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Meniere's Disease Treatment |
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Medical Options
The mainstay of treatment for Meniere's disease involves drugs to reduce the dizziness and drugs to reduce the fluid overload of the inner ear. For dizziness, vestibular sedatives like Compazine, Dramamine, Antivert (meclizine), Phenergan, and Valium (diazepam) are prescribed. Since these provide symptomatic relief, they usually are needed only when dizziness is present.
Treatment can also include diuretics and a low salt diet. The diuretics alone will not help if a liberal salt intake is occurring, so we recommend a 1200-1500mg low salt diet. Commonly prescribed diuretics are:
- Hydrochlorothiazide (HCTZ)
- Maxzide
- Aldactone
- Lasix (furosemide)
- Diamox (acetazolamide)
- Some diuretics also cause potassium to be lost in the urine, so potassium supplements are a must.
We recommend that diuretics be continued until no symptoms remain in the ear, exclusive of tinnitus, which may never completely resolve. Once the dizziness ceases and inner ear pressure and hearing loss improve, a slow withdrawal of the medication can begin.
Occasionally, blood tests suggest the possibility that an autoimmune disorder may underlie the disease. If so, a short course of steroids (Medrol or prednisone) may be recommended. The side effects of prolonged steroids are significant, so they must be used carefully. However, when an immune cause is identified, steroids plus diuretics may be the only effective treatment and the disease can be put into remission by such regimen.
With close follow-up and the aforementioned medical therapy, approximately 80-85% of patients with Meniere's disease will be controlled. Occasional spells of dizziness may occur, but with medication they can be minimized. Most experts feel that once a patient has developed classical spells, their ears will remain “prone” to relapses, even is they have been well-controlled by medication.
Surgical Options
Only a minority of patients need surgery, however, when medical treatment fails and there are incapacitating symptoms, surgical treatment is an option. At UCSD Medical Center, we believe that no patient should ever have to suffer from continued severe vertigo in this disease, as it can always be remedied. The types of therapy depend upon how good the hearing is.
- Endolymphatic Sac Surgery
This is an ear operation that is done to drain and open the endolymphatic sac, the site that is responsible for resorbing inner ear fluid. This is a mastoid operation that takes approximately 1-2 hours. This is done under general anesthesia and the patient may stay over night or, if doing well, go home that afternoon. This operation will usually not cause hearing loss and carried with it the risks associated with any ear operation: hearing loss, dizziness, and facial nerve weakness. This surgery had a success rate of 60-70% in control of vertigo. We usually do not perform this surgery solely for hearing loss, as it is impossible to predict if hearing will improve after the surgery in time.
Sometimes there will be dramatic hearing improvement, but tinnitus is rarely affected. Since this site of drainage for the inner ear is at the end of the drainage system, it requires that the ducts (tubes) that carry the fluid be open all the way to it, for the surgery to be successful. If the ducts are blocked upstream, then opening the sac will not have the desired effect. Unfortunately, there is no way to determine this preoperatively. This is a conservative, nondestructive procedure that is often recommended as a first step in attempting to control the illness.
- Vestibular Nerve Sectioning
This procedure is done with a neurosurgeon and is an intracranial approach. The procedure takes approximately 1-2 hours and requires a three to five day hospital stay. In this microsurgery, the facial nerve is first positively identified by electrical stimulation and then the eight nerve is exposed and the balance portion is identified and cut. The hearing nerve is spared.
Sometimes the separation between the hearing and vestibular nerves is not distinct. In this case, the surgeon must estimate the percentage of the nerve that is balance and perform the neurectomy with out exact knowledge of how much of the nerve carries hearing fibers and how much carries balance. Since vertigo is the compelling reason for doing the surgery, we usually recommend that we err on the side of taking more of the nerve rather than less, in order to ensure relief from vertigo, even at the expense of some hearing. The risks of the surgery include: deafness, persistent dizziness, facial nerve weakness, meningitis, cerebrospinal fluid leakage, stroke and bleeding. While these risks are exceedingly small, they nevertheless need to be considered.
This operation is reserved for patient who have good hearing, severe vertigo, and who either have failed the endolymphatic sac procedure or only wish to undergo one, definitive operation. The success rate for relief of attacks of vertigo is 90-95%. Since the balance nerve has been cut and no information gets to the brain from the diseased labyrinth, some unsteadiness, particularly in the dark or with quick turns, can remain permanently.
- Cochleosacculotomy
This is a procedure that attempts to drain fluid and create a fistula upstream rather than down at the endolymphatic sac. It is a procedure that can be performed in thirty minutes under local anesthesia and as an outpatient. It does not destroy balance function but tries to restore normal physiological function. It is a good choice for patients with severe dizziness and relatively poor hearing, especially if they are elderly and might have a hard time compensating from destruction of their balance system. The major drawback to this procedure is that there may be significant hearing loss from it (especially high frequency) and, over time, symptoms might return due to closure of the internal fistula. The success rate is approximately 65-70%.
- Labyrinthectomy
This is an excellent, safe, definitive destructive procedure in which the balance organs are systematically drilled away under general anesthesia. Hospital stay is usually three to five days. Hearing will be lost from the procedure so it is recommended for patients with severe vertigo and poor hearing. It has a high cure rate for vertigo (90-95%), but in elderly with poor vision, or any preexistent brain dysfunction, there can be a problem adjusting to the loss of balance function.
- Gentamycin Chemical Labyrinthectomy
This is an outpatient procedure that capitalizes on the known toxicity of this antibiotic to the inner ear. This drug, in drop preparation, is instilled on a daily basis into the ear canal or through a catheter into the middle ear through a small hole made in the eardrum. Over time, enough of the antibiotic will be absorbed into the inner ear to cause a destructive effect on the balance system.
Unfortunately, the drops also have a potential to destroy hearing and cause tinnitus, so that it must be used with great caution in hearing ears. Because absorption of the drops is unpredictable and susceptibility varies, the end result will vary from patient to patient. Therefore, patients may still have instability because of the incomplete “labyrinthectomy.” This is a good technique in patients to ill to undergo surgery or who have poor hearing, but it is still a destructive procedure and compensation issues raised above pertain to this procedure as well.
Each of these techniques are designed to alleviate the symptoms of a patient with intractable Meniere's disease. This discussion is to allow you to reiterate what your doctor has told you and should not be substituted for a frank discussion about your own personal case.
Make an appointment
To schedule a consultation, please call (619) 543-6631 (Hillcrest Medical Center) or (858) 657-8590 (Perlman Ambulatory Care Center).
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