• Meniere's Disease

    Understanding Meniere's Disease

    Meniere's disease is a disorder of the inner ear which affects all of its functions in varying and unpredictable ways. The inner ear is a fluid-filled chamber divided into hearing and balance canals. It is the part of the ear where sounds and movements are converted to nerve impulses that travel to the brain. There, the information is perceived as hearing and balance. Both canals share the same fluids, which is the reason that hearing and balance functions are often affected simultaneously.

    Inner Ear DiagramThe classical description of Meniere's syndrome is a patient with episodes of dizziness, fluctuating hearing loss, a noise in the ear (tinnitus), and fullness in the ear.

    The dizziness is quite variable. Often there are attacks of severe disequilibrium with a sensation of everything spinning in circles. It is similar to the feeling one experiences when jumping of a fast merry-go-round. Other sensations described are that the surroundings become unstable and float or swim around. Some people do not experience the disequilibrium, but rather suddenly find themselves falling to the ground. These sensations of a loss of equilibrium are all called vertigo.

    The vertigo episodes can last for seconds, minutes, or hours They frequently trigger the same reflexes in the brain which often accompany motion sickness, such as nausea, vomiting, cold sweats, and blurring or movements in the vision making it difficult to read.

    Meniere's disease develops when the fluid pressure in the inner ear builds up. The reason for this occurring is completely unknown. Inside the inner ears is a membranous sac filled with endolymph. Perilymph fills the remainder of the inner ear and surrounds the membranous sac. Meniere's disease results when the endolymph pressure raises. As the pressure expands the membranous sac it distorts the sensory organ and hair cells. The result is a sensation of fullness or pressure in the inner ear and often the pressure irritates the hearing sensory hair cells causing some tinnitus and hearing loss.

    Balance CanalIf the pressure continues to worsen, a rupture of the membranous sac may occur, mixing the endolymph and perilymph. These two fluids have opposing concentrations of salts and their mixture produces a catastrophic effect on the hair cells resulting in the severe attacks of vertigo and accompanying loss of hearing.

    Balance Canal RuptureAfter the vertigo subsides, most people feel physically exhausted and remain unsteady when they try to stand. The unsteadiness and weakness may last for several days, sometimes for weeks. The inner ear must compensate after the Meniere's injury and the process can be speeded up by increased activities. Exercise helps the balance system recover faster. The exercise must involve walking or running in order to improve coordination; stationary bikes and treadmills will not help.

    After doing well with walking, the compensation may be further improved by adding head movements such as looking around at objects in the distance. Eventually, moving objects such as cars or birds should be followed without causing excessive vertigo. The vertigo and unsteadiness are usually the most disabling effects of Meniere's disease.

    Many people with Meniere's disease suffer a hearing loss in the affected ear. The vertigo episodes are often accompanied by a temporary loss of hearing. Often people are so distressed by the vertigo that the hearing loss may go unnoticed. Over a period of years, the hearing loss may become more permanent. Occasionally there is a sudden permanent hearing loss, but this is fortunately rare.

    Whenever the hearing is injured, there may be noises in the ear as a symptom of the injury. This noise in the ear or head (tinnitus) tends to fluctuate and becomes worse before or during the vertigo attack. The tinnitus is most commonly a low pitched "waterrushing" noise similar to a stream or the sound heard with a sea shell over the ear Some people hear higher pitched ringing type noises.

    These three components (vertigo, fluctuating hearing loss, and tinnitus) are the most common forms of Meniere's disease. Some people only experience one or two of the symptoms, which can be in any combination; it usually affects only one ear. Often there is a warning sign that an attack may be starting with a fullness or a blocked up sensation in the ear. Most people learn to recognize this symptom and prepare for the episode as best as possible.

    Meniere's disease is highly unpredictable. Most people initially have frequent repetitive attacks over several week periods. Sometimes there are only a few attacks in a whole lifetime; others may have recurrent episodes with no relief. The specific effects and severity of symptoms widely vary as well. When it is brought under control, most people experience only one or two spells of significant vertigo per year. Each spell may be followed by imbalance (or disequilibrium) that can last days to weeks, then subsides. Most spells are less severe than the vertigo experienced before the Meniere's is brought under control. Over several years the condition may eventually go into remission, but treatment must continue to prevent recurrence.

    Untreated, Meniere's disease may result in a progressive loss of balance and hearing function because of the repeated pressure injuries to the inner ear organs. In the early stages, the fluctuations in hearing usually return back up to normal.

