European "State of the Union" on diagnosis & treatment of Meniere's Disease

A group (European Academy of Otology & Neurotology (EAONO) Working Group on Vertigo Guidelines) in Europe put out a position paper a few months ago (August 2018) on diagnosing and treating Meniere's Disease in modern times.

You could call it a "State of the Union" address on Meniere's Disease from an European perspective... It's a good read to keep up from the perspective of the medical community.

You can read the whole paper here for free: http://www.advancedotology.org/sayilar/98/buyuk/317-3211.pdf

If it's too long for you, I'll share my bullet points from reading it...

~ As of today, there is still nothing definitive or final about treating Meniere's Disease as yet. It's still all over the map, mostly due to lack of randomized double-blind studies.

~ Meniere's Disease is characterized with episodic vertigo and fluctuating low to medium frequency sensorineural hearing loss, fullness, and tinnitus being manifested at least with two episodes. The duration is mentioned to be between 20 min to 12 hours. Some hearing loss is usually expected.

~ Meniere's Disease has some commonalities with several disorders, including migraines and autoimmune diseases. Several lines of evidence also suggest genetic factors and up to 10% of patients have family members who also have MM.

~ A couple large studies identified 5 subtypes of Meniere's Disease:

- Group 1 was the most common (observed in 53% of MM patients) which included patients without a familial history of MD, migraine, or autoimmune disorders.

- Group 2 (8%) had delayed Meniere's Disease and was characterized by hearing loss that predated vertigo episodes.

- Group 3 (13%) had family connections with Meniere's Disease.

- Group 4 (15%) was associated with migraine with or without aura.

- Group 5 (11%) fell in the autoimmune disorder category.

- ...in addition to the above, a gene (variant rs4947296) has been found in bilateral MM patients (18%) with an autoimmune disorder.
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DIAGNOSING

~ Low to medium frequency sensorineural hearing loss as mentioned above is the most significant finding of Meniere's Disease and they recommend mandatory audiograms when diagnosing the disease.

~ Also recommended is testing for eye movement (nysotagamus). They recommend Videonystagmography (VNG) for this yet caloric tests are also still applicable. Previously Electrocochleography was the standard but it has faded over time.

~ There was some discussion on the use of MRI of the inner ear as part of the diagnostic process but it is not required or necessary in place of traditional diagnostic techniques above.

FIRST LINE (PREVENTATIVE) TREATMENT

~ If the patient has parallel conditions such as allergies, migraines, or autoimmune arthritis, this should be treated. They also recommend investigating family history of hearing loss and/or vertigo since they believe genetic testing will be able to identify variants of the disease in 30% of cases, paving the way for gene therapy down the road.

~ Diet: reduction of sodium and caffeine may help some patients.

~ Betahistine is still recommended as it may work for some; 48mg/day for 3-6 months is suggested.

~ Diuretics were cited as a common first-line treatment but that there has been no good evidence showing it is effective.

SECOND LINE (PREVENTATIVE) TREATMENT

In the event the above, including refraining from sodium and caffeine, doesn't work, move on to the next line of treatment of steroids:

~ Intratympanic treatment has been very popular since the last two decades as being practical to apply even in the office.

~ For the above, dexamethasone is more practical to use than methylprednisolone causes a burning sensation.

~ For the most part, studies are not in harmony about using steroids for treating MM... However, it is considered being "safe" in not further complicating hearing loss.

~ It can be effective in the short-term but eventually fizzles out to where only 5% are able to avoid surgery.

THIRD LINE TREATMENT

~ Long story short, Endolymphatic sac surgery is pretty much considered a placebo effect and there are several well designed randomized, double-blind, placebo-controlled studies of which there is low support for the surgery.

~ On a side note, there is some positive benefit from injecting dexamethasone into the sac and that sac shunt procedures would benefit from steroid instillation when the shunt is placed.

FOURTH LINE TREATMENT

~ Intratympanic Gentamicin injection has received more interest of late because of its strong effect over Meniere's "episodes".

~ Although there is a risk of hearing loss, several clinical studies have been designed to find the lowest risk of application for maximum control of vertigo.

~ Vestibular rehabilitation can resolve post-injection issues (dizziness, unsteadiness, etc.)

~ The recommended application of gentamicin is one injection of 26.7 mg/mL concentration.

FIFTH LINE TREATMENT

~ The only methods for Meniere's Disease that have high evidence of success are labyrinthectomy and vestibular neurectomy. The efficiency of both techniques are considered good.

~ Vestibular neurectomy will leave the cochlear nerve untouched and is believed to be most efficient for those with drop attacks and incapacitating Meniere's Disease.

~ Labyrinthectomy is the oldest surgical method to treat Meniere's Disease and today is limited to older patients. The technique can be associated with cochlear implantation within the same stage in case of profound bilateral hearing loss.

CONCLUSION

"The definition of MD has reached a large international consensus, diagnosis and especially treatment still represent a debated topic. The main aim of this position paper is to identify a common path for medical professionals dealing with Meniere’s disease diagnosis and treatment based on literature evidences and expert opinions."

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Despite this being recent, I do wonder if they are behind the curve on other more novel treatment methods such as anti-virals or upper cervical adjustments, etc. which have seemed to help a great deal of folks here. I know a lack of enough studies is part of the culprit.

Ray

 

solari updated European "State of the Union" on diagnosis & treatment of Meniere's Disease

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I'm guessing the medical community wants more studies to be sure it is effective. I get that but there are also older procedures being done that are also not very effective either... This is at least non-invasive and worth a shot.

Ray