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Updated 2008 Aug 11 11:29 AM: review article notation (Lancet 2008 Aug 2) Links added to drug topics vestibular rehabilitation may improve subjective dizziness in patients with unilateral peripheral vestibular dysfunction (Cochrane Library 2007 Issue 4) General Information (including ICD-9/-10 Codes) Description:
z rare idiopathic disorder of inner ear characterized by recurrent, spontaneous Also called:
z Meniere's syndrome (if secondary to known cause) ICD-9 Codes:
{ 386.01 active Meniere's disease, cochleovestibular { 386.02 active Meniere's disease, cochlear { 386.03 active Meniere's disease, vestibular ICD-10 Codes:
Organs Involved:
z inner ear, specifically cochlea, vestibular apparatus and membranous z rates of bilateral involvement reported to vary from 2% to 78%(1,2 ) Who is most affected:
z reviews vary regarding ages of peak onset { ages 40-60 years (Acta Otolaryngol 1985 Mar-Apr;99(3-4):445 as http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 z may affect women more often than men (1.3:1)(2 ) or may affect men and Incidence/Prevalence:
true incidence unknown due to inconsistency in establishing diagnosis(1 ) z estimated prevalence of Meniere's disease
{ 157 per 100,000 persons in United Kingdom References - Laryngoscope 1983 Sep;93(9):1217 as referenced in(2 ), Acta Otolaryngol Suppl 1995;519:206, Arch Otolaryngol 1978 Feb;104(2):99 z annual age-adjusted incidence 15.3 per 100,000 in Rochester,
Minnesota (1951-1980)
{ based on 180 cases of Meniere's disease identified over 30 years { slight female preponderance (16.3:13.3) but not significant { Reference - Laryngoscope 1984 Aug;94(8):1098 z most common causes of vertigo in general practice are benign
positional vertigo, acute vestibular neuronitis, and Meniere's
disease
{ these 3 diagnoses accounted for 93% diagnoses among 70 patients with vertigo presenting to 13 general practitioners in prospective { Reference - Br J Gen Pract 2002 Nov;52(482):809 unknown, likely caused by multiple factors(1,3 ) { anatomical abnormality of temporal bone(3 ) { viral infection leading to antigenic mimicry and persistent „ theory supported by evidence of immune complex deposition in endolymphatic sac (Otolaryngol Head Neck Surg 1996 Mar;114(3):360) „ conflicting evidence regarding IgE titers to certain viruses in { ischemia of endolymphatic sac and inner ear(2 ) Pathogenesis:
http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 z increased volume of endolymph (potassium-rich fluid) in inner ear due to overproduction or inadequate absorption causes expansion of z progressive distension (and/or rupture) of membranous labyrinth (endolymphatic hydrops), which contains cochlear and vestibular apparatus(1,2 ) z vertigo and balance problems may be caused by injury to vestibular apparatus from endolymphatic hydrops (change in the volume and/or compostion of cochlear fluid)(1 ) z hearing loss may result from injury to cochlea from endolymphatic hydrops z presence of endolymphatic hydrops not absolute requirement for diagnosis z distention of endolymphatic compartment (scala media) in cochlea also { Reissner's membrane separates endolymphatic compartment (scala media) from perilymphatic compartment (scala vestibuli) { Reissner's membrane ruptures in some patients, resulting in mixture { shift in electrolyte balance with mixture of perilymph and endolymph „ alteration of depolarization and repolarization of vestibular „ disruption of hair cell motility leads to deafness „ disruption of vestibular neural function leads to vertigo Possible risk factors:
{ 7.7% patients with Meniere's disease have family history of Meniere's disease with autosomal dominant inheritance, about 60% penetrance (J Laryngol Otol 1995 Jun;109(6):499) z metabolic dysfunction affecting sodium and potassium balance in inner ear Complications:
z decreased quality of life (Otol Neurotol 2001 Nov;22(6):888) Associated conditions:
z endolymphatic hydrops (increased endolymph pressure in membranous z Meniere's disease associated with migraine
{ among 78 patients with Meniere's disease, 56% lifetime prevalence of { among 78 orthopedic patients (controls), 25% lifetime prevalence of http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 { Reference - Neurology 2002 Dec 10;59(11):1700 z Meniere's disease associated with treated hypothyroidism
{ 50 patients with Meniere's disease compared to 50 matched controls without Meniere's disease who were evaluated for dizziness { 16 (32%) cases vs. 2 (4%) control were taking thyroid hormone { Reference - Arch Otolaryngol Head Neck Surg 2004 Feb;130(2):226 { DynaMed commentary - conclusion should be considered hypothesis- generating given small numbers and case-control design z Lermoyez’s syndrome - rare variant of Meniere’s disease in which progressive deterioration of hearing is followed by vertigo, after which hearing improves (Laryngorhinootologie 1996 Jun;75(6):372) Chief Concern (CC):
z classic triad of symptoms(1,3 )
{ vertigo - illusion of movement of self or one's surroundings (e.g. „ vertigo may present as abnormal unpleasant sensation of „ patient often complains of dizziness, but whenever possible, dizziness should be clarified since it can mean { progressive sensorineural hearing loss z other common symptoms(1 )
z drop attacks - sudden unexplained falls without loss of consciousness or History of Present Illness (HPI):
z clinical course varies between patients(2 ) z frequently presents initially with episodes of intense vertigo, then later progressive hearing loss (low and high frequency) z ask about frequency and duration of acute attacks and severity of { duration of acute attacks ranges from minutes to hours, usually 2-3 http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 { acute episodes can occur in clusters (about 6-11 per year) { periods of remission can last several months z between attacks, patients may be asymptomatic or may have z typical stages of Meniere's disease(3 )
„ vertigo is predominant symptom, typically rotatory or rocking and associated with nausea and/or vomiting „ pallor and sweating may occur with vertigo, but no loss of „ often preceded by aura of fullness or pressure in ear or side of head lasting 20 minutes to several hours „ hearing reverts to normal between attacks { stage 2 - vertigo and fluctuating hearing loss „ hearing loss is established, but continues to fluctuate „ sensorineural deafness primarily affecting lower pitches „ vertigo reaches peak severity then becomes less severe „ remission is highly variable, often lasting several months „ hearing loss progressively worsens, and becomes bilateral „ episodes of vertigo disappear, although patient may still be z frequency and duration of vertigo attacks
{ based on prospective cohort of 243 consecutive patients with definite diagnosis of Meniere's disease referred to vestibular laboratory, with disease duration ranging from recent onset to 41 years „ continuous vertigo for 5% patients. continuous vertigo was more common (21%) in patients who had Meniere's disease for { Reference - Arch Otolaryngol Head Neck Surg 2004 Apr;130(4):431 Medication History:
