Treatments are and always have
been listed here in approximate order
of least invasive, least costly,
increasing to most invasive, most costly.
There is no cure.
There is no known cause of Meniere's
Disease, there is no known cure for Meniere's Disease,
and there is no cure on the horizon. That's not "negative thinking"; that's
simply the fact of the matter and there is no point in denying it or
offering false or gratuitous hope. Click
here to see the latest research. The good news is that
Meniere's Disease is not fatal, that there are many possible
"symptomatic" treatments (treatments for the symptoms) with which
patients can try to lessen or at least manage their symptoms, and that
some patients experience temporary spontaneous remissions of varying
periods of time. However, some patients are unresponsive to
virtually all treatments, including invasive surgery, and will become
disabled. See this and other pages
of this website for further information.
Treatment in brief.
Most, but not all, treatments are for symptoms
believed to be caused by excess endolymphatic fluid. Unless
otherwise indicated, the treatments described below appear to be
founded on the theory that Meniere's Disease symptoms result from
excess endolymphatic fluid in the inner ear ("idiopathic endolymphatic
hydrops"). While this is the prevailing theory, it is not the
definitive theory or the only theory.
Sometimes patients are confounded in their quest
for treatment because there is no qualified doctor in their town.
The solution to this problem is simple:
go out of town.
Visit our doctors
page for strategies on obtaining a treatment plan from an out-of-town
specialist who coordinates treatment with your local doctor.
Which treatments work.
No one treatment works for everyone, yet every
treatment seems to work for someone. We each seem to respond
differently to various treatments. Some patients are nearly
symptom-free just by observing a low-sodium diet (see below). Other
patients may need more complex and/or more invasive treatment.
Other patients seem unresponsive to any treatment — even invasive
surgery.
The bottom line: each patient tries to
find the treatment (or treatments) that works best for each one of us.
Our lay and
inexpert speculation: perhaps there are ten (or more or fewer)
currently unknown diseases that each have the same symptoms as what we
now call "Meniere's Disease," and we each have one (or perhaps two or
three) of the ten (or more or fewer) of the currently unknown
diseases. *IF* this is true, then ten patients could be diagnosed with
"Meniere's Disease," yet each one could have a different disease, and
each one could respond differently to various treatments.
Note on temporary spontaneous
remission. While not a
"treatment," some patients experience temporary unexpected
("spontaneous") remission (cessation or reduction in symptoms) lasting
days, weeks, months, or even years. There is no way to determine
who will, or who won't, experience temporary spontaneous remissions,
and there is no way to determine how long a temporary spontaneous
remission might last.
Treatment though clinical trials (clinical studies).
The U.S. government has a website for
information on clinical trials:
www.clinicaltrials.gov.
Click here
to search clinicaltrials.gov for clinical trials related to Meniere's Disease.
This link is at the top of each of our pages.
These clinical trials are usually conducted by the
NIH (National Institutes of Health). Clinical
trials (clinical studies) are usually "controlled." This means that there are two groups, the test group and the control group.
The test group is treated in some way. The control group is
"pretend-treated," usually with a placebo ("fake" drug).
Such studies
may last one year, more or less. The results of both groups are
compared to see whether patients in the test group improved
significantly compared to the control group. You might or might
not like to participate in a controlled clinical trial. Remember, in a
controlled trial, one group
will always be given placebo ("fake") treatment. However,
control groups are necessary in research and patients in the control
group make very useful contributions to medical science. If you
are interested in participating in a clinical trial, talk to your
doctor.
The International Federation of
Pharmaceutical Manufacturers and Associations (IFPMA) has a website
for searching for clinical trials:
www.ifpma.org/clinicaltrials.html.
Treatment with dietary and lifestyle adjustments.
Purpose. The purpose of dietary and
lifestyle modification therapies is to reduce all symptoms by reducing
conditions that may initiate or exacerbate (worsen) symptoms.
Sodium (salt)
avoidance.
Physicians frequently prescribe a low-salt diet
to reduce the amount of sodium in the body.
Sodium in the body increases fluid retention.
Common table salt is, of course, sodium chloride, and is normally the
primary source of sodium in the body. On the theory that
Meniere's Disease symptoms may result from excess endolymphatic fluid
in the inner ear, physicians often counsel patients to reduce overall
fluid in the body, with the hope that endolymphatic fluid will be
reduced in the process. To reduce sodium intake and, therefore,
reduce bodily fluids, physicians often counsel a low-salt diet and, in
addition, prescribe diuretics to
further reduce the bodily fluids.
Results vary.
Some patients anecdotally report a strong
correlation between salt ingestion and onset or worsening of symptoms.
Other patients anecdotally report no correlation between salt and
symptoms at all.
What's a low-sodium (low-salt diet)?
Descriptions vary. Some say the less the better.
Some degree of sodium intake is necessary to stay healthy. Many
patients attempt to keep their sodium intake under 1,000 mg. per day.
A few say that they succeed. Ask your doctor how much sodium is
right for you.
Amazon. com. Click
here to search for low-salt books.
(We do *not* get a commission.)
Alcohol avoidance.
Some patients report that alcohol intake is
devastating. Others report no effects whatsoever on their Meniere's
Disease symptoms after imbibing.
Caffeine avoidance.
Many patients report that caffeine intake is
devastating. Some patients report that caffeine has no effect
whatsoever on their Meniere's Disease symptoms.
Nicotine avoidance.
Physicians nearly always prescribe cessation of
smoking, and many Meniere's Disease patients -- who can -- quit out of
necessity.
Stress avoidance.
Stress is suspected to have a role in Meniere's
Disease, although stress is not well suited for objective measurement
and is not well documented.
Treatment by identifying and avoiding triggers of symptoms.
