1

I. Introduction
Meniere's disease is a condition which affects the hearing and balance of an
individual. It may occur as a result of a combination of genetic and environmental factors.
It affect an individual physically; it can affect all the aspects of his life including
employment, relationships, sports and social activities. Consequently, it can undermine a
person's mental well-being, confidence, self-esteem and sense of independence. Most
people diagnosed with Meniere's experience a prolonged process of psychological
adjustment.
Menieres disease usually first occurs in people between the age of 20 and 50
years. It affects more than 2.4 million people in the United States. More common in adults,
it has an average age of onset in the 40s, with symptoms usually beginning between the
ages of 20 and 60 years of age. It appears too equally common in both genders and
occurs bilaterally in about 20% of patients. About 50% of the patients who have the
Menieres disease have a positive family history of the disease.
Severe, debilitating attacks alternate with symptom-free periods. Patients often
have certain manifestations before an attack of vertigo such as headaches, increasing
tinnitus, and fullness in affected ear. Patients describe the tinnitus as a continuous, low-
pitched roar or a humming sound, which worsens just before and during an attack.
Hearing loss occur first with the low frequency tones but progresses to include all levels
and with repeated attacks, can become permanent.
The vertigo with periods of whirling may even cause patients to fall. It is so intense
that even while lying down, the patient often holds the bed or ground to keep from falling.
Severe vertigo usually lasts 3 to 4 hours, but patient may feel dizzy long after the attack.
Nausea and vomiting are common. Other manifestations include rapid eye movements
(nystagmus) and severe headaches.
II. DEFINITION OF THE DISEASE
Menieres disease also known as idiopathic endolymphatic hydrops, is
a disorder of the inner ear resulting in the clinical triad of vertigo, tinnitus, and hearing
loss. Three of the most recognizable indication of Menieres disease are tinnitus, vertigo,
and fluctuating hearing loss. Menieres disease is an inner ear condition that may trigger
disruptions in your balance.

MENIEREs DISEASE
 2

Menieres disease is an abnormal inner ear fluid balance caused by a

malabsorption in the endolymphatic sac or a blockage in the endolymphatic duct.
Endolymphatic hydrops, a dilation in the endolymphatic space, develops, and either
increased pressure in the system or rupture of the inner ear membrane occurs, producing
symptoms Menieres disease.
While there is no known cure for this disorder, there are steps that you can take to
lessen the impact it has on your daily life. A common starting point of these episodes is
a feeling of fullness in the ear that leads to tinnitus and mild hearing loss. Shortly after
these symptoms begin, you may begin to suffer vertigo, a feeling of dizziness not unlike
what you might experience after quickly spinning around several times. You may feel
nauseated and your balance may be impaired.
Episodes vary in length, sometimes ending as quickly as twenty minutes or lasting
for hours. It is common for Menieres disease episodes to appear in clusters, with
individuals enjoying periods of remission between groups of episodes. Symptoms vary
from episode to episode in terms of intensity and duration. If you notice any of these
symptoms, it is important to consult with your doctor to rule out more serious conditions.
Three Stages of Menieres disease
Early stage - sudden and unpredictable episodes of vertigo. Often the patient will
experience nausea, dizziness and vomiting during the episodes. An episode may last
from about 20 minutes to a full 24 hours. During episodes there will be some hearing
loss, which returns to normal after it is over. The ear may feel uncomfortable and
blocked, with a sense of fullness or pressure (aural fullness). Tinnitus is also common.
Middle stage - vertigo episodes continue, but are usually less severe. Tinnitus and
hearing loss, on the other hand, get worse. Some patients during this stage may
experience periods of complete remission - symptoms just go away and seem to have
gone forever. These periods of remission can last several months.
Late stage - vertigo episodes become even less frequent, and in some cases never
come back. Balance problems, though, and may continue.
Patients will feel especially unsteady when it is dark and they have less visual input
to help maintain balance.
Hearing and tinnitus typically get progressively worse.

