Meniere's Disease Treatments and Medications

Meniere’s disease is a puzzling and chronic condition of the inner ear. When it first manifests, vertigo attacks can come on suddenly. Fortunately, these attacks abate as the condition progresses, but only to be replaced by hearing loss and balance problems. Living with Meniere’s will be a lifetime project, but treatments can help.

What is Meniere's disease?

Meniere’s disease is a condition in which fluid builds up in the inner ear. Swelling in the inner ear causes vertigo (spinning sensation and dizziness), ringing in the ears (tinnitus), hearing problems, and pressure or “fullness” in the ear. Meniere’s typically involves only one ear, but both ears can be affected in some cases. Meniere’s is a rare condition, but estimates vary widely because the condition is substantially underdiagnosed. According to The National Institute on Deafness and Other Communication Disorders (NIDCD), around 620,000 people in the U.S. have Meniere’s, and 45,500 are newly diagnosed every year.

Meniere’s is a chronic and slowly progressive disorder of the inner ear that can interfere with daily life. Severe cases can be disabling, making people unable to work or perform daily functions, such as driving. As a progressive disease, Meniere’s passes through three separate stages. In the earliest stage, vertigo attacks are the primary symptom, clustering in six to 11 episodes per year followed by a few months or even years of complete remission. In later stages, vertigo becomes less common. Most patients with Meniere’s don’t have vertigo attacks eight years after diagnosis. In the later stages, hearing loss and balance problems become the principal symptoms. For most patients, hearing loss can be corrected with hearing aids, but some patients will lose their hearing in the affected ear.

The inner ear is filled with a fluid called endolymph. It is produced by a gland called the endolymphatic sac and circulates through the three major structures in the inner ear: the cochlea, the vestibule, and the semicircular canals. The cochlea translates sounds into nerve signals to the brain. The other two structures sense the movement of the head and gravity and send those signals to the brain. All three structures use movement or disturbances in the endolymph to sense sound or movement.

In Meniere’s disease, the endolymphatic sac produces too much fluid, a condition known as endolymphatic hydrops. The swelling interferes with the ability of the inner ear to sense movement or sound, resulting in hearing loss and dizziness.

No one is certain what causes Meniere’s disease, but it is believed to be an autoimmune disorder. The body’s immune system, designed to attack foreign invaders, mistakenly targets the endolymphatic sac, resulting in an overproduction of endolymph.

How is Meniere's disease diagnosed?

The diagnosis of Meniere’s disease is made from an assessment of symptoms, hearing tests, eye tests, and imaging. Many patients may start with a general practitioner or emergency room physician, but the condition will be definitively diagnosed and treated by an otolaryngologist, a doctor who specializes in conditions of the ear, nose, and throat.

The defining symptom of Meniere's disease is unpredictable episodes of vertigo that last longer than 20 minutes. Vertigo feels like one’s head or the world is spinning around. In Meniere’s disease, vertigo can sometimes be severe, last for hours, and take several days to recover from.

Besides vertigo, other Meniere’s disease symptoms include:

• Ringing or roaring in the ear (tinnitus)

• Hearing loss

• Pressure in the ear

• Nausea and vomiting due to dizziness

• Uncontrolled horizontal eye movements (nystagmus)

“Drop attacks,” or sudden falls without loss of consciousness, are also common.

A healthcare provider will first try to identify if the problem is caused by the brain, the inner ear, or the circulatory system. To help determine the cause, be prepared to answer questions during the medical history, such as:

• Are there hearing problems?

• Headaches?

• Does dizziness start when standing up suddenly?

• Have you had previous episodes of vertigo?

• Do you have ringing in the ears?

In the medical history, the doctor will also assess for risk factors for Meniere’s disease, such as:

• Age

• Family history of inner ear problems

• Excess salt in the diet

• Stress

• Autoimmune disorders

• History of viral infections

• Allergies

A physical examination will include an ear exam, testing the facial nerves, and examining the eyes for involuntary movements.

The physician will test hearing with a tuning fork to determine which ear is affected and to determine if the inner ear or middle ear has a problem. Involuntary eye movements (nystagmus) will be measured by an electronystagmography (ENG) device, Frenzel goggles, or infrared goggles.

An otolaryngologist will perform a vestibular evoked myogenic potential (VEMP) test to measure how well the inner ear is working. Finally, all patients will undergo a full audiometric examination conducted by an audiologist to determine the exact nature of any hearing loss. Patients will also undergo magnetic resonance imaging (MRI) to identify any possible nerve problems such as infections, tumors, swelling, or neurological issues.

Meniere's disease treatment options

Treatment of Meniere’s disease focuses either on lowering inner ear fluid (endolymphatic) or controlling symptoms. No treatment cures the disease, so treatment is a trade-off of improving symptoms with the fewest side effects. Treatment will start with the most conservative treatments: diet, physical therapy, and medications to control vertigo.

Low-sodium diet

Reducing sodium in the diet may help lower the fluid build-up in the inner ear, helping to prevent Meniere disease attacks. A salt-restricted diet is a first-line therapy for Meniere’s disease.