While the cause of Meniere's Disease is unknown,
there are "triggers" that can (for known or unknown reasons) initiate
or exacerbate (worsen) symptoms in *some* patients. Most patients find it helpful to identify and avoid --
or treat -- triggers, when possible, thereby indirectly treating the
symptoms of Meniere's Disease.
Triggers are highly individualized.
No one trigger affects all patients. One might have a trigger that no one else has, and one might not have
a trigger that many other patients have. Statistics aren't
useful here. It's not a matter of "how likely" it is for one to
have a particular trigger or how many (if any) other patients have a
particular trigger. Either one has the trigger or one
doesn't.
If "it" triggers your symptoms, "it" triggers your
symptoms, no matter what "it" is, and regardless of whether "it" triggers symptoms for anyone else.
Triggers known to affect many (but not all)
patients.
Allergies, including food allergies.
Allergies, including food allergies, are believed
by many researchers to have a role in triggering Meniere's Disease symptoms in
*some* patients. Identification and treatment of allergies may or may not help
reduce Meniere's symptoms or frequency of occurrences, depending upon
the patient.
Some patients seek allergy testing in order to see
whether avoidance of allergenic reactions may help to reduce the
frequency and/or intensity of Meniere's Disease episodes.
Anecdotally, this strategy seems to help some patients, but not all
patients.
Dr. Jennifer
Derebery, House Ear Institute, Los
Angeles, studies the relationship of allergies to Meniere's Disease.
Dr. Gwen Morse and Dr. John House have authored
a
paperdescribing evidence of a
relationship between the menstrual cycle and Meniere's Disease
responses in some women. "Results from this study provide
evidence that a unique relationship does exist between the menstrual
cycle and Meniere's disease responses for some women. Knowledge gained
from this study is beneficial in identifying the importance of
appropriate clinical assessment methods of menstruate women with
Meniere's disease. Recommendations include further research with
larger samples and testing of different symptom management strategies
for women of different perimenstrual symptom patterns."
Pregnancy.
Some women patients anecdotally report that their
symptoms worsened during pregnancy; others reported that their
symptoms lessened during pregnancy
Some women patients anecdotally report that their
symptoms of Meniere's Disease first appeared either during pregnancy
or soon after delivery. Most patients anecdotally report that
their symptoms did not first appear during pregnancy or soon after
delivery.
Visual stimuli.
Some patients anecdotally report that certain
visual events, especially parallel vertical lines, will trigger
dizziness and other symptoms. Here are some examples:
Streets and highways lined with trees or telephone
poles.
Supermarket aisles.
Some motion pictures.
Sound.
Sound can induce dizziness in the Meniere's patient (as well
as in patients with certain other disorders). Sound-induced dizziness is
sometimes call Tullio's Syndrome or Tullio's Phenomenon.
Dr. Timothy Hain -- Sound-induced dizziness, or Tullio's Phenomenon, can
occur in five different disorders, including Meniere's Disease.
Some patients anecdotally report that changes in
barometric pressure can trigger symptoms. Some patients so
affected track weather patterns very closely in an attempt to
anticipate increases in symptoms.
Physical exercise and exertion, including sexual intercourse.
We know of no clinical research on the effect of
physical exercise and exertion, including sexual intercourse, on the symptoms of Meniere's Disease.
Some patients anecdotally report that they
experience attacks of Meniere's symptoms brought on by physical
exercise, including attacks during sexual intercourse. Other patients do not
have this experience.
Some patients anecdotally credit a so-called "healthy
lifestyle," including what they believe to be "eating right" and
regular physical
exercise, with improvements in their overall health and well-being,
including reduced symptoms of Meniere's Disease. Other patients
see no improvements in their symptoms.
Post hoc, ergo propter hoc (after this, therefore
because of this).Datanation.com. If a patient improves after treatment "x"
(say, grapefruit juice), a patient may think that the grapefruit juice
improved the patient's Meniere's Disease. However, the mere fact
that improvement followed a treatment is not evidence that the
improvement was *caused* by the treatment. (Correlation is not
causation.)
Clinical trials.The best medical studies (trials) based on science are those that are
randomized, double-blind, placebo-controlled, that are subsequently
peer-reviewed and published in professional medical journals, and that are
replicated by independent researchers.
There is no medical evidence to support the
effectiveness of herbs, vitamins, or minerals in the treatment of
Meniere's Disease. (See for yourself at
PubMed.) It is always prudent to
thoroughly research the effects and drug interactions of any
medication that you contemplate taking,
whether prescription, over-the-counter (OTC), herbal, vitamin,
mineral, supplemental, or whatever. Talk to your pharmacist and to
your physician.
Ginkgo biloba.
Some patients believe that "ginkgo" acts as a
vasodilator that improves blood flow to the head, improving their
symptoms. Other patients report no effect at all. Moreover, ginkgo has
its detractors, who believe that it is a dangerous anti-coagulant,
especially when teamed up with certain other drugs, such as aspirin.
The moral: do your homework; study up before taking any substance, and
be sure to discuss with your physician.
Some patients believe that niacin improves the
blood flow to the head (frequently producing a temporary,
characteristic facial "flush"), which improves their symptoms. Other
patients report no effect at all. Niacin in chronic (continuing)
overdoses can cause liver damage. Talk to your physician.
Chiroweb.
"Parkinson's Disease, Meniere's Syndrome,
Trigeminal Neuralgia and Bell's Palsy: One Cause, One Correction," by
Michael T. Burcon, D.C. (Doctor of Chiropractic), Dynamic
Chiropractic, May 19, 2003, Volume 21, Issue 11.
Symptomatic relief after treatment of
temporomandibular disorder (TMD) and cervical spine disorders (CSD) in
patients with Meniere's disease: a three-year follow-up.