z medications that can affect vestibular system include http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 Family History (FH):
z ask about family history of Meniere's disease(1 ) Social History (SH):
ask about how condition affects quality of life, such as(1 ) General Physical:
z no physical exam findings specific to Meniere's disease(1 ) z blood pressure (supine and standing)(1 ) z hearing tests (Weber and Rinne's tests)(1 ) z examine cervical spine for vertigo associated with cervical spondylosis and z for patients presenting with vertigo, consider evocative testing (Hallpike maneuver) to rule out benign positional paroxysmal vertigo (BPPV) z examine cranial nerves to consider other causes of vertigo, deafness and z Romberg test and finger-nose test for assessment of gait and coordination z evaluate deep tendon reflexes and sensation for signs of peripheral Making the diagnosis:
z clinical diagnosis based on history and physical exam(1 ) z American Academy of Otolaryngology-Head and Neck Surgery diagnostic { vertigo ≥ 2 spontaneous episodes lasting ≥ 20 minutes during single { tinnitus with or without perception of aural fullness { sensorineural hearing loss confirmed by audiometry on at least 1 http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 occasion (may be difficult to confirm in early stages of disease(1 )) { (symptoms may not be present simultaneously or in same pattern) { Reference - Otolaryngol Head Neck Surg 1995 Sep;113(3):181 as referenced in(1,2 ), commentary can be found in Otolaryngol Head Neck Surg 1996 Jun;114(6):835 Rule out:
z other causes of vertigo
{ benign paroxysmal positional vertigo (common cause of vertigo)(1,3 ) { vestibular neuronitis - sudden onset of acute vertigo, nausea and infective labyrinthitis(3 ) - vertigo only occurs in acute phase { secondary or delayed endolymphatic hydrops - otosclerosis, trauma, labyrinthine fistula or thrombosis(1,3 ) { cerebellopontine tumors(1,3 ), such as acoustic neuroma (rare cause of vascular lesions(1,3 ), such as vascular loop compression of cranial z other causes of unsteadiness(3 )
{ active chronic suppurative otitis media { peripheral neuropathy as cause of unsteadiness z Cogan's syndrome (keratitis, hearing deficit, tinnitus, vertigo, polyarteritis { vasculitis manifestations relatively uncommon in retrospective review of 60 patients with Cogan syndrome (Mayo Clin Proc 2006 Apr;81(4):483 EBSCOhost Full Text)
http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 { case presentation of Cogan syndrome can be found in N Engl J Med EBSCOhost Full Text
Testing to consider:
z audiometry for diagnostic confirmation of sensorineural hearing loss z glycerol dehydration test may be specific audiometric test but may be z MRI of cerebellum and pontine angle might be used to rule out tumor or z consider prolactin level, especially in severe cases
{ study of 42 Meniere's patients hospitalized for neurectomy of vestibular nerve for relief of incapacitating vertigo { 14 (33%) had hyperprolactinemia (> 20 mcg/L), 6 were further investigated and had prolactinoma confirmed by MRI { Reference - Neuropsychopharmacology 2002 Jan;26(1):135 in BMJ Imaging studies:
z MRI of temporal bone may show abnormal findings in Meniere's
{ based on MRI studies in 21 patients with Meniere's disease (12 had unilateral, 9 had bilateral disease) compared to images from 30 { endolymphatic duct appeared less visible in patients with Meniere's { distance from posterior semicircular canal to posterior temporal border bilaterally reduced in patients with Meniere's disease { no differences between symptomatic and asymptomatic ears in { no relationship between visualization of endolymphatic duct and disease progression or response to treatment { Reference - Acta Otolaryngol 2000 Aug;120(5):615 EBSCOhost
Full Text
z American College of Radiology (ACR) Appropriateness Criteria for vertigo and hearing loss can be found at National Guideline Clearinghouse 2006 Sep 4:9602 Other diagnostic testing:
z audiometry
{ hearing loss confirmed by audiometry to be sensorineural hearing loss is part of diagnostic criteria for Meniere's disease(1 ) audiometric assessment may be impractical during acute attack(1 ) hearing loss may be transient in early stages of disease(1 ) { test loudness recruitment
„ defined as abnormal growth of perceived loudness with „ must have normal hearing in unaffected ear to detect abnormality (by comparison) in affected ear „ 100% sensitive in series of 200 patients with Meniere's disease (Acta Otolaryngol 1959 Nov-Dec;50:472), but not specific for Meniere's disease http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ Reference - Otolaryngol Clin North Am 1997 Dec;30(6):987 { glycerol dehydration test
„ measures audiometric response to oral dose of glycerol(3 ) „ improvement in scores for hearing low frequency sound and „ glycerol dehydration test reported to have 47-60% sensitivity and 93-98% specificity for endolymphatic hydrops (Otolaryngol Clin North Am 1997 Dec;30(6):987) „ results of glycerol test may be affected by suggestion
„ patients with typical Meniere's syndrome randomized to have glycerol test done twice with same dose of glycerol but with different flavors, once with suggestion that hearing would improve and once with suggestion that hearing would worsen „ audiologist unaware of patient instructions (suggestion) „ patients usually responded as instructed „ Reference - J Otolaryngol 1979 Apr;8(2):145, also published in Adv Otorhinolaryngol 1979;25:49 z electrocochleography
{ highly characteristic waveform in hydrops(3 ) { negative results may occur in early or late stages of disease(3 ) { electrocochleography may be useful for diagnosis of
endolymphatic hydrops
„ based on prospective study of electrocochleography recordings from > 500 ears with diagnosis suggestive of Meniere's disease „ Reference - Acta Otolaryngol 2000 Jun;120(4):480 EBSCOhost Full Text
{ EMLA cream may reduce discomfort associated with
transtympanic electrocochleography (level 2 [mid-level]
evidence)
„ 46 patients having unilateral transtympanic electrocochleography were randomized to EMLA cream as „ EMLA cream associated with less discomfort during procedure „ Reference - Auris Nasus Larynx 1998 May;25(2):137 z anti-68kd antibody may be present in inner ear material of patients with Meniere's disease (Laryngoscope 1995 Dec;105(12 Pt 1):1347), commentary can be found in Laryngoscope 1997 Mar;107(3):405 Prognosis:
z normal lifespan (Meniere's disease is not fatal) z quality of life affected, especially if progressive hearing loss or intractable http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 z long-term outcomes appear similar with or without surgical
intervention