MENIEREs DISEASE
 3

III. RISK FACTORS WITH RATIONALES

The inner ear contains fluid-filled tubes called labyrinths. These tubes, along with
a nerve in your skull, will aid you to know the position of your body and maintaining your
balance at the same time. The exact cause of Meniere disease is unknown. It may occur
when the pressure of the fluid in part of the inner ear gets too high.
In some cases, Meniere disease may be related to:
Head injury
Middle or inner ear infection
Other risk factors include:
Alcohol use
Allergies
Family history
Recent cold or viral illness
Smoking
Stress
Use of certain medicines
Meniere Disease is a Fairly Common Disorder
Allergies: Any kind of allergy to substances like dust, pollen, or food products
like wheat, nuts, dairy products, seafood may trigger inner ear symptoms of
dizziness, ringing, hearing loss, etc. and it may aggravate Meniere's disease.
Autoimmune: There is some evidence that the body's own immune mechanism
may be responsible for the disorder.
Dietary: There is some evidence that shows excess salt intake can exacerbate
the said condition.
Excess fluid in the inner ear: The inner ear is a group of connected passages
and cavities called a labyrinth. The outside of the inner ear is made of bone (bony
labyrinth). Inside is a soft structure of membrane (membranous labyrinth).
Normally, there is a presence of fluid in the membrane system of the inner ear.
This fluid plays a very important role in maintaining the balance of an
individual.

MENIEREs DISEASE
 4

When there is a defect in the membranes of the inner ear like swelling,
scarring, infection, injury etc. the fluid bursts out of the membrane entering other
areas and causing damage, which affects the sense of balance.
Heredity: Meniere's disease could be a result of genetic variation and it could
run in families.
Migraine: There is an increased prevalence of migraine in patients with
Meniere's disease. About one third of patients with Meniere's also experience
migraines.
Viral Infection: There is a possibility that virus could be responsible for the
disorder.
Other: Some other probable causes are stress, smoking and alcohol.
Increased Risk
The following factors may increase the risk of developing the condition:
Autoimmunity when your immune system attacks your own tissues and organs
by mistake.
Genetic (inherited) factors for example, if you have a family history of the
condition.
Chemical imbalance in the fluid in your inner ear as a result of too little or too
much sodium or potassium in your body.
Problem with the blood vessels there's a link between Menieres disease
and migraines, which are thought to be caused by the narrowing and widening of
blood vessels.
Some viral infections such as meningitis.
Modifiable and Non-Modifiable
Associated with aging
Middle-ear infection
Head trauma
The following will explain the cause of Meniere's disease is considered to trigger:
1. Allergy
In patients with Meniere found that 30% of them have food allergies.
Relationship between allergies with Meniere's disease are as follows:

MENIEREs DISEASE
 5

endolymphatic sac may be the target organ of mediators that are released in the
body when holding a reaction to certain foods. Antigen-antibody complexes may
interfere with the ability of the sac endolymphatic filtration. There is a relationship
between allergy and viral infection that causes hydrops of endolymphatic sac.
2. Autoimmune
There is also a presumption of experts stating that endolymph hydrops is
not a cause of Meniere's disease. It is said by Honrubia in 1999 and Rauch in 2001
that the autopsy study found endolymph hydrops in 6% of people who do not suffer
from Meniere's disease. Much research is now focused on immunologic function
in endolymphatic sac.
Some experts argue Meniere's disease caused by an autoimmune disorder.
Brenner conducted a study in 2004 said that in about 25% of patients with
Meniere's disease is also found to thyroid autoimmune diseases. Additionally in
2002 Ruckenstein also getting in approximately 40% of patients with Meniere's
disease obtained positive results in the examination of the blood such as
autoimmune arthritis factor, antiphospholipid antibodies and Anti Sjoegren.
(Nuzulul Zulkarnain Haq: 2009)
3. Head trauma
Scarring caused by trauma to the inner ear can be considered disturbing the
hydrodynamic flow of endolymphatic. This assumption is reinforced by the
Meniere's patients who have a history of temporal bone fracture.
4. Hereditary
In the study found 1 in 3 patients had a parent who suffered from Meniere's
disease as well. Hereditary predisposition is considered to have a relationship with
anatomical abnormality or abnormalities in the channel endolymphatic immune
system.
5. Herpes Virus (HSV)
Herpes viruses are found in patients with Meniere's. Once there was a
report that 12 out of the 16 patients with Meniere herpes simplex virus DNA in
endolymphatic sac.

