Patients who do not respond well to the previously described management should be referred to a specialist for additional treatment options. An otolaryngology specialist may administer intratympanic medications to patients with Ménière’s disease who have not responded to primary medical therapy.
Patients in the US who have not responded positively to lifestyle or diuretic medication are commonly offered treatment with intratympanic dexamethasone. The primary goal of this therapy is to improve vertigo without affecting a patient’s hearing; an added effect may be a potential positive impact on the immune system.11 Studies show that intratympanic steroid injection results in control of vertigo in patients with Ménière’s disease, but up to four injection treatments may be required for optimal effectiveness.2,7 Improvement of vertigo is achieved in more than 80% of patients who undergo intratympanic steroid injections.9
An option reserved for patients with severe, frequent vertigo related to Ménière’s disease is a type of chemical ablation of the labyrinth induced by injecting gentamicin into the middle ear.2 Gentamicin has a toxic effect on the vestibular hair cells in the inner ear, resulting in elimination of vestibular function.2 Intratympanic gentamicin is reported to reduce symptoms from Ménière’s disease, but this treatment is only recommended for patients with unilateral disease because it may induce permanent hearing loss.11
The primary care clinician needs to be aware of these intratympanic procedures and encourage patients to follow up with the specialist if additional treatments are indicated.
Portable Pressure Device
Use of the Meniett device is a minimally invasive treatment for Ménière’s disease based on the principle of using alternating pressure to stimulate the flow of endolymph.11 This handheld device delivers low-pressure pulses within the inner ear through a standard ventilation tube in order to increase exchange of fluids and improve homeostasis.8 The Meniett device should be used for five-minute intervals three times per day.12
Several studies have shown excellent results in patients who use the Meniett device routinely for several weeks.2,12 As noted, the use of this device, which is obtained by prescription from an otolaryngologist, requires placement of ventilation tubes.
A traditional Chinese medical approach, acupuncture is one complementary and alternative medicine therapy that has been studied as a treatment option for Ménière’s disease. Studies on the use of acupuncture to treat vertigo demonstrate a beneficial effect for persons with this disease. While the optimal number and frequency of treatments has not been determined, all types of acupuncture studied showed benefit. Acupuncture has a positive effect in both acute episodes of vertigo in those without Ménière’s disease and in patients who have had Ménière’s disease for many years.13
An additional adjunctive treatment option to consider for patients with residual disequilibrium is vestibular rehabilitation. Vestibular rehabilitation is designed to desensitize or retrain the balance system response through a series of exercises and activities supervised by a physical or occupational therapist. This rehabilitation may improve balance in patients with Ménière’s disease who have undergone medical or surgical intervention used to treat vertigo. Patients who have significant balance problems occurring between acute vertigo episodes may also benefit from vestibular rehabilitation.6
Surgical intervention should be the last resort to treat Ménière’s disease due to the higher risk involved with any surgical procedure and the potential adverse effect on hearing. Endolymphatic sac decompression surgery involves removing a portion of the mastoid bone, resulting in decompression of the sac adjacent to the sigmoid sinus. This procedure has been used for more than 40 years to control vertigo and has the advantage of preserving hearing.7,9 However, the benefit of this procedure is now somewhat controversial and possibly related to a placebo effect.6 Researchers also report positive results with the use of tenotomy surgery, which involves severing tendons to the stapedius and tensor tympani muscles in the middle ear.14
No surgical procedure should be considered without the recommendation of an otolaryngology specialist. The decision should be made based on the severity of the disease and its effect on the patient, weighed against the risks involved in such an invasive treatment option.
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