Meniere's Disease

( Endolymphatic Hydrops ) Meniere's Disease is a disorder characterized by dizziness and/or vertigo, hearing loss, ringing in the ear, and/or a feeling of fullness in the ear.

Treatment for Meniere's Disease

Episodic vertigo is the most common reason for patients to seek and pursue treatment for Meniere’s disease.

Dietary Modifications

Initially, treatment is focused on the diet. Reducing sodium intake can help in reducing the water content of the inner ear. It is unreasonable to go on a diet that is not palatable and realistic over time. We ask patients to voluntarily reduce their intake of sodium, keeping moderation in mind. Avoiding adding salt to meals and curtailing intake of snacks high in sodium, including canned foods and fried foods, can be helpful.

Caffeine and nicotine can be stimulants to the vestibular system and cause episodes of vertigo.  Reducing coffee, tea, chocolate, and carbonated soda—or switching to decaffeinated versions—can be helpful. Reducing or eliminating smoking is not only good for Meniere’s disease but also good for your health in general.

Diuretics

If episodes of vertigo persist despite changes in diet, medication called diuretics can be helpful. These are water pills designed to act on your kidneys to excrete fluid from the body.  They have a similar effect on the endolymphatic sac.  A common diuretic used in the treatment of Meniere’s disease is a combination of hydrochlorothiazide and triamterene (Dyazide). Triamterene is added to help retain and prevent excessive loss of potassium.  Despite triamterene, potassium loss may still occur.  A common sign of low blood potassium level is cramping pain in the calf.  Bananas or dietary potassium supplements can be taken to offset low potassium levels.

These diuretics are usually used to treat high blood pressure. Consequently, these medications can cause low blood pressure. Close monitoring of blood pressure and potassium levels by your primary care physician is recommended.

Serc (Beta-Histine)

Popularized in Europe, this agent is thought to increase blood supply to the inner ear. It is important to note that the FDA has not approved its use in the US.

Meniett Device

Popularized in Europe, this is a device that requires tympanostomy tube insertion. Here, pulsed airwaves supposedly “push” the endolymph back into position. European studies report incredible results. Unfortunately, we have been unable to duplicate their results here in the US. The device costs $ 3,000 and is only available through Medtronic.

Other options are available and include transtympanic decadron or gentamicin, decadron perfusion of the inner ear, endolymphatic sac surgery, vestibular neurectomy and labyrinthectomy surgery.

Steroid treatment of the inner ear may offer beneficial effects for the symptoms of Meniere’s disease. Administration of steroids to the inner ear is an attempt to reduce the inflammation within the inner ear.

Intratympanic Steroid Treatment

A powerful way of delivering steroid to the inner ear is by injection into the middle ear through the tympanic membrane. From here, the steroid diffuses through the round window (one of the two openings into the cochlea of the inner ear)membrane and enters the inner ear. The procedure is done in the office. This is a relatively painless procedure that involves anesthetizing the tympanic membrane and then injecting the steroid thereafter. A repeat audiogram is done two weeks later. If there is improvement, a repeat injection is offered.

There is a 1% chance of a persistent 1 mm perforation of the eardrum at the injection site. This may require patching the eardrum.  Patients may experience temporary disequilibrium that can last up to 30 minutes.  I have never had a patient who has had additional hearing loss or persistent disequilibrium after the injection.

Decadron Perfusion of the Inner Ear

A sponge containing decadron (a steroid) is placed over the opening to the inner ear.

This is a more powerful way of delivering steroid to the inner ear. This involves general anesthesia for approximately one hour. During the procedure, the eardrum is elevated and the round window (one of the two openings into the cochlea of the inner ear) membrane is perfused with high-dose steroid. An absorbable pad soaked in concentrated steroid is left at the round window membrane.

Transtympanic Gentamicin

This form of treatment involves injection of medication through the eardrum into the middle ear. The medication, which is then taken up by the inner ear, destroys the hair cells of the inner ear. The medication, Gentamicin, is an antibiotic that is toxic to the hair cells of the hearing and balance organ. The idea is to destroy enough of the hair cells to eliminate the vertigo.

