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Ménière’s Options: Data Supporting Diagnosis and Treatment Remain Limited

More evidence is being gathered for the diagnosis and management of Ménière’s disease, but it remains a condition that has to be diagnosed clinically, with treatments progressing from the use of medicine to injections to surgery. The diagnosis and the treatment options were reviewed Sunday during “Evidence-Based Management of Ménière’s Disease.”

“There is a lot of practice variation in how Ménière’s is being managed,” said Seth R. Schwartz, MD, MPH, the Miniseminar moderator. “It is in the queue for the Academy Foundation’s guideline development, and there is intent to develop a clinical practice guideline in the next several years.”

The cause of Ménière’s is not understood, but it is known that swelling in the endolymphatic space is a characteristic of the condition, said Dr. Schwartz, a neurotologist and director of The Listen for Life Center at Virginia Mason Medical Center. MRI shows promise as a newer diagnostic tool. More powerful magnets allow MRI to get high-resolution ear scans that are coupled with contrast techniques to see dilation of the endolymphatic space.

“The data are not strong enough to make MRI indicated for diagnosis yet,” he said. “Some of it has to do with the fact that the techniques that are used are not widely available at every center. It requires a 3-tesla magnet for the MRI. There are some specific protocols that have been used to enhance the ability to look at the inner ear on those studies, and those are not widely available yet.”

The lack of data keeps MRI as an adjuvant diagnostic tool, as is electrocochleography, which records an electrical signal from the cochlea that can be abnormal in Ménière’s. However, other conditions can cause the pattern, and those who recently developed Ménière’s may not exhibit the pattern, Dr. Schwartz said.

Heather M. Weinreich, MD, MPH, an assistant professor in the Division of Otology, Neurotology, and Skull Base Surgery at Johns Hopkins Medical School, said data supporting medical treatment for Ménière’s disease is lacking. Diuretics, a first choice for many, are not greatly effective, but they may be a good option for patients with high blood pressure. Betahistine, in a large meta-analysis, showed benefit, but in a recent randomized control trial, it failed to perform better than placebo. For diet, reduced intake of sodium has been found to help reduce problems, she said.

Other treatment options are a Meniett device to alter pressures in the ear and vestibular rehabilitation, including the use of virtual reality and cognitive therapy, Dr. Weinreich said.

Michael E. Hoffer, MD, professor of otolaryngology and neurological surgery at the University of Miami, discussed intratympanic injections, focusing on gentamicin and steroids. The treatments and the doses have changed over the years based on data and common practices.

“Using intratympanic therapy comes with a responsibility to understand what we are doing and how it affects patients,” he said. Factors affecting therapy include disease status, level of disability, comorbidities, age, and unique patient issues.

Michael D. Seidman, MD, director of the Division of Otologic/Neurotologic/Skull Base Surgery at Florida Hospital, discussed surgical options, starting with labyrinthectomy. It leads to complete deafness in the operated ear and is considered the gold standard, leading to a 93-95 percent vertigo control rate. Other options include endolymphatic sac decompression, which has been shown to control vertigo in 50-75 percent of patients, and vestibular neurectomy, which has similar control rates to the labyrinthectomy and can spare hearing but requires a craniotomy.

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