MENIEREs DISEASE
 6

In addition it has been reported also in Meniere's patients who were given
antiviral therapy are improved. But this assumption has not been proven entirely
because they still need further research.
IV. CLINICAL MANIFESTATIONS WITH RATIONALES
Symptoms of Menieres disease include fluctuating progressive sensorineural
hearing loss; tinnitus or a roaring sound feeling of pressure or fullness in the ear; and
episodic, incapacitating vertigo, often accompanied by nausea and vomiting. These
symptoms range in severity from a minor nuisance to extreme disability, especially if the
attacks of vertigo are severe. At the onset of the disease, perhaps only one or two of the
symptoms are manifested.
The principle symptoms include:
Vertigo - usually the most striking Meniere's disease symptom, which includes:
o A feeling that you are spinning, even when you are stationary
o Dizziness
o Irregular heartbeats (palpitations)
o Nausea
o Sweating
o Vomiting
An episode of vertigo may last from a few minutes to a number of hours. As it is
difficult to predict when a vertigo attack may occur, patients should have their vertigo
medication handy at all times. Vertigo can interfere with driving, operating heavy
machinery, climbing ladders/scaffolding, and swimming.
Tinnitus - you sense noise or ringing, buzzing, roaring, whistling or hissing in your
ear, which is generated from inside your body. You will be more aware of it either
during quiet times or when you are tired.
Hearing loss - hearing loss may fluctuate, especially early on in the course of the
disease. The patient may also be especially sensitive to loud sounds. Eventually,
most people experience some degree of long-term hearing loss.
The following symptoms are also possible (known as secondary symptoms):
Anxiety, stress, depression - because of Meniere's disease's unpredictability
many patients become, anxious, depressed and stressed.

MENIEREs DISEASE
 7

The disease can have a detrimental impact on the sufferer's work,

especially if they have to climb ladders or operate machinery. As hearing gets
progressively worse the patient may find it more difficult to interact with other
people.
Some people cannot drive, further limiting their independence, job
prospects, freedom and access to social contacts. It is important for patients who
experience stress, anxiety and/or depression to tell their doctor.
V. MEDICAL MANAGEMENT WITH DESCRIPTION
Most patient can be successfully treated with diet and medication. Many patients
can control their symptoms by adhering to a low-sodium (200mg/day) diet. The amount
of sodium is one of the many factors that regulate the balance of fluid within the body.
Sodium and fluid retention disrupts the delicate balance between endolymph and
perilymph in the inner ear. Psychological evaluation may be indicated if a patient is
anxious, uncertain, fearful or depressed.
1. Non-Surgical Management
Although there is no cure, there is a treatment that can help the patient manage
some of the symptoms of Meniere's disease.
a. Teach patients to move the head slowly to prevent worsening of the vertigo.
b. Nutrition and lifestyle changes can reduce the amount of endolymphatic fluid.
c. Encourage the patients to stop smoking because of the blood vessels
constricting effects.
1. 1. Medications for vertigo - the individual may be prescribed medication to be
taken during an episode of vertigo to reduce the intensity of an attack. These
may include:
1.2. Motion sickness drugs - examples include meclizine (Antivert) or diazepam
(Valium). They may help with the spinning sensation, as well as nausea and
vomiting.
1.3. Drugs for nausea - prochlorperazine has been shown to be effective in the
treatment of nausea during a vertigo episode.
1.4. Diuretics - a combination of triamterene and hydrochlorothiazide (Dyazide,
Maxzide) will reduce fluid retention.

MENIEREs DISEASE
 8

By reducing the amount of fluid the body retains the patient's fluid
volume and pressure in the inner ear may improve, resulting in less severe
and less frequent Meniere's disease symptoms.
Long-term diuretic medication may deplete body levels of minerals,
such as potassium. Patients should supplement their diet with potassium-rich
foods, such as bananas, cantaloupe, spinach, sweet potatoes and oranges.
a. Nicotonic Acid
b. Antihistamines such as diphenhydramine hydrochloride (Benadryl,
Allerdryl) and dimenhydrinate (Dramamine, Gravol) and antivertiginous
drugs, such as meclizine (Antivert, Bonamine) help reduce the severity
of or stop an acute attack.
c. Antiemetics, such as chlorpromazine hydrochloride (Thorazine, Novo-
Chlorpromazine), droperidol (Inapsine), promethazine (Phenergan), and
ondansetron (Zofran), help reduce the nausea and vomiting. Diazepam
(Valium, Apo-Diazepam) calms the patient to rest quietly during an
attack. Intratympanic therapy with gentamycin and steroids can prevent
manifestations; however, this therapy results in some hearing loss.
1.5. Dietary changes - there are some dietary changes which can help reduce
fluid retention. Generally, the less fluid retention a patient has the less severe
and frequent his/her symptoms Meniere's disease symptoms will be.

