New Guideline to Improve Ménière's Disease Diagnosis, Treatment

Megan Brooks

April 14, 2020

A new clinical practice guideline from the American Academy of Otolaryngology‒Head and Neck Surgery Foundation (AAO-HNSF) is providing evidence-based recommendations for the diagnosis and treatment of Ménière's disease.

A disorder of the inner ear, Ménière's disease causes spontaneous attacks of vertigo, each lasting 20 minutes to 12 hours. It also includes low- to mid-frequency sensorineural hearing loss in the affected ear before, during, or after an episode of vertigo.

With the new guideline, "we are really trying to improve diagnosis accuracy to allow timely treatment to improve patient quality of life, while being cost effective and not putting people through a bunch of tests that don't help with diagnosis," Gregory Basura, MD, PhD, chair of the guideline development group, told Medscape Medical News.

Ménière's "can take weeks, months, even years to make a definitive diagnosis because you are relying on patient reporting of symptoms," noted Basura, who is from the University of Michigan Medical Center, Ann Arbor.

"Objective testing with imaging and some different physiologic measures is getting better but still it remains a clinical diagnosis," he said.

The guideline was published online April 8 in Otolaryngology–Head and Neck Surgery.

"The Great Mimicker"

Basura noted that vestibular migraine is "the great mimicker" of Ménière's disease.

"A lot of patients with vestibular migraine can present with symptoms that seem consistent with Ménière's disease but they aren't, and the guideline makes note of this," Basura said.

The guideline provides several "key action statements" to guide clinicians based on the best available evidence in the literature.

First, it notes that definite or probable Ménière's disease should be diagnosed in patients presenting with two or more episodes of vertigo lasting 20 minutes to 12 hours (definite) or up to 24 hours (probable); fluctuating or nonfluctuating sensorineural hearing loss, tinnitus, or pressure in the affected ear; and when these symptoms are not better accounted for by another disorder.

It should also be determined if patients meet diagnostic criteria for vestibular migraine when assessing for Ménière's disease, and an audiogram should be used when assessing for diagnosis.

Other key recommendations include the following:

  • Offer MRI of the internal auditory canal and posterior fossa in patients with possible Ménière's disease and audiometrically verified asymmetric sensorineural hearing loss.

  • Do not routinely order vestibular function testing or electrocochleography to establish the diagnosis.

  • Educate patients with the disease about the natural history, measures for symptom control, treatment options, and outcomes, as well as on dietary and lifestyle modifications that may reduce or prevent symptoms.

  • Offer a limited course of vestibular suppressants to patients for management of vertigo only during Ménière's disease attacks.

  • Consider offering diuretics and/or betahistine for maintenance therapy to reduce symptoms or to prevent attacks, but do not prescribe positive pressure therapy.

Clinicians can also offer, or refer to a clinician who can offer, the following recommendations:

  • Intratympanic (IT) steroids to patients with active Ménière's disease not responsive to noninvasive treatment

  • IT gentamicin to those with active disease not responsive to nonablative therapy

  • Labyrinthectomy to those with active disease who have failed less definitive therapy and have nonusable hearing

  • Vestibular rehabilitation/physical therapy for patients with chronic imbalance but not for managing acute vertigo attacks

Patients diagnosed with Ménière's disease and hearing loss should be counseled on the use of amplification and hearing assistive technology.

Finally, the guideline notes that resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss, and any change in quality of life in patients with Ménière's disease after treatment, should be documented.

Funding for the development of the guideline was provided by AAO-HNSF. A complete list of disclosures for the writing committee are listed in the original article.

Otolaryngol Head Neck Surg. Published online April 8, 2020. Full text

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