{ based on retrospective study comparing 83 patients with Meniere's disease who had surgery and 50 patients who declined surgery { control of vertigo among non-surgical patients „ 71% at last follow-up of mean 8.3 years { control of vertigo among surgical patients „ 40% at 2 years after endolymphatic subarachnoid shunt „ 70% at mean 8.7 years after endolymphatic subarachnoid „ 93% at mean 4.4 years after neurectomy { Reference - Otolaryngol Head Neck Surg 1989 Jan;100(1):6 Treatment overview:
z refer to ear, nose and throat (ENT) specialist to confirm diagnosis z explanation of disorder and variable prognosis z hearing amplification may be only clearly beneficial treatment z treatments to provide rapid relief during acute attack may include anticholinergic, antihistamine, benzodiazepine or phenothiazine (grade C
recommendation [lacking direct evidence])
z low-salt diet plus diuretics reported to improve vertigo and delay hearing loss (level 3 [lacking direct] evidence)
z no clear evidence that diuretics have any beneficial effects on Meniere’s disease, but triamterene 50 mg/hydrochlorothiazide 25 mg (Dyazide) associated with improvement in vestibular symptoms in 1 trial (level 2
[mid-level] evidence)
{ self-management with vestibular rehabilitation may reduce symptoms associated with Meniere's disease (level 2 [mid-level] evidence)
{ vestibular rehabilitation improves subjective dizziness in patients with unilateral peripheral vestibular dysfunction (level 1 [likely reliable]
evidence) (in trials not specific to Meniere's disease)
z betahistine hydrochloride (Serc) 16 mg 2-3 times daily might reduce { insufficient evidence regarding betahistine for Meniere's disease, { betahistine dihydrochloride may be effective for vertigo due to Meniere's disease (level 2 [mid-level] evidence)
{ betahistine may be more effective than prochlorperazine maleate or flunarizine but less effective than trimetazidine (level 2 [mid-level]
evidence)
{ generic betahistine available in United States by prescription through z intratympanic gentamicin may reduce frequency of or eliminate vertigo attacks (level 2 [mid-level] evidence)
z multiple other medications have very limited evidence of benefit z Meniett device (portable low-intensity alternating pressure generator) http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 appears safe and effective for vertigo symptoms (level 2 [mid-level]
evidence)
z various hearing-sparing surgeries appear to have similar efficacy to each other, but endolymphatic shunt procedure appears no better than placebo surgery (level 2 [mid-level] evidence)
z dietary modification in Meniere's disease not evaluated in randomized trials, z low salt diet (< 2 g/day) has been recommended (grade C
recommendation [lacking direct evidence])
{ thought to be useful for decreasing production and accumulation of endolymph for prevention of vertigo(2,4 ) { not evaluated in randomized trials(4 ) { DynaMed commentary -- diet expected to have very little influence on { low-salt diet plus diuretics reported to improve vertigo and
delay hearing loss (level 3 [lacking direct] evidence)
„ based on uncontrolled retrospective study „ 54 patients with Meniere's disease who were treated with diuretics and low-salt diet were evaluated „ 79% had complete or substantial control „ 19% had limited or insignificant improvements „ Reference - Otolaryngol Head Neck Surg 1993 Oct;109(4):680 „ similar results reported in series of 500 consecutive patients treated with low sodium diet and diuretics, in review of 20 years of practice at University of Michigan (Ann Otol Rhinol Activity:
moving around after acute attack may promote vestibular rehabilitation(1 ) z vestibular rehabilitation exercises
{ may be useful for patients who have(1 ) „ acute attacks of vertigo that are far apart and have motion- „ recurrent motion-provoked imbalance despite treatment { self-management with vestibular rehabilitation may reduce
symptoms associated with Meniere's disease (level 2 [mid-
level] evidence)
„ based on randomized trial without attention control „ 360 patients with Meniere's disease were randomized to receive vestibular rehabilitation self-management booklet vs. symptom control self-management booklet vs. waiting list control http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ vestibular rehabilitation consisted of provoking controlled dizziness by making repeated head movements to promote neurological and psychological habituation „ symptom control consisted of using applied relaxation, challenging negative beliefs, and lifestyle modification to reduce „ both intervention groups reported greater enablement „ vestibular rehabilitation associated with reduced symptoms, anxiety, handicap and negative beliefs „ symptom control associated with reduced handicap „ 37.5% vestibular rehabilitation vs. 39.2% symptom control vs. 15.8% control group reported improvement at 6 months „ Reference - Psychosom Med 2006 Sep-Oct;68(5):762, commentary can be found in Evid Based Med 2007 Aug;12 { other trials showing reduction in dizziness symptoms with vestibular rehabilitation were not specific to Meniere's disease „ vestibular rehabilitation may improve subjective
dizziness in patients with unilateral peripheral vestibular
dysfunction (level 2 [mid-level] evidence)
„ based on Cochrane review with clinical heterogeneity „ systematic review of 21 randomized trials evaluating vestibular rehabilitation in community-dwelling adults with symptomatic unilateral peripheral vestibular dysfunction „ vestibular rehabilitation was compared to sham intervention (control), non-vestibular rehabilitation interventions or other forms of vestibular rehabilitation „ comparing vestibular rehabilitation vs. control/placebo „ methods of vestibular rehabilitation varied across trials so unclear if meta-analysis is appropriate despite lack of statistical heterogeneity „ 48.9% vestibular rehabilitation vs. 26.5% control/placebo patients had subjective improvement in dizziness in analysis of 4 trials with 565 patients (p < 0.00001, NNT 5) „ movement-based vestibular rehabilitation less effective than physical maneuvers for BPPV for short-term cure rate (62% vs. 93%, p = 0.004) in 1 trial with 71 patients „ Reference - systematic review last updated 2007 Aug 22 (Cochrane Library 2007 Issue 4:CD005397) „ vestibular rehabilitation (based on head and eye
exercises, delivered by primary care nurse) reduces
symptoms of chronic dizziness that may be of
labyrinthine origin (level 1 [likely reliable] evidence)
„ 170 patients with dizziness for at least 2 months http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 (excluding patients with documented nonlabyrinthine cause of dizziness) and dizziness in response to head and eye exercise movements were randomized to vestibular rehabilitation vs. control (3-month delay) „ vestibular rehabilitation included 30-40 minutes with trained nurse for instructions on head and neck exercises to be done twice daily for 12 weeks or until exercises no longer provoked dizziness, and follow-up telephone calls „ 10 patients dropped out but intention-to-treat analysis „ at 3 months, vestibular rehabilitation significantly improved scores for vertigo symptoms (9.9 vs. 13.3, with 3-point difference considered clinically significant), movement-provoked dizziness (14.6 vs. 20.7 on 36-point scale), postural stability, and dizziness handicap (31.1 vs. 35.9 on 75-point scale) „ Reference - Ann Intern Med 2004 Oct 19;141(8):598 EBSCOhost Full Text, editorial can be found in Ann