There are advantages and disadvantages to this form of treatment. The attractive feature is that surgery is not required. The downside of this treatment is the potential for hearing loss.  Gentamicin is toxic to hair cells of both the balance and hearing organs, and once the medicine reaches the middle ear, absorption into the inner ear is uncontrolled and variable.  Multiple injections may be required in order to achieve the desired effect.

Endolymphatic Sac Surgery

A shunt is placed in the endolymphatic sac, a reservoir for endolymph, to shuttle fluid out of the sac and into a cavity created in the mastoid.

Another option is a surgical procedure to help drain the endolymphatic sac. Of the surgical options, this is the most conservative operation with minimal risk to hearing. Unfortunately, control of vertigo occurs in only 60 percent of patients undergoing this operation. There is no way to predict who will or will not respond favorably.

Under general anesthesia, an incision is made behind the ear. The mastoid bone is entered and the endolymphatic sac is decompressed, meaning that the bony covering is removed. The sac is then opened and a shunt tube is inserted. The fluid that would normally enter the sac is shunted away from the inner ear and into the cavity created by the surgery, where it is then reabsorbed.

This procedure takes about 2 hours to perform and patients go home the same day. The ear may protrude slightly shortly after surgery, but it should return to its original position in two to three weeks. Numbness around the ear is common and can last for several months.

Vestibular Neurectomy

Step 1: A retrolabyrinthine vestibular neurectomy is illustrated. An incision is made behind the ear.

Step 2: The mastoid bone and surrounding muscles are exposed.

Step 3: A mastoidectomy is done exposing the semicircular canals, venous sinus, and dura covering the brain. The dotted line represents the incisions made within the dura.

Step 4: Spinal fluid is drained and the brain relaxes, exposing the trigeminal nerve (responsible for the conduction of facial sensation), the vestibulocohlear nerve (hearing and balance), and the facial nerve.

This is an operation to divide the balance nerves and interrupt the connection between the inner ear and the brain. 90-95 percent of patients who undergo this operation for Meniere’s disease will not have another spell of vertigo. After the operation, disequilibrium lasts until the brain learns to compensate and adapt to the lack of input from one inner ear. This compensation occurs more quickly in patients who are more active after surgery.  Anti-dizzy medication such as meclizine and diazepam seem to slow the compensation process.

There are three different approaches or ways to get to the vestibular nerves.

The middle fossa approach is the least commonly used and involves an incision above the ear followed by removal of bone over the brain. The roof of the canal through which the balance nerves run is removed and the nerves are then divided.

Another approach is the retrolabyrinthine approach, which involves incisions behind the ear similar to the endolymphatic shunt procedure. The covering of the brain (dura) is opened and spinal fluid is drained. The balance nerves are then divided.

A third approach is the suboccipital approach, which involves an incision further behind the ear and removal of bone over the covering of the brain. Spinal fluid is drained, and the balance nerves are visualized and then divided.

The fibers of the hearing and balance nerves run very closely together. Infrequently, some hearing loss may occur.  Depending on the level of hearing present, the hearing can be monitored during the course of the operation. The facial nerve lies close to the hearing and balance nerves. Just like hearing, the status of facial nerve functioning can also be monitored. While under general anesthesia, recording electrodes are placed in the facial muscles. These electrodes detect contractions of the facial muscles, and the signals are transmitted to a speaker so the surgeon may hear the responses.

Labyrinthectomy

This is an operation to surgically remove a portion of the inner ear. Nearly all patients with Meniere's disease will be vertigo-free after a labyrinthectomy. Total and complete hearing loss will result in the operated ear. This is an operation that is recommended to patients who have no useful hearing in the dysfunctional ear. Just as in vestibular neurectomy, after the operation, disequilibrium lasts until the brain learns to compensate and adapt to the lack of input from one inner ear.

The operation requires general anesthesia and an incision behind the ear. Using a high-powered drill, the mastoid bone is entered and the semicircular canals are removed.