The Medical Consumer's Advocate

Meniere's disease

 

Q: I was diagnosed with Meniere's disease a year ago and am still in the dark about what causes it and what I can expect for my future. The vertigo can be almost unbearable sometimes but no one seems to be able to recommend anything to relieve it. Can you help?

 

A: Your comment, "no one seems to be able to recommend anything to relieve it," suggests you have not seen an appropriate specialist. If so, you may not have been correctly diagnosed in the first place. Even when correctly diagnosed, Meniere’s is often incorrectly treated by nonspecialists. Thus, your first task is to find an ear, nose and throat surgeon or an otologist who can help you with your problem.

Meniere’s disease typically consists of discrete episodes during which four symptoms are present: severe vertigo, hearing loss, tinnitus, and aural pressure. At least in the early stages of the illness, these symptoms occur primarily during an episode; as the illness progresses, some symptoms (especially the tinnitus and hearing loss) may persist between attacks. Attacks last less than one day– usually for only two or three hours. It is typical for the patient to have several attacks in a short interval, followed by a long remission (which may last months to years), followed by another series of attacks. In most patients, vertigo attacks cease after several years, but the individual is left with permanent hearing loss. Approximately half of the patients with Meniere’s have bilateral disease, and in such patients, hearing loss is usually severe enough to require the use of hearing aids.

What causes Meniere’s disease? The inner ear, which is responsible for both hearing and balance, is a collection of fluid-filled chambers encased in the bony skull base. There are two separate fluid compartments within the inner ear, and these are divided by a thin membrane. In Meniere’s disease, there is a relative overabundance of fluid in one of these compartments. This causes distortion of, and damage to, the membrane that divides the two compartments. We do not know whether this membrane distortion causes the symptoms of Meniere’s disease, or is merely an incidental byproduct of the (as yet poorly understood) disease process which causes the symptoms.

How is Meniere’s disease treated? The most widely accepted medical treatment of Meniere’s disease involves a salt restricted diet and use of diuretics (medications which increase urinary output.) In addition to this, vertigo attacks are treated symptomatically with medications such as Valium and Antivert. Antiemetics (drugs that treat nausea) and antidepressants are also occasionally useful. Many doctors advocate avoidance of stress (physical and emotional), and avoidance of alcohol and caffeine.

Surgical treatment is reserved for patients who do not respond to medical treatment. This is true of roughly 10% of Meniere’s disease patients. If the patient still has useful hearing in the affected ear, the goal of surgery is to relieve symptoms and conserve hearing. Endolymphatic sac surgery "decompresses" the fluid-glutted compartment. This is considered by some authorities to be a "sham" surgery, benefitting the patient primarily via a placebo effect. Needless to say, this is a controversial operation, and a careful patient will discuss the evidence for and against this operation with his/her surgeon.

If the patient has no useful hearing in the affected ear, a variety of other options are available, including chemical ablation of the balance system (typically, by injecting the drugs streptomycin or gentamicin into the patient’s middle ear), cutting of the balance nerve (vestibular nerve section), and surgical removal of the inner ear (labyrinthectomy.) These procedures have a sounder scientific basis than the endolymphatic sac operation. Chemical ablation is the least risky of the three procedures, and is, arguably, the first line surgical therapy for Meniere’s patients who lack useful hearing.

Recently, new protocols have been developed that permit chemical ablation in patients with normal hearing. In other words, researchers have developed methods whereby hearing is preserved while the offending portions of the balance system are ablated. If your ENT is unfamiliar with these protocols, he/she may need to do a bit of reading and phone-calling to get the necessary information. Alternatively, you may need to consult with an otologist (an ENT who has taken additional training in the medical and surgical treatment of ear problems.)

I want to emphasize the importance of correct diagnosis of this disease. There are a number of illnesses which mimic Meniere’s disease; for example, neurosyphilis can have a similar presentation. These other illnesses are treated differently than Meniere’s disease. Also, as I suggested in my opening paragraph, some poor clinicians label ANY case of recurrent vertigo with the diagnosis of Meniere’s. To avoid suffering unnecessarily due to such errors, I want to urge you again to seek consultation with an appropriate specialist.

Incidentally, a very fine informational web page on Meniere’s disease is maintained by Alec Salt, Ph.D., at the Washington University School of Medicine in St. Louis. This site contains information on the symptoms, causes and treatments of the disease, and a list of links to other Meniere’s disease web pages.

 

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