What is Meniere’s Disease?
Ménière’s disease is a chronic condition of the inner ear. The disorder results in episodes of severe vertigo, or dizziness, a decrease in hearing, ringing in the ear called tinnitus, and a feeling of fullness in the ear. It most commonly affects one ear, but it can affect both ears. The episodes can negatively impact quality of life because they are often unpredictable and debilitating. It is estimated by the National Institute on Deafness and Other Communication Disorders that about 615,000 people in the United States are diagnosed with Ménière’s disease. It most commonly arises in individuals between the ages of 30 and 50. Between 10% and 15% of cases are diagnosed after the age of 65. Researchers continue to study the condition because there are multiple possible causes, varying prognosis between individuals, and no singular treatment that is effective for all suffering with the disease.
What Causes Meniere’s Disease?
Ménière’s disease is caused by an imbalance or change in the production and absorption of endolymph of the inner ear. Contained within the bony labyrinth of the inner ear are the organ of balance (the semicircular canals, utricle, and saccule), and the organ of hearing (the cochlea). Within these walls lie sensitive tissues called the membranous labyrinth which are filled with endolymph. Endolymph is a specialized fluid that when set in motion either by movement of the body or sound waves, begins the sequence of activating hearing and balancing neurons. Changes in the endolymph can inappropriately stimulate the semicircular canals and negatively affect specialized hearing receptor cells in the cochlea.
Changes in endolymph may result from a variety of conditions. Autoimmune disorders may be a factor for some. There is a higher prevalence of autoimmune disorders in people diagnosed with Ménière’s disease. In addition, there is also a higher prevalence of individuals suffering from migraines who have Ménière’s disease suggesting a common cause. Some Ménière’s sufferers have found relief treating respiratory and food allergies which may indicate the disease is brought on by allergens. There is evidence that Ménière’s disease can be the result of vascular issues, infection, genetic factors, inflammatory disease, and diet. Because there is such a range of possibilities for Ménière’s disease, it can be challenging to find the best form of treatment.
What are the symptoms of Meniere’s disease?
Ménière’s disease is characterized by four symptoms. The first and most debilitating is recurrent, unpredictable episodes of vertigo lasting between 20 minutes and 12 hours. The vertigo is often accompanied with nausea and vomiting and has lasting effects for hours or days after the episode. The second symptom is hearing loss in the affected ear. In the early stages of Ménière’s disease hearing loss can fluctuate, but at further stages of the disease hearing loss will remain more constant. The third symptom is ringing in the ears or tinnitus. Tinnitus may be constant or come and go. The final symptom is a plugged feeling or a sensation of fullness in the ear. Most cases of Ménière’s disease affect only one ear, but there is a small percentage of cases in which both ears are affected by Ménière’s disease.
How is Meniere’s disease diagnosed?
There is not one definitive assessment to diagnose Ménière’s disease. As a result, evaluating symptoms, using hearing and vestibular assessments, and ruling out other possible causes are needed in the diagnosis process. Symptoms of two or more spontaneous episodes of vertigo, hearing loss, tinnitus, and aural fullness will be present. Diagnosis should be made by an otolaryngologist, or ear nose and throat specialist, with supporting evidence from the audiologist.
A hearing test can be used to determine the type and configuration of hearing loss. This test will be performed by an audiologist in a sound treated room using specialized calibrated equipment. The patient will be asked to respond when a tone is heard, even if it is very faint. The audiologist will present a range of pitches, or frequencies, to the patient to determine their thresholds through air conduction headphones and bone conduction headphones. Speech understanding is tested by presenting a list of words at a level the patient finds comfortable. The patient repeats each word as it is perceived.
This battery of testing may need to be performed multiple times as hearing can change in the affected ear during an episode and may improve after the episode has resolved. During an episode, low frequency sensorineural hearing loss is commonly diagnosed. After the episode, hearing may return to previous levels.
Hearing loss is less likely to improve as the disease progresses and commonly results in hearing loss across all frequencies in the affected ear. After diagnosis, regular hearing assessments should be scheduled to monitor for changes in hearing levels and word understanding.
Vestibular testing can be performed to evaluate the balance system by measuring eye-movement. Nystagmus is a type of eye-movement occurring with vertigo where the eyes move one direction and quickly snap back to the center. Nystagmus can be easily measured with electronystagmography (ENG) by using electrodes or videonystagmography (VNG) using video Frenzel goggles.
ENG is made up of multiple assessments. First, spontaneous, or involuntary nystagmus is measured. Second, is saccade testing. Saccades are the fastest eye movement a patient can produce. This test measures the ability of the eyes to quickly shift from one point of fixation to another. Next, the gaze test measures nystagmus when the eyes are fixed without head movement. Fourth is the tracking test which requires a patient to fixate on a moving target at varying speeds. Fifth, positional testing can bring on nystagmus. This test looks at the effect of head and body movement as well as stationary positions. The final test of the ENG battery is thermal caloric testing which tests each horizontal semicircular canal individually. Warm and cool temperature changes in the ear create movement of the endolymph in the vestibular system as if the head was moving. This test may be performed using controlled water or air temperature in the ear canal. An additional vestibular test is the head impulse test (HIMP). The use of the high-speed video goggles during this test is advantageous but not required. In this test the patient’s head is quickly moved and saccades are measured.
