Meniere's Disease

Affecting the inner ear, Ménière’s disease is a condition that causes vertigo (attacks of a spinning sensation), hearing loss, tinnitus (a roaring, buzzing, or ringing sound in the ear), and a sensation of fullness in the affected ear. Because Ménière’s disease affects each person differently, your doctor will suggest strategies to help reduce your symptoms and will help you choose the treatment that is best for you.

What is Ménière’s disease?

Ménière’s disease, also called idiopathic endolymphatic hydrops, is a disorder of the inner ear. Although the cause is unknown, it probably results from an abnormality in the fluids of the inner ear. Ménière’s disease is one of the most common causes of dizziness originating in the inner ear. In most cases only one ear is involved, but both ears may be affected in about 15 percent of patients. Ménière’s disease typically starts between the ages of 20 and 50 years. Men and women are affected in equal numbers.

What are the causes?

Although the cause is unknown, it probably results from an abnormality in the fluids of the inner ear. The theory is that too much inner ear fluid accumulates either due to excess production or inadequate absorption. In some individuals, especially those with involvement of both ears, allergies or autoimmune disorders may play a role in producing Ménière’s disease.

People with Ménière’s disease have a “sick” inner ear and are more sensitive to factors, such as fatigue and stress that may influence the frequency of attacks.

How is a diagnosis made?

The physician will take a history of the frequency, duration, severity, and character of your attacks, the duration of hearing loss or whether it has been changing, and whether you have had tinnitus or fullness in either or both ears. When the history has been completed, diagnostic tests will check your hearing and balance functions. They may include:

For hearing

  • An audiometric examination (hearing test) typically indicates a sensory type of hearing loss in the affected ear. Speech discrimination (the patient’s ability to distinguish between words like “sit” and “fit”) is often diminished in the affected ear.

For balance

  • An ENG (electronystagmograph) may be performed to evaluate balance function. In a darkened room, recording electrodes are placed near the eyes. Warm and cool water or air is gently introduced into each ear canal. Since the eyes and ears work in coordination through the nervous system, measurement of eye movements can be used to test the balance system. In about 50 percent of patients, the balance function is reduced in the affected ear.

  • Rotational testing or balance platform, may also be performed to evaluate the balance system.

Other tests

  • Electrocochleography (ECoG) may indicate increased inner ear fluid pressure in some cases of Ménière’s disease.

  • The auditory brain stem response (ABR), a computerized test of the hearing nerves and brain pathways, computed tomography (CT) or, magnetic resonance imaging (MRI) may be needed to rule out a tumor occurring on the hearing and balance nerve. Such tumors are rare, but they can cause symptoms similar to Ménière’s disease.

How is it treated?

Treatment may include:

  • a low salt diet and a diuretic (water pill)
  • anti-vertigo medications, e.g., Antivert® (meclizine generic), or Valium® (diazepam generic)
  • intratympanic injections
  • a Meniette® device

Your otolaryngologist will help you choose the treatment that is best for you, as there are things to consider with each. For example, while anti-vertigo and anti-nausea medications will reduce dizziness, they may cause drowsiness. Other treatments also carry both positive implications as well as drawbacks. Intratympanic injections involve injecting medication through the eardrum into the middle ear space where the ear bones reside. This treatment is done in the otolaryngologist’s office. The treatment includes either making a temporary opening in the eardrum or placing a tube in the eardrum. The drug may be administered once or several times. Medication injected may include gentamicin or corticosteroids. Gentamicin alleviates dizziness but also carries the possibility of increased hearing loss in the treated ear that may occur in some individuals. Corticosteroids do not cause worsening of hearing loss, but are less effective in alleviating the major dizzy spells. A Meniette® device is another option. This device is a mechanical pump that is applied to the person’s ear canal for five minutes three times a day. A ventilating tube must be first inserted through the eardrum to allow the pressure produced by the Meniette® to be transmitted across the round window membrane and change the pressure in the inner ear. The success rate of this device has been variable.

When is surgery recommended?

If vertigo attacks are not controlled by conservative measures and are disabling, one of the following surgical procedures might be recommended:

  • The endolymphatic sac shunt or decompression procedure is an ear operation that usually preserves hearing. Attacks of vertigo are controlled in one-half to two-thirds of cases, but control is not permanent in all cases. Recovery time after this procedure is short compared to the other procedures.

  • Selective vestibular neurectomy is a procedure in which the balance nerve is cut as it leaves the inner ear and goes to the brain. While vertigo attacks are permanently cured in a high percentage of cases, patients may continue to experience imbalance. Similar to endolymphatic sac procedures, hearing function is usually preserved.

  • Labryrinthectomy and eighth nerve section are procedures in which the balance and hearing mechanism in the inner ear are destroyed on one side. This is considered when the patient with Ménière’s disease has poor hearing in the affected ear. Labryrinthectomy and eighth nerve section result in the highest rates for control of vertigo attacks.
    Although there is no cure for Ménière’s disease, the attacks of vertigo can be controlled in nearly all cases.

What are the symptoms?

Symptoms of Ménière’s disease include episodic vertigo (attacks of a spinning sensation), hearing loss, tinnitus (a roaring, buzzing, or ringing sound in the ear), and a sensation of fullness in the affected ear.

Vertigo is often accompanied by nausea and vomiting. Attacks may last for 20 minutes to two hours or longer and fatigue and an off-balance sensation may last for hours to days. During attacks, patients may be unable to perform their usual activities, needing to lie down until the vertigo resolves.

Hearing loss is often intermittent, occurring mainly at the time of the attacks of vertigo. Loud sounds may seem distorted and cause discomfort. Usually, the hearing loss involves mainly the lower pitches, but over time this often affects tones of all pitches. After months or years of the disease, hearing loss often becomes permanent.

