Menieres Disease
Theresa Pitt, Aud.D., F.S.H.A.A., Audiology Services
in S.E. Ireland.
(Acknowledgements to the Otolaryngology Department at the University of Washington)
Meniere's Disease
Meniere's disease, first described in 1861 by the French physician
Prosper Meniere, is characterized by multiple symptoms, all associated
with excessive fluid in the inner ear involving both the hearing and
balance organs. Excessive fluid in the cochlea (hearing organ) = cochlear hydrops. Excessive fluid in the semicircular canals (balance
organ) results in dizziness and is vestibular hydrops. Almost
all Meniere's patients have both cochlear and vestibular hydrops.
NORMAL HEARING:
Sound travels along the external ear canal, causing the eardrum to
vibrate. Three small bones of the middle ear (malleus, incus, and
stapes) conduct this vibration from the ear drum to the cochlea of the
inner ear, causing waves of fluid in the cochlea to stimulate its
delicate hearing cells (hair cells). Movement of the hair cells
generates an electrical current in the auditory nerve, which in turn
transmits signals to the brain. Through various interconnections these
signals are recognized as sound.
SYMPTOMS:
The symptoms of Meniere's are dizzy spells (vertigo) associated with
hearing loss, tinnitus, and a feeling of fullness in the ear. These
spells occur to varying degrees and last from 20 minutes to a full day.
About 80 percent of patients with Meniere's experience the problem in
only one ear. Meniere's can occur at any age but it most frequently
begins between the ages of 30 and 50. The cause of Meniere's is unknown.
Possible contributors are stress, excessive salt intake, and, occasionally,
endocrine problems, such as low thyroid function, abnormal glucose (sugar) metabolism, or an inability to handle fats (high cholesterol and/or triglycerides.) Uncommon disorders that mimic Meniere's are auto-immune labyrinthitis, syphilis, head injury, or viral infection of inner ear.
EVALUATIONS:
Tests determine the existence and cause of Meniere's in each patient,
though it is not necessary to perform all the tests listed below in
every case. Tests are:
Auditory: pure tones and speech discrimination
Glycerol: changes in loudness and/or clarity after drinking glycerine (A
positive result is specific for active Meniere's; a negative result may
indicate inactive Meniere's, especially when the hearing loss has been
present for some time.
Electronystagmography: balance canal function as seen through eye movements
General health evaluation
Auditory brainstem response(ABR) and Otoacoustic emission tests
Balance testing
Antibody measurement
Glucose (sugar) metabolism
Blood: (evaluating for systemic infection)
Magnetic resonance imaging of the inner ear and hearing nerve
MEDICAL MANAGEMENT:
1. No smoking: Patients must abstain from tobacco totally. Nicotine is
toxic to the inner ear. Continued use may render all treatments listed below ineffective.
2. Low sodium (low salt) diet: To decrease the amount of fluid in the inner ear, patients are placed on a low sodium diet. This means no additional salt in cooking or at the table.
3. Diuretic: A diuretic is advisable to decrease the body's sodium and
water content, but some diuretics decrease potassium excessively. To
prevent this, patients should eat potassium-rich foods every day. Good
sources of potassium are salt substitutes, orange juice, bananas,
dried fruits, raisins, cantaloupe, nectarines, potatoes, and salt-free peanuts. Occasionally, severe weakness and "flulike" symptoms may be caused by potassium loss. It is important for patients with these symptoms to be checked promptly by a physician.
4. No caffeine: Caffeine products (for example, coffee, tea, cola beverages, and chocolate) should not be used by patients with Meniere's.
Numerous patients have reported attacks within minutes of caffeine use.
Decaffeinated products are fine.
5. Stress avoidance: Episodes of Meniere's frequently occur at times of severe stress and fatigue or immediately following such episodes. Patients should try to avoid
situations that produce undue stress. At times, professional counselling
is necessary to help patients with stressful problems.
6. Watch for food allergy: In certain patients, episodes of Meniere's are caused by
specific foods (for example, chocolate, red wine, wheat, beer, shellfish, and milk products). While this is uncommon, it is desirable to keep a list of foods ingested at the meal preceding each episode to see if any particular food is consistently present.
7. Innovar Therapy: Some patients with frequent vertigo attacks are helped by an intravenous injection of Innovar. This is a potent anesthetic agent and must be given
in hospital as a one-time treatment.
PROGNOSIS:
By using these forms of medical management, the disease can be controlled in about 70 percent of patients. This means that attacks of vertigo will be prevented or will be minimal, if they occur. Unfortunately, tinnitus (head noises) seldom disappears. If treatment is started while a patient's hearing is still fluctuating, it is sometimes improved by medical management and may be stabilized in the more advanced disease. In some patients, however, hearing loss will continue to worsen.
It is important to remember that Meniere's involves both ears in only 20
percent of patients, and if it is going to involve both ears, it usually
does so in the first 2 or 3 years. Medical management is usually
effective within 2 months; if not the case, surgery may be considered. A
low sodium diet is continued until there are no episodes of dizziness
for 2 years, although the diuretic treatment can usually be
discontinued a year after the last episode of dizziness.
SURGICAL TREATMENTS:
There are many surgical treatments for Meniere's disease, if and when
surgery becomes necessary. The most successful treatments are:
1. Endolymphatic sac surgery. When hearing in the involved ear is good
but dizzy spells continue in spite of medical management, an
endolymphatic sac surgery is sometimes chosen. The sac is a part of the
inner ear that absorbs fluid and extends into the mastoid process behind
the ear.Sac involvement in Meniere's is poorly understood but may
increase fluid absorption. Performed under general anesthesia, this
surgery initially relieves the dizziness in about 75 percent of
patients. Long-term relief is achieved in 50-60 percent of cases.
Hearing is usually not affected. These results are very similar to a
placebo operation. Hearing occasionally improves after surgery but in
about 4 percent of patients, hearing worsens as a complication of the
surgery. Tinnitus is not usually changed and dizziness is unusual
immediately after surgery. Patients are hospitalized overnight.
2. Vestibular nerve section. This procedure is definitive (like
labyrinthectomy) but it preserves hearing in over 90 percent of cases.
It is a more serious operation, requiring an incision behind the ear and
5 to 7 days in the hospital. Risks include meningitis and a leak of
spinal fluid. Control of vertigo is achieved in 95 percent of cases.
3. Labyrinthectomy In patients with severe Meniere's uncontrolled by
medical management and where hearing is no longer adequate for
communication, a labyrinthectomy has a 95 percent success rate in
eliminating major spells. General anesthetia is necessary. Following
surgery, there is no hearing or balance function in the operated ear.
Patients are usually dizzy after surgery, but gradually stabilize as the
unoperated ear takes over the balance function. The dizziness usually
lasts 3 to 5 days, but may persist for several weeks. In elderly
patients, it is occasionally prolonged. Tinnitus may not be changed by
the surgery, in fact, it may worsen. Hearing is totally and permanently
destroyed in the operated ear.
Other Resources on Vestibular Disorders on the Internet are on the Adresses page of this Site
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