Meniere's Syndrome / Meniere's Disease / Endolymphatic Hydrops

 

 

What is Meniere's syndrome? 

Meniere's syndrome and endolymphatic hydrops both refer to a condition of excess pressure accumulation in the inner ear. Symptoms include:

	Fluctuating hearing loss (hearing that is good sometimes and bad sometimes)
	Occasional vertigo (usually a spinning sensation, sometimes violent)
	Tinnitus or ringing in the ears (usually low tone roaring)
	Aural fullness (pressure sensation in the ears)

 

See E-Medicine Chapters on Meniere's written by Dr. Li (below)

E-Medicine article on Medical Treatment

E-Medicine article on Surgical Treatment

 

What causes it? What is Happening? 

There are two fluids that fill the chambers of the inner ear. Too much pressure from these fluids will stretch these nerve-filled membranes and may cause hearing disturbance, ringing in the ears, vertigo, imbalance and a pressure sensation in the ear. Inner ear inflammation or infections: Autoimmune disease, (Lupus, Rheumatoid dz), Syphilis, Allergy, High Cholesterol or Triglyceride in the blood stream, Thyroid hormone disease Diabetes.

 

How is it diagnosed? 

The following tests may be required.

	Hearing test: to document the patient's present hearing acuity and subsequent fluctuations. Sometimes the patient does not notice a loss in the high frequencies.
	Blood tests: "EAR-LABS". To rule out obvious salt/sugar chemical imbalances, infections, hormonal problems. Allergy testing: This is usually done by blood test initially, and the confirmed by skin testing.
	ENG: Test of the inner ear functions - particularly the semicircular canals. The ENG measures their response to warm and cold water. The test should be done on an empty stomach, and after discontinuing Antivert, antihistamines and sedatives for two weeks (these drugs may alter the results of the test). It may make the patient somewhat dizzy or nauseated. The test tells whether the inner ears are weak.
	ECOG: A test specific for distortion of the nerve-containing membranes of the inner ear, presumably due to pressure fluctuations of the perilymph. It is most accurate when Meniere's is active.
	ABR: A test to see if there is anything that slows the transmission of sound impulses to the brain along the hearing nerve.
	MRI Scan: Brain scan that looks for abnormal masses or abnormal anatomy. Please note tumors are rarely found but very important to rule out.

 

How is it treated? 

Treatment Strategy depends on the following:

	Severity of Symptoms
	Hearing Balance function
	Ability to identify affected ear
	Age / Medical condition
	Type of employment - Roofer vs. desk job personnel

 

Dietary Management - i.e. avoid foods with high sodium content, foods with high cholesterol or triglyceride content foods with high carbohydrate content chocolate, excessive sweets-candy, etc. caffeine and tobacco

 

Medical Treatment

The goal of medications are to mask the vertigo and/or decrease the fluid pressure load in the inner ear. We usually start with a dietary protocol which involves reduction of: Salt, caffeine, chocolate, red wine and refined sugars, artificial or otherwise. Next, we will move onto medications. In an acute attack, we use medications that dull the sensation of vertigo using:

	Antivert: 1 tablet every 8 hours or as needed.
	Droperidol: 1-2 drops under the tongue during severe attacks.

 

If the patient has nausea or vomiting we can try antiemetics

	Compazine:  10 mg orally or rectal suppository for nausea (use when too sick for pills).
	Phernagan: 25 mg orally or by rectal suppository

 

Caution:  Do not drive or operate heavy machinery while dizzy or taking above medication as they may impair your judgement and reflexes.

 

Prevention of attacks may be achieved by reducing inner ear pressure. This can sometimes be done using diuretics, aka "water pills".

	Dyazide:  l “water pill” a day in the mornings. (decreases the fluid pressure load)
	Diamox

Neptazane: reduces fluid pressure in the CSF give as 50-100 mg 3 times a day.

 

Caution:  Do not take Dyazide or other water pills if you have low blood pressure or are already taking antihypertensive medication.  If in doubt, ask your family physician.

 

Steroids can be used to reduce inner ear inflammation and settle down hydrops in acute situations. It can be dramatically effective for the immediate problem. However, due to side-effects, we do not use it long term.

	Medrol Dose pack: take as directed, 6 tabs day 1, 5 tabs day 2 until the pack is gone.
	Prednisone: 10 mg tablets in an as directed manner.

Dexamethasone: 4 mg daily for 2 weeks, then .75 mg every other day for 1 month.

 

Caution:  Steroids can have, but are not limited to the following side effects: GI upset, gastritis, ulcers (take with meals) insomnia and irritability and mood changes. Prolonged use may cause weight gain, rounded face, body changes, adrenal suppression and possible hip problems.

 

Surgical Treatment See Vertigo Surgical Protocol

	Transtympanic Medications: See linked page.
	Dexamethasone Perfusion: It would seem to make sense that if oral steroids work, they may work even better through the inner ear. This is done via the same method as Streptomycin Perfusion but using steroids instead.
	Streptomycin Perfusion: An antibiotic that specifically affects the balance nerve is placed through a small puncture in the eardrum. A small amount is also given intravenously. This antibiotic essentially deadens the balance nerve and usually (90%) spares the hearing. Success has been reported to be about 90% although relapses are possible.
	Endolymphatic Sac Decompression: Decreases the pressure build up of the endolymph by removing bone that encases the endolymph reservoir sac. This allows the sac to expand more freely and allows the pressure to dissipate. This has approximately a 65-80% chance of (1) controlling vertigo (2) stabilizing hearing acuity. It is a relatively low risk procedure that can preserve hearing.
	Vestibular Nerve Section: For patients with useful hearing in both ears, cutting the diseased balance nerve can often cure the symptoms. This has the advantage of a high cure rate (about 95 %) and can preserve hearing in the operated ear. The surgery involves both an otologist and a neurosurgeon and is more complex than the endolymphatic sac decompression.
	Labyrinthectomy: Has the advantage of a high cure rate, (greater than 95 %) and is useful in the patient whose hearing on the affected side has already been destroyed by Meniere's. It involves removal of the diseased inner ear organs but does not require entry into the cranial cavity and is thus less complex than the vestibular nerve section.

 

Other Options...

	Vestibular Rehabilitation balance retraining is important for many reasons. Improved preparedness for impending attacks. Improved tolerances of attacks Overcoming damage to the inner ear system after attacks.
	Electrical Stimulation for Meniere's. A certain subset of tinnitus patients have Meniere's syndrome. These patients, in an on going study done by Dr. Li, have shown some success in reducing: Tinnitus, Aural fullness, and Vertigo with interesting improvement rates!
	Meniett Device: Use of this device requires a tube to be placed in the ear drum. The device pumps air into the middle ear to and fro in a specific "micropressure" pulse pattern. Somehow, in some patients, this serves to reduce or eliminate symptoms of Meniere's disease. Patients use it for a few minutes each day. Unfortunately we have not been overwhelmed by the results.