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Feature Article

Ménière’s disease. A guide to management

Melville da Cruz
OPEN ACCESS

Figures

© CR8D4UCOLORADO/ ISTOCKPHOTO.COM
© CR8D4UCOLORADO/ ISTOCKPHOTO.COM

Abstract

Ménière’s disease is an uncommon cause of recurrent vertigo that should be distinguished from other common causes of balance disturbance, such as vestibular migraine and positional vertigo. Stepwise introduction of dietary restriction of sodium, lifestyle changes and medication can reduce the frequency and severity of attacks in most patients. Hearing loss can be treated initially with hearing aids and, in the later stages, a cochlear implant.

Key Points

  • Ménière’s disease is characterised by recurrent attacks of vertigo, fluctuating hearing loss, tinnitus and a sensation of aural fullness.
  • Attacks are sudden in onset, typically accompanied by an intense sensation of movement, nausea, vomiting, diarrhoea and sweating, and can last hours.
  • Treatment options for acute attacks include ondansetron, prochlorperazine and diazepam.
  • In most patients, attack frequency and severity can be reduced by a stepwise approach of dietary restriction of sodium, lifestyle changes and medication; surgical treatment is rarely required.
  • Referral to a specialist is best for initial diagnosis and evaluation.
  • GPs have an important role in ongoing management of patients with Ménière’s disease.

Ménière’s disease is characterised by recurrent attacks of vertigo accompanied by fluctuating sensorineural hearing loss, tinnitus and a sense of aural fullness. Prosper Ménière in 1861 correctly attributed the attacks to a disorder of the inner ear, suggesting that the mechanism of causation could be similar to migraine or inner ear vasospasm, a differential diagnosis which is still relevant for the disease today.1 

Meniere's disease today

The differential diagnosis of vertigo is broad, often leading to all cases of vertigo being labelled as Ménière’s disease. To clarify the diagnosis, treatment and prognostication of patients with Ménière’s disease, the American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS) published guidelines for the classification of Ménière’s disease (Box 1).2 Although the category of ‘certain Ménière’s disease’ is used only as a research definition, as it requires postmortem histological examination of the temporal bone, the other categories are clinically useful.

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Clinical features and natural history

The hallmark of an acute Ménière’s attack is prolonged vertigo. The vertigo is characterised by a sudden unheralded intense sensation of movement, most commonly rotation or spinning, lasting at least 20 minutes and accompanied by nausea, vomiting, diarrhoea and sweating. The duration and character of the vertigo is important in the diagnosis of Ménière’s disease because episodes lasting a few seconds or minutes are more likely to be due to benign paroxysmal positional vertigo (BPPV) or, if longer than eight to 12 hours, to vestibular neuritis or cerebellar stroke. Feelings of light-headedness, pressure or vague disturbances of balance are more likely to be due to nonotological causes, such as postural hypotension, hyperglycaemia, hyperventilation, panic attacks or anxiety.

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Figures

© CR8D4UCOLORADO/ ISTOCKPHOTO.COM
© CR8D4UCOLORADO/ ISTOCKPHOTO.COM
Associate Professor da Cruz is an Ear Nose and Throat Surgeon at Westmead Hospital, University of Sydney, and a Cochlear Implant Surgeon at Sydney Cochlear Implant Centre, Sydney, NSW.