Electrocochleography (ECOG) is an additional test that can be helpful in diagnosing Ménière’s disease. It records an auditory evoked potential. This test is not very convenient as it requires electrode placement on the eardrum. The best recordings come from a needle electrode placed through the eardrum. This test can evaluate each ear separately, but positive results cannot distinguish between Ménière’s disease and other disorders such as a perilymphatic fistula, a small leak of fluid from the perilymphatic space in the labyrinth.
The ENT may order further tests to rule out other possible diagnoses. An MRI of the internal auditory canal is one such test. This imaging study can rule out the possibility of an acoustic neuroma, a growth of cells that press against the eighth cranial nerve resulting in hearing and balance problems. Other tests may include blood analysis to determine if there are any co-occurring health issues such as an autoimmune disorder. Allergy testing may also be beneficial.
How is Meniere’s disease treated?
Unfortunately, not one treatment method is appropriate or effective for all people suffering with Ménière’s disease. Some treatments improve the symptoms of Ménière’s without significant negative effects while others should be considered only after all other options have been attempted.
If adjusting one’s lifestyle does not have the desired improvement, medications may be prescribed. Diuretics can reduce vestibular involvement by reducing salt and water in the system. Some examples of these medications include hydrochlorothiazide, acetazolamide, and chlorthalidone. Betahistine is a histamine analog that is thought to increase blood flow to the inner ear. It has been used with inconclusive results. More studies are needed. Other medications such as meclizine may be prescribed to help relieve symptoms during an episode. It is also important to treat any health conditions, even if they seem unrelated.
Some have tried hyperbaric oxygen therapy to increase oxygen levels in the inner ear and improve the circulation of endolymph. This treatment is not universally accepted. Occasionally patients may find relief in positional maneuvers, but this varies between people with Ménière’s and between episodes.
Medication can be administered locally using an injection through the tympanic membrane, or eardrum. This medication can be a steroid such as dexamethasone or methylprednisolone, or they can be toxic to the vestibular system such as gentamicin or streptomycin. Gentamicin has been found to control vertigo in 70 to 89% of cases, but it carries the risk of hearing loss.
Physical therapy can play a role in managing Ménière’s disease. Physical therapists can help educate patients to reduce the risk of injury during an episode. They may be able to improve baseline balance and can provide help for the patient that required invasive medical procedures to control vertigo.
Although symptoms of hearing loss are often secondary to those of vertigo, treatment of hearing loss is equally important to manage. Hearing loss can be treated with hearing aids, communication strategies, and auditory training. If an extended period of time occurs between the onset of hearing loss and when the patient seeks treatment, auditory deprivation may occur. Therefore, early intervention is important.
Patients with Ménière’s disease have special considerations such as asymmetrical hearing loss and fluctuating hearing loss. The audiologist can diagnose and monitor changes in hearing. In addition, the audiologist is trained to fit fluctuating hearing loss with hearing devices that are flexible and will not over-amplify causing further damage.
We have treated many patients with Ménière’s disease at Norfork Audiology using hearing aids and strategies to improve communication at their work, home, and social settings reducing the negative effects of tinnitus.
Surgical treatment is a last resort. Endolymphatic sac surgery has been used in the past but does not have a significant rate of improvement. Surgeries known to be effective are labyrinthectomy, where the sensory cells in the semicircular canals are destroyed, and vestibular neurectomy, where the vestibular portion of the eighth nerve is dissected. Surgical risks include cerebral spinal fluid leak, total loss of hearing on the surgical ear, injury to the facial nerve, loss of balance, and vomiting and nausea.
Why do people get Meniere’s disease?
There are no definitive answers as to why people get Ménière’s disease. It may be triggered from allergens or infectious agents. Vascular changes may play a role. There is evidence that inflammatory diseases and autoimmune disorders may contribute. A small percentage of cases indicate a genetic link. Researchers do agree that whatever the triggering factor, changes in the absorption and production of the endolymph result in symptoms of Ménière’s disease.
Meniere’s Disease Home Treatment
Symptoms of Ménière’s disease are unpredictable and debilitating. As a result, it is difficult to treat at home. Seeking evaluation and treatment with an ear nose and throat physician and an audiologist is recommended. Other life-threatening health issues may mirror symptoms of Ménière’s disease, so it is important to be diagnosed by qualified medical professionals.
Once properly diagnosed, a patient may consider noting lifestyle triggers that may be altered to keep episodes at bay, however changes in medications and alternative treatment options are not advised without consulting the ear nose and throat physician. At Norfolk Audiology, we offer services to diagnose and monitor hearing loss. We can also assist with properly fit amplification to meet the needs of a fluctuation and asymmetrical hearing loss. We are available with communication treatment options including hearing aids and communication strategies. We can also help provide relief for the negative effects of tinnitus through strategies and sound therapy.