Download Meniere`s Disease

PAUL E. HAMMERSCHLAG, MD, FACS
650 FIRST AVENUE
NEW YORK, NEW YORK 10016
(212) 889-2600
Meniere’s Disease
Meniere’s Disease is a symptom complex of vertigo, ringing noises in the ear (tinnitus),
feeling of ear (aural) pressure, and fluctuating hearing loss. Prosper Meniere initially
described this symptom complex in 1861. He was the first physician to suggest that this
symptom complex was due to an inner ear problem as opposed to central nervous system
disorder such as a stroke or tumor.
The attack of vertigo is commonly preceded by aural fullness in one or both ears. Hearing
may fluctuate or diminish along with changes in tinnitus prior to the attack of vertigo. An
episode of vertigo may last for a few hours. Imbalance, nausea and vomiting may also
occur. After a severe attack of vertigo most people are exhausted and need to sleep for a
few hours.
The frequency of attacks of vertigo is variable: frequent attacks every few days to periods
without and attacks for several months. In other situations, the attacks may occur on a
regular basis. Meniere’s Disease is usually confined to one ear. There is bilateral ear
involvement in about 5 - 50% of cases, depending on which reports are cited. Meniere’s
Disease affects approximately 0.2% of the population. While acute attack can be
incapacitating and frightening, the disease itself is not life threatening.
Between the acute attacks most people are free of symptoms or have minimal imbalance.
The tinnitus and hearing loss may persist even though it can fluctuate. In its most severe
presentation, Meniere’s Disease can progress to permanent loss of hearing in the affected
ear and unexpected falling attacks (“drop attacks”).
What causes Meniere’s Disease?
Symptoms of Meniere’s Disease (vertigo, tinnitus, and hearing loss) are thought to occur
from paralysis of inner ear nerve endings by abnormal release inner ear fluid toxic to inner
ear structures after rupture of inner ear compartments. It is felt that there is either an
overproduction of inner ear fluid or inadequate absorption of this fluid. Repeated rupture
release of the irritative inner ear fluid and healing leads to cumulative scarring of the inner
ear structures resulting in permanent decrease in hearing and balance function. The cause
of inner ear fluid leakage is unknown but this process may be due to a variety of causes
such as autoimmune disease, inner ear head injuries, allergies, viral infection, and genetic
predisposition. It is possible that these symptoms may be a common expression of an inner
ear injured by different events.
How is Meniere’s Disease Diagnosed?
A diagnosis of Meniere’s Disease is based on clinical symptoms, hearing tests,
examination by your physician and exclusion of other diagnoses. Supplementary tests may
include audiological testing, balance tests such as electronystagmography (ENG), blood
tests for other causes of dizziness, and radiological studies. At times, a difficult diagnosis
of atypical Meniere’s Disease will become more apparent as the disease process is
monitored, which may exclude other diseases causing similar symptoms.
How is Meniere’s Disease Treated?
While there is no cure for Meniere’s Disease at this point, there are several strategies for
managing the condition and controlling its symptoms.
An initial approach to managing Meniere’s Disease is usually with a low salt diet regimen.
Decreased sodium intake also reduces the fluid in the inner ear. Generally, this means that
salt intake should be less than 1.5gms per day. There are several books that can assist in
determining which foods are high in salt. These can be obtained in any major bookstore of
health food store. A highly recommended book is Barbara Kraus’s Complete Guide to
Sodium, Signet, 1987, a paperback book listing the sodium contents of most foods. A
consultation with a dietician or nutritionist may be of assistance. A diuretic such as
Dyazide or Hygrotin is frequently used. Other medications such as Neptazin or Verapamil
may be utilized. Prednisone, a steroid, may be beneficial in certain clinical situations.
Vestibular suppressants such as Meclizine or Lorazapam may be used as needed.
If medical therapy is successful, one should see a clinical response within two months. If
this regimen is helpful, then our patients usually follow this diet for two years before
“graduation to a regular diet”.
In addition to avoiding salt containing foods, one should also consider the elimination of
caffeine containing fluids and food such as coffee, tea and chocolate. Caffeine may
exacerbate symptoms, particularly tinnitus. For those patients who have migraine
associated vertigo and headaches. Alcohol may also trigger migraine-associated vertigo.
