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Inner Ear, Meniere Disease, Medical Treatment: Treatment & Medication
Updated: Mar 25, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
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Treatment
Medical Care
Medical therapy is directed toward the mitigation of symptoms and/or their prevention.
In general, medications that decrease symptoms (eg, meclizine [Antivert], droperidol [Inapsine], prochlorperazine [Compazine], diazepam [Valium], lorazepam [Ativan], alprazolam [Xanax]) only mask the vertigo. These masking agents are vestibulosuppressants and work by dulling the brain's response to signals from the inner ear.
Some diuretics or medications with diuretic-like properties (eg, hydrochlorothiazide and triamterene [Dyazide], hydrochlorothiazide [Aquazide], acetazolamide [Diamox], methazolamide [Neptazane]) decrease fluid pressure in the inner ear. These medications help prevent attacks but do not help after the attack is triggered.
Steroids have also been helpful in treating endolymphatic hydrops because of their anti-inflammatory properties. Steroids can reverse vertigo, tinnitus, and hearing loss, probably by reducing endolymphatic pressure. Steroids can be given orally, intramuscularly, or even transtympanically. Although the transtympanic route is controversial, it is gaining wider acceptance throughout the otologic community.
Aminoglycosides are a class of antibiotics that were serendipitously discovered to be preferentially toxic to the vestibular (balance) end organ. Destruction of the vestibular end organ renders the brain insensitive to fluctuations in inner ear pressure brought on by Ménière disease. Given systemically, aminoglycosides affect both ears. Although aminoglycosides can be used to treat extremely severe bilateral Ménière disease, such treatment leaves the patient with little or no balance function. The resulting complete loss of inner ear function (ie, Dandy syndrome) can be debilitating.
One innovation in the treatment of Ménière disease is the Meniett device. Its use is not precisely a medical treatment, and the device itself does not require surgical installation. It does, however, require insertion of tympanostomy tube so that the device can work; therefore, its use may qualify as a surgical treatment. The Meniett device delivers pulses of pressure to the inner ear via the tympanostomy tube. Although no one knows exactly why this works, some patients have symptomatic relief when the device is used on a daily basis. Because it is new, long-term results have not been fully evaluated.
The histamine agonists that are used in countries outside of the United States must be mentioned. Medications such as betahistine (Serc) are widely used in Europe and South America. Although its mechanism of action is somewhat controversial, many have reported success with its use in mitigating symptoms of Ménière disease. Unfortunately, since betahistine (Serc) is not US Food and Drug Administration approved, it is not discussed much in the United States.
Surgical Care
Surgical treatment is discussed in detail in the article Inner Ear, Ménière Disease, Surgical Treatment. Briefly, the 4 most generally accepted management options are endolymphatic sac decompression or shunt, vestibular nerve section, labyrinthectomy, and transtympanic medication perfusion.
Consultations
Because many differential diagnoses exist, consultations with the following specialists are recommended:
- Neurologist
- Cardiologist
- Endocrinologist
- Internal medicine specialist
Diet
- Patients who are not severely affected may choose to manage their disease through diet.
- Dietary management of endolymphatic hydrops is based on the avoidance of substances that may trigger or exacerbate fluid pressure buildup in the inner ear. As with systemic hypertension, the goal of managing Ménière disease is to reduce the total volume of body fluid. This reduction, in turn, may reduce the fluid volume in the inner ear.
- Avoidance of salt is one of the mainstays of therapy because sodium seems to play a major role in fluid retention in the inner ear.
- Patients should avoid foods with high sodium content (eg, pizza, preserved foods, smoked fish).
- Sodium nitrate is used in many preserved and smoked foods; therefore, these foods are high in sodium content.
- A rigid salt-restricted diet is recommended (ie, 1.5 g sodium), under the guidance of a nutritionist.
- Avoidance of other trigger substances has also been shown to help. The following should be avoided: caffeine; nicotine; chocolate, which has shown to be a potent trigger substance; tobacco; alcohol, particularly red wine and beer; foods with high cholesterol or triglyceride content; foods with high carbohydrate content; and excessive sweets and candy.
Activity
Endolymphatic hydrops does not preclude regular activity. Exercise is recommended in moderation. Because of the unpredictable nature of the disease, balance-intensive dangerous tasks (eg, ladder use, precarious activities) should be avoided.
Medication
Medical therapy is directed toward the mitigation of symptoms and/or their prevention. Only a few representative drugs from each category are included below.
