Ménière’s Disease
- Disha Singh (38)
- Bhalkikar Anand (31)
Definition
Ménière’s disease, also called endolymphatic hydrops, is a disorder of
the inner ear where the endolymphatic system is distended with
endolymph. It is characterized by
(i) vertigo
(ii) sensorineural hearing loss
(iii) tinnitus
(iv) aural fullness.
Patholo
gy
The main pathology is distension of endolymphatic system, mainly
affecting the cochlear duct (scala media) and the saccule, and to a
lesser extent the utricle and semicircular canals. The dilatation of
cochlear duct is such that it may completely fill the scala vestibuli; there
is marked bulging of Reissner’s membrane.
● Defective Absorption by
Endolymphatic Sac
● Vasomotor disturbance
● Allergy
AETIOLOGY ● Sodium and water retention
● Hypothyroidism
● Autoimmune and viral
aetiologies
Age and sex: commonly seen in the
age group of 35–60 years, males
are affected more than females.
Usually, disease is unilateral but
Clinical the other ear may be affected after
a few years.
Features Cardinal symptoms of Ménière’s
disease are
(i) episodic vertigo,
(ii) fluctuating hearing loss,
(iii) tinnitus and
(iv) sense of fullness or pressure in
the involved ear.
Investigations
Pure Tone Audiometry: There is sensorineural hearing loss. In early
stages, lower frequencies are affected and the curve is of rising type.
When higher frequencies are involved curve becomes flat or a falling type.
(A) Audiogram in early Meniere’s disease.
Note:Hearing loss is sensorineural and more in
lower frequencies—the rising curve. As the
disease progresses, middle and higher
frequencies get involved and audiogram
becomes flat or falling type (B & C).
Speech Audiometry: Discrimination score is usually 55–85% between
the attacks but discrimination ability is much impaired during and
immediately following an attack.
Special Audiometry Tests: They indicate the cochlear nature of disease
and thus help to differentiate from retrocochlear lesions, e.g. acoustic
neuroma
Electrocochleography: It shows changes diagnostic of Meniere’s
disease. Normally, ratio of summating potential (SP) to action potential
(AP) is 30%. In Meniere’s disease, SP/AP ratio is greater than 30%
Caloric Test: It shows reduced response on the affected side in 75% of
cases. Often, it reveals a canal paresis on the affected side (most
common) but sometimes there is directional preponderance to healthy
side or a combination of both canal paresis on the affected side and
directional preponderance on the opposite side.
Glycerol Test: Patient is given glycerol (1.5 mL/kg) with an equal amount
of water and a little flavouring agent or lemon juice. Audiogram and
speech discrimination scores are
recorded before and 1–2 h after ingestion of glycerol. An improvement of
10 dB in two or more adjacent octaves or gain of 10% in discrimination
score makes the test positive. There is also improvement in tinnitus and in
the sense of fullness in the ear. The test has a diagnostic and prognostic
value.
Treatment
GENERAL MEASURES MANAGEMENT OF ACUTE
ATTACK
1. Reassurance.
2. Cessation of smoking. 1. Reassurance and psychological
support to allay worry and anxiety.
3. Low salt diet.
2. Bed rest with head supported on
4. Avoid excessive intake of water. pillows to prevent excessive movements.
5. Avoid over-indulgence in coffee, tea 3. Intravenous fluids and electrolyte
and alcohol. administrationto combat their loss due to
vomiting.
6. Avoid stress and bring a change in
lifestyle. 4. Vestibular sedatives to relieve
vertigo.dimenhydrinate,
7. Avoid activities requiring good body promethazine,prochlorperazine
MANAGEMENT OF CHRONIC PHASE
1. Vestibular sedatives. Prochlorperazine 10 mg, thrice a day, orally for
two months and then reduced to 5 mg thrice a day for another month.
2. Vasodilators. Betahistine 8–16 mg, thrice a day, given orally, also
increases labyrinthine blood flow by releasing histamine in the body.
3. Diuretics. Thiazide diuretics (hydrochlorothiazide), 12.5 mg daily can
be used.
4. Elimination of allergen
5. Hormones. Investigations should be directed to find any endocrinal
disorder such as hypothyroidism, and appropriate replacement therapy
given.
SURGICAL TREATMENT
Conservative Procedures.
They are used in cases where vertigo is disabling but hearing is still useful
and needs to be preserved.
(a) Decompression of endolymphatic sac.
(b) Endolymphatic shunt operation.
(c) Selective section of vestibular nerve. The nerve is exposed by
retrosigmoid or middle cranial fossa approach and selectively sectioned. It
controls vertigo but preserves
hearing.
Destructive Procedures.
Labyrinthectomy: Membranous labyrinth is completely destroyed either by
opening through the lateral semicircular canal by transmastoid route or
through the
oval window by a transcanal approach. This gives relief from the attacks of
Meniett device therapy
Intermittent Low-Pressure Pulse Therapy. It is observed that intermittent
positive pressure delivered to inner ear fluids brings relief from the
symptoms of Meniere’s disease. Not only there is improvement in vertigo,
tinnitus and ear fullness, but hearing may also improve.
Intermittent positive pressure waves can be delivered through an
instrument called Meniett device. A prerequisite for such a therapy is to
perform a myringotomy and insert a ventilation tube so that the device
when coupled to the external ear canal can deliver pressure waves to the
round window membrane via the ventilation tube. Pressure waves pass
through the perilymph and cause reduction in endolymph pressure by
redistributing it through various communication channels such as the
endolymphatic sac or the blood vessel.
REFERENCES
● Diseases of Ear, Nose and Throat by PL Dhingra
● Textbook of Ear, Nose, Throat and Head-Neck Surgery, Clinical and
Practical By P Hazarika
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