ear, nose, and throat disorders
Meniere Disease
Treatment of Meniere Disease
Symptom relief with antiemetics, antihistamines, or benzodiazepines Diuretics and low-salt diet Rarely vestibular ablation by medications or surgery Meniere disease tends to be self-limited. Treatment of an acute attack is aimed at symptom relief and done in a staged fashion; the least invasive measures are done first, and then if the measures are ineffective, ablative procedures are sometimes done. Anticholinergic antiemetics (eg,prochlorperazine25 mg rectally or 10 mg orally every 6 to 8 hours;promethazine25 mg rectally or 25 mg orally every 6 to 8 hours) can minimize vagal-mediated gastrointestinal symptoms;ondansetronis a second-line antiemetic. Antihistamines (eg,diphenhydramine,meclizine, orcyclizine; dosage is the same for these drugs: 50 mg orally every 6 hours) or benzodiazepines (eg,diazepam5 mg orally every 6 to 8 hours) are used to sedate the vestibular system. Neither antihistamines nor benzodiazepines are effective as prophylactic treatment. Some physicians also use an oral corticosteroid burst (eg,prednisone60 mg orally once a day for 1 week, tapered over another week) or intratympanicdexamethasoneinjections for an acute episode. Traditional migraine preventive medications (eg, tricyclic antidepressants, serotonin-norepinephrinereuptake inhibitors [SNRIs]) are also beneficial in some patients with Meniere disease. A low-salt (<1.5 g/day) diet, avoidance of alcohol andcaffeine, and a diuretic (eg,hydrochlorothiazide25 mg orally once a day oracetazolamide250 mg orally 2 times a day) may help prevent or reduce the incidence of vertigo attacks and are commonly used first steps. However, there are no well-designed studies that clearly prove the efficacy of these measures for Meniere disease. Because there is strong overlap between Meniere disease and migraine disorders, a trial of traditional migraine preventive medications (eg,nortriptyline,venlafaxine) may also be considered for refractory or recurrent episodes. Although more invasive, endolymphatic sac decompression relieves vertigo in most patients, spares vestibular function, and poses minimal risk of hearing loss. Thus this procedure is still classified as a vestibular-sparing treatment. When vestibular-sparing treatments are ineffective, an ablative procedure is considered. Intratympanicgentamicin(chemical labyrinthectomy—typically 0.5 mL of a 40 mg/mL concentration) is injected through the tympanic membrane. Follow-up with serial audiometry is recommended to check for hearing loss. The injection can be repeated in 4 weeks if vertigo persists without hearing loss. Ablative surgery is reserved for patients with frequent, severely debilitating episodes who are unresponsive to less invasive modalities. Vestibular neurectomy (an intracranial procedure) relieves vertigo in about 95% of patients and usually preserves hearing. A surgical labyrinthectomy is done only if preexisting hearing loss is profound. Unfortunately, there is no known way to prevent the natural progression of hearing loss. Most patients sustain moderate to severe sensorineural hearing loss in the affected ear within 10 to 15 years. 