What is the diagnosis and management of Meniere's disease?

From the Guidelines

Meniere's disease diagnosis is primarily based on clinical presentation, with characteristic symptoms including episodic vertigo, tinnitus, aural fullness, and hearing loss. Management involves a multidisciplinary approach, with initial treatment often consisting of a low-sodium diet and diuretics, such as acetazolamide 250-500mg orally twice daily, to reduce endolymphatic pressure 1.

Key Considerations

• The goals of treatment are to prevent or reduce the severity and frequency of vertigo attacks, relieve or prevent hearing loss, tinnitus, and aural fullness, and improve overall quality of life 1.
• In cases of severe vertigo, intratympanic injections of gentamicin 20-30mg or corticosteroids, such as dexamethasone 4-12mg, may be administered, with treatment duration and frequency tailored to individual patient response 1.
• Betahistine 16-48mg orally three times daily may also be prescribed to alleviate vertigo and improve vestibular function 1.

Diagnostic Criteria

• Definite or probable Meniere's disease can be diagnosed in patients presenting with 2 or more episodes of vertigo lasting 20 minutes to 12 hours and fluctuating or nonfluctuating sensorineural hearing loss, tinnitus, or pressure in the affected ear 1.
• The diagnosis is based on clinical presentation and may involve additional testing, such as audiograms and video- or electronystagmograms, to rule out other disorders 1.

Treatment Approaches

• Treatment approaches to Meniere's disease are many and typically include modifications of lifestyle factors (e.g., diet), medical, surgical, or a combination of therapies 1.
• The choice of treatment depends on the hearing status and whether it is usable or not, with nonablative procedures advocated for patients with usable hearing and surgical or chemical inner ear ablative treatments considered for those with no meaningful hearing 1.

From the Research

Diagnosis of Meniere's Disease

• Diagnosis is made with a characteristic patient history, including discrete episodes of vertigo lasting 20 min or longer, accompanied by sensorineural hearing loss, aural fullness, and tinnitus 2
• Workup includes audiometry, a contrast-enhanced MRI of the internal auditory canals, and exclusion of other diseases that can produce similar symptoms 2
• Diagnosis is based on clinical criteria and requires the observation of an episodic vertigo syndrome associated with low- to medium-frequency sensorineural hearing loss and fluctuating aural symptoms (hearing loss, tinnitus, and/or fullness) in the affected ear 3
• Diagnosis can also be made by MR of the inner ear 4

Management of Meniere's Disease

• Treatment begins with conservative measures, including low salt diet, avoidance of stress and caffeine, and sleep hygiene 2
• Medical therapy with a diuretic is the usual next step 2
• If symptoms are not controlled, options include intratympanic (IT) steroids and betahistine 2
• Next tier treatments include the Meniett device and endolymphatic sac surgery, but the efficacy of both is controversial 2
• Ablative therapies like intratympanic gentamicin are considered if the above measures fail to provide symptomatic control of vertigo 2
• Sodium restriction, betahistine, intratympanic gentamicin, or steroids and eventually surgery, such as cochlear implantation, are also treatment options 3
• Long-term management has several steps, including diet, diuretics, intratympanic injection of corticosteroid or gentamicin and surgery (endolymphatic sac surgery, grommet insertion, surgical labyrinthectomy) 4
• Medical treatment tends to control vertigo and to cure the possible causes of endolymphatic hydrops (autoimmune disease, syphilis, metabolic and endocrine derangements, etc) 5
• Many patients with Meniere's disease can be managed using nonablative therapy, such as intratympanic steroids and endolymphatic shunt surgery, prior to ablative techniques such as intratympanic gentamicin 6

Symptomatic Control

• Benzodiazepines and anti-emetics are used for symptomatic control during vertigo episodes 2
• Rehabilitative options for unilateral vestibular weakness include physical therapy and for unilateral hearing loss include conventional hearing aids, contralateral routing of sound (CROS) and osseointegrated hearing aids 2