Evidence-based Management of Meniere Disease

Educational Objectives

The goal of this program is to improve diagnosis and management of Meniere disease. After hearing and assimilating this program, the clinicians will be better able to:

1. Perform a differential diagnosis for Meniere disease.
2. Develop management strategies for Meniere disease.

Summary

Cause: theorized to be endolymphatic hydrops; swelling in the inner ear caused by a mechanical obstruction or allergy leads to rupture and distention of membranes and mixing of sodium and potassium; these lead to episodic dysfunction of the inner ear with vertigo and hearing loss

Diagnostic criteria from the American Academy of Otolaryngology — Head and Neck Surgery:definite — ≥2 vertigo episodes that last for 20 min to 12 hr; documented low- to medium-frequency sensorineural hearing loss in one ear that is associated with vertigo episodes; tinnitus or fullness of the ear; and not better accounted for by another diagnosis; probable — ≥2 vertigo episodes that last 20 min to 24 hr and are associated with fluctuating aural symptoms and accompanied by tinnitus and fullness of the ear; sensorineural hearing loss is absent

Workup: audiogram should be obtained first; imaging is not diagnostic but rules out other diseases; vestibular testing is not recommended; vestibular migraine needs to be ruled out

Diagnostic criteria for vestibular migraine: include headache that lasts for 4 to 72 hr with 2 of the following characteristics: unilateral location, pulsatile quality, moderate or severe intensity, or aggravated by physical activity; other criteria include nausea or vomiting, photophobia, or phonophobia during episodes; definite — history of headache, episodes of vertigo of at least moderate severity, and migraine symptoms that occur with at least 2 attacks of the vertigo (eg, headache, photophobia, phonophobia, or visual or other auras); probable — history of migraine headaches that precipitate vertigo in >50% of the episodes and are caused by classic triggers, eg, food, sleep irregularities, and hormonal changes

Management

General approach: concurrent migraine should be treated first; includes diet and behavior modification, diuretics, betahistine, novel agents, and labyrinthectomy

Sodium restriction: intake should be kept to ≤2000 mg/day and maintained at a steady level to avoid peaks and troughs that can trigger episodes; clinical trial that compared patients with low vs high sodium excretion who were given a low-sodium diet (2 g/day) showed an increase in aldosterone after 2 yr but no improvement in clinical outcomes

Diuretics: evidence to support a role is lacking; Cochrane review could not find enough randomized controlled trials that compared diuretics with placebo; systematic review showed that the majority of studies on diuretics were retrospective case series or observational studies that had highly heterogeneous outcomes; no evidence is available to support or refute restriction of sodium, caffeine, and alcohol, but diuretics are listed as an option in the guidelines from the American Academy of Otolaryngology–Head and Neck Surgery

Betahistine: targets histamine 3 receptors and causes an increase in cochlear blood flow, microvascular circulation, and histamine turnover in the central nervous system and vestibular system; has a dampening effect by decreasing vestibular input from the peripheral system; Cochrane review showed a lack of evidence for efficacy in reduction of vertigo, hearing loss, tinnitus, and aural fullness; a systematic review that analyzed a subgroup of patients with Meniere disease showed an odds ratio of 3.37 for improvement of vertigo symptoms; double-blind randomized controlled trial showed no improvement with low- or high-dose betahistine compared with placebo; possible reasons for lack of efficacy are attributed to the inability to give high doses and first-pass metabolism by monoamine oxidase A and B; high doses should be avoided to prevent bronchospasm; caution should be exercised in patients with asthma, drowsiness, lethargy, nausea, vomiting, headaches, or peptic ulcers

Novel agents: vasopressin — randomized clinical trial showed that interventions to modulate vasopressin (increased water intake, positive pressure, and sleep) improved vertigo and hearing loss more than placebo, but no difference in efficacy was observed among the 3 interventions; antisecretory factor — endogenous production can be altered with dietary consumption in specially processed cereals or egg yolk powder with high concentration of antisecretory factor (eg, Salovum); study showed that consumption of specially processed cereal improved symptoms, but drop-out rate was high; 2 studies showed that consumption of specially processed cereal led to greater reduction in vertigo episodes and severity of tinnitus and improvement in overall quality of life compared with intravenous injections of glycerol and steroids (eg, dexamethasone)

Readings

Baloh RW. Vestibular migraine I: mechanisms, diagnosis, and clinical features. Semin Neurol. 2020;40:76-82; doi: 10.1055/s-0039-3402735; Christopher LH, Wilkinson EP. Meniere's disease: Medical management, rationale for vestibular preservation and suggested protocol in medical failure. Am J Otolaryngol. 2021;42:102817; doi: 10.1016/j.amjoto.2020.102817; Crowson MG et al. A systematic review of diuretics in the medical management of Ménière's disease. Otolaryngol Head Neck Surg. 2016;154:824-834; doi: 10.1177/0194599816630733; Lopez-Escamez JA et al. Diagnostic criteria for Menière's disease. J Vestib Res. 2015;25(1):1-7. doi:10.3233/VES-150549; Viola P et al. The role of endogenous antisecretory factor (AF) in the treatment of Ménière's disease: A two-year follow-up study. Preliminary results. Am J Otolaryngol. 2020;41(6):102673. doi:10.1016/j.amjoto.2020.102673.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Weinreich was recorded virtually at the 45th Midwinter Symposium of Practical Challenges in Otolaryngology, held February 22, 2021, and presented by the University of Illinois College of Medicine, Chicago, Department of Otolaryngology-Head and Neck Surgery. For information about future CME activities from this sponsor, please visit https://www.uicentskimeeting.org/. Audio Digest thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT541802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.