Vestibular rehabilitation

Physical therapy will focus on training the brain to use sensory clues other than the inner ear to maintain balance and prevent vertigo. These include exercises to practice balance, stabilize the gaze, reduce visual dependency for balance, and exercises that involve using the eyes along with head and body movements. Vestibular rehabilitation can be carried out by a vestibular rehabilitation specialist, a physical therapist, an audiologist, or done at home.

Meniett therapy

The Meniett device uses low-frequency air pulses to displace excess fluid in the ear. A small ventilation tube has to be inserted into the eardrum to allow the pulses to pass into the middle ear. Studies are mixed as to its effectiveness, but it may be useful as a second-line therapy for some patients. The device, however, must be used several times every day.

Medications

Medications can be used to treat or prevent episodes of vertigo, nausea, and tinnitus. Antivertigo drugs or vestibular suppressant agents primarily reduce the brain’s sensitivity to the nerve signals from the inner ear. Corticosteroid injections into the inner ear help reduce swelling. Finally, for people with severe vertigo attacks, gentamicin injections are used to kill off (ablate) inner ear tissues.

Surgery

Surgical procedures are used only for debilitating vertigo symptoms in cases that do not respond to less invasive procedures.

• Endolymphatic sac decompression and shunt: A surgeon will make an incision in the endolymphatic sac that allows fluid to drain out through a shunt. Alternatively, some surgeons may pinch the duct leading from the sac closed with metal clips. Endolymphatic sac decompression reduces Meniere’s symptoms while preserving hearing.

• Vestibular neurectomy (vestibular nerve section): A surgeon cuts the vestibular nerve that connects to the vestibular part of the inner ear to the brain. This cuts off the nerve signals that cause vertigo. Signals from the hearing part of the inner ear, the cochlea, are preserved. Hearing in the ear is not destroyed, but there may be some hearing loss.

• Labyrinthectomy: For the most debilitating cases, the surgeon will remove the semicircular canals, the vestibule, and the cochlea. A labyrinthectomy destroys all hearing in the affected ear, so it’s only reserved for patients with hearing loss so severe that it can’t be corrected with a hearing aid.

Meniere's disease medications

Medical treatment of Meniere’s either reduces fluid in the inner ear or is meant to control symptoms. Therapy will begin with the most conservative drugs—diuretics to reduce inner ear fluid and antihistamines to treat vertigo attacks.

Diuretics

Diuretics cause the body to shed excess fluid in the urine. These drugs help reduce the build-up of fluid in the inner ear to prevent and reduce. Diuretics are a first-line medical therapy along with a low-salt diet to reduce Meniere’s symptoms. The most commonly prescribed are Dyazide (triamterene and hydrochlorothiazide) and Diamox (acetazolamide).

Vestibular suppressants

Vestibular suppressants are used to control active episodes of dizziness and nausea brought on by an episode of vertigo. Although these medications belong to other drug classes, they all work by suppressing nerve signals from the inner ear balance organs.

Worldwide, the first-line therapy for Meniere’s vertigo attacks is betahistine, an antihistamine that reduces swelling and improves blood flow in the inner ear. However, betahistine is not available in the United States, so promethazine is more commonly prescribed as a first-line therapy for vertigo attacks. Meclizine is another drug that blocks histamines, but it works by slowing down the part of the central nervous system that responds to signals from the inner ear.

Other vestibular suppressants also work by slowing down the central nervous system. They include prochlorperazine (an antipsychotic), ondansetron (a drug that prevents nausea), benzodiazepines (diazepam or lorazepam), and antidepressants such as amitriptyline. However, these drugs can have serious and frequently-experienced side effects.

Corticosteroids

A small-dose injection of a corticosteroid, such as methylprednisolone or dexamethasone, through the eardrum into the inner ear will block substances that cause swelling. Symptom remission can be rapid and last for several weeks. The effects, however, are not permanent. Some otolaryngology doctors may prescribe oral steroids for Meniere’s, but this is rare.

Aminoglycoside antibiotics

Aminoglycosides are antibiotics—drugs used to treat bacterial infections—that are toxic to the inner ear, that is, they kill cells in the inner ear. Gentamicin is the preferred drug because it primarily kills off vestibular (balance) cells rather than cochlear (hearing) cells, so it may be less likely to affect hearing. The idea is to weaken vestibular signals to the brain to the point where they no longer provoke vertigo or nausea. Gentamicin is typically injected through the eardrum and removed from the inner ear after about 30 minutes. Low-dose or high-dose injections are repeated daily, weekly, or monthly until vertigo episodes have subsided. The injections are then discontinued when vertigo attacks have abated. There is no standard protocol or dosage; some healthcare providers will only use a single low-dose injection.

What is the best medication for Meniere's disease?

Meniere’s disease is not perfectly understood. For this reason, medications are used to relieve symptoms of Meniere’s while minimizing side effects. Not every medicine works the same in every person, so there is no best medication for Meniere’s.

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Best medications for Meniere’s disease