These measures are known to help:

Many smaller meals evenly distributed throughout the day helps regulate
body fluids. Rather than three large meals a day, try to go for six smaller
ones.
Eat less salt - the less salt you consume the less fluid your body will retain.
Do not add any salt to your meals. Cut out most junk foods.
Cut out MSG (monosodium glutamate) - any foods with MSG added
should be struck off your shopping list.
Caffeine - caffeine has been shown to make tinnitus louder. If you avoid
caffeine completely you may find symptoms improve.

MENIEREs DISEASE
 9

Smoking - a significant number of patients report improved symptoms after

they give up smoking.
Stress, anxiety - experts are not sure whether stress/anxiety cause
symptoms or whether they are caused by the disease.
However, some studies indicate that good stress and anxiety
management may help lessen the intensity of symptoms.
If your levels of anxiety, stress, and possibly depression are affecting
your life, or if you would like to have better control, talk to your doctor.
Professional psychotherapy, as well as some medications have been
known to help many patients with Meniere's disease.
A hydrops diet may stabilize body fluid levels to prevent excess endolymph
accumulation.
The basic structure of this diet involves:
1.5.a. Limit foods high in salt or sugar. Beware of foods with hidden salts and sugars.
1.5.b. Eat meals and snacks at regular intervals to stay hydrated. Missing meals or
snacks may alter the fluid level in the inner ear.
1.5.c. Eat fresh fruits, vegetables, and whole grains. Limit the amount of canned,
frozen or processed foods with high sodium content.
1.5.d. Drink plenty of fluids. Water, milk, and low-sugar fruit juices are recommended.
Limit intake of coffee, tea, and soft drinks. Avoid caffeine because of its diuretic
effect.
1.5.e. Limit alcohol intake. Alcohol may change the volume and concentration of the
inner ear fluid and may worsen symptoms.
1.5.f. Avoid monosodium glutamate (MSG), which may increase symptoms.
1.5.g. Avoid Aspirin and aspirin-containing medications. Aspirin may increase
tinnitus and dizziness.
Summary:
Avoiding monosodium glutamate (MSG).
Drinking adequate amounts of fluids daily.
Avoiding caffeine-containing fluids and foods.
Limiting alcohol intake to one serving per day.

MENIEREs DISEASE
 10

Avoiding foods or fluids with a high salt content.

Distributing food and fluid intake evenly throughout the day and from
day to day.
Coordinate with a dietician for more information about diet therapy for reduction of
Menieres manifestation.
1.6. Vestibular rehabilitation therapy - patients who have problems with their
balance between episodes of vertigo may benefit from exercises and activities
aimed at helping the body and the brain regain the ability to process balance
data properly.
1.7. Pressure Pulse Treatments
Meniett device, which use a tympanostomy tube to apply low-pressure
micro pulses to the inner ear several times daily, have helped reduce episodes
in some patients with Menieres disease (National Institute on Deafness and
other Communication Disorders or NIDCD), 2010. This action displaces inner
ear fluid and prevents o relieves manifestations.
2. Surgical Management
2.1. Endolymphatic Decompression with drainage and a shunt
The effectiveness of this procedure varies. The endolymphatic sac is drained,
and a tube is inserted for continued fluid drainage. Some patients report relief of
vertigo with retention of their hearing. Vertigo is present immediately after
surgery from movement of the vestibules of the inner ear during surgery.
Reassure the patient that the vertigo is a temporary result of the surgical
procedure, not the disease.
2.1.a. Middle ear injections - some middle ear injections (injected into the
middle ear) may improve symptoms of vertigo. They include:
Gentamicin - this is an antibiotic that reduces the balancing function
of the ear so that the other ear takes over the body's balance.
Gentamicin may reduce the severity and frequency of vertigo attacks.
There is a risk of further hearing loss.
Steroids - some patients report better control over vertigo attacks
with such steroids as dexamethasone.

