What is the recommended management for Meniere's disease?

Management of Ménière's Disease

Begin with lifestyle modifications (low-sodium diet 1500-2300 mg/day, limit caffeine and alcohol) and patient education, then escalate to diuretics or betahistine for maintenance therapy, followed by intratympanic gentamicin for refractory cases with active disease unresponsive to medical management. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis using established criteria:

• Definite Ménière's disease requires ≥2 spontaneous vertigo attacks lasting 20 minutes to 12 hours, audiometrically documented low-to-mid-frequency sensorineural hearing loss in the affected ear, fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness), and exclusion of other causes. 1
• Obtain an audiogram in all patients being assessed for Ménière's disease to document hearing loss patterns and establish baseline function. 1
• Rule out vestibular migraine, which can closely mimic Ménière's disease but typically presents with photophobia, phonophobia, bilateral auditory symptoms, and stable (not fluctuating) hearing loss. 1

Stepwise Treatment Algorithm

First-Line: Conservative Management

Dietary and lifestyle modifications form the foundation of treatment:

• Sodium restriction to 1500-2300 mg daily based on American Heart Association guidelines (not older Ménière's-specific recommendations). 1
• Limit caffeine intake, alcohol consumption, and tobacco use to reduce symptom triggers. 1
• Maintain adequate hydration, regular sleep patterns, and stress management as these factors can precipitate attacks. 1
• Identify and manage allergies which may contribute to disease activity. 1

Patient education is mandatory and should cover natural history, treatment expectations, symptom control measures, and quality of life impacts. 1

Second-Line: Pharmacological Maintenance Therapy

When conservative measures fail to control symptoms:

• Diuretics may be offered for maintenance therapy to reduce symptoms or prevent attacks, though evidence quality is limited. 1
• Betahistine may be offered as maintenance therapy, particularly in European practice where it is commonly used. 1, 2
• Vestibular suppressants should be limited to short courses during acute attacks only—not for chronic use—as they do not address underlying pathophysiology and risk dependency. 1

Acute Attack Management

During active vertigo episodes:

• Prescribe vestibular suppressants for limited duration including antihistamines (meclizine, diphenhydramine) or benzodiazepines for acute symptom relief. 1, 2
• Anti-emetics help control nausea and vomiting during attacks. 2
• Avoid chronic vestibular suppressant use as this prevents central compensation and may worsen long-term balance outcomes. 1

Third-Line: Intratympanic Therapies

For patients with active Ménière's disease unresponsive to conservative and medical management:

Intratympanic gentamicin is the preferred ablative approach:

• Should be offered to patients with active disease not responsive to nonablative therapy. 1
• Reduces vestibular function in the treated ear without requiring complete ablation to achieve vertigo control. 3, 4
• More effective than continued medical management alone for refractory cases. 3

Intratympanic steroids represent a less aggressive option:

• May be offered to patients with active Ménière's disease as a hearing-preserving alternative. 1
• Consider before gentamicin in patients with usable hearing who wish to avoid vestibular ablation. 1

Fourth-Line: Surgical Interventions

Reserved for patients who have failed all medical and intratympanic therapies:

For patients with usable hearing (Class A or B/C: discrimination ≥50%, PTA ≤50 dB):

• Endolymphatic sac decompression may be considered as a hearing-sparing procedure. 1, 4
• Vestibular nerve section offers very high vertigo control rates while preserving hearing. 4

For patients with nonusable hearing (Class D: discrimination <50%):

• Labyrinthectomy provides definitive vertigo control but eliminates residual hearing. 4
• Should be reserved as last resort for unilateral disease with deafness. 4

Adjunctive Therapies

Vestibular rehabilitation/physical therapy should be offered to patients who have failed less definitive therapy and have nonusable hearing, or for chronic imbalance between attacks. 1

Hearing aids or cochlear implantation address progressive hearing loss and improve quality of life. 1, 5

Critical Management Pitfalls

• Do not prescribe positive pressure therapy (e.g., CPAP-like devices) as it does not improve symptoms and may worsen the condition. 1
• Avoid routine MRI unless atypical features suggest alternative diagnoses like vestibular schwannoma or central pathology. 1
• Do not delay escalation in patients with frequent debilitating attacks, as prolonged active disease worsens quality of life and may accelerate hearing loss. 1
• Recognize that 35% of Ménière's patients also meet criteria for vestibular migraine—consider noninvasive therapeutic trials for migraine before pursuing surgical or ablative interventions. 6
• Monitor for bilateral involvement which occurs in 25-40% of cases and may alter surgical decision-making. 5

Expected Outcomes

• More than 85% of patients achieve symptom control with lifestyle modifications, medical treatment, or minimally invasive procedures. 4
• Placebo response rates approach 60% in clinical trials, making natural disease fluctuation difficult to distinguish from treatment effects. 1
• Hearing may stabilize, worsen, or fluctuate over time; vertigo attacks typically become less frequent in later disease stages, though residual imbalance may persist. 1