Vascular insufficiency to the inner ear has long been proposed as a mechanism for Ménière’s disease. Betahistine (a histamine analogue) has been used in this context for decades with the aim of improving inner ear perfusion. Testing in animals suggests that this improves blood flow in the stria vascularis of the cochlear duct. A recent clinical trial in humans showed betahistine to be useful in reducing the frequency and severity of vertiginous episodes and to some degree in helping tinnitus. There was no effect on hearing loss or aural fullness.
Betahistine has minimal side effects (gastric irritation), and the dose is easily varied, allowing it to be titrated against the frequency and severity of vertiginous attacks. It is available as 8 mg, 16 mg and 24 mg preparations. An initial regimen of 16 mg twice daily is a useful starting point, with the dose reduced by half each month. Higher doses may be useful for patients with more resistant disease. Betahistine has very little interaction with other medications, making it safe for use in older patients with Ménière’s disease.
Corticosteroid treatments for Ménière’s disease are a more recent intervention, based on the possible autoimmune basis of the disease and recent experience with use of intratympanic corticosteroids to treat sudden sensorineural hearing loss. In addition to their possible immune-modulating effects, corticosteroids are likely to influence the sodium and fluid dynamics of the inner ear through their mineralocorticoid properties, making them a theoretically attractive treatment. However, few clinical trials have investigated the use of corticosteroids for vertigo control to date. It may be reasonable to administer a short course of oral corticosteroids (prednisone 1mg/kg/ day for 10 days) or to consider intratympanic injection (dexamethasone 4 mg, single dose) for patients with Ménière’s disease who experience a sudden drop in hearing thresholds.
Hearing aids and tinnitus management
Later in the course of Ménière’s disease, hearing loss starts to become intrusive. Unilateral hearing loss has limited impact in quiet listening environments but becomes significant with background noise. Directional hearing and music appreciation are also impaired. Bilateral hearing loss in bilateral Ménière’s disease is more intrusive. Hearing aids can be useful in this situation, but a particular challenge is the fluctuating hearing loss seen in Ménière’s disease. This has been partially addressed with self-programming and adjustable hearing aids, which allow patients to adjust the power and processing setting of the hearing aid to suit their current hearing thresholds. If hearing loss is severe then cochlear implants are highly effective in restoring hearing.10
Tinnitus can be a particularly distressing symptom. Management strategies include education, sound therapy, short-term drug therapy with benzodiazepines or sedating antidepressants, tinnitus retraining therapy and cognitive behavioural therapy.11
Semi-invasive and surgical treatments
Several nonevidence-based surgical operations and ‘sham’ procedures have been used in the past with some benefit, most likely because of a strong placebo effect. Most have now become historical, but insertion of grommets (tympanostomy tubes) is still used and may have a benefit on vertigo control and aural fullness. As it is a simple procedure able to be performed under local anaesthesia, is temporary and has a low risk of complications (persistent perforation, otorrhoea) grommet insertion is worth considering.