MENIER'S DISEASE

1. DR. AZAD MEENA
JR 1ST ENT
DR. T. KUMAR UNIT

2.  Menieres disease, also called
endolymphatic hydrops , is disease of
inner ear where endolymphatic system
is distended with endolymph.
 It is characterized by
1) vertigo
2) sensory neural hearing loss
3) tinnitus
4) aural fullness

3.  The main pathology is distension of endolymphatic
system, mainly affecting the cochlear duct (scala
media) and saccule and to lesser extend the utricle
and semicircular canals.
 The dilatation of cochlear duct is such that it may
completely fill the s. Vestibuli, there is marked
bulging of reissners membrane,which may even
herniate through halicotrema in the apical part of
s. Tympani.

4.  The distended saccule may come to lie
against the stapes footplates.
 The utricle and saccule may show out
pouching into semicircular canal.

5.  Exact cause of menieres disease is not yet
known. Various theory have been postulated.
 It is possible that menieres disease is
multifactorial, resulting in common end poin of
endolymphatic hydrops with classical
presentation
 This can be result of
1) increased production of endolymph
2) decreased absorbtion of endolymph
3) both of above

6.  Normally endolymph is carried by
endolymphatic duct to sac where it is absobed.
 Obstruction of endolymphatic sac and duct
may responsible for raised endolymph
pressure.
 Ischaemia of sac may be responsible for poor
vascularity and thus poor absorbtion by sac.
 Distension of membranous labyrinth leads to
rupture of reissners membrane thus mixing of
perilymph and endolymph,which is responsible
for attack of vertigo.

7.  There is sympathetic overactivity resulting in
spasm of internal auditory artery and its
branch, thus interfaring with the function of
cochlear and vestibular sensory
neuroepithelium. This responsible for
deafness and vertigo.
 Anoxia of capillaries of stria vascularis also
causes increased permeability, with
transudation of fluid and increased
production of endolymph.


8.  Allergen may be a foodstuff or an inhalant. In
these case, inner ear act as a “shock organ”
producing excess of endolymph
 Nearly 50% of patient with menieres disease
have concomitant inhalant or food allergy.
4). SODIUM AND WATER RETENSION
5). HYPOTHYROIDISM – About 3% cases are
due to hypothyroidism. such case benefit
from thyroid replacement theraphy.

9.  It is also suggested on basis of experimental
and cliniacal observation.
 summary:-

10.  Commonly seen in the age group of 35-60
yesrs.
 Male are more affected than female.
 Usually, disease is unilaterally but other ear
may affected after few years.
 Cardinal symptoms is:-
a) episodic vertigo
b) fluctuating hearing loss
c) tinnitus
d) sense of aural fullness

11.  It comes in attacks.
 The onset is sudden.
 Patient gets feeling of rotation of himself or his
environment.
 Sometimes, there is “to and fro” or “up and down”
movement.
 Attack comes in clusters, with periods of spontaneous
remission lasting for weeks, months and years.
 Usually an attack is sccompanied by nausia and
vomiting with ataxia nystagmus.
 Usually there is no warning symptoms of ongoing
attack of vertigo but sometimes patient may feel a
sense of ear fullness, change in character of tinnitus
and discomfort in ear.

12.  Severe attacks may be accompanied by other
symptoms ofvagaldisturbances such as
abdominal cramps, cold sweats, pallar and
bradycardia.
 Some case show tullio phenomenon.
 It is a condition where loud sounds or noise
produce vertigo and is due to distended
saccule lies against stapes footplate. it is also
seen in when three functioning windows in
ear.

13.  It is usually accompanies vertigo or may presede
it.
 Hearing improves after the attack and may be
nomal during the periods of of remission.
 Improvement in hearing during remission may
not be complete, some hearing loss being
added in every attack leading to slow and
progressive deterioration of hearing which is
permanent.
 DISTORTION OF SOUND – some patients
complain of distorted hearing. A tone of
perticular frequency apear normal in one ear
and of higher in other leading to diplacusis
 Intolerance to loud sound.

14.  It is low pitched roaring type and aggrevated
during acute attacks.
 Sometimes, it has a hissing character.
 It may persist during period of remission.
 Change in intensity and pitch of tinnitus may
be the warning symptom of attack.
4. SENSE OF EAR FULLNESS:- like other
symptoms it also fluctuats. It may accompany
or before an attack of vertigo.

