Meniere's Disease Part 3 - Medical Management

👂 Meniere's Disease - Medical Management

Treatment of Meniere's disease is divided into four broad categories:

1️⃣ General measures

2️⃣ Medical management

3️⃣ Transtympanic and intratympanic therapies

4️⃣ Surgical management

This post covers the first three categories.

📋 General Measures

1- Reassurance

⭐ The patient's anxiety is very high because of the symptoms they experience.

The nature of the disease, what to expect, why it happens and how the symptoms will be treated must be explained.

⭐ Particularly helpful during the acute phase of an attack, when vertigo can be very debilitating.

2- Salt Restriction

👉 Salt intake should not exceed 1.5 to 2 grams per day

3- Cessation of Smoking

⭐ Must be completely stopped, as nicotine causes vasospasm, which worsens the disease.

4- Other Advice

• Avoid excessive intake of water
• Avoid excessive coffee, tea and alcohol
• Avoid stress
• Mental relaxation exercises and yoga
• Bed rest during an acute attack

💊 Medical Management

Three groups of drugs are used:

1️⃣ Vestibular sedatives

2️⃣ Diuretics

3️⃣ Vasodilators

1- Vestibular Sedatives

👉 Purpose: To relieve vertigo

⭐ Administered intravenously or intramuscularly only when vomiting precludes oral administration.

Name the common Vestibular Sedatives used in Meniere's disease and mention their dosages as well.

Which vestibular sedative is preferred when the patient has vertigo along with anxiety?

2- Diuretics

⭐ First line drugs in Meniere's disease.

Drugs Used

• Hydrochlorothiazide
• Acetazolamide
• Hydrochlorothiazide with triamterene

What is the Mechanism of Action of diuretics in Meniere's disease?

Which diuretic is used during an acute attack of Meniere's disease?

3- Vasodilators

A- Betahistine

⭐ The more commonly used vasodilator.

An analogue of histamine, with:

• Weak H1 agonistic property
• Potent H3 antagonist property

What is the Mechanism of Action of Betahistine in the treatment of Meniere's disease?

What is the Dose of Betahistine used in the treatment of Meniere's disease?

B- Carbogen Inhalation

• A very good cerebral vasodilator
• Inhalation improves labyrinthine circulation

What is the composition of Carbogen?

💉 Transtympanic & Intratympanic Therapies

1️⃣ Meniett device (Transtympanic low pressure therapy)

2️⃣ Intratympanic injection of corticosteroids

3️⃣ Intratympanic injection of gentamicin

1- Meniett Device (Transtympanic Low Pressure Therapy)

⭐ The patient can self-administer the treatment at home.

What is the Indication of Meniett Device in the treatment of Meniere's disease?

🧠 Mechanism of Action

Delivery of intermittent positive pressure to the inner ear fluids.

Prerequisite

👉 Myringotomy with insertion of a grommet (ventilation tube)

What is the Pathway of the Pressure Waves in Meniett device?

Symptoms Relieved

• Vertigo
• Tinnitus
• Fullness in the ear

⭐ Hearing may also improve.

What is the dose of usage of Meniett Device in treatment of Meniere's disease?

2- Intratympanic Injection of Corticosteroids

📌 Indication

Patients who have failed a combination of dietary restrictions and medical therapy with vasodilators and diuretics for 6 months.

What is the Mechanism of Action of Corticosteroids in treatment of Meniere's disease?

Drugs Used

• Dexamethasone
• Methylprednisolone

What are the Methods of Administration of Corticosteroids in treatment of Meniere's disease?

3- Intratympanic Injection of Gentamicin

📌 Also Known As

👉 Partial Chemical Labyrinthectomy

⭐ Gentamicin is an ototoxic drug, but has greater vestibular toxicity relative to cochlear toxicity.

👉 This helps control the vestibular symptoms while sparing hearing.

What are the Indications of Intratympanic Injection of Gentamicin in treatment of Meniere's disease?

What is the Mechanism of Action of Intratympanic Injection of Gentamicin in treatment of Meniere's disease?

Administration

Same pathways as for intratympanic corticosteroids.

Dose

• 40 mg/ml, diluted with lidocaine or sodium bicarbonate buffer to make 30 mg/ml
• Weekly injections

Outcome

✅ Total control of vertigo in 60 to 80% of cases

⚠️ The patient may develop imbalance or visual vestibular mismatch.

What are the Complications of Intratympanic Gentamicin therapy?

What is Acute Vestibular Deafferentation Syndrome?

🧠 Viva Pearls

• Treatment of Meniere's disease is divided into general measures, medical management, transtympanic and intratympanic therapies, and surgical management.
• Salt intake is restricted to 1.5 to 2 grams per day.
• Smoking must be stopped completely, as nicotine causes vasospasm.
• Vestibular sedatives are used to relieve vertigo.
• Diuretics are the first line drugs, and act by reducing endolymphatic volume and pressure.
• Betahistine is an analogue of histamine, with weak H1 agonistic and potent H3 antagonist properties.
• Betahistine reduces the frequency and intensity of vertigo, with minimal effect on tinnitus.
• The Meniett device delivers intermittent positive pressure and requires a grommet in place.
• Intratympanic gentamicin is also known as partial chemical labyrinthectomy.
• Gentamicin has greater vestibular than cochlear toxicity, so hearing is spared.
• Intratympanic gentamicin gives total control of vertigo in 60 to 80% of cases.

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