The pharmacological treatment of Menière's disease

The management of Menière's disease often provides a formidable clinical challenge largely because its precise aetiology is unknown. There is no known ‘cure’ once the condition is established, but drugs may be helpful in treating both the acute attacks of vertigo, and in more long-term management, particularly in the earlier fluctuant stage. These remedies are largely symptomatic and there are few if any properly controlled studies of their efficacy. Suppressant drugs may act centraly at neurotransmitter sites, or peripherally on the labyrinth. Conventional diuretics and osmotically acting agents have been given to reduce the endolymph fluid volume Histamine anlogues directly reduce inner ear fluid pressure mainly by increasing the cochlear blood flow. and are probably the treatment of choice. Otovestibulotoxic drugs given systemically to cause chemical labyrinthine ablation are frequently effective in abolishing attacks of vertigo but often resulted in disabling oscillopsia and ataxia. There is now evidence that local administration by intratympanic injection may well be more efficacious resulting in selective partial end organ ablation. To date innovative immune modigying regimes have not proved helpful.     

Intratympanic gentamicin for unilateral Menière's disease: results of therapy

Intratympanic gentamicin for unilateral Menière's disease: results of therapy Patients with Menière's disease that remains refractory to conservative treatment have traditionally been subjected to ablative surgery. The purpose of this prospective study was to evaluate the use of intratympanic gentamicin in eliminating incapacitating vertigo, while preserving hearing. Over the past 8 years, 83 patients have received between 1 and 6 intratympanic injections of gentamicin in an out‐patient setting, with duration of therapy titrated to individual symptom response and effect on hearing. Using established AAO‐HNS guidelines, we present data on 50 patients who have a minimum of 2 years follow‐up. Control or significant improvement of definitive Menière's attacks was achieved in 92% of patients and hearing preserved or improved in 76%. Only one patient experienced profound sensorineural hearing loss. We feel this treatment option should be considered and offered to patients in whom medical treatment has failed.     

Non-invasive perilymphatic pressure measurement in patients with Menière's disease

The MMS-10 Tympanic Displacement Analyser is a new device to measure the perilymphatic pressure in humans. This instrument was used in 25 patients with Menière's disease (28 affected ears) and a group of 50 young normal hearing subjects. No significant differences were found in perilymphatic pressure measurements between the groups. Although measurement parameters showed large inter-individual variation, the intra-individual correlation was good. In patients with Menière's disease, no relationship was found between perilymphatic pressure, hearing thresholds, blood pressure, gender or age.     

Prognostic value of electrocochleography in patients with unilateral Menière's disease undergoing saccus surgery*

Although a controversial operation, saccus surgery has continued to be used in patients with severe Menière's disease in whom hearing preservation is the objective. The aim of this study was to determine if electrocochleography (ECoG) could predict the patients who would be free of vertigo, 2 and 5 years after surgery. Seventy patients with severe Menière's syndrome underwent ECoG prior to endolymphatic sac surgery. Eighty‐four per cent of the patients had an abnormal electrocochleogram. The patients were interviewed 2 and 5 years after surgery. At 2 years, 4/10 (40%) patients with normal ECoG were relieved of dizziness compared to 38/51 (75%) with abnormal ECoG (P < 0.05). At 5 years, 5/8 (63%) patients with normal ECoG were relieved of dizziness compared to 30/30 (100%) with abnormal ECoG (P < 0.001). The patients with a normal ECoG do have less severe measurable hearing impairment (P < 0.05) although they are more likely (P < 0.05) to complain of constant tinnitus. Their history of dizziness is longer and their dizziness more disabling before surgery. In conclusion, patients with a normal ECoG will be less likely to benefit from saccus surgery in the first 5 years. These patients may represent a different nosological entity.     