EBSCOhost Full
Text, commentary can be found in Ann Intern Med 2005
Feb 15;142(4):309
EBSCOhost Full Text, Am Fam
Physician 2005 Jul 15;72(2):330 full-text „ vestibular rehabilitation may reduce symptoms of
dizziness and vertigo (level 2 [mid-level] evidence)
„ based on randomized trial with multiple methodologic „ 159 patients from 10 general practices with diagnoses of or medications prescribed for dizziness were identified „ average duration of dizziness 6-8 years „ patients were excluded if unable to perform vigorous head and body movements, dizziness was non-vestibular, or patients had multiple or serious central disorders „ patients with dizziness (idiopathic or due to vestibular dysfunction) randomized to Vestibular Rehabilitation exercises (40-minute session given by nurse that included education about causes of dizziness, standard head and body movements, and training in relaxation) vs. regular medical treatment „ several serious challenges to validity of study include „ 27% lost to follow up at 6 months (37% treatment „ positive effect noted at 6-month follow-up in treatment group for all areas measured except perceived handicap „ 26% vs. 17% patients rated themselves as better http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ 29% vs. 23% patients rated themselves as better „ Reference - Br J Gen Pract 1998 Apr;48(429):1136 PDF, editorial can be found in Br J Gen Pract 1998 Apr;48(429):1128 PDF, commentary can be found in Br J Gen Pract 1998 Jul;48(432):1434 PDF, J Fam Pract 1998 Sep;47(3):176 Counseling:
z advice for patients with Meniere's disease(1 ) { keep medication easily available and accessible, especially in patients { avoid high risk activities (e.g. driving, operating dangerous „ in United Kingdom, patients required to inform Driver and Vehicle Licensing Agency of diagnosis, driving restrictions depend on type of license and symptom control { patients with symptomatic tinnitus should avoid silent environments z psychological support in Meniere's disease may have positive effect on disease management, but not evaluated in randomized trials(1,4 ) z self-management through information booklets may reduce
symptoms associated with Meniere's disease (level 2 [mid-level]
evidence)
{ based on randomized trial without attention control { 360 patients with Meniere's disease were randomized to receive vestibular rehabilitation self-management booklet vs. symptom control self-management booklet vs. waiting list control { vestibular rehabilitation consisted of provoking controlled dizziness by making repeated head movements to promote neurological and psychological habituation { symptom control consisted of using applied relaxation, challenging negative beliefs, and lifestyle modification to reduce amplification of dizziness by anxiety „ both intervention groups reported greater enablement than „ vestibular rehabilitation associated with reduced symptoms, „ symptom control associated with reduced handicap { 37.5% vestibular rehabilitation vs. 39.2% symptom control vs. 15.8% control group reported improvement at 6 months { Reference - Psychosom Med 2006 Sep-Oct;68(5):762, commentary can be found in Evid Based Med 2007 Aug;12(4):111 Medications:
z treatments to provide rapid relief during acute attack (grade C
recommendation [lacking direct evidence])(1,3 )
{ intramuscular prochlorperazine (Compazine) for severe symptoms http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 { oral prochlorperazine or antihistamine (e.g. cinnarizine, cyclizine, promethazine or diazepam) for 7 days if symptoms less severe { reassess if symptoms do not improve after 7 days of treatment { for short-term use only, prolonged use can cause extrapyramidal adverse effects, especially in elderly patients { no randomized trials identified to evaluate benzodiazepines, betahistine, cinnarizine, or phenothiazines for treatment of acute { meclizine (Antivert) may reduce vertigo
„ based on randomized crossover trial (with only 4 Meniere's „ 31 patients with vertigo (only 4 had Meniere's disease) randomized to meclizine 25 mg vs. placebo orally 3 times daily for 1 week each in crossover fashion „ 27 (87%) patients included in statistical analysis „ 19 (70%) vs. 10 (37%) had improvement in frequency of „ 18 (67%) vs. 9 (33%) had improvement in severity of „ Reference - Arch Neurol 1972 Aug;27(2):129 { glycopyrrolate (Robinul)
„ glycopyrrolate 2 mg twice daily as needed for 4-6 weeks (but not placebo) associated with reduced symptoms in trial with 37 patients with Meniere's disease (Laryngoscope 1998 Oct;108 z betahistine
{ antagonist to histamine H3 receptors, used for vertigo { has been described as both antihistamine and vasodilator, also shown to affect cochlear blood flow through cholinergic receptors in rats (Am { Serc is brand name for betahistine hydrochloride { preferred antivertiginous drug in Europe (Otolaryngol Clin North Am { consider trial of betahistine 16 mg 3 times daily for 6-12 months to { insufficient evidence regarding betahistine for Meniere's
„ based on Cochrane review of limited evidence „ systematic review of 6 randomized trials evaluating betahistine „ no trial had highest methodological quality, no trial assessed „ most trials suggested reduction in vertigo „ reductions in tinnitus were inconsistent „ Reference - systematic review last updated 2000 May 22 (Cochrane Library 2001 Issue 1:CD001873) http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 { betahistine dihydrochloride may be effective for vertigo due to
Meniere's disease (level 2 [mid-level] evidence)
„ based on randomized trial with allocation concealment not „ 81 patients aged 18-65 years with recurrent vertigo due to Meniere's disease were randomized to betahistine 16 mg vs. placebo twice daily for 3 months „ betahistine associated with improvement in frequency, intensity and duration of vertigo attacks, associated symptoms and quality of life „ Reference - Eur Arch Otorhinolaryngol 2003 Feb;260(2):73 EBSCOhost Full Text
{ betahistine hydrochloride associated with improved symptoms
in patients with Meniere's disease (level 2 [mid-level]
evidence)
„ based on crossover trial with 21% dropout rate „ 28 patients with Meniere's disease given betahistine 32 mg vs. placebo daily for 16 weeks then crossed over to alternate treatment after 4 week washout „ betahistine associated with improved vertigo, tinnitus and „ Reference - Postgrad Med J 1976 Aug;52(610):501 { betahistine hydrochloride may be more effective than
prochlorperazine maleate (level 2 [mid-level] evidence)
