Today we have several effective treatments for Ménières disease (MD). The symptoms in Ménière disease can vary a lot over time, but in most cases, we find a treatment option that works and the dizziness goes away.
The variation in the disease has made it very difficult to assess the effectiveness of the different treatments in medical trials. Because of this, you as a patient, might experience that different doctors will give you slightly different advice on treatments options.
I will try to give an overview of the different treatment options here.
Non-pharmaceutical options:
Patients with MD are more vulnerable to dietary and environmental factors, and triggers may include high salt intake, caffeine, alcohol, nicotine, stress and allergies (food and environmental). Among patients with identified triggers, avoidance or minimization of exposure to these substances, as well as treatment for allergies if appropriate, may alleviate or ameliorate symptoms.
Salt restriction is often recommended although there is a lack of data supporting the efficacy of this approach. The US-based database UptoDate recommends a maximum intake of 2 to 3 g of sodium daily in Ménière patients, with the daily sodium intake evenly spread across meals to avoid a large bolus at any time. Our clinic simply recommends to avoid excess intake of salt since studies lack support of cutting out salt, and also because of too low sodium blood levels also can give dizziness symptoms.
Vestibular rehabilitation is a form of rehabilitation that is more commonly used in other vestibular conditions, but can also be helpful in individuals with MD. It seems to especially helpful in the end-phase of MD and also if the individual experience sensitivity to sudden changes in the field of vision (like looking at tree branches moving or striped walls),
Pharmaceutical options:
Medications to take during an attack
Regular motion sickness tablets like Postafen can be used in attacks, but the most effective one seems to be Stemetil (proklorperazin).
Stemetil is effective for reducing dizziness in a Ménière attack and is harmless if used sporadically. If too much Stemetil is used over time it can give reversible side effects that mimics Parkinsons disease (extrapyramidal side effects).
Prophylactic medication that you take every day
Diuretics
For many years diuretics have been used to treat Ménières disease. Multiple low evidence–level studies report that oral diuretic therapy may be beneficial in the medical management of Ménière’s disease. Improvement in vertigo episode frequency was consistently reported, with less convincing evidence for improvement in hearing outcomes.
In Norway, all MD patients are supposed to initially try diuretics treatment. Only if this is ineffective, other medications can be prescribed on “blue prescription”, that is subsidized by the government. This is the reason we always try with diuretics first. Diuretics are cheap with very little side effects. There is a small risk of developing kidney stones, and the blood potassium (k+) levels can also become lower if used over time. Because of this we recommend that the patient take a break, and stop using them every 3-6 months and see what happens. If you use them over a longer time, ask your GP (fastlege) to check your Na/K levels a couple of times a year.
Betaserc (betahistin)
Nobody knows for sure how betahistin works. Pharmacologically it is a strong H3(histamin) receptor antagonist and weak H1 (histamin) receptor agonist. Several studies have been performed and these studies have not proven any effect.
Even so, several doctors and patients have anecdotal experience of very good betahistin effect on several of the dizziness symptoms that comes with Meniers disease. Since this effect has not been proven in studies you might experience that some doctors are positive towards betahistin and others are more sceptical against using it.
It is a harmless medication, but side effects like stomach pain and minor allergic reactions may occur.
Our clinic recommend that you try betahistin after diuretics have been tried. We usually increase the dosage until we see effect, or until side effects occur, in which case the dosage is reduced to a tolerable level.
SPC (Specially processed cereals)-flakes
SPC flakes is a specially processed oat meal that makes the body produce antisecretoric factor (af). Af is a protein in the inner ear.
This treatment is complety harmless unless you have gluten intolerance.
In some cases this treatment can reduce the dizziness attacks.
Invasive (surgical) treatments
Intratympanic injection of corticosteroid (cortison)
By injecting cortison directly into the middle ear, the cortison concentration in the inner ear can get very high without getting cortison side effects in the entire body.
Several studies have shown that this treatment might be very efficient in reducing the dizziness attacks.
Studies have not proved that this treatment can improve hearing, but some patients have experienced hearing improvement if the treatment is given early in the Ménières disease, before the hearing loss has become permanent.
There is a 5% risk that the small hole created in the eardrum does not heal afterwards.
Grommet (dren)
Biochemical processes in the cells in the ear creates a negative pressure in the middle ear. This pressure is regulated when you swallow. When we install a grommet in the ear this vacuum effect is equalized and the middle ear pressure is kept constant.
For some individuals with Ménière this helps against dizziness attacks and especially on the pressure sensation in the ear. If the pressure sensation is the most prominent symptom, we often recommend grommet as one of the first treatments.
Intratympanic injection of Gentamycin
Gentamycin is an antibiotic that damages the receptor cells in the inner ear. By injecting this we create a damage to the balance system. In 90% of the cases, it makes the dizziness attacks go away.
The damage to the balance system creates a new form of unsteadiness and the patients need vestibular rehabilitation afterwards. In most cases this makes the unsteadiness go away. Elderly patients, however, may experience unsteadiness several years after Gentamycin treatment.
There is also a 30% risk of damaging the hearing further with this treatment.
Some individuals develop Ménière disease in both ears. Gentamycin treatment might weaken the balance function some. This is usually not a problem if you have normal balance function on the other side. However, if at a later stage, MD is also developed on the other side, theoretically one might expect more problems with balance if one or both ears are Gentamycin-treated. The long-term balance function after Gentamycin injections on the first ear has not been evaluated fully.
Because of these side effects we always try cortison injections and/or grommet before considering Gentamycin injections or surgery.
Pressure-giving devices
MeniQ and Meniett are two devices that have been used. Some patients seem to have had effect with these. In order to use Meniett you need to have a grommet installed first. At the moment these devices are difficult to obtain in Norway.
Surgery
There are several types of surgery performed in Ménières disease. Complete destruction of the balance system can be done by cutting the balance nerve (neurectomy) or by drilling out the inner ear (labyrinthectomy). These surgeries are very rarely done, since Gentamycin injections can achieve almost the same effect with lower risk.
Another surgery is saccotomi where bone is removed around the endolymphatic sac. This is believed to improve pressure regulation in the inner ear. This operation has lower risk than the other two mentioned above and is occasionally performed in Norway.
If the hearing is impaired on both ears and speech perception is difficult, cochlear implant surgery may be an option. Ménières disease is one of the conditions where a cochlear implant usually have a good result. Cochlear implant is only an option if the hearing is very bad and hearing aids have been tried and does not give sufficient hearing. Talk to your ENT doctor about referral to a cochlear implant center if you think you might be a candidate for a cochlear implant.
Sources:
www.uptodate.com
The book «Det snurrar» av Geisler and Karlberg
Several papers (more citations will soon be added)
By:Karl Nordfalk