Pure‐tone and speech audiometry in patients with Menière's disease

The aim of this study was to reinvestigate many of the claims in the literature about hearing loss in patients with Menière's disease. We carried this out on a well‐defined group of patients under well‐controlled circumstances. Thus, we were able to find support for some claims and none for many others. As part of a diagnostic protocol, pure‐tone and speech audiometry was performed on 111 patients with Menière's disease according to the ‘Definition Menière Groningen’. This was a prospective clinical cohort study. Affected ears of patients suffering from Menière's disease show reduced hearing, both in pure‐tone and in speech audiometry. A classification method was devised to determine audiogram shape in an objective manner. The results of this method indicate that affected ears more frequently show ‘low’ or ‘low + high’ hearing losses (P = 0.006). The shape of the hearing loss does not depend on the duration of the affection of the disease. In combination with the fact that the average hearing loss does not correlate with the duration of the disease, this leads to the conclusion that, if a classification of the hearing loss in Menière's disease is possible, such a classification cannot be connected to the duration. This conclusion is further supported by the fact that no relationship is found between the duration of the disease and the classification of the hearing loss over the 3 months before hospital admission, as given by the patients in a questionnaire. A relationship between the (objective) audiometric data and the (subjective) classification of the hearing loss by the patient seems to be present, but is not very strong. Correlations between pure‐tone and speech audiometry are present as in non‐Menière ears (r = 0.899, P < 0.001), and no indications are found of reduced speech discrimination relative to the expectation based on pure‐tone loss. The audiogram shape does not appear to play any additional role in speech discrimination (in addition to the influence of the average pure‐tone loss).     

The AAO–HNS Committee on Hearing and Equilibrium Guidelines for the diagnosis and evaluation of therapy in Menière's disease: have they been applied in the published literature of the last decade?

The AAO–HNS Committee on Hearing and Equilibrium Guidelines for the diagnosis and evaluation of therapy in Menière's disease: have they been applied in the published literature of the last decade? To assess how effectively the American Academy of Otolaryngology–Head and Neck Surgery Committee on Hearing and Equilibrium (AAO–HNS CHE) guidelines for the diagnosis and evaluation of therapy in Menière's disease have been applied in the last 11 years of published literature. This was a MedLine‐based review. Some 79.7% of papers attempted to use the AAO–HNS CHE guidelines. However, only 50% of these publications managed to use the AAO–HNS CHE criteria in the diagnosis and evaluation of therapy correctly. In order to advance our understanding of this condition, improved application of the AAO–HNS CHE guidelines by authors and editors alike is required in the reporting of results of the therapy of Menière's disease.     

Intratympanic gentamycin in severe Méniére's disease

From 1982 to 1987, 20 patients with disabling attacks of vertigo and severe hearing loss due to unilateral Meniere's disease were treated with local intratympanic gentamycin. In 18 patients control of vertiginous attacks was achieved. Hearing deteriorated in 8 patients. In spite of complete control of attacks a disabling ablation type of unsteadiness and dizziness affected 7 patients. Two patients required additional treatment after 5–8 months remission. Intratympanic gentamycin seems to be a less useful method of treating severe unilateral Meniere's disease than previously stated. It is, however, a possible alternative to surgical labyrinthectomy with a fair chance of residual hearing preservation.     

A new approach to surgery for Menière’s disease: talking about surgery

Many patients experience a remission of their Menière’s disease between the time that surgery is agreed and their admission to hospital for the procedure. In a series of 23 consecutive patients where surgery appeared to be indicated for control of the vertigo of Menière’s disease, 12 settled within 6–8 weeks of agreeing that something would be done, and thereby avoided any surgical procedure. It is suggested that these patients may have been experiencing the same effect as provided by the conservative surgical procedures. In the absence of any clear evidence for a specific surgical effect from any conservative operation for Menière’s disease, the authors put forward the suggestion that abandoning all the conservative procedures in favour of the protocol of planned surgery should be considered; wait for 2 months and, if the incapacitating episodic dizziness continues, one should proceed to a deafferenting procedure.     