MENIEREs DISEASE
 11

Dexamethasone is less effective than gentamicin, but has a much

lower risk of causing further hearing loss.
Surgery - this may be an option if the patient did not respond to other treatments, or
if symptoms are very severe. Surgery options include:
2.2. Endolymphatic sac decompression - a small portion of bone is removed
from over the endolymphatic sac. Occasionally, a shunt is placed (a tube that
drains excess fluid from the inner ear).
2.3. Hearing aid - a patient with Meniere's disease who has suffered hearing loss
from the affected ear may benefit from a hearing aid. A hearing aid is an
instrument to help in hearing.
2.4. Labyrinthectomy - a portion of the inner ear is surgically removed. This
takes away both the hearing and balance function of the affected ear. This
procedure is only done if the patient is either totally, or almost totally deaf in
that ear.
2.5. Vestibular nerve section - the vestibular nerve is cut. This nerve connects
the balance and movement sensors in the inner ear to the brain. A vestibular
nerve section is aimed at preserving hearing in the affected ear, while
addressing the problems with vertigo.
3. Auditory Test/Assessment
3.1. Audiogram - this exam determines the extent of hearing loss caused by
the disease. An audiometer produces tones of varying loudness and pitch.
The patient listens with headphones and indicates when he/she hears a
sound, or when a sound is no longer present. The test only works if the
patient has normal hearing in one ear - the specialist can then make a
comparison. An audiogram may not be so effective during the early stage
because hearing loss is usually temporary. The test may also determine
whether the hearing problem is in the inner ear or the nerve that connects
the inner ear to the brain (auditory nerve).
3.2. Balance Assessment - Many people with Meniere's disease have some
degree of ongoing balance problems, even when their sense of balance
appears to return to normal between episodes of vertigo.

MENIEREs DISEASE
 12

3.3. Electronystagmography (ENG) - this assesses eye movement to evaluate

balance function. Muscles that control eye movement are linked to balance-
related sensors in the inner ear - it is this link that allows people to turn their
head while focusing their eyes steadily on a single point. Electrodes are
placed on the skin near the eyes and on the patient's forehead.
Warm and cool water or air is introduced into the ear canal.
Involuntary eye movements in response to this simulation are measured.
Abnormalities may indicate an inner ear problem.
3.4. Rotary-chair testing - this test also measures inner ear movement by
assessing eye movement. It is usually better tolerated than the ENG. The
patient sits in a chair in a small, dark booth. Electrodes are placed near the
eyes and a computer-guided chair rotates gently back and forth at varying
speeds. The movement stimulates the inner balance system and causes
nystagmus (eye movements) that are recorded by a computer and
monitored with an infrared camera. Rotary chair testing does not provide
specific diagnostic information about each ear individually - unlike the ENG.
3.5. VEMP (vestibular evoked myogenic potentials) testing - this test
measures the function of the sensors in the vestibule of the inner ear that
detects acceleration movement. These sensors are slightly sensitive to
sound. When exposed to sound the neck muscles contract at varying
degrees. VEMP testing can indirectly measure inner ear function.
3.6. Post-urography - this test determines which part of the balance system the
patient relies on the most, and which may cause problems. The patient
wears a safety harness, stands barefoot on a special platform and has to
keep his/her balance under various conditions. We rely on various senses
for balance, including vision, inner ear, or sensations in our skin, muscles,
tendons and joints.
A doctor may wish to rule out other possible diseases and conditions, such as a
brain tumor or multiple sclerosis. In order to do so, the following tests may be
ordered:

MENIEREs DISEASE
 13

3.7. MRI (magnetic resonance imaging) scan - a magnetic field and radio
waves created a 3-D image of the brain on a computer screen (monitor)
3.8. CT (computerized tomography) scan - many X-ray images produce
cross-sectional images of internal structures of the body
3.9. Auditory brainstem response audiometry - a computerized measure of
auditory function using responses produced by the auditory nerve at the
brainstem. This test is also known as brainstem evoked response
audiometry. This test can determine whether a tumor is disrupting the
function of the auditory nerves.
VI.NURSING MANAGEMENT WITH DESCRIPTION
1. Early Stage: Provide nursing care during acute attack.
a. Provide a safe, quiet, dimly lit environment and enforce bed rest.
b. Provide emotional support and reassurance to alleviate anxiety.
c. Administer prescribed medications, which may include antihistamines,
antiemetics, and possibly, mild diuretics.
2. Middle Stage: Instruct the client on self-care instructions to control the number
of acute attacks.
a. Discuss the nature of the disorder.
b. Discuss the need for a low-salt diet.
c. Explain the importance of avoiding stimulants and vasoconstrictions (e.g.
caffeine, decongestants, and alcohol).
d. Discuss medications that may be prescribed to prevent attacks or self-
administration of appropriate medications during an attack, which may
include anticholinergics, vasodilation, antihistamines, and possibly,
diuretics or nicotinic acid.
3. Late Stage: Discuss, prepare and assist the client with surgical options.
Nursing Diagnosis:
Risk for Injury related to altered mobility because of gait disturbance and vertigo.
Goal: Keep free from injuries related to an imbalance and / falls.
Expected outcomes:
Not to fall due to impaired balance.

