RISK FACTORS: Caucasian, Stress, Allergy, Increased salt intake, Noise
GENERAL MEASURES
. Medications are given primarily for symptomatic relief of vertigo and nausea. There is no medication available
that influences the disease process.
. For attacks, bedrest with eyes closed and protection from falling. Attacks rarely last longer than four hours.
. Streptomycin therapy for bilateral Meniere disease, when conventional management has failed. Streptomycin
may be administered over a period of several days or weeks intentionally to damage the neuro-epithelium of the balance centers and reduce their function. Hearing must be carefully monitored during this time so that the treatment does not proceed to the point of damaging the hearing structures. This form of treatment should be administered only by an otolaryngologist and after careful patient education.
SURGICAL MEASURES
. Hearing good:
. Endolymphatic sac surgery, either (1) decompression or (2) drainage of endolymph into mastoid or
subarachnoid space
. Alternative procedure is to cut the vestibular nerve (intracranial procedure)
. A newer procedure involves placement of gentamicin through the tympanic membrane into the middle ear
space
. Another newer procedure is to place a ventilation tube through a myringotomy opening in the ear drum, and then use a pressure producing instrument called a Meniett device so as to apply pressure intermittently to the inner ear several times a day. This has been found helpful for the relief of dizziness, based on a large series of patients treated in Scandinavia.
. Hearing poor, but usable:
. Can do sac procedure, nerve section, or gentamicin instillation depending on quality of hearing
. Meniett device may also be used when hearing is poor
. Hearing not useful: Destruction of inner ear (labyrinthectomy)
ACTIVITY
. Limit activity during attacks
. Between attacks patient may be fully active, but this may be limited by (1) fear of impending attack, (2) unsteadiness following attacks, (3) ear fullness or tinnitus, or (4) hearing loss in involved ear that may severely
limit the patients ability to perform work duties or to participate in social life
DIET Limit total intake during attacks because of nausea. Otherwise diet is usually not a factor unless attacks are brought on by certain foods. A restricted salt diet may be useful in some cases.
DRUG(S) OF CHOICE
. Acute attack. For severe episode, one of the following may be used. Adult doses are indicated
. Atropine 0.2-0.4 mg IV
. Diazepam (Valium) 5-10 mg IV slowly
. Transdermal scopolamine, 1 patch, or smaller segment of patch, applied to skin surface and not replaced sooner than 3 days
. Maintenance. Adult doses are indicated (frequently must be reduced to avoid sedating effects)
. Meclizine (Antivert, Bonine) 25-100 mg orally, either at bedtime or in divided doses
. Ergotamine-belladonna-phenobarbital (Bellergal Spacetabs), one q 12 hr
. Diazepam (Valium), 2 mg (or less) tid
ALTERNATIVE DRUGS
. Acute attack
. Droperidol, 1.5-2.5 mg IV slowly (in hospital setting)
. Promethazine (Phenergan) 12.5-25 mg IV slowly
. Diphenhydramine (Benadryl) 50 mg IV slowly
. Carbogen (5% carbon dioxide and 95% oxygen) by mask from tank
. Maintenance
. Dimenhydrinate (Dramamine) 50 mg q4-6h po
. Promethazine (Phenergan) 12.5-25 mg q4-6h po
. Diphenidol (Vontrol) 25-50 mg tid po
. Diphenhydramine (Benadryl), 25-50 mg q6-8h po. Maximum, 100 mg/24 hours
. Chlorothiazide (Diuril) 500 mg daily po with potassium supplement
PATIENT MONITORING The most common complaint by Ménière patients regarding prior treatment is that the primary care physician did not take the condition seriously and that he or she did not seem interested in providing ongoing care. Because of the emotional impact alone, these patients need close followup care. It is important to monitor the status of their hearing, since it is at risk, and to continue to consider the possibility of a more serious underlying problem such as an acoustic tumor.
PREVENTION/AVOIDANCE
• Reduce stress
• Reduce salt intake
• Don’t smoke
• Avoid significant noise exposure, or use ear protectors
• Avoid use of ototoxic medications (aspirin, quinine, kanamycin, and many others)
POSSIBLE COMPLICATIONS
• Failure to diagnose acoustic neuroma
• Loss of hearing
• Injury during attack
• Inability to work
EXPECTED COURSE/PROGNOSIS
• Alternating attacks and remission
• Over time the balance problem tends to resolve, but the hearing worsens
• The great majority of patients can be managed successfully with medication. About 5-10% of patients require surgery for incapacitating vertigo.
• Very important not to overlook acoustic tumor, which produces an identical clinical picture