on Menieres from different links.
MENIERE'S DISEASE INFORMATION
Meniere's Disease is a disorder
of the inner ear or labrynth. The most prominent symptoms of this disease include episodes of dizziness or vertigo, fluctuating
hearing loss, tinnitus (ringing in the ear) and nausea and/or vomiting.
An attack of Meniere's Disease is usually preceded by fullness in one or both ears.
Hearing fluctuates or changes in tinnitus may also precede an attack. A Meniere's attack generally involves severe vertigo
(spinning or whirling), imbalance, nausea and/or vomiting. These are the classic symptoms of mm (morbus menieres). While the
classic symptoms of mm are not always present, hearing loss can precede episodes of vertigo by several years. In most cases
it has been documented that the vertigo usually comes first in Meniere's Disease, while the percentage of those who have the
hearing lost first is on the increase.
Menieres can be very debilitating to some patients, while others only experience
mild symptoms. Vertigo is the most prominent symptom of mm and this symptom usually brings more patients to the ER than any
of the other symptoms of mm. Most patients describe an attack as a sudden spinning or swirling sensation where nausea and/or
vomiting usually accompany the symptoms. In some cases the violent vertigo is experienced, while other patients feel more
off balance than dizzy. These attacks vary in time, some may be a few minutes, a few hours or even some cases may last for
a few days.
There is no known cause of menieres but some experts speculate that the herpes virus
is somehow involved or the immunologic function of the endolymphatic sac----immune disease. For the most part the underlying
cause of mm is unknown but is most often attributed to viral infections of the inner ear, head injury, a hereditary disposition
or food allergy.
It is difficult for doctors to diagnose mm as there are other diseases that can
mimic mm. A number of these diseases are of the peripheral and central nervous systems. A misdiagnosis can seriously compromise
treatment protocols and the patient's health.
Vertigo is caused by excessive fluid in the inner ear. This fluid stretches the
membranes which then decreases the hearing and can also cause the tinnitus. If these membranes are stretched too much, rupturing
of the membranes occurs and causes vertigo.
Diagnosis is made based on a combination of the right set of symptoms (usually dizziness
and hearing disturbance), hearing tests which document that hearing is reduced after an attack, and then gets better, and
the exclusion of alternative causes. The process of diagnosis usually includes a hearing test, a ENG and several other tests
along with CT scans and MRI scans.
In the inner ear, symptoms are thought to be caused by endolymphatic hydrops, excessive
accumulation of fluid in one of the very delicate membranes - lined chambers of the labrynth. Symptoms may be worsened by
stressful situations, execessive alcohol, dietary, sodium, caffeine, smoking and possibly food sensitivities.
In most cases mm is intermittently bothersome, there are periods of increased symptoms
which may occur without warning, followed by periods of what some would call remission. However, this is not always the case
and at times takes a much more serious course in some patients with frequent disabling attacks of vertigo, hearing loss, constant
roaring (tinnitus). It is not possible to predict what will happen with a patient as everyone is different and also responds
differently to treatments.
To try to introduce uniformity into the diagnosis and treatment of Ménière’s
disease, the American Academy of Ophthalmology and Otolaryngology introduced guidelines in 1972, which
were revised by the American Academy of Otolaryngology-Head and Neck Surgery in 1985 and 1995. Based on control
of vertigo, disability, and effects on hearing, these guidelines are now a widely accepted tool for
Clinically, three stages are generally recognised.
Stage I—In the early phase of the disease, the predominant symptom
is vertigo. This is characteristically rotatory or rocking and is associated with nausea or vomiting. Signs of
vagal disturbance, such as pallor and sweating, may occur, but loss of consciousness is not a feature.
The episode is often preceded by an aura of fullness or pressure in the ear or side of the head and usually
lasts from 20 minutes to several hours. Between the attacks hearing reverts to normal and examination of
the patient during this period of remission invariably shows normal results.