Abstract at PubMed. According to
the abstract, results showed that a coordinated treatment of TMD and
CSD in patients with Meniere's disease is an effective therapy for
symptoms of this disease. The results suggested that Meniere's disease
has a clear association with TMD and CSD and that these three ailments
appeared to be caused by the same stress, nervousness, and muscular
tension.
Treatment with devices.
Pressure pulse devices. Pressure pulse devices, as
the term suggests, deliver pulses of air pressure. First, an
opening (tympanostomy) is created in the eardrum and a tympanostomy
tube is inserted to maintain the opening so that it doesn't heal over.
Pulses of air pressure are delivered through the tube into the middle
ear. The structure that separates the middle ear from the inner
ear has two membranes, known as the oval window and the round window.
The theory is that the pulses of pressure are somehow conveyed by
virtue of the two membranes to the inner ear, and that the
endolymphatic fluid in the inner ear is somehow in turn affected in
some positive way that provides relief from the symptoms of Meniere's
Disease. The exact mechanism of how this might work is not
known.
Meniett device.
The Meniett
device is a portable air pressure pulse generator originally
developed by the Swedish company Pascal Medical AB and now marketed in
the U.S. by Medtronic Xomed.
From the Meniett website here:
"Although the actual mechanisms are still not fully understood, one
theory is that the action of the pressure pulses on the fluid system,
combined with other physiologic reactions in the ear, forces the
excess endolymphatic fluid back into the endolymphatic sac."
December 2006 -- A
study published in the medical journal Archives of
Otolaryngology -- Head and Neck Surgery, published by the American
Medical Association, reports highly encouraging results in a two-year
survey of patients using the Meniett Device. (Arch Otolaryngol Head Neck Surg.
2006 Dec;132(12):1311-6.)
This studyshows the Meniett Device and the Enttex P-100
device "beneficial," equally so. The Enttex P-100 device was
preferred for its greater convenience and its much lower cost compared
to the Meniett device.
Enttex P-100 device.
The Enttex P-100
device debuted in June 2005. It is described as a manual
type of air pressure pulse delivery device, positioned as a lower-cost
alternative to the "expensive device" (obviously, a reference to the
Meniett device).
According to this website, the following paper was
presented at the conference: Franz, B., Melbourne, Australia,
P-100 for Treatment of Meniere's Disease, A Clinical Study.
(Enter the site, click on "scientific program" on the left, then click
on "preliminary program" on the bottom, then download "Preliminary
Scientific Program.) Alternatively, click here. We
have not seen either the study or an abstract.
This studyshows the Meniett Device and the Enttex P-100
device "beneficial," equally so. The Enttex P-100 device was
preferred for its greater convenience and its much lower cost compared
to the Meniett device.
Tinnitus retraining therapy is the state of the
art treatment for tinnitus (resulting from Meniere's Disease or
otherwise), and is HIGHLY EFFECTIVE for MOST patients!
TRT involves a conditioning to the presence of the tinnitus rather
than actually eliminating the tinnitus.
During training,
the technique uses a masking device that resembles a hearing aid.
University of Maryland at Baltimore Tinnitus and
Hyperacusis Center.
A treatment for tinnitus
(resulting from Meniere's Disease or otherwise), which involves
treating the outside of the ear with a small electric current.
including a description of electrical
stimulation (note that this page is headed "Treatment of Annoying
Tinnitus at the Georgia Tinnitus Clinic"; it is unclear to us how the
"Georgia Tinnitus Clinic" relates to the "Atlanta Ear Clinic").
September 7, 2005: A study on the use of
vestibular rehabilitation therapy (VRT) in the treatment of Meniere's
Disease has been added to PubMed:
The Role of Vestibular Rehabilitation in the Treatment of Meniere's
Disease. The authors are affiliated with the U.S. Naval
Medical Center in San Diego. According to the abstract, the role
of VRT for Meniere's Disease patients in general is limited, due to
the fluctuating nature of the rotational vertigo. Apparently,
the authors feel that VRT is useful as post-operative therapy when the
vestibular system of the ear has been rendered useless through
vestibular nerve section (VNS) surgery, surgical labyrinthectomy, or
surgical labyrinthectomy.
It is always prudent to thoroughly research the
effects and drug interactions of any medication that you contemplate
taking. Talk to your pharmacist and to your physician.
Diuretics are often prescribed
to treat Meniere's Disease, often in conjunction with a low-salt diet
(see above), apparently for the purpose of reducing body fluids in
general and endolymph in particular. This treatment presumes
that the patient suffers from (idiopathic) endolymphatic hydrops
(excess endolymphatic fluid).
For unknown reasons, a patient's Meniere's Disease
symptoms may not be responsive to one diuretic drug yet may be very
responsive to another diuretic drug. Thus, one should discuss
with one's doctor trying at least two different diuretics before
concluding that "diuretics don't work for me."
An osmotic diuretic named "isosorbide" is used to
treat Meniere's Disease in Japan, according to
this study. (Note: There is an "isosorbide"
(isosorbide
dinitrate), a vasodilator, that is used to treat angina
pectoris (chest pain due to heart disease) in the U.S. The two
are
NOT the same.) Studies of treatment of Meniere's Disease
in Japan with isosorbide date back more than 20 years. Whether
there any reason to think that the osmotic diuretic isosorbide would
be any more effective than the diuretics
triamterene/HCTZ (Maxzide, Diazide) or acetazolamide (Diamox) that are
commonly prescribed in the U.S. is hard to say. Some people seem
to do better on triamterene/HCTZ than acetazolomide, and vice versa.
Perhaps some people would do better on isosorbide and perhaps not.
Like all things Meniere's, nothing is certain.
