Treatment Ladder for Meniere’s

ladderI mentioned last week that some patients respond to one of the several different treatment options for Meniere’s disease, but there is no one treatment that is right for every patient. That is why there are so many different treatments for Meniere’s. Physicians often employ a “treatment ladder” in an attempt to find an effective treatment for each patient. Click on the photo to enlarge it.

Since the diagnosis of Meniere’s disease is often uncertain in the early stages, most physicians want to try conservative treatments that have no potential for harm, and frankly, buy some time to see if the patients symptoms worsen or become more clearly indicative of Meniere’s disease.
menieres ladder

A low-salt diet, while not much fun, won’t hurt you and may also have some other health benefits, so that is the starting point in the treatment of most suspected Meniere’s patients. Adding a diuretic may further the goal of the salt-restricted diet (reduced fluid retention). Both low-salt diets and diuretics are harmless, cheap, and easy to try.

When and if the symptoms continue, more aggressive and expensive measures may be considered. The treatment ladder above is provided by Medtronic (which makes and markets the Meniett), and I agree that they have placed the Meniett appropriately on the treatment ladder. It is not cheap, and it requires surgical insertion of a ventilating tube through the eardrum (which can be an in-office procedure).

If that doesn’t work, endolymphatic sac surgery might be recommended. Sac Decompression surgery is not destructive or ablative, and there is a plausible theory as to why it might help. Read more about it here.

If the symptoms persist and are intolerable after these steps up the ladder, destructive measures may be considered. All the previous steps are intended to regulate fluid levels and fluid pressure within the inner ear. Destructive methods are essentially an admission that the conservative attempts to regulate fluid have not worked, so the goal becomes to weaken the sensors in the inner ear that respond to changes in fluid pressure. In other words, the fluid pressure may rise and fall, but your ear will be less aware and the symptoms will be less.

The first line of destructive treatments is gentamicin injection, and Dr. Tim Hain does a great job of describing it here. More aggressive measures such as vestibular nerve section and labyrinthectomy should be discussed by the surgeon, so will not be discussed here.

Next week, we will discuss the difficulty inherent in making a firm diagnosis of Meniere’s disease.

Photo courtesy of http://driverlayer.com/img/ladders/20/image?tab=1

Photo courtesy of Medtronic

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.