What it is
The hallmark of Ménière’s disease are attacks of Vertigo (the sensation of the room spinning), along with hearing loss and tinnitus (ringing in the ear). Fullness or pressure in the ear may also precede the attack or occur during the episode. Most symptoms dissipate after an attack but the hearing loss may begin to persist with repeated attacks.
The suspected culprit of this syndrome is a fluid imbalance in the inner ear or possibly a problem with salt and fluid homeostasis (body fluid equilibrium). Ménière’s affects people of all ages, genders, and races, although it is most common in those middle aged and older.
What causes it
Patients with Ménière’s disease often exhibit dilation of one of the two fluid spaces in the inner ear. The cause behind this fluid balance is unknown. It has been speculated that ear injury, heredity, autoimmunity and allergy are underlying causes of Ménière’s; however, none of these have been proven with certainty as the cause. It is possible that the same set of symptoms can be manifested by different causes in different people.
Symptoms
Attacks may occur spontaneously, but sometimes you may experience a warning symptom before an acute attack, such as fullness or pressure in one ear. Other common symptoms include:
- Vertigo (a sensation of the room spinning)
- Tinnitus (ringing in the ear)
- Fluctuating hearing loss
- Distorted sounds
- Difficulty understanding speech
- Cold sweats, nausea, vomiting, and/or diarrhea
- Generalized weakness
Attacks often come in clusters with long periods in between them. Recurrence is a cardinal feature, but the intervals between attacks are unpredictable. Symptoms can last from one to several hours. Hearing loss can take a day or longer to return to normal, but as the disease progresses, hearing loss can become permanent or lead to intolerance of loud noises.
Your ear specialist will diagnose Ménière’s disease based primarily on a careful history as well as a physical examination, but you may need additional tests to confirm the diagnosis.
How to treat it
Overall treatment options include self-care, preventive measures, medications and surgery. Prior to initiation of any therapy, confirmation of diagnosis by an ear specialist is recommended to ensure you are on the corrent treatment pathway. It is essential to rule out other potential diseases and to clarify treatment options with a specialist.
Self-Care
To minimize symptoms at home, follow these strategies:
- Lie in a dark room with your eyes closed
- Minimize stress and anxiety as much as possible and regulate sleep habits
If these strategies aren’t enough, see your ear specialist for further evaluation.
Medical Prevention
Although nothing can completely prevent Ménière’s disease, these lifestyle measures can potentially minimize attacks:
- Follow a low-salt diet (less than 2 grams sodium daily)
- Avoid canned foods, smoked meats and fish
- Avoid or reduce caffeine, tobacco and nicotine
- Avoid foods high in cholesterol, triglycerides and carbohydrates
- Avoid sweets and candy, including chocolate
- Avoid alcohol, in particular red wine and beer
Other cautions include:
- Avoid exposure to loud noises
- Use of blood pressure medications, which can impact attacks
- Manage stress, which can trigger attacks
- Avoid falls if you should feel dizzy
Treatment Options
Meniett Device
This small, portable pump delivers low-pressure pulses to the middle ear via a plastic probe placed in the ear canal in order to restore the fluid balance in the inner ear. Placing an ear tube in the eardrum is required; this allows the pulses to reach the inner ear. The procedure can be done in the office. Treatments can then be self-administered, usually three times per day for five minutes each time.
Medications
Acute Attacks
Motion sickness prescription medications (Valium, Ativan, Antivert) obtained from your doctor may be beneficial during an attack. They can help shorten the attack and reduce the severity of your symptoms by suppressing the vestibular system. In addition, corticosteroids are also used to treat acute attacks. These can be prescribed in oral form (e.g., Medrol dose pack) or as a direct infusion (an intratympanic infusion through the eardrum) into the middle ear. Steroids work by decreasing inflammation in the inner ear, often lessening the duration and severity of an attack. Patients are sometimes treated with steroids a few times per year as symptoms develop.
Preventive Medications
Diuretics, such as Dyazide, Maxide, Spironolcatone, and Lasix, assist with salt-wasting and imbalance. Diuretics, however, can decrease potassium levels, leading to muscle cramps. You should stop use if cramps develop, and you must check labs every 6-12 months.
Betahistine (SERC) is an an antihistamine thought to prevent inflammation in the inner ear and lessen the attacks. It can upset the stomach because it can increase acid production, as it works to encourage histimine production here. If you experience severe acid reflux or have a history of ulcers, you should avoid Betahistine.
Calcium-Channel Blockers (CCB) such as Verapamil may work to stop blood vessel spasms in the inner ear, and thereby lessen attacks. Often a CCB can be taken along with additional blood pressure medications but this should be reviewed with your ear doctor and primary care physician. However, it’s important to monitor for low blood pressure and lightheadedness with this medication.
Surgery
While most people (over 90%) respond well to management strategies, for those who don’t, there are surgical treatments that can help. One treatment approach focuses on improving pressure in the middle ear. Another approach focuses on destroying the balance system in the affected ear. This approach is designed to prevent abnormal signals from reaching the brain, thereby eliminating symptoms. Generally, this approach is reserved for end-stage patients, whose symptoms are debilitating and usually have no hearing remaining.
Endolymphatic sac decompression
To decrease pressure buildup of the endolymph (inner ear fluid), this procedure removes a portion of the bone that encases the fluid reservoir, allowing the sac to expand, thereby dissipating the pressure. There is a small risk of permanent hearing loss, but that risk is relatively low. About two-thirds of patients are helped in the short-term, but they may need additional procedures in the long-term.
Chemical labyrinthectomy
This procedure selectively destroys the balance portion of the inner ear by injecting a medication (gentamicin) into the middle ear through the eardrum. If one injection doesn’t improve symptoms, you may need a series of them. The procedure can be done on an outpatient basis without use of a general anesthetic. Following the procedure, you may experience increased imbalance. Exercises can help the good ear’s balance system to compensate for the loss in your bad ear. Hearing loss is also a risk factor.
Surgical labyrinthectomy
Performed under general anesthesia, which requires a hospital stay, this surgical procedure removes the entire hearing and balance organ on the affected ear. Although this is the most definitive procedure for eliminating vertigo attacks, your hearing will also be permanently lost, so this procedure is reserved only for those without useful hearing. Your remaining ear provides hearing and balance as long as it remains unaffected by Ménière’s or other conditions. You may experience increased imbalance after surgery, but balance exercises or therapy can help with that.
Vestibular Nerve Section
For patients who still have useful hearing, but for whom debilitating vertigo hasn’t responded to prior therapy, this surgical procedure cuts the balance nerve on the affected side while preserving the hearing nerve. To access the nerve, the procedure requires a craniotomy, which is the removal of part of the skull that is replaced at the end of the procedure.