„ based on small crossover trial with high dropout rate „ 30 patients with confirmed Meniere's disease were given betahistine vs. prochlorperazine for 4 months then crossed over to alternate treatment after 1 month washout „ betahistine associated with better therapeutic effect than „ betahistine and prochlorperazine comparable for number of vertigo attacks in analysis of 17 patients „ Reference - Ann Clin Res 1976 Aug;8(4):284 { betahistine dihydrochloride may be more effective than
flunarizine for treatment of vertigo (level 2 [mid-level]
evidence)
„ patients with recurrent vertigo of peripheral vestibular origin were randomized to betahistine dihydrochloride 48 mg orally vs. flunarizine 10 mg orally daily for 8 weeks „ 52 patients completed study and were analyzed „ vertigo evaluated using Dizziness Handicap Inventory (a validated self-assessment questionnaire, but not previously used to evaluate anti-vertigo medications) „ betahistine associated with significantly greater improvement on Dizziness Handicap Inventory and „ Reference - Acta Otolaryngol 2003 Jun;123(5):588 http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 EBSCOhost Full Text
„ 55 patients with recurrent paroxysmal vertigo characteristic of Meniere's disease were randomized to betahistine vs. „ betahistine associated with decreased duration and severity of vertigo attacks at 1 and 2 months, number of attacks, vestibular dysfunction and cochlear symptoms „ flunarizine associated with decreased duration and severity of vertigo attacks at 1 month only „ flunarizine - drowsiness, asthenia, depression „ Reference - Acta Otolaryngol Suppl 1991;490:1 { trimetazidine may be more effective than betahistine (level 2
[mid-level] evidence)
„ based on 2 randomized trials published in French „ 45 patients with possible Meniere's disease were randomized to trimetazidine 20 mg vs. betahistine 8 mg „ 5 patients dropped out, 40 patients analyzed „ comparing trimetazidine vs. betahistine „ 79% vs. 57% had improvement in overall evolution of disease (p = 0.027, NNT 5 favoring trimetazidine) „ 53% vs. 24% had complete disappearance of „ no differences in hearing or tinnitus „ trimetazidine associated with improved vertigo intensity, but not confirmed by analysis of available data „ Reference - Ann Otolaryngol Chir Cervicofac 1990;107 Suppl 1:20 [French] as referenced in(4 ) „ 20 patients with definite or probable Meniere's disease were randomized to trimetazidine 20 mg vs. betahistine 8 mg given 3 times daily for 3 months „ no differences in hearing, tinnitus, aural fullness, or „ trimetazidine associated with increased self-reported improvements in duration and intensity of vertigo „ Reference - Ann Otolaryngol Chir Cervicofac 1990;107 Suppl 1:11 [French] as referenced in(4 ) z diuretics
{ diuretics not recommended for prevention of recurrent attacks(1 ) { proposed mechanism of action - resorption of endolymph { no clear evidence that diuretics have any beneficial effects on
Meniere’s disease
http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ systematic review of randomized placebo-controlled trials of „ no trials of high enough quality met inclusion criteria for this „ 3 crossover trials (Acta Otolaryngol 1967 Apr;63(4):347, Fortschr Med 1982 Mar 11;100(10):431, ORL J Otorhinolaryngol Relat Spec 1986;48(5):287) were excluded due to inability to extract pre-crossover results „ Reference - systematic review last updated 2006 May 19 (Cochrane Library 2006 Issue 3:CD003599) { triamterene 50 mg/hydrochlorothiazide 25 mg (Dyazide)
associated with improvement in vestibular symptoms (level 2
[mid-level] evidence)
„ based on double-blind crossover trial in 33 patients „ no significant effect on hearing or tinnitus „ Reference - ORL J Otorhinolaryngol Relat Spec 1986;48(5):287 { low-salt diet plus diuretics reported to improve vertigo and
delay hearing loss (level 3 [lacking direct] evidence)
„ 54 patients with Meniere's disease who were treated with diuretics and low-salt diet were evaluated „ 79% had complete or substantial control „ 19% had limited or insignificant improvements „ Reference - Otolaryngol Head Neck Surg 1993 Oct;109(4):680 z intratympanic gentamicin
{ chemical labyrinthectomy (vestibular ablation) { used for patients who have failed conservative management and are { adverse effects include cochlear toxicity (hearing loss), ataxia, { intratympanic gentamicin may reduce frequency of or
eliminate vertigo attacks (level 2 [mid-level] evidence)
„ 22 patients with active Meniere's disease were randomized to gentamicin 4 mL (30 mg/mL) vs. placebo injected in middle ear every 6 weeks until symptoms controlled (maximum cumulative dose 360 mg in 12 applications or 6 months) „ mean number of applications 1.5 with gentamicin vs. 2.8 with „ both treatments associated with decreased mean number of http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 vertigo attacks per year compared to baseline (74 to 0 with gentamicin, 25 to 11 with placebo) „ Reference - Acta Otolaryngol 2004 Mar;124(2):172 EBSCOhost Full Text
{ intratympanic gentamicin might be more effective than
intratympanic dexamethasone for controlling vertigo (level 2
[mid-level] evidence)
„ based on small controlled trial published in Turkish „ 45 patients with Meniere's disease were given intratympanic gentamicin (40 mg/mL) 0.7 mL or dexamethasone (4 mg/mL) „ only 9 of 21 patients in dexamethasone group completed „ gentamicin associated with 92% rate of control of vertigo symptoms (22 patients) and 8% deterioration in hearing (2 patients) „ dexamethasone associated with 67% control of vertigo „ Reference - Kulak Burun Bogaz Ihtis Derg 2006;16(5):193 { intratympanic gentamicin might be effective for achieving
complete or substantial vertigo control (level 3 [lacking
direct] evidence)
„ based on 2 systematic reviews of mostly uncontrolled cohort „ systematic review of 15 prospective and retrospective cohort studies evaluating intratympanic gentamicin in 627 patients „ 74.7% achieved complete (class A) vertigo control (95% „ 92.7% achieved complete or substantial (class B) vertigo „ efficacy not affected by fixed vs. titration treatment „ no clinically important or statistically significant hearing „ Reference - Laryngoscope 2004 Dec;114(12):2085 „ systematic review of 35 studies evaluating intratympanic gentamicin injections in patients with Meniere's disease „ 89% patients had complete or substantial vertigo control (range 73-100%) in analysis of 34 studies „ 26% patients had hearing loss (range 0-90%) in analysis „ 57% patients had subjective improvement in tinnitus „ pooled results for 16 studies with minimum 2 years „ 87% patients had vertigo improvement (range 76- http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ 24% patients had hearing loss (range 0-75%) „ insufficient data to determine ideal dose or method of „ Reference - J Otolaryngol 2003 Dec;32(6):351 EBSCOhost Full Text
{ intratympanic gentamicin reported to be associated with long-
term relief of vertigo in most patients (level 3 [lacking direct]
evidence)