15.  Patient often shows signs of emotional upset
due to fear of repitition of attacks.
 Earlear, emotional stress was considerd the
cause of menieres disease.

16.  OTOSCOPY:- No abnormality seen in
tympanic membrane.
 NYSTAGMUS:- it is seen only durig acute
attack. Quick component of nystagmus is
towards the unaffected ear.
 TUNNING FORK TEST:- indicates SNHL.
Rinne test is positive.
Absolute bone conduction is reduced in
affected ear.
Weber lateralised to better ear.

17.  1. PURE TONE AUDIOMETRY:- Indicates SNHL
A) In early stage:- low frequency affected and curve is
rising type
B & C) Later stage:- higher frequencies are involved curve
becomes flate or falling type

18. 2. ELECTROCOCHLEOGRAPHY:- It shows changes
diagnostic of menieres disease.
normally, ratio of summating paotential (SP) to
action potential is 30%. But in menieres disease
SP/AP ratio is greater than 30%

19. 3. GLYCEROL TEST:-
The test has a diagnostic and prognostic value.
Glycerol is dehydrating agent. When given orally, it
reduce endolymph pressure so that improvement
in hearing.
Patient is given glycerol (1.5ml/kg) with an equal
amount of water with a little flavouring agent like
lemon juice.
Audiogram and speech discrimination score are
recorded before and 1-2 hours after ingestiom of
glycerol.
An improvement of 10 dB and gain of 10% in
discrimination score makes the test positive.
There is also improvement in tinnitus and sense of
aural fullness.

20. 4. SPEECH AUDIOMETRY:-
 descrimination score is usually 55-85%
between the attacks but discrimination ability
much impaired during and immedietely
following an attack.
5. SPECIAL AUDIOMETRIC TEST:- they indicate the
cochlear nature of disease.
 A). Recruitment test is positive.
 B). Short increment sensitivity index (SISI) score
is better than 70%in two third of patient (normal
15%)
 C). Tone deacay test:- there is decay of less
than 20 dB.

21. A) COCHLEAR HYDROPS
B) VESTIBULAR HYDROPS
C) DROP ATTACK
D) LERMOYS SYNDROME

22.  Only cochlear sign and
symptoms of MD are
present
 Vertigo is absent
 In these case there is block
at the level of ductus
reuniens, so that
endolymph pressure is
limited to cochlea only.
Level of
block

23.  Also called tumerkins otolithic crisis.
 It is due to deformation of otolithic membrane of
utricle or saccule due to change in endolyphatic
pressure
 In these case there is sudden drops attack without
lack of consciousness.
 There is not vertigo and fluctuations in hearing
loss.
 Patient gets a feeling of having been pushed to the
ground.
 It is uncommon manifestion of of MD and occurs
either early or late couse of disease.


24.  Here symptoms of MD are seen in reverse order.
 First progressive deterioration of hearing
followed by an attack of vertigo, at which time
hearing recovers.
 D). VESTIBULAR HYDROPS
 In this varient only vastibular symptoms of MD
seen and cochlear symptoms are normal.

25. CLASSIFICATION Guidelines were given by AAOHNS.
 .Certain meniers-
confirmed by histopathology
 Definite Meniere’s –
> 2 spontaneous attacks of vertigo each lasting > 20
min
Hearing loss documented by PTA on atleast 1
occasion
Tinnitus or aural fullness on affected side
 Probable Meniere’s –
> 2 spontaneous attacks of vertigo + U/L hearing loss
+ tinnitus + aural fullness, all at the same time
 Possible Meniere’s –
> 2 attacks of spontaneous attacks of vertigo without
any auditory impairment

27.  GENERAL MEASURE:-
1) Reasurance. Patients anxiety can be relieved by
reasurance and by expalaing the true nature of
disease
2) Cessation of smoking. Nicotine causes
vasospasm. Smoking should be completely
stopped. For some pationts, this may be only
tratment
3) Low salt diet.
4) avoid axcessive intake of water.
5) avoid over intke of alcoho, coffee and tea.
6) Avoid stress and bring a lifestyle chamge

28.  During the acute attack, patient is
apprenhensive. Head movements provoke
giddiness. Therefore t/t consist of:
1) REASSURANCE And psychological support to
stop anxiety and worry.
2) BED REST with head supported on pillow to
prevent excessive movements.
3) IV FLUID and electrolyte administration to
combat their loss due to vomiting.