We are hearing anecdotal reports from patients who
are (perhaps by their own demand) being treated with antiviral drugs
such as acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex)
-- with mixed results. This apparently responds to a few studies
finding a tenuous (in our view) connection between the herpes simplex
virus (HSV) and Meniere's Disease. (Read
more at the herpes simplex virus section of our Cause Page.)No study in PubMed states for a
fact that HSV is a cause of Meniere's Disease. There are
almost no studies to be found at
PubMed on the subject of treating Meniere's Disease with
acyclovir or other antiviral drugs and none that finds that an
antiviral drug is effective in treating vertigo caused by Meniere's
Disease (for example,
this study by Dr. Derebery, et al., of the House Ear Clinic in
Los Angeles).
"Effectiveness of
Acyclovir on Meniere's Syndrome III Observation of Clinical Symptoms
in 301 cases," Mitsuo Shichinohe, M.D., Ph.D., The Sapporo Medical
Journal, Vol. 68, No. 4-6, December, 1999.
The full text of this paper is available in
English at Dr. Shichinohe's website
here in eight
separate download files (one download file for each of eight pages) in
.pdf format.
This study is not listed in PubMed. The Sapporo
Medical Journal is published bySapporo Medical University,
Sapporo Japan. The "III" in the title means that this is the
third paper in a series of three authored by Dr. Shichinohe, none of
which appears inPubMed.
The other two papers are cited in footnotes 1 and 2 of this study.
As of January 8, 2007, Dr. Shichinohe is listed as author or co-author
of five articles in PubMed (click
here).
Results: In this study,
patients were each treated with 2,000 mg/day of acyclovir for an
average period of two weeks. There were 250 patients who were
ultimately evaluated. In 82.5% of cases diagnosed as Meniere's
Disease, 85% of cases diagnosed as Meniere's Syndrome (symptoms of
Meniere's Disease but other basic diseases could not be completely
excluded), and 89.1% of cases diagnosed as vestibular dysfunction,
vertigo disappeared, and tinnitus and hearing were improved. No
side effects were observed.
Limitations: This study was not randomized,
not double-blind, not blind, and not controlled. As stated in
the study, patients "knew" of the effectiveness of acyclovir and
"wished" the treatment. We have not found any subsequent citations to
this study in PubMed.
We have found no replication of this study. A randomized,
double-blind, placebo-controlled clinical trial of the antiviral drug
famciclovir (Famvir) for reduction of Meniere's disease symptoms by
Dr. Derebery, et al., of the House Ear Clinic in Los Angeles,
reported in 2004, found no "dramatic" effects on "vertigo or
dizziness" and that famciclovir simply "may" suppress the fluctuation
of hearing.
Comment: Despite the limitations of
Dr. Shichinohe's study, the results are impressive. While a
viral etiology (cause) of Meniere's Disease has not been positively
established, there are researchers who suspect, even in the absence of
persuasive evidence, that a virus, and particularly the herpes simplex
virus (HSV), *may* be a factor in *some* cases diagnosed as Meniere's
Disease. We believe that it can be worthwhile for patients to
discuss this study with their doctors, together with other relevant
studies.
These drugs are intended to sedate the vestibular
system to reduces the effects of vertigo (the spinning sensation).
Not surprisingly, these "vestibular sedatives" can have a side effect
of drowsiness. Yet, some patients complain that the vestibular
sedatives make them drowsy. Such is the nature of medicine:
one trades off the benefit of the treatment in exchange for acceptance
of the side effects. In this case, one makes a choice as to
whether one would prefer vertigo or drowsiness. However, what
many patients fail to understand is that they can work with their
doctors to adjust the dosage of the vestibular sedatives to reach the
point at which the patient is willing to accept the trade-off:
the point at which the vertigo is sufficiently controlled and at which
the patient is willing to accept that particular degree of drowsiness
as a side effect. One's doctor may either adjust the strength of
the prescription or simply advise the patient to break or cut the
pills.
Antivert (Meclizine) is the
antihistamine meclizine hydrochloride, which is also a vestibular sedative, purpose of
which in the treatment of Meniere's Disease is to prevent or reduce vertigo and hence
the resultant nausea by sedating the vestibular system.
Information on meclizine hydrochloride is available
at
MedLinePlus (NIH).
Meclizine hydrochloride 25 mg.
tablets may be purchased over-the-counter in the U.S. and elsewhere
under various brand name and private label products sold for car, air,
and seasickness, including Dramamine II and Dramamine Less Drowsy
Formula (but not regular Dramamine), Bonamine, and Bonine.
Names and formulations vary and are subject to change; be sure to
read the ingredients and potency listed on the package.
Also available in generic form, over the counter
(but sometimes "behind the counter," meaning one asks the pharmacist
for it but a prescription is not required).
Generic meclizine hydrochloride can be
bought by mail without prescription at Amazon.com and
elsewhere.
Dramamine (but not Dramamine II or Dramamine Less Drowsy
Formula), Gravol (Canada) (dimenhydrinate).
Dramamine (but not Dramamine II or Dramamine Less Drowsy
Formula) and Gravol (Canada) are brand names for the antihistamine
dimenhydrinate, which is also a vestibular sedative,
the purpose of which in the treatment of Meniere's Disease is to prevent
or reduce vertigo and hence the resultant nausea by sedating the vestibular
system. Names and formulations vary and are subject to change; be sure to
read the ingredients and potency listed on the package.
Phenergan is a brand name for the antihistamine
promethazine hydrochloride, which is also a vestibular sedative, the purpose of
which in the treatment of Meniere's Disease is to prevent or reduce
vertigo and hence the resultant nausea by sedating the vestibular system.
Those who are currently
experiencing nausea and vomiting and are unable to "keep down" the
oral form may well find that rectal suppositories of this drug are
much more effective.
