Meniere's Disease - Sample Consultation |
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This consultation is part of a series of consultations with Head and Neck Surgery specialists at the University of California, San Diego. The case is a hypothetical patient chosen to represent a composite of the usual and most common patients with this specific disorder. Where gender, age or race make a difference, these will be specifically cited. Where they do not make a difference, they may be omitted. The consultation is presented for purposes of general information. Specifics about an individual case and specific treatment must be discussed between the patient and the treating physician.
The patient is a 42-year-old female who was referred by her primary care physician with a diagnosis of Meniere’s disease.
Doctor: Good morning, and welcome to UCSD. What can I do for you today?
Patient: I really hope you can help me. My problems began about six months ago when I had a terrible attack of vertigo. I was at home watching the news, when all of a sudden there was high-pitched ringing in my right ear and the entire room began spinning. I was really scared. My husband took me in to the emergency room. Things slowly settled down over the following 2 hours, but I was still nauseous. The emergency room doctors gave me some medicines that helped with the nausea. They let me go home later that night, but I still had a lingering sensation of dizziness for the next 2 days.
Doctor: Was that the only episode?
Patient: I was okay for about two weeks, but then it happened again. I went up to my room and laid down until the spinning sensation quieted down. I was able to see my primary care doctor the next day, and he ordered some lab tests and an audiogram. He gave me a prescription for a medicine called Valium to take during the acute attacks and told me to avoid salty foods. I’ve been trying to follow his advice but it is not working. I have had two more vertigo spells since then; I've missed almost 3 weeks of work; and I am afraid to drive.
Doctor: Let me begin by asking a few more questions. Do you ever notice a sensation of fullness or pressure in your right ear?
Patient: Yes, I do!
Doctor: Do you have ringing in your ears?
Patient: I usually get some ringing in my right ear after the attacks, but it isn’t too bad right now.
Doctor: Do these attacks affect your hearing?
Patient: Yes. For a few days after the attacks, sound on the right is muffled; it seems to get a little better over time.
Doctor: Have you had pain or headaches associated with these attacks?
Patient: No.
Doctor: Have you had ear infections or drainage from either of your ears?
Patient: No.
Doctor: Have you ever had surgery on your ears?
Patient: No.
Doctor: Do you take any medicines?
Patient: Just a Valium when I get an attack.
Doctor: I would like to take a look at your ear. (Doctor examines the patient's ears, looks at the ear drums, and checks the tuning fork tests.) Everything looks normal in your canal, ear drum and middle ear space. Your tuning fork tests indicate there is a slight sensorineural hearing loss on the right.
Doctor: It is likely your symptoms are caused by a condition we call Meniere’s disease. This is also known as endolymphatic hydrops. We have looked at the inner ears of patients with your symptoms and have found an enlargement of the endolymphatic space, one of the fluid-filled spaces in the inner ear. We don’t know what causes Meniere’s disease, but it seems that as the fluid accumulates in the inner ear, it can affect hearing and balance. The acute attacks may be caused by a tiny rupture in the membrane surrounding the endolymphatic space; and this causes the severe vertigo and hearing loss. With time, the hole seals off, and the ear makes a partial recovery. However, over the course of several years, the hearing and balance functions can become permanently damaged.
Patient: Is there anything we can do to confirm the diagnosis?
Doctor: Unfortunately, there isn’t a perfect test for Meniere’s disease, and we don’t have the ability yet to take pictures of the inner ear with enough detail to diagnose endolymphatic hydrops. We can, however, do some tests to look at your baseline hearing and balance function.
Patient: I would like to undergo those tests. What about in the meantime - - is there anything I can do?
Doctor: In addition to a low-salt diet, we usually recommend that patients take a low dose of a common blood pressure medication called hydrochlorothiazide (HCTZ). It affects the kidneys and promotes the elimination of salt from the body. It seems to reduce the frequency and severity of the attacks of vertigo, but may take up to 6 weeks work. I would be happy to prescribe it for you. You will need to take supplemental potassium and have your potassium levels checked periodically because this medication has the effect of lowering the body’s potassium levels.
Patient: Okay. I’ll start on the hydrochlorothiazide and get the audiology tests you suggested.
The patient returns 3 weeks later with the hearing and balance test results.
Doctor: Welcome back. How have you been?
Patient: I think I’m doing a little better. I haven’t had any of the really severe attacks; but I still have a little ringing and fullness in my right ear.
Doctor: Let me show you your audiogram. There is mild high-frequency sensorineural hearing loss on your right side, and your speech discrimination score is down a little bit. You balance tests indicate your right side is a little weaker, and the electrocochleography test is consistent with cochlear hydrops.
Patient: What is going to happen to me?
Doctor: The usual course of Meniere’s disease is progressive, but the frequency and severity of attacks tend to diminish with time. Up to 80% of patients progress to moderate sensorineural hearing loss. In as many as 40% of patients, this condition goes on to affect the other ear.
Patient: So what should I do now?
Doctor: Well, if you are holding up okay right now, you can stick with the hydrochlorothiazide and behavioral modifications. Things to try include a low-salt diet (less than 2 grams per day), avoiding excessive caffeine, smoking cessation, and incorporation of stress-reducing activities into your day. There are surgical options as well, but they are, of course, more invasive, and we should try the medical approach first.
Patient: Thank you for all the information. I’ll follow your advice and see how things go.
The patient calls the office 4 weeks later, in tears, having had another attack of dizziness. The nurse schedules another appointment with the doctor.
Patient: I’m miserable. I thought I was getting better; but it happened again. This time I missed my son’s eighth grade graduation. What are the surgical options you offer for this problem?
Doctor: The simplest procedure is insertion of a pressure equalization tube. This may help by reducing the effects of pressure changes on the middle ear and subsequently the inner ear. This procedure also allows patients to try the Meniette device. It is a new device that you hold up to your ear canal. It produces controlled puffs of air designed to push some of the extra fluid out of the inner ear.
Doctor: A more involved procedure, called endolymphatic sac surgery, is designed to reduce the fluid in the endolymphatic space. This involves a mastoidectomy, where we drill into the bone behind the ear and place a small drain into the endolymphatic sac. This surgery has the advantage of hearing preservation, but it is more dangerous because we are operating close to the brain. Furthermore, we can’t guarantee this procedure will work in everyone.
Doctor: Another treatment that can preserve hearing and help some patients is the injection of medications directly into the middle ear space. We can inject steroids into the middle ear and allow them to diffuse across the round window into the inner ear. They may work by improving blood flow and reducing inflammation in the inner ear.
Doctor: Finally, there are destructive procedures with the purpose of disabling the balance system in the affected ear. These include chemical and surgical labyrinthectomy and vestibular nerve sectioning. These treatments provide the best relief from acute attacks of vertigo; but they can damage the residual hearing.
Patient: Which treatment do you recommend?
Doctor: I will be happy to explain in more detail the risks and benefits of the treatments we offer. Since you have functional hearing in your right ear, I would recommend starting with one of the options that will continue to preserve your hearing. Consider a pressure equalization tube and the Meniette device. Steroid injection is also a reasonable alternative. My goal is to allow you to make an informed and educated decision that you are comfortable with.
Division of Otolaryngology/Head & Neck Surgery
La Jolla Clinic: Perlman Ambulatory Care Center
9350 Campus Point Drive
La Jolla, CA 92037
(858) 657-8590 |