2. MENIERE’S DISEASE
• Ménière’s disease is an abnormal inner ear fluid balance
caused by a malabsorption in the endolymphatic sac.
Evidence indicates that many people with Ménière’s disease may
have a blockage in the endolymphatic duct. Regardless of the
cause, endolymphatic hydrops, a dilation in the
endolymphatic space, develops. Either increased pressure in
the system or rupture of the inner ear mem- branes occurs,
producing symptoms of Ménière’s disease.
3. SIGNS AND SYMPTOMS
• Fluctuating, progressive sensorineural hearing loss
• Tinnitus or a roaring sound
• A feeling of pressure or fullness in the ear
• Episodic, incapacitating vertigo often accompanied by nausea and
vomiting
4. SUBSETS OF MENIERE’S
COCHLEAR MENIERE’S
• Is recognized as a fluctuating, progressive sensorineural hearing loss
associated with tinnitus and aural pressure in the absence of vestibular
symptoms or findings.
VESTIBULAR MENIERE’S
• Is characterized as the occurrence of episodic vertigo associated with
aural pressure but no cochlear symptoms. In some patients, cochlear or
vestibular Meniere's disease develops first. In most patients, however, all
of the symptoms develop eventually.
5. ASSESSMENT AND DIAGNOSTIC
FINDINGS
• Vertigo is usually the most troublesome complaint, it can lasts minutes
to hours, possibly accompanied by nausea or vomiting .
• A careful history is taken to determine the frequency, duration, severity,
and character of the vertigo attacks.
• Patients also complain of diaphoresis and a persistent feeling of
imbalance or disequilibrium, which may last for days.
• Complaints that awaken them at night, Between attacks, however, they
usually feel well. The hearing loss may fluctuate, with tinnitus and aural
pressure waxing and waning with changes in hearing. The tinnitus and
feeling of aural pressure may occur only during or before attacks, or
they may be constant.
6. ASSESSMENT AND DIAGNOSTIC
FINDINGS
• Findings of the physical examination are usually normal, with the
exception of the evaluation of cranial nerve VIII.
• Sounds from a tuning fork (ie, Weber test) may lateralize to the ear
opposite the hearing loss, the one affected with Ménière’s disease.
• An audiogram typically reveals a sensorineural hearing loss in the
affected ear. This can be in the form of a “Pike’s Peak” pattern, which looks
like a hill or mountain, or it may show a sensorineural loss in the low
frequencies.
• As the disease progresses, the hearing loss increases. The
electronystagmogram may be normal or may show reduced vestibular
response. There is, however, no absolute diagnostic test.
7. MEDICAL MANAGEMENT
• Most patients with Ménière’s disease can be successfully treated with
diet and medication therapy.
• Many patients can control their symptoms by adhering to a low-sodium
(2,000 mg/day) diet. The amount of sodium is one of many factors that
regulate the balance of fluid within the body. Sodium and fluid retention
disrupts the delicate balance between endolymph and perilymph in the
inner ear. Psychological evaluation may be indicated if the patient is
anxious, uncertain, fearful, or depressed.
8. PHARMACOLOGIC THERAPY
• Pharmacologic therapy for Ménière’s disease consists of antihistamines
such as meclizine (Antivert), which suppress the vestibular system.
Tranquilizers such as diazepam (Valium) may be used in acute
instances to help control vertigo.
• Antiemetics such as promethazine (Phenergan) suppositories help
control the nausea and vomiting and the vertigo because of their
antihistamine effect.
• Diuretic therapy (eg, hydrochlorothiazide) sometimes relieves
symptoms by lowering the pressure in the endolymphatic system.
• Intake of foods containing potassium (eg, bananas, tomatoes,
oranges) is necessary if the patient takes a diuretic that causes
potassium loss.
9. PHARMACOLOGIC THERAPY
• Vasodilators, such as nicotinic acid, papaverine hydrochloride
(Pavabid), and methantheline bromide (Banthine), have no scientific
basis for alleviating the symptoms, but they are often used in
conjunction with other therapies.
10. SURGICAL MANAGEMENT
• Although most patients respond well to conservative therapy, some continue to
have disabling attacks of vertigo. If these attacks reduce their quality of life,
patients may elect to undergo surgery for relief. However, hearing loss, tinnitus,
and aural fullness may continue, because the surgical treatment of Ménière’s
disease is aimed at eliminating the attacks of vertigo.
ENDOLYMPHATIC SAC DECOMPRESSION
• Endolymphatic sac decompression, or shunting, theoretically equalizes the
pressure in the endolymphatic space. A shunt or drain is inserted in the
endolymphatic sac through a postauricular incision. This procedure is favored by
many otolaryngologists as a first-line surgical approach to treat the vertigo of
Ménière’s disease because it is relatively simple and safe and can be performed on
an outpatient basis.
11. SURGICAL MANAGEMENT
MIDDLE AND INNER EAR PERFUSION
• Ototoxic medications, such as streptomycin or gentamicin, can be
given to patients by infusion into the middle and inner ear. These
medications are used to decrease vestibular function and decrease
vertigo.
• The success rate for eliminating vertigo is high, about 85%, but the risk
of significant hearing loss is also high. This procedure of inner ear
perfusion usually requires an overnight stay in the hospital. After the
procedure, many patients have a period of imbalance that lasts
several weeks.
12. SURGICAL MANAGEMENT
INTRAOTOLOGIC CATHETERS
• In an attempt to deliver medication directly to the inner ear, catheters
are being developed to provide a conduit from the outer ear to the
inner ear. The route of the catheter is from the external ear canal
through or around the tympanic membrane and to the round window
niche or membrane. Medicinal fluids can be placed against the round
window for a direct route to the inner ear fluids.
13. SURGICAL MANAGEMENT
VESTIBULAR NERVE SECTION
• Vestibular nerve section provides the greatest success rate
(approximately 98%) in eliminating the attacks of vertigo. It can be
performed by a translabyrinthine approach (ie, through the hearing
mechanism) or in a manner that can conserve hearing (ie, suboccipital or
middle cranial fossa), depending on the degree of hearing loss. Most
patients with incapacitating Ménière’s disease have little or no effective
hearing. Cutting the nerve prevents the brain from receiving input
from the semicircular canals.
14. LABYRINTHITIS
• Labyrinthitis, an inflammation of the inner ear, can be bacterial or viral in
origin. Although rare because of antibiotic therapy, bacterial labyrinthitis usually
occurs as a complication of otitis media. The infection can enter the inner ear by
penetrating the membranes of the oval or round windows. Viral labyrinthitis is a
common medical diagnosis, but little is known about this dis- order, which affects
hearing and balance. The most commonly identified viral causes are mumps,
rubella, rubeola, and influenza. Viral illnesses of the upper respiratory tract and
herpetiform dis- orders of the facial and acoustic nerves (ie, Ramsay Hunt
syndrome) also cause labyrinthitis.
15. CLINICAL MANIFESTATIONS
• Sudden onset of incapacitating vertigo
• Usually nausea and vomiting
• Various degrees of hearing loss
• Tinnitus
• The first episode is usually the worst; subsequent attacks, which usually
over a period of several weeks to months, are less severe.
16. MANAGEMENT
• Treatment of bacterial labyrinthitis includes intravenous antibiotic
therapy, fluid replacement, and administration of a vestibular
suppressant, such as meclizine, and antiemetic medications. Treatment
of viral labyrinthitis is tailored to the patient’s symptoms.