Stage II—As the disease advances the hearing loss becomes established
but continues to fluctuate. The deafness is sensorineural and initially affects the lower pitches. The paroxysms
of vertigo reach their maximum severity and then tend to become less severe. The period of remission is highly
variable, often lasting for several months.
Stage III—In the last stage of the disorder the hearing loss stops
fluctuating and progressively worsens, both ears tending to be affected so that the prime disability is deafness.
The episodes of vertigo diminish and then disappear, although the patient may be unsteady, especially in
Currently, the treatment of Menière’s disease is empirical. As yet, no
treatment has prospectively modified the clinical course of the condition and thereby prevented the progressive
hearing loss. The reasons for this are fourfold. Firstly, the precise aetiology is unknown. Secondly, the
placebo effect of drugs in this disorder is widely recognised. Thirdly, the disorder has a tendency
to relapse and remit. Finally, the clinical course of the condition is such that over several years the vertigo
eventually disappears in about 70% of patients. Nevertheless, there are numerous conservative and surgical
measures available to otolaryngologists that are aimed principally at abolishing the frightening and
disabling vertigo with which patients present.
Time spent giving a complete explanation of the disorder and
an outline of the anticipated course of the disease is therapeutic in itself and invariably has a positive
effect on the subsequent management. Clinically, three situations arise in which drug treatment may
Acute attacks—Drugs aimed at sedating the vestibulo-brain stem
axis are particularly useful in aborting acute attacks. These include prochlorperazine, cinnarizine, promethazine,
and diazepam. Longer term use of drugs such as prochlorperazine is inadvisable as the attendant sedation
may be unacceptable, and the risk of extrapyramidal side effects from protracted use requires caution,
particularly in elderly people.
Maintenance treatment—Dietary salt restriction and the use of diuretics
such as frusemide, amiloride, and hydrochlorothiazide is an attempt to modify the endolymphatic hydrops itself.
The basis for this is historical rather than scientific as the data from the few controlled studies
that exist are conflicting and the placebo effect is clinically significant. Vasodilators are used for
prophylaxis on the basis that hydrops is due to ischaemia of the stria vascularis. The histamine analogue betahistine
has been subject to some scientific scrutiny, and several controlled clinical studies have shown a significant
improvement in vertigo, hearing loss, and tinnitus in the short term. Currently, betahistine with or
without a diuretic constitutes the favoured means of providing maintenance medical treatment. Drugs such as cinnarizine,
propranolol (particularly if the patient has a history of migraine), and corticosteroids are also used empirically
by some clinicians if the patient’s symptoms are refractory to the above measures.
Ablative treatment—The toxic effects of aminoglycosides on the
sensory neuroepithelium of the inner ear have long been recognised. Medical ablation of the end organ with systemic
streptomycin controls vertigo and has been useful in advanced bilateral Ménière’s disease when poor
but aidable hearing precludes surgical intervention. Cumulative doses of streptomycin, however, carry
a risk of cochlear toxicity, and the incidence of ataxia and oscillopsia becomes unacceptable. The indications
for this form of treatment are therefore now limited, particularly with the current interest in intratympanic
delivery of gentamicin. Several series show a rate of control of vertigo of around 90%, though a cochleotoxic
effect is seen in 15-25% of cases. The future for intratympanic aminoglycosides in Ménière’s disease
is therefore promising.
the result of medical treatment or as a consequence of the clinical course of Ménière’s disease, around
70% of patients have a sustained period of remission. This implies that a quarter of patients continue to have
clinically important episodes of vertigo, and surgical treatment must be considered for them. The various
surgical procedures advocated in Ménière’s disease continue to arouse great controversy among
otolaryngologists. The decision to operate and choice of procedure are often dictated by the individual surgeon’s
understanding and experience of a particular technique and of the threshold for surgical intervention. Broadly
speaking, surgical procedures for Ménière’s disease are classified as destructive or non-destructive
with respect to hearing.