The current role of local intratympanic Gentamicin therapy in the management of unilateral Menière’s disease

Over the past 5 years 25 patients suffering from disabling unilateral Menière’s disease have been treated in our unit with local intratympanic Gentamicin therapy with the specific intent of creating a medical labyrinthectomy, together with preservation of hearing on the treated side. Results from the 16 patients who have completed a 2-year follow-up show that substantial control of vertigo was obtained in all subjects, while 87% experienced complete control of vertigo following treatment. In 66% this was achieved in association with a complete medical labyrinthectomy (no caloric response to an iced water stimulus). In 94% of patients the hearing on the treated side has remained unaffected, but tinnitus was largely unchanged. The simple treatment protocol uses a customized self-retaining intratympanic catheter system (courtesy of Exmoor Plastics Ltd). The findings suggest that local Gentamicin therapy is an effective treatment in patients with incapacitating unilateral Menière’s disease and is associated with low morbidity and good hearing preservation and thus provides a potentially superior alternative to the surgical treatment options currently available.     

Lack of utility of metabolic screening in Méniére's disease

The incidence of disturbances of carbohydrate and lipid metabolism were studied in two groups of patients; one group with Ménière's disease, the other with otosclerosis. Our observations do not support the notion that metabolic disturbances are the principal causes of the symptom complex in Ménière's disease. Results of thyroid function tests were also normal in all Ménière's patients tested.     

Vestibular neurectomy vs. chemical labyrinthectomy in the treatment of disabling Menière's disease: A long-term comparative study

Objective

To compare the efficiency of vestibular neurectomy (VN) and chemical labyrinthectomy (CL) in the treatment of Menière's disease's disabling vertigo, and to assess their subsequent effects on hearing.

Methods

This is a retrospective study of 58 VN procedures and 35 CL procedures. Treatment results were assessed by caloric testing and pure-tone audiometry performed before and after treatment. Subjective success was defined by the number of recurrent attacks of vertigo and by the AAO-HNS vertigo scale.

Results

Caloric testing revealed strong vestibular hyporeflexia in 91.0% of VN cases and 86.0% of CL cases. Vertigo recurred in 7.0% of cases in the VN group and in 11.4% of cases in the CL group. Mean pure-tone auditory thresholds increased from 45.00 dB HL to 50.84 dB HL (p = 0.19) in the VN group and from 69.11 dB HL to 74.51 dB HL (p = 0.41) in the CL group.

Conclusion

Vestibular neurectomy and chemical labyrinthectomy offer similar control of vertigo in patients with Menière's disease. CL is a simple, minimally invasive procedure that emerges as an effective method for treating Menière's disabling vertigo without causing significant hearing deterioration.     

Effects of glycerol intake and body tilt on otoacoustic emissions reflect labyrinthine pressure changes in Menière’s disease

It is known that by influencing stapes stiffness thus the ear’s impedance, changes in intracranial and intralabyrinthine pressure induce a characteristic phase shift in otoacoustic emissions (OAE) around 1 kHz in human ears. Thus, if the regulation of pressure in intralabyrinthine compartments were abnormal in Menière patients, OAEs might help detect it. Body tilt, which acts on intracranial pressure, and administration of an osmotically active substance provide two simple ways of manipulating intralabyrinthine pressure. Here, 14 patients with typical signs of an attack of unilateral endolymphatic hydrops were submitted to postural changes and a glycerol test. Their OAEs initially collected in upright position served as references, then OAEs were measured in supine position, and back to the upright posture one and 3 h after glycerol intake. Twenty control subjects were also tested for body tilt. The main effect of body tilt and glycerol was a phase rotation of OAEs peaking around 1 kHz. Its frequency dependence matched the one due to a pressure-related change in stapes or basilar membrane stiffness predicted by the ear model of Zwislocki (1962). The average glycerol-induced phase shifts were similar in size in Menière vs. asymptomatic ear and audiometric thresholds were stable after glycerol intake in line with the model predicting little change in the magnitude of the transfer function. These data support a simple conductive pressure-related mechanism explaining the action of glycerol on inner ear responses. The fact that the mean postural shift was three times larger in Menière than asymptomatic and control ears suggests an additional effect in allegedly hydropic ears.