Ménière's disease and
cochlear hydrops
What is Ménière's disease and
why does it cause vertigo?
Ménière's disease is a common
cause of repeated attacks of vertigo. It
is characterized by episodes of roomspinning
vertigo that vary in duration
from a few minutes to several hours.
Hearing loss and head noise (tinnitus)
usually accompany these attacks, and
a sensation of pressure and fullness in
the ear is usually present. The attacks
of vertigo may occur suddenly. Violent
spinning, whirling and falling, associated
with nausea and vomiting, are common
symptoms. Clearly, an active case of
Ménière's can be quite debilitating for
patients.
The episodes of vertigo generally are due to increased pressure of the inner ear fluids. Fluids in the inner ear chambers are constantly being produced and absorbed by the inner ear. Any disruption to this delicate process results in over-production or underabsorption of the fluids. This leads to increased fluid pressure (hydrops) that in turn produces vertigo and hearing loss. This usually affects only one ear, but research at the Institute shows it affects both ears in approximately 20% of patients.
Can you further explain
the symptoms associated
with Ménière's and related
disorders?
Attacks of vertigo may recur
at irregular intervals. Ménière's is
unpredictable. The individual may be
free of vertigo symptoms for years at a
time, and between attacks the individual
tends to remain free of symptoms,
though hearing loss may continue.
Occasionally hearing impairment,
head noise and ear pressure occur
without vertigo. This type of Ménière's
disease is called cochlear hydrops.
Similarly, episodic vertigo and ear
pressure may occur without hearing loss
and tinnitus; this is called vestibular
hydrops. Treatment of both of these
conditions is the same as for Ménière's disease.
Is it possible that these
symptoms may have other
causes?
A thorough evaluation is necessary to
determine if the patient is suffering
from Ménière's, cochlear hydrops or
another disorder. The four hallmark
symptoms of Ménière's are episodic
vertigo, tinnitus, fluctuating hearing
loss and ear fullness, though many
Ménière's patients may have two or
fewer hallmark symptoms. It's important
to note that according to the American
Academy of Otolaryngology – Head
and Neck Surgery, a true definition
of Ménière's requires that three of the
hallmark symptoms be present. If
Ménière's is suspected, it is important
to try to determine the cause of the
increased fluid pressure. It's possible that
metabolic, toxic, allergic, circulatory or
stress and emotional factors play a part
in some cases.
How are Ménière's or cochlear
hydrops diagnosed?
The diagnosis of Ménière's
disease in patients is based on the
history from the patient. The history
includes episodic vertigo, fluctuating
hearing loss, tinnitus and fullness in
the involved ear. Most patients will
report an increase in the tinnitus and
fullness prior to and during the vertigo
attacks. In addition, between attacks the
patients are symptom free other than a
possible hearing loss.
Diagnosis of Ménière's disease can
be challenging since its symptoms are
also seen in a range of other disorders.
The presence of symptoms alone does
not guarantee the presence of Ménière's
disease, and there is not a homogenous
population of Ménière's patients, which
makes unequivocal diagnosis difficult.
However, a thorough examination
of all possible causes of symptoms
enables us to diagnose with a fairly high
level of confidence. The diagnostic
test developed by House Research (Ear) Institute researcher Manny Don, Ph.D., which
involves monitoring auditory brainstem
response (ABR) in electrophysiology,
has been helpful in further confirming
a diagnosis of Ménière's for those
patients who display 3-4 of the classic
symptoms.
How do you treat Ménière's
disease?
Treatment of Ménière's disease may
be medical or surgical, though the
House Clinic generally favors a
medical approach as the first course
of treatment. Treatment is aimed at
improving the inner ear circulation and
controlling the fluid pressure changes
of the inner ear chambers. At times it
is necessary to proceed to a surgical
intervention.
Medical treatment of Ménière's
disease varies with the individual
patient according to suspected
cause, magnitude and frequency of
symptoms. It is effective in decreasing
the frequency and severity of attacks in
about 80% of patients. Treatment may
consist of medication to stimulate the
inner ear circulation, decrease the inner
ear fluid pressure or prevent inner ear
allergic reactions.