„ based on uncontrolled prospective study „ 103 patients with Meniere's disease treated with intratympanic „ 80% patients achieved complete control of vertigo „ 15.5% patients reported continued unsteadiness „ Reference - Laryngoscope 2007 Aug;117(8):1474 { titration method of intratympanic gentamicin injection
reported to be more effective than other techniques (level 3
[lacking direct] evidence)
„ based on systematic review limited by heterogeneity and only „ systematic review and meta-analysis of 27 studies evaluating intratympanic gentamicin delivery technique in 980 patients with Meniere's disease „ 81.7% with titration method (daily or weekly doses until onset of vestibular symptoms) in 6 studies with 269 patients, titration method more effective than other „ 66.7% with low-dose technique (1-2 injections with retreatment for recurrent vertigo) in 8 studies with 253 patients, low-dose technique less effective than other techniques (p < 0.001) „ 76.1% with multiple daily dosing (3 times daily for ≥ 4 „ 75% with weekly dosing (weekly injections for 4 total „ 70.5% with continuous microcatheter delivery in 4 „ rates of effective vertigo control (complete plus substantial „ 96.3% with titration method in 6 studies with 269 patients, titration method more effective than other techniques (p < 0.05) „ 86.8% with low-dose technique in 8 studies with 253 patients, low-dose technique less effective than other techniques (p = 0.05) „ no significant differences with multiple daily dosing (91.1%), weekly dosing (89.3%), or continuous (88.3%) http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ 13.1% with weekly dosing in 2 trials with 84 patients, trend toward less hearing loss than other techniques (p = 0.08) „ 34.7% with multiple daily dosing in 7 trials with 218 patients, associated with more hearing loss than other techniques (p < 0.02) „ no significant differences with low-dose (23.7%), titration „ estimated rate of profound hearing loss 6.6% overall, no significant differences between techniques „ Reference - Otol Neurotol 2004 Jul;25(4):544, commentary can be found in Otol Neurotol 2005 May;26(3):554 (commentary can be found in Otol Neurotol 2005 Sep;26(5):1094) { review of intratympanic gentamicin for Meniere's disease can be found in Laryngoscope 2000 Feb;110(2 Pt 1):236 z intratympanic latanoprost may be associated with reduction of
vertigo and improvement in speech discrimination (level 2 [mid-
level] evidence)
{ 10 patients aged 39-65 years with unilateral Meniere's disease were randomized to latanoprost vs. placebo (0.2-0.4 mL) injected into { latanoprost associated with reduction of vertigo or dysequilibrium (p = 0.039) and improved speech discrimination (p ≤ 0.05) { few patients had clinically relevant improvements (4 for vertigo, 2 for { no significant differences in visual analog score assessments of { Reference - Otolaryngol Head Neck Surg 2005 Sep;133(3):441 z intratympanic dexamethasone has very limited evidence of benefit
{ intratympanic dexamethasone injection might be effective for
treatment of Meniere's disease (level 2 [mid-level] evidence)
„ 22 patients with Meniere's disease (Shea's stage III) > 18 years old were randomized to intratympanic dexamethasone 4 mg/mL vs. placebo daily for 5 days „ 4 (36%) placebo patients dropped out due to need for „ comparing dexamethasone (11 patients) vs. placebo (7 „ 9 (82%) vs. 4 (57%) had completely controlled vertigo „ 2 (18%) vs. 2 (29%) had substantially controlled vertigo „ 48% vs. 20% had improvement in tinnitus „ 35% vs. 10% had improvement in hearing loss „ 48% vs. 20% had improvement in aural fullness „ none of these differences were statistically significant http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ Reference - Otolaryngol Head Neck Surg 2005 Aug;133(2):285 { intratympanic dexamethasone appears no better than placebo
in late stage Meniere's disease (level 2 [mid-level] evidence)
„ based on small randomized crossover trial „ 20 patients with unilateral Meniere's disease (Shea's stage IV) in private otology practice were randomized to intratympanic dexamethasone vs. placebo for 3 days each „ no significant differences in hearing loss or tinnitus „ Reference - Am J Otol 1998 Mar;19(2):196 „ DynaMed commentary -- this study involved patients in late stage Meniere's disease after vertigo had resolved, so does not provide information regarding treatment of vertigo { relief of vertigo in case series cannot be distinguished from
spontaneous remission (level 3 [lacking direct] evidence)
„ dexamethasone 4 mg/mL by intratympanic injection over 4 weeks reported to provide complete relief of vertigo in 11 of 21 patients (52%) at 3 months and 9 of 21 patients (43%) at 6 months in prospective case series (Laryngoscope 2001 Dec;111(12):2100) „ dexamethasone by intratympanic injections plus intramuscular routes did not significantly improve symptoms (aural fullness, hearing loss, tinnitus and vertigo) in series of 17 patients with Meniere's disease; 76% achieved sufficient control of vertigo, but this might be expected from spontaneous remission (ORL J Otorhinolaryngol Relat Spec 2000 May-Jun;62(3):117) z interventions with limited evidence of efficacy in single trials
{ combination cinnarizine plus dimenhydrinate appears to have
similar efficacy as betahistine dimesylate (level 2 [mid-level]
evidence)
„ based on randomized trial without placebo control „ 82 patients with Meniere's disease for ≥ 3 months with paroxysmal vertigo attacks, cochlear hearing loss and tinnitus were randomized to combination tablet containing cinnarizine 20 mg plus dimenhydrinate 40 mg (Arlevert) vs. betahistine dimesylate 12 mg 3 times daily for 12 weeks „ both treatments improved vertigo symptoms, tinnitus, and associated vegetative symptoms, but no significant differences between groups „ cinnarizine plus dimenhydrinate associated with improved „ Reference - Int Tinnitus J 2002;8(2):115 { oral prednisone may improve vertigo episodes and tinnitus
(level 2 [mid-level] evidence)
„ based on small open-label randomized trial „ 16 patients with Meniere's disease with limited vertigo control and severe disability were given diphenidol 25 mg/day plus acetazolamide 250 mg every 48 hours and randomized to prednisone 0.35 mg/kg orally vs. no additional treatment daily for 18 weeks „ prednisone associated with reduced frequency and duration of http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ no differences in aural fullness or hearing „ Reference - Otol Neurotol 2005 Sep;26(5):1022 { hydroxyethylrutosides associated with improved audiometric
findings and trend toward symptom improvement (level 2
[mid-level] evidence)
„ based on randomized crossover trial with non-significant trend „ 39 patients with well-defined Meniere's disease were randomized to hydroxyethylrutosides 2 g vs. placebo for 3 months and then crossed over to alternate treatment „ hydroxyethylrutosides improved audiometric findings for air and bone conduction at frequencies of 250, 500, 1,000, 2,000 and „ hydroxyethylrutosides associated with trend for greater „ Reference - J Laryngol Otol 1984 Mar;98(3):265 { diphenidol associated with improved vertigo, dizziness or