Tinnitus and fullness of the ear may come and go with changes in hearing, occur during or just before attacks, or be constant.

What should I do during an attack?

Lie flat and still and focus on an unmoving object. Often people fall asleep while lying down and feel better when they awaken.

How can I reduce the frequency of Ménière’s disease episodes?

Avoid stress and excess salt ingestion, caffeine, smoking, and alcohol. Get regular sleep and eat properly. Remain physically active, but avoid excessive fatigue. Consult your otolaryngologist about other treatment options.

TREATMENT OF ACUTE SPELLS

  • Sedative medication (Valium, Ativan, etc.).
  • Anti-nausea and anti-vomiting medication (Tigan, Phenergan, Compazine, etc.).
  • Rest.

MEDICAL PREVENTIVE TREATMENT

  • Stress management.
  • Exercise.
  • Avoidance of caffeine, tobacco and alcohol.
  • Low-sodium diet 1500-2000 mg/day.
  • Lipoflavins and vitamins (Lipo-Flavonoid Plus™) available over the counter (OTC).
  • Diuretic medications (Dyazide™) once or twice daily.
  • Fluid intake
  • Vestibular or labyrinthine exercises.
  • Allergy treatment.
  • Treatment with local overpressure with the Meniett Low Pressure Pulse Generator Medtronics Xomed. Non-destructive, non-invasive, safe, portable, simple.

Stress Management

While no one believes that stress causes Meniere's Disease, most people with the disease recognize a relationship between stressful events and the recurrence of their symptoms. Many patients believe that stress is a factor in how well they can prevent recurrent attacks and cope with the disruption caused by Meniere’s Disease. Not knowing when the next attack of vertigo may occur is a significant stress all by itself. For these reasons, patients with Meniere’s Disease are advised to manage their stress as much as possible. Professional counseling may be helpful in this regard.

Low-Sodium Diet

The value of a low-sodium diet in treating Meniere’s Disease has been known since 1931, and many patients notice they develop vertigo after eating salty foods. The FDA recommends an intake of no more than 2,400 mg of sodium per day, yet most people consume 3,000 to 4,000 mg a day. People can safely get by with a 240 mg/day sodium diet. Experts do not agree about the ideal level of sodium for individuals with Meniere’s Disease— some say 1,800 mg/day, others say 1,500 mg/day. Either diet level takes effort to be successful.

Diuretic Therapy

Diuretics (water pills) reduce the body's total sodium count and, with it, the amount of water in the body. Because fluids shift from compartment to compartment, loss of salt and water into the urine will shrink the amount of fluid in the body generally as well as in the inner ear. This approach makes sense because people with Meniere’s Disease have too much fluid in the inner ear. However, some individuals do not tolerate diuretics well and others do not appear to benefit from them. Diuretics cause the kidneys to increase the amount of sodium, chloride, potassium, and other chemicals in the urine. These chemicals are called electrolytes because they are electrically charged. A side effect of the sodium and other electrolyte removal is a passive increase in the amount of water in the urine. This type of treatment is known as diuresis. There are several classes of diuretic agents. The most widely used type for Meniere’s Disease is the thiazide class, which includes hydrochlorthiazide (HCTZ). This is often combined with another, potassium-sparing agent, triamterene, in a drug called Dyazide™. Dyazide™is probably the most frequently prescribed diuretic for Meniere’s Disease because it is safe, effective, and does not require taking extra potassium. Dyazide™is a combination of triamterene (37.5 mg) and hydrochlorthiazide (25 mg).

Fluid Intake

Adequate fluid intake, particularly water, is vital for proper kidney function, and may be equally important for proper inner ear function. The part of the inner ear that forms the endolymph contains cells that have the same structure and function as the distal tubule cells of the kidney. In fact, many drugs that affect kidney function can also affect fluid regulation in the inner ear. Thus, adequate water intake may be as important to inner ear function as it is to kidney function. For individuals who take diuretics, adequate water intake is especially important. There has to be enough fluid flow to remove the extra salt excreted as a result of diuretic treatment. Diuretics cannot work if the volume of water in the body is low.

SURGICAL TREATMENT

If medical therapy fails, surgical treatment may be indicated. Two distinct strategies have been employed. One approach is directed toward increasing the absorption of endolymph (the fluid in the hearing and balance canals of the inner ear), since there is an excess of endolymph in patients with Meniere’s Disease. The other approach aims at decreasing the inner ear's vestibular balance function in order to reduce symptoms of vertigo.

Endolymphatic sac surgery

In principle, endolymphatic sac surgery is a non-destructive, surgical manipulation of the endolymphatic sac aimed at increasing fluid drainage from the inner ear. The effectiveness of this approach varies.

Vestibular nerve section

This surgical technique decreases vestibular function to control symptoms of vertigo, either by denervation or destruction of the affected ear. It is a more serious and costly operation, which includes the risk of meningitis and a leak of spinal fluid. In 95% of cases, control of vertigo is achieved. Hearing is preserved in over 90% of cases.

Chemical labyrinthectomy

This treatment has recently become widely used because of its associated low cost and low risk. For unilateral cases, intratympanic gentamicin reduces vertigo by decreasing residual balance function on the affected side, but with a 30% risk of hearing loss. For bilateral cases, intramuscular streptomycin has been used. All destructive procedures result in decreased vestibular function on the treated side, which many patients consider a fair exchange once central compensation has stabilized their balance function.

Labyrinthectomy

In cases where hearing can be sacrificed or is already lost, surgical removal of the labyrinth (the balance organs of the inner ear) has a 95% success rate in eliminating major vertigo attacks. After this surgery is performed, the hearing and balance functions of the operated ear are completely and permanently destroyed. The unoperated ear will provide hearing and balance, as long as the disease or other conditions do not affect it.



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