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Providers | Office Policies | Services | Audiology Services | For Our Patients | Patient Education |
What is Meniere's Disease?
Meniere's
Disease, also known as endolymphatic hydrops, is a disorder affecting the
fluids of the inner ear. Normally, the fluids of the inner ear move in response
to sound waves to allow us to hear and in response to head movement to give us
our sense of position. With Meniere's Disease, there is an excessive amount of
fluid within the inner ear chamber. The cause of this disorder is unknown. In
most cases only one ear is involved, although it may be seen in both ears in 15
to 20% of patients. Classic Meniere's Disease is characterized by intermittent
attacks of vertigo, hearing loss, ringing and fullness of the ear. Vertigo is
the sense of spinning dizziness. Attacks last from 20 minutes to as long as
several hours and may be associated with nausea and vomiting. The frequency of
the attacks is variable and unpredictable. The hearing loss may fluctuate, just
as with the attacks of vertigo. Tinnitus and fullness may also fluctuate
unpredictably. The severity of the symptoms is variable and may only be a
nuisance or become disabling.
Diagnosis
The diagnosis of
Meniere's is in many ways a diagnosis of exclusion, as there is no single
finding or test which is definitive. A thorough otologic and neurologic history
and physical examination is performed. It is important to determine the nature
of the symptoms of dizziness, their duration and frequency. A review of the
patient's health is important in order to rule out other systemic problems
which may mimic Meniere's, including thyroid disease, diabetes, hypertension or
other neurologic disorders. The physical examination is typically normal,
unless the patient is seen during an attack. A hearing test (audiogram) is
almost always obtained. The hearing loss seen in Meniere's disease is most
often sensorineural (inner ear) in nature. Typically, the hearing loss is
greater in the lower frequencies, but may involve all frequencies. Tests may
also be obtained to gain information about the inner ear balance system.
Electronystagmography (ENG) is test that evaluates the balance system. The
study measures eye movements, which reflexively move in response to various
stimuli to the inner ear. Warm and cool stimuli to the ear canal may be helpful
in determining which ear is weaker. Other tests of the balance system, such as
platform posturography, may be obtained depending on the nature of one's
symptoms. Radiographic imaging is usually necessary to rule out other potential
causes for the patient's symptoms. Magnetic Resonance Imaging (MRI) images the
hearing and balance nerves to be certain that a tumor or other anomalies may or
may not be causing these symptoms.
Treatment
Medical Therapy
The primary goal of medical therapy is
to limit the fluid load on the inner ear. Just as with other medical conditions
that cause excessive fluid accumulation in other parts of the body, a diuretic
(water pill) is the key component of medical therapy. In order for the diuretic
to be of optimal benefit, it is critical that patients restrict the intake of
salt. In fact, "binging" with salty foods may result in attacks of vertigo.
Anti-vertigo medications, such as Antivert (meclizine) and Valium (diazepam),
are helpful in relieving symptoms of vertigo. It is important to remember that
these medications do not prevent attacks, but only relieve symptoms. Thus, they
should only be taken as needed.
Changes in diet and lifestyle are
critical in the management of Meniere's Disease. A low sodium (salt) diet is
critical in preventing attacks. Furthermore, it is important to avoid caffeine,
nicotine and alcohol. Stress is also an aggravating factor and if possible,
should be avoided.
Surgical Treatment
80% of patients with
Meniere's Disease will see their symptoms come under excellent control with
medical therapy. If a patient continues to have severe, disabling attacks of
vertigo in spite of medical therapy, surgical alternatives should be
considered.
Endolymphatic-mastoid shunt is a 45 minute surgical
procedure. This is performed through an incision in the crease behind the ear.
The mastoid is opened and the endolymphatic sac is identified. This structure
is the natural drainage sac of the inner ear. The endolymphatic sac is then
incised and a shunt is placed in order to relieve the inner ear of the
excessive fluid build-up seen in Meniere's Disease. The shunt material is
typically made of thin silastic. The procedure may be performed either on an
outpatient basis or as an overnight stay. Recovery is typically one week. This
is the only procedure we perform designed to change the way the inner ear
works. As such, results are variable. Long term outcomes suggest that 65-70 %
of patients will be completely cured of all symptoms and require no further
medication. An additional 15% of patients will have significant improvement,
but still require medical therapy for control of symptoms. In about 15% of
patients, symptoms may continue to be disabling and require alternative
surgical intervention. Hearing is improved or stabilized in the majority of
patients.
Selective Vestibular Neurectomy is a 2 hour surgical
procedure. This is performed through an incision behind the ear. A window of
bone is removed and the lining of the brain (dura) is opened. The hearing and
balance nerve (eighth cranial nerve) is identified as it passes between the
inner ear and brainstem. The hearing and balance nerve fibers are separated.
The balance fibers are cut while preserving the hearing nerve. The patient is
observed overnight in the ICU and the overall hospital stay is 2 to 5 days.
Recovery may take up to 6 weeks. While one can live with only one inner ear,
the brain must compensate for the loss. The acute response to loss of inner ear
function may result in spinning vertigo for about 24 hours. The patient's
equilibrium will recover over a period of 2 to 5 days to the point where one
can ambulate, although it may take 6 weeks for full compensation to be
achieved. Occasionally, physical therapy is recommended to regain full balance.
Attacks of vertigo are permanently eliminated in nearly all patients, while
hearing is preserved.
Labyrinthectomy with or without sectioning
of the eighth cranial nerve is a 90 minute surgical procedure. This is
performed through an incision in the crease behind the ear. The mastoid is
opened and the inner ear surgically destroyed and at times the nerve endings of
the eighth cranial nerve are cut. This will permanently eliminate attacks of
vertigo, but also results in permanent loss of hearing in the operated ear.
Keeping in mind the 15-20% incidence of Meniere's involving both ears, this
procedure is reserved for only select situations in which there is severe
non-serviceable hearing in the affected ear. While compensation is still
required to regain balance, this is typically not as prolonged as seen with
selective vestibular neurectomy. This is because in these situations, the
Meniere's has resulted in a severly weakend inner ear and compensation has
already begun preoperatively. Typically the hospital stay is 1-2 days.
Transtympanic perfusion is a procedure in which an antibiotic
(gentamycin), which is toxic to the inner ear, is directly injected through the
eardrum. The solution is then absorbed into the inner ear through the round
window. This is an office-based procedure, which is technically the least
complex that we perform for Meniere's Disease. While the goal is to eliminate
the function of the affected balance organ, the inner ear hearing (cochlear)
function may be affected as well. Permanent hearing loss has been reported in
as many as 30-40% of patients. Furthermore, there may be incomplete destruction
of the balance organ, resulting in lingering disequilibrium and/or recurrent
attacks of vertigo.
It is important to remember that there is no
perfect surgical solution for every case of Meniere's Disease. When attacks
become disabling in spite of medical therapy, surgery should be considered in
consultation with your surgeon.
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Acoustic Neuromas