Since the exact cause and pathogenesis of Ménière’s disease are still unknown, there is no cause-specific and radical treatment method worldwide. However, after long-term clinical practice and research by domestic and foreign scholars, we can adopt different comprehensive treatment strategies at different stages of the disease process to control vertigo attacks and prevent deafness from worsening. The comprehensive treatment means include: lifestyle adjustment, medication, middle ear pressure treatment, tympanic chamber injection treatment, surgery, etc.
I. Lifestyle modification.
Certain factors can cause episodes of vertigo in patients with Ménière’s disease, such as high salt diet, caffeine intake, mental stress, etc. Therefore, avoiding these triggering factors can reduce the frequency and extent of episodes. A salt-restricted diet is the basis of treatment for Ménière’s disease, and it is recommended that the patient’s daily sodium chloride intake should not exceed 1 g. Emotional stress is also related to the frequency and degree of Ménière’s disease attacks and requires appropriate psychological adjustment.
II. Drug therapy.
In the early stage of Ménière’s disease, drug treatment is divided into two cases: vertigo control treatment in the attack period and maintenance treatment in the interval.
1. Vertigo control in the attack period
Anti-vertigo drugs with vestibular nerve inhibitory effect and symptomatic drugs for nausea and vomiting reactions are available, including.
(1) Vestibular nerve inhibitors: mostly used in the acute attack period, they can weaken the activity of vestibular nucleus and be used for a short time to control vertigo, usually not more than 3 days. Diazepam, diphenhydramine, diphenhydramine, etc. are commonly used.
(2) Anticholinergic drugs: such as scopolamine and scopolamine, etc., can relieve nausea and vomiting.
2.Intermittent maintenance treatment
The main purpose of drugs is to reduce endolymphatic pressure and vestibular excitation, mainly including.
(1) vasodilators: they can change the metabolism of ischemic cells, selectively diastasize the blood vessels in the ischemic area and relieve local ischemia. Commonly used are flunarizine (Cipro), betahistine, ginkgo biloba and so on. Betahistine also has the effect of reducing the excitability of the vestibular nucleus, and is currently the main drug for intermittent treatment.
(2) Diuretic dehydration drugs: They can change the fluid balance in the inner ear, reduce endolymph and control vertigo. The commonly used ones are dihydroketuria, acetazolamide, etc. Long-term use must guard against electrolyte disorders.
(3) Glucocorticoids: Based on the immune response theory, dexamethasone and prednisone can be used for treatment, but long-term use is not recommended.
(4) Vitamins: If it is caused by metabolic disorder or vitamin deficiency, vitamin therapy can be given, and vitamin B1, B12, vitamin C, etc. are commonly used.
(3) Middle ear pressure treatment
Experimental studies have shown that changes in middle ear pressure can affect pressure and flow in the inner ear. meniett is a portable device that generates low-intensity alternating pressure and is used in the patient’s external ear canal to transmit pressure to the round window through the tympanic ventilation tube. This device has been approved by the FDA for use in Meniere’s disease as a non-invasive treatment, but the long-term results remain to be seen.
IV. Intra-drum injection therapy
This treatment uses the semi-permeable mechanism of the round window membrane, where the drug injected in the tympanic chamber can enter the inner ear for therapeutic purposes by osmosis. The tympanic chamber injection drugs used for the treatment of Meniere’s disease include glucocorticoids and gentamicin.
1. For patients who are not satisfactorily controlled by oral medication, intra-dural injections of dexamethasone or methylprednisolone are available and can usually be performed on an outpatient basis. Glucocorticoids not only increase cochlear blood flow, but also inhibit immune-mediated inflammatory responses. In addition, the discovery of glucocorticoid receptors in the inner ear suggests that steroids may also affect fluid homeostasis.
Gentamicin intra-dural injection, also known as “chemical vagotomy,” is a treatment for vertigo that takes advantage of the ototoxicity of aminoglycoside antibiotics to disrupt the vestibular function of the inner ear. Gentamicin intra-drum injection should be the first choice when the patient has frequent vertigo attacks, when the previous treatments are not effective, and when there is significant hearing loss. It is worth noting that this therapy may lead to further damage of hearing.
V. Surgical treatment
There are still a small number of patients with severe vertigo symptoms after drug treatment, such as frequent vertigo attacks and obvious hearing loss, which seriously affects the work and quality of life of patients, and then surgical treatment should be considered.
The choice of surgery should be decided according to the severity of deafness, vertigo and other symptoms as well as the patient’s age, occupation and lifestyle. For example, young people and patients who need to be employed would benefit more from choosing surgery than retired elderly people, while the vestibular disruption style can have balance disorders after surgery and is not suitable for patients who work at high places.
Depending on whether vestibular function and hearing are preserved, surgery can be divided into three categories: conservative surgery, partially disruptive surgery and disruptive surgery.
1.Conservative surgery
Theoretically, the hearing is not damaged, and the principle of surgical treatment is to reduce the endolymphatic pressure and alleviate the vestibular symptoms caused by the irritation of the semicircular canal.
(1) Endolymphatic bursal surgery: It is suitable for patients with low frequency hearing loss of 30 dB or less, who have failed conservative treatment and patients with refractory and bilateral Ménière’s disease. The endolymphatic bursa procedure has been in clinical practice for a century since its inception, and a large number of conclusive clinical data have confirmed that the overall efficiency of the procedure in controlling vertigo is 60% to 80%. Because of its physiological requirements and less destructive surgical approach, most scholars prefer endolymphatic bursa surgery as the first choice of surgical treatment for patients who have failed to respond to conservative treatment.
(2) Semicircular canal obstruction: Semicircular canal obstruction surgery was first applied to the treatment of intractable benign paroxysmal positional vertigo, and in recent years it has been used to treat intractable Ménière’s disease with good results, and the total efficiency of vertigo control is over 90%. Cochlear implantation in conjunction with semicircular canal obstruction is the latest advancement in the treatment of Ménière’s disease, with the aim of reconstructing hearing and reducing tinnitus while controlling vertigo.
2.Partial destructive surgery
Vestibular neurotomy is suitable for patients with severe vertigo with frequent attacks, who still have good hearing in the affected ear, and who have been treated conservatively for more than 6 months or in whom endolymphatic sac surgery is ineffective; there are three surgical routes: transcranial middle fossa, posterior transcranial vagus and posterior transsigmoid sinus, whose long-term efficacy is more certain, but all require craniotomy.
3.Destructive surgery
Labyrinthectomy requires complete removal of the peripheral vestibular receptors and the peripheral nerve fibers innervating the receptors, blocking the transmission of vestibular nerve impulses.
Indications are: persistence of vertigo after endolymphatic capsule surgery or recurrence after surgery, where the affected ear no longer has functional hearing and the contralateral hearing is normal. Labyrinthectomy is an effective surgical treatment with a vertigo control rate of up to 99%.
In conclusion, there is no specific treatment for Meniere’s disease so far, but only individualized and comprehensive treatment according to each patient’s condition, choosing different protocols at different periods of the disease course and requiring long-term follow-up observation.