29. 4)VESTIBULAR SEDATIVES to relieve vertigo. They
should be given intravenously or intramuscularly
because of vomiting. Drug used in acute attack are
 Dimenhydrinate:- 50 mg iv stat
 Prochlorperazine:- 10 mg iv or 12.5 mg im
 Diazepam:- 5-10 mg iv. It reduce anxiety. Also
supress medial vestibular activity.
 Atropine:- 0.4 mg subcutaneosly

30. 5) vasodilators:- carbogen (5% Co2 with 95%
O2) is a good cerebral vasodilator and its
inhalation improves labyrinthine circulation.

31. 1). VESTIBULAR SEDATIVE:-
prochlorperazine 10 mg TDS Orally for 2 month
than dose reduced
to
5mg tds orally for 1 month
2). VASODILATORS Betahistine 8-16 mg TDS
orally. It icrease labyrinthine blood flow by
releasing histamine in the body.
3). DIURETICS furosamide 40 mg taken alternate
day with potassium supplement helps to control
recurrent attacks, if not controlled by above
measures. hydrochlorthiazide 12.5mg daily can
also be used

32. 4). ELIMINATION OF ALLERGENS:- Sometimes, a
food or inhalant allergen is responsible for
attacks.
 it should be found and eliminated or
desensitisation done.
5). HORMONES:- shoud be directly fine out
endocrinal disorder like hypothyroidism,
appropriate replacement therapy given.
 About 80% case can be effectively managed by
medical theraphy alone

33.  Gentamycin is maily vestibulotoxic.
 It has been used biweekly injection into middle
ear. Drug is absorbed through the round window
and causes destruction of vestibular labyrinth.
 60-80% patients gets some relief from
symptoms.
 Hearing loss in 4-30% patients withthis mode of
therapy.

34.  It is a wick made og polyvinyl acetate
 It directly delivers drug from external canal to
inner ear through roound wibdow. So patient
can avoid repeated intratymoaniv injection.

35.  1) CONSERVATIVE PROCEDURES:- they are used
in case where vertigo is disabling but hearing is
still useful and need to be preserved.
a) endolymphatic sac decompression
b) endolymphatic shunt operation
c) sacculotomy
d) cochleosacculostomy
e) section of vestiblar nerve
d) ultranic destruction of vestibular labyrinth

36. 1).DECOMPRASSION OF ENDOLYMPHATIC SAC
sucess rate is 81.6%
Donaldson line:- a imaginary line passing through
horizontal scc and bisects the posterior scc.this is
landmark for endolymphatic sac,which is located
below and along this line.

37. 2). ENDOLYMPHATIC SHUNT OPERATION.
A tube is put, connecting endolymphatic sac with
subarachnoid space, to drain excess endolymph.

38. 3) SACCULOTOMY:- (ficks operation)
 It is puncturing the saccule with a needle
through stapes footplate.
 A distended saccule lies against stapes
footplate, can be easily penetrated.

39. 4).SECTION OF VESTIBULAR NERVE:-
 The nerve is exposed by retrosygmoid or
middle cranial fossa aproach and selectively
sectioned.
 It control vertigo but preserves hearing.
5). Ultrasonic destruction of vestibular
labyrinth. cochlear function is preserved.

40. 2). DESTRUCTIVE PROCEDURE:- they totally
destroy cochlear and vestibular function so it is
used only when cochlear function is not
serviceable.
 Labyrinthectomy:-
 Membranous labyrinth is completely destroyed.
 It give relief from attacks of vrtigo.

41.  It is observed that intemittent positive pressure
deliverd to inner ear fluid brings relief from
symptoms of MD.
 Intemittend positve pressure wave can be delivered
through an instrument called meniett device.
 A prerequisite for this thearpy is insertion of
grommet tube so that device can deliver pressure
pressure waves to round window membrane via
grommet tube.

42.  Pressure wave passes through perilymph and
causes reduction o in endolymph pressure by
redistributing it through endolymphatic sac or
the blood vessels.

43.  Used for 5 minute 3 times a day.
 Patient can self administer the treatment at home.