Various vasodilating drugs are used
to stimulate the inner ear circulation
and are prescribed together with antidizziness
medication. Vasoconstricting
substances (such as caffeine or
nicotine) have an opposite effect and,
therefore, should be avoided. Diuretics
("water pills") and a low sodium diet
are usually prescribed to decrease the
inner ear fluid pressure.
Ménière's disease may be caused
or aggravated by metabolic or allergic
disorders. Special diets or drug therapy
are indicated at times to control these
problems.
On rare occasions, intra-tympanic
injections of steroids are used to help
reduce hydrops in the inner ear.
Surgical Treatment of Ménière's Disease
Labyrinthectomy usually is advised only when the hearing is poor; it results in total loss of residual hearing in the operated ear and a temporary increase in vertigont
In labyrinthectomy cases and section of the vestibular nerve, hearing is already severely impaired. The operation results in total loss of hearing in the operated ear and frequently a temporary increase in vertigo. Fortunately, the attacks of spinning vertigo are eliminated in nearly every instance. Persistent unsteadiness, however, may continue for a period of weeks or months until the opposite ear stabilizes the balance system.
When necessary, this operation can be performed if other surgery is not successful.
Middle fossa section of the vestibular nerve may be advised when hearing is good in the involved ear. Up to 5% of patients may develop a severe hearing impairment in the operated ear. Fortunately, the attacks of vertigo are eliminated in nearly every instance. Persistent unsteadiness, however, may continue for a period of weeks or months until the opposite ear stabilizes the balance system. Complications of all craniotomies are extremely rare but can include the risk of meningitis, CSF leak, temporary facial weakness, and stroke.
There are some additional potential risks that occur in very rare cases that may require prolonged hospitalization and healing including post-surgery infection or hematoma – collection of blood under the skin incision. In most instances the distressing symptoms of vertigo can be greatly benefited or eliminated by medical or surgical management.
Recurring episodes of vertigo
and other symptoms of
Ménière's can be scary and
debilitating, leading to loss of
work, anxiety and frustration
for many patients. What is the
general treatment outlook and
prognosis for improvement for
these patients?
The general treatment outlook is good
and patients can be optimistic that with a
treatment approach that is tailored to their
individual case, they will find relief. In
most instances the distressing symptoms
of dizziness can be greatly benefited or eliminated by medical treatment. Again,
80% of patients with Ménière's and
related disorders have found relief from
bouts of dizziness with certain prescribed
medications and diuretics, sometimes
in combination with dietary changes or
treatment for allergies. For some patients,
surgical management of the symptoms is
beneficial.
Isn't there a fairly new device
that can be implanted in the
eardrum to relieve vertigo from
Ménière's?
Yes, early studies conducted in the U.S.
and overseas with the Meniett® device
have shown some success in reducing the
severity and frequency of vertigo episodes
for Ménière's patients. The Meniett is
a low-pressure pulse generator that is
designed to help restore the balance in
the hydrodynamic system of the inner ear
by transmitting low-pressure pulses to the
middle ear. It is believed that the energy of
the pressure pulses causes a displacement
of inner ear fluids, which may relieve
endolymphatic hydrops and symptoms of
Ménière's disease. However, this device
still has limited availability and long-term
results are not yet known.
Are there any additional treatments or interventions in the pipeline?
There don't seem to be new treatments in development outside of a study of delivery of gentamicin (an antibiotic) to the intra-tympanic membrane of the inner ear for management of Ménière's. That study is still in its preliminary phase in the House Ear Institute's Clinical Studies Department, but gentamicin treatment has a 25% chance of causing irreversible sensorineural hearing loss, so early results suggest that the shunt surgery may preserve hearing better.
At House Clinic, most treatment options are offered.
Call to make an appointment
House Clinic
2100 West 3rd Street
Los Angeles, CA 90057
(213) 483-9930