Vestibulosuppressants
These agents decrease symptoms and, in general, only mask vertigo. They work by dulling brain's response to signals from the inner ear.
Meclizine (Antivert, Marezine, Meni-D)
Decreases excitability of middle ear labyrinth; blocks conduction in middle ear vestibular-cerebellar pathways.
Adult
12.5 mg PO tid or prn; not to exceed 25 mg PO q6h prn
Pediatric
<12 years: Not established
>12 years: Administer as in adults
May increase toxicity of CNS depressants, neuroleptics, and anticholinergics
Documented hypersensitivity; patients who are nursing
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Patients with angle-closure glaucoma, prostatic hypertrophy, pyloric or duodenal obstruction, or obstruction of bladder neck
Benzodiazepines
These drugs appear to potentiate effects of gamma-aminobutyric acid (GABA) and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters by binding to specific receptor sites.
Diazepam (Valium)
Effective in panic attacks; depresses all levels of CNS, including limbic and reticular formation, possibly by increasing GABA activity.
Adult
2.5-10 mg PO/IV/IM q4-6h prn; individualize dosage, increase cautiously to avoid adverse effects
Pediatric
1-2.5 mg PO/IV/IM tid/qid
Phenothiazine, narcotics, barbiturates, MAO inhibitors, and other antidepressants that potentiate its action
Documented hypersensitivity; infants <6 mo; acute narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Patients receiving other CNS depressants; caution in patients with low albumin levels or hepatic failure (may increase toxicity)
Corticosteroids
These agents are helpful in treating endolymphatic hydrops because of their anti-inflammatory properties; steroids can reverse vertigo, tinnitus, and hearing loss, probably by reducing endolymphatic pressure.
Prednisone (Orasone, Meticorten, Sterapred)
Inactive and must be metabolized to active metabolite prednisolone; conversion may be impaired in liver disease; anti-inflammatory activity; used to treat various allergic and inflammatory diseases; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and by reversing increased capillary permeability.
Adult
40-60 mg PO qd as starting dose; taper to 0 over 7-14 d
Pediatric
4-5 mg/m2/d PO
1-2 mg/kg PO qd
Taper over 2 wks as symptoms resolve
May inhibit cyclosporine metabolism; adverse effects from increased cyclosporine level, including convulsions, may occur; drugs that induce hepatic enzymes (eg, phenobarbital, phenytoin, rifampin) may increase clearance, requiring increased dose; drugs such as troleandomycin and ketoconazole may inhibit metabolism and decrease clearance; may increase clearance of aspirin; salicylate level may increase when withdrawn; may affect function and availability of oral anticoagulants (eg, warfarin)
Documented hypersensitivity; viral, fungal, or tubercular skin lesions; increased risk of multiple complications in patients receiving glucocorticoids; use safer alternative if available
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adverse reactions (eg, nervousness, insomnia, GI upset) may occur; reactions relatively uncommon when used for only few days
Diuretics
These drugs help prevent attacks by decreasing fluid pressure load in the inner ear but do not help after the attack is triggered.
Hydrochlorothiazide (Esidrix, HydroDIURIL, Microzide)
Inhibits reabsorption of sodium in distal tubules, increasing excretion of sodium, water, potassium, and hydrogen ions.
Adult
25-100 mg PO qd; not to exceed 200 mg/kg/d
Pediatric
<6 months: 2-3 mg/kg/d PO divided bid
>6 months: 2 mg/kg/d PO divided bid
May decrease effects of anticoagulants, antigout agents, and sulfonylureas; may increase toxicity of allopurinol, anesthetics, antineoplastics, calcium salts, loop diuretics, lithium, diazoxide, digitalis, amphotericin B, and nondepolarizing muscle relaxants
Documented hypersensitivity; anuria; renal decompensation
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Patients with renal disease, hepatic disease, gout, diabetes mellitus, and erythematosus
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| Overview: Inner Ear, Meniere Disease, Medical Treatment |
| Differential Diagnoses & Workup: Inner Ear, Meniere Disease, Medical Treatment |
 Treatment & Medication: Inner Ear, Meniere Disease, Medical Treatment |
| Follow-up: Inner Ear, Meniere Disease, Medical Treatment |
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References
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Further Reading
Keywords
meniere's disease, menieres disease, meniere disease, meniere, inner ear, meniere disease medical treatment, endolymphatic hydrops, cochleovestibular hydrops, cochlear hydrops, vestibular hydrops, Meniere syndrome, Ménière syndrome, Meniere disease, Ménière disease, Meniere's syndrome, Ménière's disease
