyle and diuretic therapy, acute vestibular suppression, intratympanic options, and surgical interventions, and how should it be modified for comorbid hypertension, renal impairment, or pregnancy?

Treatment of Meniere's Disease

Start all patients with sodium restriction (1500-2300 mg daily), caffeine and alcohol avoidance, plus a diuretic for maintenance therapy; if vertigo persists after several months, escalate to intratympanic steroids, then intratympanic gentamicin for refractory cases, reserving surgery only for those who fail all medical options. 1, 2

First-Line: Lifestyle and Dietary Modifications

Begin with conservative management as the foundation for all patients: 1, 2

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

The evidence for dietary modifications is limited (Grade C), based primarily on observational studies rather than robust RCTs, but individual patients may have identifiable triggers that improve symptom control when avoided. 3 The risk of hyponatremia from sodium restriction has not been reported in studies and can be minimized with appropriate nutritional counseling. 3

Second-Line: Maintenance Pharmacotherapy

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

Betahistine cannot be definitively recommended due to questionable efficacy—the BEMED trial found no significant difference between betahistine and placebo in reducing vertigo attacks. 1, 2 This represents a critical shift from older recommendations, as recent high-quality evidence does not support its routine use. 1

Titrate down or stop medications once symptoms subside, as treatment windows vary from 10 days to 24 years. 1

Contraindications and Special Populations:

• Exclude patients with comorbid renal or cardiac disease that contraindicates diuretics 3
• For pregnancy: avoid diuretics and gentamicin; focus on dietary modifications and vestibular suppressants only during acute attacks 3
• For renal impairment: avoid or adjust diuretic dosing; consider intratympanic steroids earlier in the treatment algorithm 3
• For hypertension: diuretics may provide dual benefit, but monitor electrolytes closely 3

Acute Vestibular Attack Management

Offer a limited course of vestibular suppressants only during acute vertigo attacks, not for chronic use: 1, 2

• Antihistamines (dimenhidrinato, meclizina) for acute symptom relief 1
• Benzodiazepines for associated anxiety, but use with caution due to dependence risk 1

Do not use vestibular suppressants for maintenance therapy or chronic management. 1

Third-Line: Intratympanic Therapies

Intratympanic Steroids

Offer intratympanic steroid injections to patients with active Meniere's disease not responsive to 3-6 months of conservative measures and diuretics. 1, 2 This provides 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy alone. 1, 2

Benefits include improved vertigo control, improved quality of life, faster return to work, and avoidance of general anesthesia compared to surgery. 3 Risks include hearing loss, tympanic membrane perforation, and persistent imbalance, requiring multiple treatments. 3

Intratympanic Gentamicin

Reserve intratympanic gentamicin for patients with persistent vertigo who have failed conservative therapies, diuretics, and intratympanic steroids. 1, 2 This achieves complete vertigo control in approximately 73.6% of patients. 1, 2

Gentamicin reduces vestibular function in the treated ear through selective ablation, though complete ablation is not typically required for vertigo control. 4 The risk of hearing loss varies by administration method—use low-dose protocols to minimize this risk. 4

Critical contraindication: Do not use in patients with contralateral disease or hypofunction, as bilateral vestibular loss causes severe disability. 3 Also contraindicated in patients with known hypersensitivity to aminoglycosides. 3

Fourth-Line: Surgical Interventions

Surgery is reserved for cases refractory to all medical treatments after several months of optimal therapy. 1, 2

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

• Endolymphatic sac decompression or vestibular nerve section to preserve auditory function 5, 2

For Patients with Non-Usable Hearing (Class D):

• Labyrinthectomy provides definitive vertigo control but sacrifices remaining hearing 5, 2

Critical consideration: 10-25% of cases eventually become bilateral, which impacts surgical decision-making—avoid ablative procedures in the only hearing ear. 1, 5

Vestibular Rehabilitation

Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy, not for acute vertigo management. 1, 2 This improves symptom control and reduces fall risk. 1, 2

Treatments NOT Recommended

Do not prescribe positive pressure therapy (Meniett device) based on multiple systematic reviews and RCTs showing no significant difference compared to placebo for vertigo control. 3, 1, 5, 2 The device may actually worsen hearing levels based on moderate-quality evidence. 1

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, 5, 2
• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment 1, 5, 2
• Assess quality of life impact using validated instruments 1, 5, 2
• Watch for drop attacks (Tumarkin's otolithic crisis) in later disease stages, which occur suddenly without warning and without loss of consciousness 1, 5

Hearing Rehabilitation Options

As hearing loss progresses despite treatment (complete restoration is not currently possible): 5

• Conventional hearing aids for patients with usable hearing 5, 2
• CROS hearing aids for patients with severely compromised speech discrimination 5, 2
• Cochlear implants for severe to profound hearing loss where amplification provides limited benefit 5, 2

Critical Clinical Pitfalls

• Recognize that up to 60% of patients show improvement with placebo in clinical trials, making treatment efficacy difficult to assess 5
• Hearing loss initially fluctuates but may eventually involve all frequencies as disease progresses 5
• Avoid prolonged use of benzodiazepines due to dependence risk 1
• There is no definitive cure for Meniere's disease—treatment focuses on symptom control and hearing preservation 1