Menieres Disease

Meniere's disease is characterized by episodic severe vertigo lasting hours, with associated symptoms of unilateral roaring tinnitus, fluctuating low-frequency hearing loss, and aural fullness. Typical onset is in the fifth decade of life. The cause is uncertain but is speculated to result from allergic, infectious, or autoimmune injury. The histopathologic finding includes endolymphatic hydrops, which is thought to be caused by either overproduction or underresorption of endo-lymph in the inner ear.

Meniere's disease is a clinical diagnosis mostly based on history. Testing may be obtained to support the diagnosis and rule out other disorders. Audiometry often demonstrates a low-frequency sensorineural hearing loss. An FTA-ABS test may be obtained to rule out syphilis. ENG may demonstrate a unilateral peripheral vestibular weakness on caloric testing. When the diagnosis is uncertain, a brain MRI with contrast is obtained to evaluate for a retrocochlear lesion. The differential diagnosis of Meniere's disease includes acute labyrinthitis, neurosyphilis, labyrinthine fistula, autoimmune inner ear disease, vestibular neuronitis, and migraine-associated vertigo.

Although Meniere's disease has a highly variable clinical course, most patients have long symptom-free periods between clusters of episodes. The majority of patients have an excellent prognosis, with symptoms burning out over several years. However, some patients have a disabling course with frequent and severe attacks. On average, a moderate sensorineural hearing loss is the end result. The disease may become bilateral in about 45% of cases (wide variability exists).

Treatment of an acute episode involves vestibular suppressants and antiemetics. As with any vestibular disorder, vestibular suppressants should be limited for use during acute symptoms because of their addictive potential and impairment of central compensation. Maintenance therapy includes reduction of sodium intake to less than 1500 mg/ day and a diuretic such as hydrochlorothiazide-triamterene (Dyazide). Patients are also instructed to minimize caffeine, alcohol, nicotine, and chocolate. Allergy treatment may be helpful in some patients. Most patients have adequate control of symptoms with this regimen.

Patients who fail conservative measures may be candidates for procedures and surgical treatment. Gentamicin, a vestibulotoxic aminoglycoside antibiotic, may be injected transtympanically into the middle ear to permeate into the inner ear. Control of vertigo may result in 90%, but with a risk of hearing loss. Endolymphatic sac decompression or shunting through a mastoidectomy appears to benefit most patients with minimal risk to hearing. Although a generally accepted procedure, adequate studies are lacking on its effectiveness. More invasive interventions, including vestibular nerve section and labyrinthectomy, are reserved for patients with severe disease who do not respond to other measures (Sajjadi and Paparella, 2008).

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