unsteadiness (level 2 [mid-level] evidence)
„ based on crossover trial in 24 patients with Meniere's disease „ Reference - Acta Otolaryngol Suppl 1975;330:120 z interventions with very limited evidence of efficacy in case series
{ methotrexate reported to be associated with improved hearing
loss and vertigo (and tinnitus to a lesser degree) (level 3
[lacking direct] evidence)
„ based on 2 case series of 64 patients with Meniere's disease and partial response to prednisone 1 mg/kg/day „ Reference - J Rheumatol 2001 May;28(5):1037, Ann Otol Rhinol Laryngol 2000 Aug;109(8 Pt 1):710 { general anesthesia reported to be effective (level 3 [lacking
direct] evidence)
„ patients with vertigo unresponsive to low salt diet, diuretic and stress reduction were treated with single injection of combination droperidol plus fentanyl (Innovar) „ 58% reported long-lasting relief of vertigo at 2-8 years „ Reference - Acta Otolaryngol 1999 Mar;119(2):189 EBSCOhost Full Text
z scopolamine patch not clearly effective in Meniere's disease (level 2
[mid-level] evidence)
{ 30 patients with acute peripheral vertigo (including 16 with Meniere's disease) were assigned to 2 placebo patches, 1 placebo and 1 scopolamine 0.5 mg transdermal patch, or 2 scopolamine patches { treatment with 1 patch was modestly more effective than placebo for patient-reported efficacy but not statistically significant { treatment with 2 patches associated with 36% discontinuation rate { Reference - J Otolaryngol Otol 1985 Jul;99(7):653 z famciclovir appears no more effective than placebo for symptom
http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 control in Meniere's disease (level 2 [mid-level] evidence)
{ 23 patients with Meniere's disease were randomized to famciclovir vs. { 25% famciclovir vs. 18% placebo patients had reduced number of { all patients had improvements in dizziness and health-related quality { Reference - Otolaryngol Head Neck Surg 2004 Dec;131(6):877 Surgery:
z hearing-sparing surgery (for patients with good hearing)
„ most commonly used conservative surgical intervention in „ endolymphatic shunt procedure appears no better than
placebo surgery (level 2 [mid-level] evidence)
„ 30 patients with Meniere's disease for 6 months to 5 years and history of typical attacks (fluctuating hearing loss, tinnitus and vertigo) occurring at least once every 2 weeks were randomized to endolymphatic sac shunt surgery draining into mastoid cavity vs. simple mastoidectomy (placebo surgery not expected to have any effect on vestibular or cochlear system) „ 73% active surgery group vs. 80% placebo surgery group were judged to have benefitted from surgery at 12 „ both groups had considerable improvement in all symptoms but no significant differences between groups „ Reference - Arch Otolaryngol 1981 May;107(5):271, also published in Ann N Y Acad Sci 1981;374:820 „ 3-year follow-up found 70% improvement in both groups and no significant differences between groups (Am J Otol „ 7-year follow-up found 70% improvement in both groups and no significant differences between groups (Ann Otol Rhinol Laryngol 1986 Jan-Feb;95(1 Pt 1):32) „ 9-year follow-up found 70% improvement in both groups and no significant differences between groups (Am J Otol 1989 Jul;10(4):259) „ retrospective reevaluation using different statistical analysis reports effectiveness for endolymphatic shunt (Otolaryngol Head Neck Surg 2000 Mar;122(3):340) „ endolymphatic sac shunt and ventilating tube insertion
appear similarly effective (level 2 [mid-level] evidence)
„ 29 patients aged 27-71 years with Meniere's disease were randomized to endolymphatic sac shunt vs. ventilating tube inserted in tympanic membrane „ both treatments associated with significant reductions in dizzy spells at 6 and 12 months, but no differences http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ no differences between groups in hearing or tinnitus, but 2 patients in shunt group developed severe hearing loss „ Reference - Acta Otolaryngol 1998 Nov;118(6):769 EBSCOhost Full Text
„ endolymphatic subarachnoid shunt reported to be
effective for long-term control of vertigo in > 50%
patients (level 3 [lacking direct] evidence)
„ 234 patients with Meniere's disease treated with endolymphatic subarachnoid shunt surgery with at least „ among 147 patients (63%) who did not require additional surgery to control vertigo, 93% reported no dizziness or „ among 40 patients (17%) who only required revisions of endolymphatic sac shunt, 96% reported no dizziness or mild to no disability „ Reference - Otolaryngol Head Neck Surg 1993 Jul;109 „ endolymphatic mastoid shunt operation reported to be
effective (level 3 [lacking direct] evidence)
„ 81% had substantial control of vertigo „ 19% had clinically important hearing improvement „ Reference - Clin Otolaryngol 1994 Jun;19(3):261 „ endolymphatic subarachnoid shunt reported to be as
effective as endolymphatic mastoid shunt (level 3
[lacking direct] evidence)
„ based on retrospective questionnaire study „ 196 of 346 patients who had endolymphatic sac surgery „ no significant differences in outcomes comparing endolymphatic subarachnoid shunt vs. endolymphatic „ endolymphatic mastoid shunt reported to have lower „ Reference - Am J Otol 1987 Jul;8(4):275 „ endolymphatic sac decompression appears as
effective as endolymphatic mastoid shunt (level 2
[mid-level] evidence)
„ 88 patients with Meniere's disease treated with endolymphatic mastoid shunt and 108 patients treated with endolymphatic sac decompression „ both procedures appeared equally effective for http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 reducing incidence and severity of vertigo attacks (67% with endolymphatic mastoid shunt vs. 66% „ Reference - Otolaryngol Head Neck Surg 2007 „ endolymphatic sac-vein decompression reported to
control vertigo and improve functional level (level 3
[lacking direct] evidence)
„ 68 patients with Meniere's disease treated with endolymphatic sac-vein decompression were „ functional level improved in 81%, remained stable „ hearing class improved in 18%, remained stable in „ Reference - Otolaryngol Head Neck Surg 2003 „ goal is to disconnect diseased labyrinth from brainstem while „ risks of neurosurgery in posterior cranial fossa include injury to cochlear nerve, facial nerve, and anterior inferior cerebellar „ vestibular nerve section may improve vertigo more with
less hearing loss than intratympanic gentamicin (level 2
[mid-level] evidence)
„ 25 patients with Meniere's disease treated with gentamicin injection and 39 patients treated with „ 95% vestibular nerve section patients had good to excellent control of vertigo vs. 80% gentamicin patients „ degree of postprocedure hearing loss greater with „ Reference - Laryngoscope 2004 Feb;114(2):216 { other less commonly performed hearing-sparing surgeries(3 ) z surgical options for patients with poor hearing