May be prepared in a
topical (tube) form for application to the skin (for
absorption through the skin) by a pharmacy if so ordered by a
prescription, but not all doctors and pharmacists are aware of this.
Stugeron (cinnarizine)
(not available in the U.S.).
Stugeron is a brand name for the antihistamine
cinnarizine, which is also a vestibular sedative,
the purpose of which in the treatment of
Meniere's Disease is to prevent or reduce vertigo and hence the resultant nausea
by sedating the vestibular system. Stugeron is commonly prescribed in the U.K., but is not available in
the U.S.
Compazine, stemzine, buccastem, stemetil,
phenotil are brand names for the anti-psychotic drug prochlorperazine, which
also has antivertiginous and antiemetic properties,
the purpose of which in the treatment of
Meniere's Disease is to control vertigo and resultant nausea.
Unlike some diseases and conditions, and some
drugs, Meniere's Disease does not cause nausea. Meniere's
Disease causes vertigo (the spinning sensation), a consequence of
which may be nausea. A consequence of the nausea may be vomiting
-- sometimes severe, even projectile, vomiting. Ideally, one
would control one's nausea by controlling one's vertigo.
However, when attempts at controlling one's vertigo are ineffective,
then one will still want to try to control the consequential nausea.
One of the problems with taking medicine to control nausea is that if
one is already vomiting, one will have difficulty in keeping down and
absorbing oral meds.
Scopolamine transdermal patch.
This patch was off the
U.S. market for some time, but it's back. Scopolamineis sometimes
prescribedas an antiemetic, antinausea drug to treat the
nausea of Meniere's Disease brought on by vertigo.
An antihistamine and
vestibular sedative, the purpose of which in treating Meniere's
Disease is to sedate the vestibular system. Those who are currently
experiencing nausea and vomiting and are unable to "keep down" the
oral form may well find that rectal suppositories of this drug are
much more effective.
Ginger root.
Although ginger root is not a "drug," we mention it
here because so many people find that ginger root, or ginger root tea,
is effective in reducing nausea.
Immunosuppressant (immuno-suppressant) drugs.
Immunosuppressant drugs include: prednisone,
methotrexate, dexamethasone, Enbrel, Remicade, etc.
(Note that dexamethasone may also be delivered intratympanically; see
below.)
Treatment of immune-mediated (induced)
conditions.(Also called immune-mediated,
autoimmune-mediated, and auto-immune-mediated conditions.)
Some researchers believe that some or all cases of
Meniere's Disease result from, or are aggravated by, an autoimmune
condition in which the immune system is overactive and erroneously
attacks certain normal cells as if they were a threat.
Immune-mediated conditions are difficult to diagnose. There is a
fine line between immune-mediated Meniere's Disease and Autoimmune
Inner Ear Disease (AIED).
Prednisoneis a
generic name for several branded drugs; it is a steroid, the purpose
of which in treating Meniere's Disease is to suppress the immune
system and/or to reduce inner ear inflammation. You should be
extremely careful in following the prescribed instructions for taking
this powerful drug, especially any instructions regarding a tapered
withdrawal. Prednisone is often prescribed for Meniere's Disease,
sometimes in combination with, or preceding, treatment with
methotrextate (MTX) or other powerful immunosuppressant drugs.
Chronic (long-term) administration of prednisone would have extremely
serious side effects that should be discussed with your doctor.
A doctor who suspects or just wants to confirm or
eliminate the possibility of an immune-mediated etiology (cause) may
prescribe a round of prednisone, even in the absence of diagnostic
tests that indicate an autoimmune etiology. Some patients may not be
responsive to a low-dose trial of prednisone yet may inexplicably
respond remarkably to a high-dose trial of prednisone. If the
patient's symptoms are reduced by the prednisone, then longer-term
immunosuppressant treatment may be recommended.
This immunosuppressant drug has
been used to treat
suspected immune-mediated cochleovestibular disorders. Note
that methotrexate should be administered carefully and is reported to
have caused deaths. See
the article at RXMED. Still, methotrexate is widely
prescribed for autoimmune diseases, especially rheumatoid arthritis.
Sometimes otologists will prescribe a therapy of methotrexate to be
administered by a rheumatologist who has more experience with
immunosuppressant drugs.
Emerging immunosuppressant drugs.
There are emerging immunosuppressant drugs, such as
Enbrel and Remicade, that are finding their way into treatment of
suspected immune-mediated Meniere's Disease. Talk to your
doctor.
Serc (betahistine hydrochloride or
betahistine dihydrochloride).
This drug is a histamine analog
that is widely
prescribed for Meniere's Disease in the U.K. and elsewhere outside of the U.S.
The branded forms are not approved by the F.D.A. and thus are not
available in the U.S., yet the generic form is legally available in
the U.S. when compounded by
compounding pharmacists by prescription.
Since betahistine
hydrochloride, a histamine analog, may help some Meniere's Disease
patients, one would logically wonder about the efficacy of histamine
in treating Meniere's Disease.
According to
this "erratum" note in a medical journal, many patients who are
scheduled for surgery experience remission before the surgery is
actually performed. The authors
suggest scheduling surgery two months in advance, possibly not in
earnest, to see whether simply scheduling the surgery will produce
remission.
The middle ear is "ventilated" by virtue of a
structure called the Eustachian tube. This tube connects the middle
ear to the pharynx (throat). It is like a valve that opens and closes.
When it opens, air pressure in the middle ear is equalized with the
outside air pressure. The Eustacian tube typically opens during
yawning and swallowing. The the function of the Eustacian tube,
and the state of air pressure in the middle ear, can be tested by
means of a tympanogram.
If the Eustachian tube is becomes dysfunctional by
blockage due to congestion, infection or otherwise, air pressure in
the middle ear can occur to the point of pain. Congestion and
infection may be treated by decongestants, antihistamines, and
antibiotics (if the infection is suspected to be bacterial in nature).
