Vertigo (Meniere’s Disease)

What is Meniere’s Disease?

In 1861, Dr Prosper Meniere, head of the Institute of Deaf Mutes in Paris, described a series of patients with episodic vertigo, tinnitus (noises in the ear) and fluctuating hearing loss. This set of symptoms is now known as Meniere’s Disease.

The cause of Meniere’s Disease

The cause of Meniere’s Disease remains unknown but is likely to be connected with a number of factors. Meniere’s Disease is associated with endolymphatic hydrops or an over-accumulation of fluids in the inner ear. Congenital or hereditary ear abnormalities, infections or trauma to the ear may be predisposing factors. The role of the immune system is being extensively investigated by the research unit at St Vincent’s Hospital.

Symptoms

In the early stages of Meniere’s Disease, symptoms consist of clusters of acute attacks of rotatory dizziness or vertigo. The sensation of dizziness may last for a number of hours with associated nausea, vomiting and sometimes diarrhoea. The attack may occur without any obvious warning, or may be associated with increased ringing in the ear (tinnitus), fullness or hearing distortion. The hearing tends to worsen during attacks and to return to normal after the acute dizziness ceases. As the disease progresses, the hearing fluctuates less but worsens progressively with continued tinnitus and fullness. Some patients have long periods without vertigo attacks.

The final or “burnt out” stage of Meniere’s is associated with a permanent hearing loss but no further vertigo attacks. Vertigo may be replaced by a feeling of unsteadiness.

Diagnosis

No single test exists to diagnose Meniere’s Disease. The diagnosis of Meniere’s Disease is made following assessment of an accurate and careful patient history, an examination and several diagnostic tests. These usually consist of a hearing test, balance investigation and x-rays.

Treatment

Acute attacks of dizziness are treated using vestibular suppressant drugs. These medications suppress dizziness and also have anti-nausea and sedative properties. Diuretics such as urea can act to remove endolymph rapidly and abort an acute attack of dizziness when there are warning signs.

Long-term treatment includes the use of reduction of dietary salt and the use of diuretic medications.

Surgical Treatment

Patients are selected for surgery when they suffer incapacitating attacks of vertigo despite maximal medical treatment including medications and diet and lifestyle changes. Selection for surgery depends more on the degree of incapacity experienced by the patient than the frequency of the attacks. Therefore, surgery is indicated for only 10-20% of patients. The two major types of surgery for Meniere’s Disease at St Vincent’s Hospital are endolymphatic sac surgery and vestibular nerve section. Endolymphatic sac surgery has been carried out since 1926 with many variations. Successful relief of vertigo occurs in about 60-80% of patients in the short-term, but many well performed long-term studies indicate a recurrence of symptoms over time.

Vestibular nerve section involves cutting the balance nerve supplying the inner ear affected by Meniere’s Disease, but preserving the hearing nerve. The patients selected for vestibular nerve section usually have residual and sometimes fluctuating hearing loss. However, some patients have severe hearing loss and may be selected for both vestibular (balance) and cochlear (hearing) nerve sections if tinnitus is a major problem. Vestibular nerve section is highly successful in the abolition of acute attacks of vertigo especially over the long-term. Most patients experience no change in hearing following vestibular nerve section but hearing loss may occur over time with the natural progression of Meniere’s Disease.

Summary

Meniere’s Disease is a potentially disabling condition. Some patients do not respond to medical treatment and will consider surgery. Endolymphatic sac surgery and vestibular nerve section surgery have a useful role in the management of Meniere’s Disease.

Selected Publications

Fagan PA, (1986) “Assessment of the Dizzy Patient” Aust Fam Phys 15: 534-540.

Fagan PA, (1989) “Meniere’s Disease”. Mod Med. 32: 56-63.

Fagan PA, (1991) “The Surgical Treatment of Vertigo”, Mod Med Austral. 55-66.

Fagan PA, (1992) “The Clinical Assessment of Vertigo”, Mod Med Aug, 20-32.

Fagan PA. (1994) “New Concepts in Otolaryngology and the Surgery of Vertigo” Proceedings of The St Vincent’s Clinic 2: 12-17.

Fagan PA (1995) “Vertigo: How to Treat”, Aust Doctor Suppl 15 Sept pp1-6.

Reid CB, Isenberg R, Halmagyi GM, Fagan PA (1996) “The Outcome of Vestibular Nerve Sction for Intractable Vertigo: The Patient’s Point of View”, Laryngoscope 106: 1553-1556.

Tonkin JP (1995) “Meniere’s Disease”, Current Therapeutics, Nov 39-43

Tonkin JP (2002) “New treatment of Meniere’s Disease”, Aust Fam Physician, Aug 31(8) 749-50