MENIEREs DISEASE
 14

Fear and anxiety is reduced.

Conduct training in accordance with the provisions.
Identify the nature of feeling full or feeling pressure in the ear that happens before
the attack.
Immediately perform a horizontal position when dizzy.
Keep the head remained silent when dizzy.
Use prescription drugs as well.
Report an effort to reduce vertigo.
General Management
1. Assess vertigo which includes history, onset, description of the attack, duration,
frequency, and the presence of symptoms related ear hearing loss, tinnitus, a
feeling of fullness in the ear. Rationale: History provide the basis for further
intervention.
2. Assess the extent of disability in connection with the activities of daily living.
Rationale: The extent of disability lowers the risk of falling.
3. Teach vestibular therapy or stress / balance in accordance with the provisions.
Rationale: This exercise can speed up the compensation maze reduce vertigo
and impaired way street.
4. Give or teach how anti-drug or vertigo and vestibular sedatives and give
instructions to patients about the side effects. Rationale: Eliminate the
symptoms of acute vertigo.
5. Encourage the patient to lie down if feeling dizzy, with fence bed is raised.
Rationale: Reduces the possibility of falls and injuries.
6. Put a pillow on both sides to limit motion first. Rationale: Movement will
aggravate vertigo.
7. Help patients locate and determine the aura (the aural symptoms) that precedes
the occurrence of any attack. Rationale: The introduction of the aura can help
determine when the need for drugs before the attack so as to minimize the
severity of the effects.
8. Instruct the patient to keep his eyes open and looked straight ahead while lying
down and experiencing vertigo.

MENIEREs DISEASE
 15

Rationale: The feeling of vertigo and reduced eye movement when

experiencing decelerations remained on guard in a fixed position.
Impaired adjustment related to disability requiring change in lifestyle because of
unpredictability of vertigo.
1. Anxiety - related to the lack of information about hearing loss (tinnitus).
Goals / Outcomes: knowledge of the disease increases.
Intervention:
Educate about tinnitus.
Assess the level of anxiety / fear.
Encourage clients to relax and avoid stress.
Assure the client that the disease can be cured.
Assess the client's level of knowledge about the disorder.
2. Disturbed Sleep Pattern related to hearing loss
Goals / Outcomes: Sleep disorders can be overcome or adapted
Intervention:
Assess the level of difficulty sleeping.
Encourage clients to adapt to the disorder.
Collaboration in sedation / sleep medications.
3. Risk for Social Isolation related to communication barriers
Goals / Outcomes: Risk of damage can minimize social interaction.
Intervention:
Assess hearing difficulties.
Assess how severe the hearing loss in the client experience.
If possible, help clients understand nonverbal communication.
Encourage clients with hearing aids every in need if available.
VII. REFERENCE
Books:
Medical-Surgical Nursing Elevent Edition by Brunner & Suddarths
pages 2112-2125 (volume 2)
Introductory Medical-Surgical Nursing Tenth Edition by Timby & Smith
pages 1008-1016

MENIEREs DISEASE
 16

Medical-Surgical Nursing Eight Edition(Patient-Centered Collaborative Care)

pages 892-902
Sites:
www.menieres.org.uk
http://www.medicalnewstoday.com/articles/163888.php
http://www.ncpnanda.top/2013/02/nursing-care-plan-for-tinnitus.html
http://www.nhs.uk/Conditions/Menieres-disease/Pages/Causes.aspx
https://www.welcomecure.com/diseases/menieres-disease/risk-factors
http://www.nurseskomar.xyz/2013/07/nursing-care-plan-formenieresdisease.html
http://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/menieres-
disease-nursing-management/

MENIEREs DISEASE