For chronic (continuing) cases, doctors sometimes
create an alternate opening to middle ear from the outer ear by
creating an opening in the eardrum and by inserting a tube called a
"pressure equalization (PE) tube" or a "ventilation tube" or,
sometimes (especially in Australia), a "grommet." ("Pressure
equalization" means "air pressure equalization.") When a PE tube
is in place, there is a continuous opening in the eardrum, and air
pressure in the middle ear is continuously "equalized" with the air
pressure outside of the middle ear. Infants suffering from middle ear
infections (otitis media) often have PE tubes inserted.
The symptom of fullness that is experienced with
Meniere's Disease feels just like air pressure in the middle ear --
but it is *not* air pressure in the middle ear. Meniere's Disease does
not affect the middle ear. Meniere's Disease has nothing to do
with the Eustachian tube, and the typical Meniere's Disease patient
has a fully functioning Eustachian tube. If so, adding a PE tube
wouldn't seem to accomplish anything. Nonetheless, doctors sometimes
insert PE tubes into patients who have fully functional Eustachian
tubes, and the patients sometimes report improvement with their
symptoms, possibly (or probably) due to a placebo effect.
Click
here to read Dr. Timothy Hain's comments on PE tubes.
Intratympanic
instillation and perfusion of drugs.
Also called transtympanic instillation and
perfusion of drugs.
Intratympanic (through the tympanic
membrane (ear drum)) instillation (insertion) and perfusion ("seeping"
through the round window separating the middle ear from the inner ear)
of various drugs, including dexamethasone (Decadron),
streptomycin, and gentamicin).
Note: The October 2004 issue (Vol. 27, pp.
955-1113) of "Otolaryngologic
Clinics of North America" is devoted to "Intratympanics (sic)
Treatment of Inner Ear Disease." The titles of the 10
substantive articles inside appear relevant and interesting to
Meniere's Disease patients. Click here
to view the contents. Viewing the full text is trickier. There
is a 30 day
trial, there is access to individual articles, and there is
access to purchasing a full issue. A more practical means of access is
to visit a hospital or medical school library. (See our research page.)
Drugs used in intratympanic instillation and
perfusion.
Nonototoxic drugs.
Corticosteroids.
Some corticosteroid drugs are
used, perhaps among other purposes, to (1) reduce inflammation and (2)
to suppress the immune system.
The apparent purpose of
intratympanic instillation and perfusion of the corticosteroid dexamethasone is to reduce
inflammation and to suppress the immune system very directly, perhaps
together with or followed by additional dexamethasone administered intravenously
and/or orally. Apparently, this therapy presumes that inflammation
and/or an autoimmune (overactive immune) condition is causing or
contributing to the symptoms. Dexamethasone is apparently not believed to be ototoxic. Some physicians believe that this procedure has great
potential for relieving vertigo while preserving, and in some cases,
even improving hearing. Others disagree. As always, see your physician
for medical advice.
The
abstract names the affiliation of the authors as "National Institute
of Neurology and Neurosurgery," which we presume refers to the
institute by that name that is located in Mexico City. According to
the abstract, in the experimental group of 11 patients who received
injections of dexamethasone, nine patients achieved "complete control
of vertigo," and the remaining two patients achieved "substantial
control of vertigo" over two years. In the control group of 11
patients who received injections of a saline solution placebo, four of
the patients achieved "complete control of vertigo," none achieved
"substantial control of vertigo," three patients achieved lesser
control of vertigo, and four patients were classified as treatment
failures and went on to receive other treatment before the end of the
two-year period. Patients in the experimental group reported
subjective improvements in the symptoms of tinnitus, aural fullness,
and hearing loss, to a greater extent than did patients in the control
group.
Labyrinth anesthesia (lidocaine).
From time to time, researchers will instill
lidocaine (sometimes together with the drug Kinetin) into the middle
ear (for subsequent perfusion into the inner ear) in hopes of
improving Meniere's Disease symptoms. Just how this might work
has not been satisfactorily explained (at least, not to us).
Note that this is a topic distinct from the use of lidocaine in
treating tinnitus (from Meniere's Disease or otherwise), above.
Dr. Timothy Hain
reports that it is "hard to understand" why lidocaine might
work to produce a remission, although he notes: "Kinetin is a plant
growth factor, pesticide, and an ingredient in skin preparations.
Perhaps Kinetin has a positive effect on Meniere's disease." We believe
that Dr. Hain was speculating on a possible factor for the outcome
described in the article, rather than rendering a judgment on the use
of Kinetin.
The purpose of intratympanic instillation and
perfusion of ototoxic drugs ("ear poisons") is to
chemically ablate (destroy) part or all of the inner ear.
Streptomycin ("strep").
The famous antibiotic streptomycin is very ototoxic,
which is one reason why it is no longer used as an antibiotic, except
in rare cases when there is no other treatment. Not only is
streptomycin toxic to the vestibule (balance function), but it is also
toxic to the cochlea (hearing function). Streptomycin may be used to
chemically ablate the balance function, but it will also destroy
whatever may be left of the hearing function, thus resulting in a
"chemical labyrinthectomy" (in effect, destruction of the entire
labyrinth). An alternative would be a
"surgical" labyrinthectomy, in which the organs of the labyrinth are
surgically removed. A high dose of gentamicin (see below) could be
used instead of streptomycin. Streptomycin may be administered
intravenously to accomplish the same result, but the destruction that
results from this procedure applies to both ears instead of one ear.
This methodology is usually used, if at all, only when the patient is
bilateral (Meniere's Disease symptoms in both ears) and has already
lost all, or nearly all, hearing in both ears.
Like streptomycin (above), gentamicin is an antibiotic, and it is
also ototoxic, although less ototoxic than streptomycin.