„ indicated in patients with end stage bilateral Meniere's disease „ extirpation of labyrinth to control vertigo http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ labyrinthectomy associated with 98.8% effectiveness for relieving vertigo in series of 81 patients (Laryngoscope 1996 { cochleosacculotomy - destructive to hearing(3 ) „ complications can include hearing loss, facial nerve paralysis, „ vestibular neurectomy associated with 97.8% effectiveness for relieving vertigo in series of 45 patients (Laryngoscope 1996 { translabyrinthine vestibular neurectomy - destructive to hearing(3 ) Consultation and referral:
z refer to ear, nose and throat (ENT) specialist to confirm diagnosis and/or if z multidisciplinary support team may be useful for disease management and { ENT specialist - can provide additional treatment options in patients { physical therapist - can teach vestibular rehabilitation techniques to { hearing therapist - can provide support and self-care advice for { audiologist - can provide confirmation of sensorineural hearing loss and self-care advice for management of tinnitus, can help with { counselor, psychologist or psychotherapist - can help patient cope Other management:
z Meniett device
{ portable low-intensity alternating pressure generator used to control { Meniett device appears safe and effective for vertigo
symptoms (level 2 [mid-level] evidence)
„ based on randomized trial without complete intention-to-treat „ 67 patients aged 33-71 years with unilateral cochleovestibular Meniere's disease had tympanostomy tube placed in affected ear and were randomized to self-administered treatment with Meniett device vs. placebo 3 times daily for 4 months „ patients had ≥ 2 definitive vertigo attacks per month for 2 months prior to study entry, despite ≥ 3 months treatment with low-sodium diet with or without diuretics „ placebo device identical to Meniett device but exerted no „ Meniett device group associated with significantly less severe vertigo, fewer days with definitive vertigo and fewer sick days „ Meniett device not associated with any complications http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 „ Reference - Arch Otolaryngol Head Neck Surg 2004 Jun;130 „ results of 2-year unblinded follow-up of 61 patients using „ patients advised to follow low-sodium diet, use Meniett device 3 times daily and maintain patent tympanostomy tube in affected ear „ 67% patients reported remission or greatly improved „ 24% patients dropped out to receive surgery „ Reference - Arch Otolaryngol Head Neck Surg 2006 { Meniett device may improve symptoms associated with
Meniere's disease (level 2 [mid-level] evidence)
„ 56 patients aged 20-65 years with active Meniere's disease and hearing loss of 20-65 dB were randomized to Meniett device vs. placebo gadget „ Meniett device associated with improvements in frequency and intensity of vertigo, dizziness, aural pressure and tinnitus vs. placebo, as measured by visual analog scales „ Reference - Acta Otolaryngol Suppl 2000;543:99 EBSCOhost Full Text
{ Meniett device may reduce vestibular symptoms in patients
with Meniere's disease (level 2 [mid-level] evidence)
„ 40 patients aged 20-65 years with active Meniere's disease and ≥ 8 attacks in previous year were randomized to Meniett device vs. placebo ventilation tube „ Meniett device associated with improvements in function and visual analog scale evaluation, and trend toward reduction in vertigo episodes „ Reference - Otol Neurotol 2005 Jan;26(1):68, also published in Ugeskr Laeger 2006 Jan 23;168(4):378 [Danish] z neither transcutaneous nerve stimulation nor applied relaxation
appear to be effective for improving tinnitus, dizziness or hearing
ability (level 2 [mid-level] evidence)
{ 20 patients with Meniere's disease were given transcutaneous nerve stimulation vs. applied relaxation and then crossed over to alternate treatment { no significant differences between groups in reducing tinnitus or dizziness, or increasing hearing ability { Reference - Br J Audiol 1994 Jun;28(3):131 z consider sound therapy or relaxation techniques in patients with { usually provided by compact disc or tape that plays soothing and relaxing sounds to distract from tinnitus { reduces difference between tinnitus sounds and background sounds http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 References including Reviews and Guidelines General references used:
z 1. Clinical Knowledge Summaries. Meniere's disease. Clinical Knowledge z 2. Minor LB, Schessel DA, Carey JP. Meniere's disease. Curr Opin Neurol. z 3. Saeed SR. Fortnightly review. Diagnosis and treatment of Meniere's disease. BMJ. 1998 Jan 31;316(7128):368-72. EBSCOhost Full Text
z 4. Clinical Evidence 2007 Mar (search date 2006 Jan) z MEDLINE search 2007 Nov 16 using PubMed Clinical Queries (therapy) for "meniere OR (endolymphatic hydrops)" Click for Details Reviews:
z review can be found in Lancet 2008 Aug 2;372(9636):406 z review can be found in Lancet 2005 Dec 17;366(9503):2137 EBSCOhost Full Text, commentary can be found in Lancet 2006 Mar
EBSCOhost Full Text
z review can be found in Am Fam Physician 1997 Mar;55(4):1185 EBSCOhost Full Text
z review can be found in Hospital Medicine 1999;60(8):574 z review of treatment of Meniere's disease can be found in Clin Otolaryngol EBSCOhost Full Text
z review of medical treatment for Meniere's disease can be found in Acta EBSCOhost Full Text
z review of vertigo can be found in Am Fam Physician 2005 Mar 15;71 z review of initial evaluation of vertigo can be found in Am Fam Physician 2006 Jan 15;73(2):244, correction can be found in Am Fam Physician 2006 Guidelines:
z American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Committee on Hearing and Equilibrium (CHE) guidelines on Meniere's disease can be found in Otolaryngol Head Neck Surg 1995 Sep;113(3):181, commentary can be found in Otolaryngol Head Neck Surg 1996 Jun;114(6):835 Patient information:
z handout from EBSCO Publishing Health Library PDF or in Spanish PDF z handout from American Academy of Family Physicians or in Spanish z handout on vertigo can be found in Am Fam Physician 2006 Jan 15;73 z handout on vertigo can be found in Am Fam Physician 2005 Mar 15;71 z information on vestibular rehabilitation therapy from Chicago Dizziness and http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008 z DynaMed topics are created and maintained by the DynaMed Editorial Team. z Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-step evidence-based method for systematic literature surveillance. DynaMed topics are updated daily as newly discovered best available evidence is identified. Special acknowledgments:
z Minh-Thu Tran provided assistance with formatting and literature review. Competing interests:
z Each participating member of the DynaMed Editorial Team has declared no competing interests (financial or otherwise) related to this topic. Please give us your feedback by clicking on the link below to send an e-mail to DynaMed: http://dynaweb.ebscohost.com/Detail.aspx?id=113932&sid=3a01e5d1-775e-4390-a8c. 20/10/2008

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