    Over time, the hearing becomes damaged to the point that it never comes back up to the normal levels, even between vertigo attacks. Eventually, in the late stages, which usually occurs over many years, the ear may stabilize at some abnormal level but the patient may become free of the vertigo episodes.

    Diagnosing Meniere's Disease

    There is no single test available which can diagnose Meniere's disease. Patients are often frustrated by the numerous physician visits and myriad of expensive tests they undergo in making the diagnosis. Vertigo is a common symptom of a multitude of conditions. The exhaustive battery of tests is designed to systematically eliminate all of these other disorders. Patients are frequently concerned that all of their tests come out normal, yet they know they have a problem. It is important to understand that test results are often normal in Meniere's disease and that information helps the doctor confirm their diagnosis.

    Therapy for Meniere's Disease

    When a strict low sodium diet is adhered to and a diuretic is taken reliably, the majority of patients can bring their disease under control and continue to lead normal lives. After 6 - 12 months, the body becomes sufficiently adapted to the low sodium diet so that the diuretic can be stopped. Strict adherence to the diet is necessary to maintain the Meniere's under control. There may still be an occasional attack, which may be treated by some of the other medications for Meniere's symptoms.

    Usually Klonopin (Clonazepam), Ativan (Lorazepam), or Artivert (Meclizine) are given to control the vertigo and can be taken up to three times a day if necessary. These medications are designed as tranquilizers but have a powerful effect on suppressing a balance disturbance in the inner ear. The medications should be taken when the sensation of an impending attack occurs or during attacks to help relieve symptoms. During exacerbation of the Meniere's disease, it may be necessary to take the medication three times a day for several days and when the attacks begin to subside the medication can be tapered off once again. Because the body builds up a tolerance to these medicines, which can reduce their effectiveness taken three times a day every day, it is important to try to reserve the medicines for periods of attacks.

    Surgery for Meniere's Disease

    The combination of diuretic, low salt diet, and symptomatic medications are effective in most Meniere patients. A small group of people continue to have disabling vertigo despite medical therapy and are considered to be candidates for surgery. There are numerous types of procedures done for Meniere's disease because there is not a single deal procedure. One common procedure (called fabyrinthectomy) involves destroying the inner ear. It is very effective in relieving the vertigo but it also may effect any hearing in that ear permanently. This procedure can be performed in the doctor's office with an injection of gentamicin, a common antibiotic that is toxic to the inner ear. It can also be performed with surgical removal of inner ear structures.

    Another operation attempts to decrease the inner ear fluid pressure by placing a drain or shunt in the inner ear This operation is called a endolymphatic shunt procedure. Theoretically, this operation should help considerably, but in practice there is a 50/50 chance of improving the vertigo over the long term.

    Living with Meniere's Disease

    The most important thing to understand about Meniere's disease is that it is a life long condition. Even when it seems to be in remission there is always the possibility that it can recur. Although unusual, there is also the possibility of Meniere's disease affecting the opposite ear. Following the low salt diet is recommended indefinitely. Diuretics are well tolerated over prolonged use if necessary. Even if surgery is done, the medical treatment must continue to protect the opposite ear.

    Because of the repeated injury to the balance organ (labyrinth), many patients feel some chronic unsteadiness and some vertigo during rapid head movements. Most people learn to avoid the types of movements or positions that cause them trouble. Exercise, as mentioned before, is the single best therapy for these symptoms. Initially it may cause increased vertigo but that is not harmful. Occasionally, physical therapy is recommended for patients who can not exercise enough on their own.

    People can usually learn to recognize the early warning signs that an attack is coming. Usually there is some increase in the tinnitus or a fullness that proceeds the episodes.

    There is some evidence that caffeine and tobacco (nicotine) can precipitate Meniere's attacks. Decaffeinated beverages are tolerated well.

    Meniere's disease is a frustrating burden to bear, as too little is understood and it is very unpredictable. Besides medical, surgical, and dietary management, many people benefit from sharing their experiences with others similarly afflicted. For that reason there are now many Meniere's support groups being organized over the country. Your doctor should be able to tell you where the nearest support group meets and how to get in contact with them.

    Lastly, your doctor will need to follow your progress and hearing tests on a periodic basis, altering your medications whenever necessary. You should not feel that you are alone in dealing with this disease. Openly discuss your concerns and feelings with your health care providers and attend a support group if you think it would help you or others.
     

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