There are three possible
reasons for intratympanic instillation of gentamicin.
1. To destroy the "dark
cells" that produce endolymph, with the objective of reducing the
production of endolymph, thus reducing the "hydrops." If this is the
reason, the hope is that the tiny hairs in the vestibule (which affect
the balance function) and the tiny hairs in the cochlea (which affect
the hearing function) will be undamaged, or at least not damaged very
much. This is usually a very low dose (in terms of volume and
strength) of gentamicin. There may be one or more injections, and the
length of time (interval) between multiple injections may vary.
2. To damage the tiny hairs
in the vestibule with the objective of impairing the transmission of
faulty vestibular (balance) data to the brain. If this is the reason,
the hope is that the tiny hairs in the cochlea will be undamaged, or
at least not damaged much, because damage to the tiny hairs in the
cochlea causes hearing loss. There may be one or more injections, and
the length of time between multiple injections may vary. This is
usually a somewhat higher dose of gentamicin that is given for purpose
1 above, but still a low enough dose to attempt to preserve whatever
hearing may remain.
3. To ablate (destroy) the
labyrinth totally, using a high dose of gentamicin, with the objective
of totally destroying the tiny hairs in the vestibule to block all
transmission of vestibular (balance) data to the brain, and accepting
the concurrent destruction of the tiny hairs in the cochlea, which
will cause deafness. This high dose of gentamicin is usually (but not
always) performed when there is little or no functional hearing left.
This is called a "chemical labyrinthectomy," because the effect is to
totally destroy all functions of the labyrinth, both vestibular and
cochlear. Streptomycin (see above) could be used for this purpose
instead of gentamicin. An alternative would be a "surgical"
labyrinthectomy, in which the organs of the labyrinth are surgically
removed.
There are different
"protocols" for each of the methodologies above, depending on
the patient and on the doctor. The strength of the gentamicin and the
interval between the instillations may vary.
August 25, 2005 -- A study on the use of
intratympanic gentamicin to treat Meniere's Disease has been added to
PubMed:
Long-term results of the transtympanic (intratympanic) gentamicin
treatment in Meniere's disease. The affiliation of the
authors is the Clinic of Otolaryngology in Warsaw, and the article is
in Polish. According to the abstract, nine patients were
followed for 24 months, of whom all nine achieved complete control of
vertigo, while hearing was improved in six patients, unchanged in two
patients, and profoundly lost in "only" one patient.
Comment: We believe that "only" one out of
nine patients deafened represents a serious risk. It seems to us
that key to the outcome of intratympanic gentamicin treatment is the
protocol used: the strength of the gentamicin, the quantity
instilled, and the interval between instillations. We believe
that a good analysis of such studies can only be made having the
specific protocols at hand. We recommend that a patient considering
intratympanic gentamicin treatment ask one's doctor for the protocol
contemplated and for the studies using that protocol upon which that
doctor is relying in selecting it. (Then sit back in your chair
and watch the reaction.)
Methodology.
Simple injection.
In the simplest of methods, an office procedure,
one lies on one's side, with the ear to be treated toward the sky and
the other ear against the bed or whatever surface one is lying upon.
A surgeon swabs the ear drum with a local anesthetic, then pokes a
needle through the ear drum and instills (injects with a syringe) a
drug toward the round window. [Note: the source of this
methodology is anecdotal reports from patients.] The patient
lies still for some period of time, and with luck the drug will pool
in the round window and perfuse through the round window to the inner
ear. The procedure may be repeated every week or every few weeks
for a few administrations.
Laser.
With this method, performed in an office, surgical
suite, or hospital, one lies on one's side, with the ear to be treated
toward the sky and the other ear against the bed or whatever surface
one is lying upon. The patient is either placed under general
anesthesia or the ear drum is swabbed with a local anesthesia.
The surgeon then uses a laser to burn a hole through the ear drum.
(Note that the laser is not used to "treat" Meniere's Disease; the
laser is merely a tool to place a hole in the eardrum.) A drug
is then instilled (injected with a syringe) toward the round window.
The patient lies still for some period of time, and with luck the drug
will pool in the round window and perfuse through the round window to
the inner ear. The patient lies for a couple of hours or so in a
recovery room in the position described above. The hole in the
eardrum heals over a couple of weeks. This method might involve
daily administration of the drug for a few days.
Gelfoam (absorbable
gelatin sponge).
With this method, performed in an office, surgical
suite, or hospital, one lays on one's side, with the ear to be treated
toward the sky and the other ear against the bed or whatever surface
one is lying upon. A surgeon uses a laser to burn a hole in the
ear drum. The surgeon then operates through the hole to place a
piece of Gelfoam in the bony niche that surrounds the round window.
The drug is instilled into through the opening in the ear drum and is
soaked up by the Gelfoam. The theory is that this method
provides a greater likelihood that the drug will actually be delivered
to the round window and perfused more effectively under more
consistent circumstances.
In one variation of the procedure, anecdotally reported by a patient, a ventilation tube (in some areas, called a
"grommet") is placed into the ear drum. This creates an opening
of some duration. Under this variation, some physicians will
have the patient self-administer the drug using a dropper, perhaps
over time.
Silverstein MicroWick
.
The Silverstein MicroWick was developed by
Dr. Herbert Silverstein at the Florida Ear and Sinus Center.
With this method, an air pressure ventilation tube (sometimes called
pressure equalization (PE) tube, or, in some areas, "grommet") is
placed into the eardrum. This creates an opening of some
duration. One end of the MicroWick is inserted through the tube
into the bony niche in the middle ear that surrounds the round window.
The other end of the MicroWick extends through the tube into the outer
ear. The patient may self-administer the drug over time.
