What is the recommended management for an adult with typical Meniere’s disease?

Management of Ménière's Disease

Begin all patients with conservative management including sodium restriction (1500-2300 mg daily), caffeine and alcohol avoidance, and a diuretic as first-line pharmacologic therapy, escalating to intratympanic therapies only after several months of failed conservative treatment. 1, 2

Initial Conservative Approach

Dietary and lifestyle modifications form the foundation of treatment:

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation in the inner ear 3, 1, 2
• Eliminate or significantly reduce caffeine consumption, as it triggers attacks in susceptible individuals 1, 2
• Limit alcohol intake, which can precipitate 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

Important caveat: The evidence for dietary modifications is limited (Grade C), derived mainly from observational studies, though no cases of hyponatremia have been reported with appropriate nutritional counseling. 1

First-Line Pharmacologic Maintenance Therapy

Diuretics are the recommended first-line pharmacologic maintenance therapy based on moderate-quality evidence from observational cohorts and Cochrane reviews demonstrating reduction in endolymphatic volume. 1, 2

• Diuretics modify electrolyte balance in the endolymph and reduce its volume 3, 1
• Titrate down or stop medications once symptoms subside, as treatment windows vary from 10 days to 24 years 1

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

Contraindications and Special Populations for Diuretics:

• Exclude patients with comorbid renal or cardiac disease from diuretic therapy 1
• In pregnancy: Diuretics and intratympanic gentamicin are contraindicated; rely on dietary measures and short courses of vestibular suppressants during acute attacks 1
• Renal impairment: Avoid or adjust diuretic dosing; consider intratympanic steroids earlier 1
• Hypertensive patients: Diuretics may provide dual blood pressure control, but monitor electrolytes closely 1

Acute Attack Management

Offer a limited course of vestibular suppressants only during acute vertigo attacks:

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

Do not use vestibular rehabilitation for acute attacks—it is reserved for chronic imbalance between attacks or following ablative therapy. 1, 2

Second-Line: Intratympanic Steroid Therapy

Offer intratympanic steroid injections to patients with active disease after 3-6 months of failed conservative measures and diuretics:

• Achieves vertigo improvement in 85-90% of cases versus 57-80% with conventional therapy alone 1, 2
• Benefits include better vertigo control, improved quality of life, and faster return to work 3, 1
• Risks include: hearing loss, tympanic membrane perforation, and persistent imbalance; often requires multiple treatment sessions 3, 1, 2

In renal impairment, consider intratympanic steroids earlier in the treatment algorithm. 1

Third-Line: Intratympanic Gentamicin

Reserve intratympanic gentamicin for patients with persistent vertigo after failure of lifestyle measures, diuretics, and steroids:

• Provides complete vertigo control in approximately 73.6% of patients 1, 2
• Risk of hearing loss varies by administration method 1

Contraindications:

• Contralateral vestibular disease or hypofunction 1
• Known aminoglycoside hypersensitivity 1
• Pregnancy 1

Surgical Options for Refractory Disease

Consider surgical interventions only for cases refractory to medical management:

Hearing-Preserving Procedures (for usable hearing):

• Endolymphatic sac decompression 4, 2
• Vestibular nerve section 4, 2

Ablative Procedures (for non-usable hearing):

• Labyrinthectomy may be offered to patients who have failed less definitive therapy and have non-usable hearing 1, 4, 2
• Sacrifices remaining hearing but controls vertigo 4

Critical consideration: 10-25% of cases eventually become bilateral—avoid ablative procedures in the only hearing ear. 2

Vestibular Rehabilitation

Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy:

• Improves symptom control and reduces fall risk 1, 2
• Not recommended for acute vertigo attacks 1

Hearing Rehabilitation

Address progressive hearing loss with appropriate amplification:

• Conventional hearing aids for patients with usable hearing 4, 2
• CROS (Contralateral Routing of Signal) hearing aids when speech discrimination is severely compromised 4, 2
• Bone-anchored devices for severe to profound hearing loss in the affected ear with normal hearing in the better ear 4, 2
• Cochlear implants for severe hearing loss where amplification provides limited benefit 4, 2

Treatment NOT Recommended

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

Essential Monitoring Requirements

Systematic documentation is critical for treatment optimization:

• Obtain audiometry at diagnosis and regularly during follow-up to document characteristic low-to-mid-frequency sensorineural hearing loss and monitor progression 4, 2
• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment 3, 1, 2
• Assess quality of life impact using validated instruments 3, 2

Critical Pitfalls to Avoid

Rule out vestibular migraine (VM): VM closely mimics Ménière's disease—inquire thoroughly about migraine history, visual auras, motion intolerance, and light sensitivity. VM may present with short (<15 minutes) or prolonged (>24 hours) vertigo, and hearing loss is typically mild, absent, or stable. 3

Watch for drop attacks (Tumarkin's otolithic crisis) in later disease stages—sudden falls without warning or loss of consciousness. 2

Recognize the naturally fluctuating course: Up to 60% placebo response occurs in clinical trials, making it challenging to distinguish between disease quiescence and treatment effect. 3, 2

Distinguish temporary fluctuations from permanent progression: Hearing loss initially fluctuates in the low-to-mid-frequency range but may eventually involve all frequencies and worsen over time despite treatment. 4