Foods containing MSG (Monosodiumglutonate), frequently found in Chinese food, may
exacerbate symptoms for some patients. With a heightened awareness of the possible
contribution of the above foods and substances towards triggering symptoms, one may
identify aggravating substances for his/her type of Meniere’s Disease.
Nicotine and cigarettes may constrict blood vessels, which may decrease the blood supply
to the inner ear making one more symptomatic.
Meniere’s Disease Refractory to Medical Therapy
Failure to control one’s symptoms with a medical regimen of diet and diuretics may
require management with surgery. The type of surgical treatment is frequently based upon
the patient’s hearing, vestibular function in the contralateral ear, general health, and age.
The least invasive surgical treatment involves placement of a pressure equalizing (PE)
tube, which is also known as tympanostomy tube, into the tympanic membrane (ear drum).
This is a very common procedure in young children for recurrent ear infections or
persistent middle ear fluid. In the adult, the procedure can be performed in the office with
anesthesia. Several days after the tympanostomy tube is inserted, a low-pressure air
generator is used to administer air pressure through the tympanostomy tube to the inner ear
for two minutes three times a day. It is felt that the air pressure to the round and oval
windows of the inner ear displace excess inner ear fluid to eliminate vertigo, reduce
tinnitus, and improve hearing. The Low Pressure Generator (Meniett Device) is purchased
from the Medtronic division of the Xomed Company when prescribed by your physician.
If this treatment is not successful, then other surgical treatments can be considered.
If usable hearing is lost in the affected ear, a destructive surgical procedure called a
labyrinthectomy may be utilized to eradicate the deficient nerve endings in the balance
system. If there is intact hearing in the affected ear, then a selective vestibular nerve
section may be indicated. These two procedures have a very high rate of success in
eliminating vertigo. These two procedures are generally not used if there is Meniere’s
Disease or inadequate balance function in the contralateral ear.
Some physicians believe that an alternative procedure such as endolymphatic shunt
procedure to relieve pressure in the inner ear may be helpful. This procedure has not been
shown to have the same high success rate in controlling vertigo as the fore mentioned
labyrinthectomy or selective vestibular nerve section. The endolymphatic shunt procedure
is a less invasive procedure for some patients and may be an initial surgical approach.
More recently, treatments with Gentamycin injections or topical application have been
advocated. Direct application of Gentamycin to the inner ear has resulted in a higher
incidence of hearing loss than when compared to the endolymphatic shunt or selective
vestibular nerve section. Systemic administration of Gentamycin with intramuscular
injection, will reduce the vestibular function in both ears which may or may not be an
acceptable side effect. Systemic use of Gentamycin is the procedure of choice when there
is vertigo from Meniere’s Disease in both ears.
It should be noted that surgical treatment is primarily used to prevent attacks of vertigo.
These procedures have not been demonstrated to affect the long-term progression of
sensorineural hearing loss associated with Meniere’s Disease. The severity of your
symptoms will also help determine the type of treatment you will receive. For example, if
one is having falling attacks, then there will be a greater need for a definitive treatment
such as surgical control of vertigo.
Acute Vertigo Attacks
Management of an acute attack of Meniere’s may be best achieved with chewable
Meclizine (Antivert). Lorazopam (Ativan) 0.5mg can be placed under the tongue.
Sometime Prednisone taken orally for a few days will also help reduce symptoms of acute
vertigo.
During an acute attack, one is essentially confined to bed rest. If vomiting is persistent and
one is unable to take fluids for more than 24 hours, your physician may advise anti-nausea
medication and/or a vestibular suppressant.
Since the acute symptoms of Meniere’s Disease are episodic, it is important to explain to
your family and friends what might happen during an attack. This way they will be less
frightened and more supportive during your attack.
If you anticipate an attack of vertigo, you need to remove yourself form situations of
potential injury. For example, if you are driving a car, obviously you need to pull off the
road. If you are having an attack during the night, be sure to use a night-light since you
will be relying more on vision to help maintain your balance. There should be no potential
obstruction on the way between the bedroom and the bathroom.
More information may be obtained from self-help groups such as Vestibular Disorders
Association (VDA) PO Box 4467, Portland, Oregon 97208-4467 or www.vestibular.org.
Meniere’s Disease, What you need to Know by P.J. Haybach, R.N, MS is an excellent
informative book for the lay reader. It may be ordered through the Vestibular Disorders
Association (VDA) at $24.95 for softbound edition.