Great explanation of the Silverstein MicroWick, with
a great illustration! There is also a online video of the
procedure used to place the MicroWick into a patient's ear!
Very nice
illustrations
of the Micro-Wick and of air pressure equalization (PE) tubes at the
Micromedics website.
Endolymphatic sac surgery.
A somewhat pricey book (2/98) by
I.K. Arenberg (inventor of the Arenberg shunt), "Treatment Options for
Meniere's Disease -- Endolymphatic Sac Surgery: Do It or Don't Do It
and Why," should be of interest to many Menierians. This surgery
is somewhat controversial; some doubt the efficacy and duration of
efficacy even under the best of circumstances. Others believe
that, given the right surgeon and the right patient, this surgery may
be helpful over a long period of time.
Endolymphatic sac decompression (ESD).
This term may be used in two ways:
Endolymphatic sac enhancement (ESE).
ESE is the enlargement of the bony cavity that
surrounds the endolymphatic sac by drilling away bone.
One-time drainage of fluid from the
endolymphatic sac to reduce fluid pressure and excess endolymph.
Because the effects of the ESD may not be
long-lasting, an endolymphatic sac shunt (ESS) (described below) may
be inserted to provide continuous drainage.
Introduction of a tiny device (valve or tube), or
surgical plastic (Silastic), into the endolymphatic sac to
continuously shunt (drain) excess endolymph, thereby reducing
dilatation, a procedure pioneered by Dr. I. Kaufman Arenberg, who
developed the Arenberg Shunt. This surgery is somewhat
controversial. Some critics say that it is a "sham" surgery
because, they say, the results are no better than a placebo.
Other critics say that the surgery is short-lived because scar tissue
covers the device within two years or so. Supporters contend
that the surgery is helpful for some patients.
Click here to
view a photo of endolymphatic sac shunt surgery (Otolaryngology
Houston).
Surgical removal of the labyrinth (balance and
hearing organs of the inner ear) of one ear. Usually performed only on
patients who are already deaf in the affected ear, because this
procedure removes both the balance and hearing mechanism in the ear.
The remaining unaffected ear "learns" to provide all balance
functions.
Vestibular nerve section (VNS) or vestibular
neurectomy (VN).
Although the VNS is described by some patients
(and doctors) as the "gold standard" for treating the symptom of
vertigo in Meniere's Disease patients, VNS is not 100% successful, for
a variety of reasons. The nerve at issue is the vestibulocochlear
(8th cranial) nerve. This nerve can be thought of as a road with a
fork at each end. At the inner ear end, hearing nerve fibers coming
from the cochlea form one branch of the fork, and balance nerve fibers
coming from the vestibule form another branch of the fork. They join
in what becomes the vestibulocochlear nerve that runs from the inner
ear to the brain. Before the nerve reaches the brain, however, the
nerve branches off into the vestibular branch and the auditory branch.
Each branch attaches to the brain at a different site. In VNS
surgery, the surgeon severs (sections) the vestibular branch, thus
interrupting the vertigo signals from the vestibule before they can
reach the brain and cause dizziness. An attempt is made to leave the
auditory branch untouched, therefore preserving whatever hearing
remains at that point in time. Of course, since VNS is merely a
treatment for the symptom of vertigo, and since Meniere's Disease is
incurable and progressive, hearing loss, tinnitus, and fullness
continue to progress in every case.
Potential problems with VNS.
Human anatomy varies quite a bit from person to
person, as is learned by medical students in their human anatomy and
cadaver dissection classes.
In some patients, *some* vestibular fibers run with
the auditory branch. Thus, they remain in service even after the
vestibular branch is severed.
It is possible that the vestibular branch does not
get completely severed.
It is possible that one has or develops Meniere's
Disease in the other ear.
Occasionally, surgeons theorize that after surgery
the severed ends of the vestibular branch have regenerated and
"rejoined" or "reconnected," although we are greatly skeptical of this
explanation.
There there is the unknown "aw shucks" factor.
Sometimes, it just doesn't work out as expected and no one really
knows why for sure.
Then there are other risks with VNS surgery.
The surgeon cuts the wrong nerve (it happens).
Sometimes the facial (7th cranial) nerve is mistaken for the
vestibular branch of the vestibulocochlear (8th cranial) nerve.
This is a devastating problem.
The facial nerve is bruised during surgery (it runs
close to the vestibulocochlear nerve).
A cerebral-spinal fluid (CSF) leak develops.
Infection is always a risk with surgery and with
hospitalization.
Complications from anesthesia.
Remaining hearing is compromised, despite the
theoretical preservation of remaining hearing (subject to the
unrelenting progression of Meniere's Disease).
Failure of vestibular nerve section.
Dr. Timothy Hain cites a
paper
by Eisenman, et al, to the effect that there was evidence that there
is retained vestibular function in about half the patients who have a
nerve section.
There are several different techniques for locating and severing
the vestibular nerve. Each technique has its advantages and
disadvantages. Talk to your doctor.
Some techniques sever the vestibular branch of the
vestibulocochlear nerve near where it connects to the brain.
This is VERY invasive "intracranial" skull base surgery -- in other
words, "brain surgery." An alternative is to sever the
vestibular branch near the inner ear. All techniques are very,
very serious surgery. Talk to your doctor.
Some doctors believe that the symptoms of Meniere's
Disease may result from physical pressure of blood vessels upon the
vestibulocochlear (8th cranial) nerve, called "microvascular
compression syndrome" (MCS) (also called "vascular compression" and
"neurovascular compression." If so, they believe, relieving the
physical pressure of the blood vessel on the vestibulocochlear nerve
may relieve the symptoms of Meniere's Disease. This involves
separating the compressing vessel from the nerve in what is called
microvascular decompression (MVD). Some doctors view MCS as a
separate disease.
