What is the pathology and treatment of Ménière disease identified in a dizziness evaluation?

Updated: Jun 26, 2018
  • Author: Wayne T Shaia, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Answer

The pathology and treatment of Ménière disease identified in a dizziness evaluation includes the following:

  • Ménière disease (or syndrome) typically manifests as a combination of 4 symptoms, namely, hearing that fluctuates in 1 ear (though Ménière disease can be bilateral), tinnitus that fluctuates in 1 ear, aural fullness, and episodes of vertigo that last for hours. However, Ménière disease often presents with just 1 or 2 symptoms of the tetrad that occur months to years before involving the entire tetrad. Low-frequency hearing loss is a typical manifestation in Ménière disease.

  • A relative overproduction or underabsorption of endolymph is thought to cause Ménière disease. The underlying etiology is unknown. Evaluate patients with suspected Ménière disease for syphilis, because patients who have late tertiary syphilis can present with identical symptoms. A fluorescein treponema antibody (FTA) test can be used for this purpose.

  • Ménière disease initially is treated with sodium restriction and possibly diuresis. Vestibular suppressants are useful during episodes. A combination of a diuretic and a vestibular suppressant controls episodes of vertigo in 60-80% of patients. Patients whose symptoms fail to respond to conservative treatment and who continue to have episodes of vertigo may benefit from a variety of treatments.

    • Transtympanic gentamicin can be used to perform a chemical labyrinthectomy to exploit the ototoxicity of this aminoglycoside. [2]

    • Endolymphatic sac decompression (ESD) can be performed. This outpatient procedure is the most commonly performed surgery for Ménière disease. Through the mastoid, the endolymphatic sac is exposed and freed of surrounding bone. Some surgeons insert a shunt to drain endolymph from the sac, though the benefit of this maneuver compared with simple decompression of the sac is not clear. With ESD, the rate of substantial control of symptoms is approximately 80% while it spares the patient's hearing.

    • Sectioning of the vestibular nerve. This procedure is performed through a posterior or middle fossa craniotomy. The vestibular division of cranial nerve VIII is cut, sparing the auditory division. The benefit of the operation is preservation of hearing in all but a few patients, with a >90% success rate in terminating episodes of vertigo.

    • Labyrinthectomy can be performed in patients with unilateral symptoms who have poor hearing that cannot be improved by a hearing aid. This procedure remains the criterion standard in the treatment of unilateral Ménière disease and the highest success rate in terminating episodes of vertigo. However, all of the remaining hearing in the treated ear is lost.


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