Meniere’s disease

Meniere’s disease is characterised by recurrent attacks of vertigo accompanied by fluctuating sensorineural hearing loss, tinnitus and a sense of aural fullness. Prosper Meniere in 1861 correctly attributed the attacks to a disorder of the inner ear, suggesting that the mechanism of causation could be similar to migraine or inner ear vasospasm, a differential diagnosis which is still relevant for the disease today.

Ménière’s disease is also called idiopathic endolymphatic hydrops and is one of the most common causes of dizziness originating in the inner ear. Attacks of dizziness may come on suddenly or after a short period of tinnitus or muffled hearing. Some people will have single attacks of dizziness separated by long periods of time. Others may experience many attacks closer together over a number of days. Some people with Meniere’s disease have vertigo so extreme that they lose their balance and fall. These episodes are called “drop attacks.”

Meniere’s disease can develop at any age, but it is more likely to happen to adults between 40 and 60 years of age. The National Institute on Deafness and Other Communication Disorders (NIDCD) estimates that approximately 615,000 individuals in the United States are currently diagnosed with Meniere’s disease and that 45,500 cases are newly diagnosed each year.

Meniere’s disease can occur at any age, but it usually starts between the ages of 20 and 50. It is a chronic (long-term) disease, but treatments and lifestyle changes can help to ease the symptoms.

Causes

The symptoms of Meniere’s disease are caused by the buildup of fluid in the compartments of the inner ear, called the labyrinth. The labyrinth contains the organs of balance (the semicircular canals and otolithic organs) and of hearing (the cochlea). It has two sections: the bony labyrinth and the membranous labyrinth. The membranous labyrinth is filled with a fluid called endolymph that, in the balance organs, stimulates receptors as the body moves. The receptors then send signals to the brain about the body’s position and movement. In the cochlea, fluid is compressed in response to sound vibrations, which stimulates sensory cells that send signals to the brain.

Factors that affect the fluid, which might contribute to Meniere’s disease, include:

• Improper fluid drainage, perhaps because of a blockage or anatomic abnormality
• Abnormal immune response
• Allergies
• Viral infection
• Genetic predisposition
• Head trauma
• Migraines

In Meniere’s disease, the endolymph buildup in the labyrinth interferes with the normal balance and hearing signals between the inner ear and the brain. This abnormality causes vertigo and other symptoms of Meniere’s disease.

Symptoms

• Episodic rotational vertigo – Attacks of a spinning sensation accompanied by disequilibrium (an off-balanced sensation), nausea, and sometimes vomiting. This is usually the most troublesome symptom. The vertigo usually last 20 minutes to four hours or longer. During attacks, patients are very disabled, and sleepiness may follow. An off-balanced sensation may last for several days.
• Tinnitus – A roaring, buzzing, machine-like, or ringing sound in the ear. It may be episodic with an attack of vertigo or it may be constant. Usually the tinnitus gets worse or will appear just before the onset of the vertigo.
• Hearing loss – It may be intermittent early in the onset of the disease, but overtime it may become a fixed hearing loss. It may involve all frequencies, but most commonly occurs in the lower frequencies. Loud sounds may be uncomfortable and appear distorted in the affected ear.
• Ear fullness – Usually this full feeling occurs just before the onset of an attack of vertigo.

Treatment

• Intermittent anti-vertigo medications, e.g lorazepam, diazepam or meclizine.
• Intratympanic injections
• Surgical intervention

While anti-vertigo and anti-nausea medications will reduce dizziness, they may cause drowsiness and can prologue the dizziness after spell. Other treatments also carry both positive implications as well as drawbacks. When is surgery recommended? The vast majority of patients with Meniere’s disease are controlled with medication and lifestyle changes.

If vertigo attacks are not controlled by conservative measures and are disabling, one of the following surgical procedures might be recommended –

• Intratympanic gentamicin injections – This is done with 2 out-patient injections of gentamicin into the middle ear. Some of the gentamicin enters the inner ear through the membranes separating the middle and inner ear. The aim of the procedure is to reduce the irritability of the inner ear and control the spells.
• The endolymphatic sac shunt or decompression procedure is an ear operation that usually preserves hearing. Attacks of vertigo are controlled in one-half to two-thirds of cases, but control is not permanent in all cases. Recovery time after this procedure is short compared to the other procedures.
• Selective vestibular neurectomy is a procedure in which the balance nerve is cut as it leaves the inner ear and goes to the brain. While vertigo attacks are permanently cured in a high percentage of cases, patients may continue to experience imbalance. Similar to endolymphatic sac procedures, hearing function is usually preserved.
• Labryrinthectomy and eighth nerve section are procedures in which the balance and hearing mechanism in the inner ear are destroyed on one side. This is considered when the patient with Meniere’s disease has poor hearing in the affected ear. Labryrinthectomy and eighth nerve section result in the highest rates for control of vertigo attacks.

Noninvasive therapies and procedures

Some people with Meniere’s may benefit from other noninvasive therapies and procedures, such as –

• Rehabilitation – If a person has balance problems between episodes of vertigo, vestibular rehabilitation therapy might improve your balance.
• Hearing aid – A hearing aid in the ear affected by Meniere’s disease might improve your hearing.
• Meniett device – For vertigo that’s hard to treat, this therapy involves applying pressure to the middle ear to improve fluid exchange. A device called a Meniett pulse generator applies pulses of pressure to the ear canal through a ventilation tube.

Alternative Treatment

• Lysine – A naturally occuring amino acid, lysine is popular treatment of vertigo.
• Manganese – Maganaese (in trace amounts) is helpful for Meniere’s disease.
• Mycostatin (Nystatin) – Studies suggest that this antifungal is very effective for intractable Meniere’s disease.
• Kava – This herbal preparation is used for anxiety and insomnia. It’s action seems to be a GABA agonist and possibly a mild 5-HT 1A action. It may be effective for anxiety.
• Ginkgo biloba is one of the most well researched herbs in the world. It has been shown to be anti-ischaemic, anti-hypoxic and a radical scavenger. It increases efficiency of metabolism, regulates neurotransmitters and boosts oxygen levels in the brain.
• Vitamin C – The next substance is a particular sort of vitamin C, a timed release form of this essential vitamin. In larger amounts, vitamin C is quickly removed from the body and excreted. A timed release form maintains adequate concentrations of vitamin C in the blood for extended periods of time
• Vitamin E (in the d-, not dl- forms) also has been shown to improve vascular health—along with a number of other good nutritional benefits. Vitamin E is much more effective when used along with vitamin C. The two vitamins work synergistically.
• Acupuncture has been widely used in the treatment of Meniere’s disease. In Meniere’s disease, the needle stimulation is performed around the ear. The stimulation of acupoints is postulated to release natural opiates from nerves resulting in endogenous analgesia