Over the past several weeks, we have been reviewing the various treatments for Meniere’s disease. Conservative treatments covered previously in this series do not have strong evidence of effectiveness. As we move towards more invasive treatments, the likelihood of a positive change is more likely, but they come with some risk. These invasive treatments are performed by ear surgeons, so detailed discussions regarding those procedures should be lead by ear surgeons (that is not me). So, to any ear surgeons reading, please consider this an invitation to contribute.
There are additional, effective treatments for Meniere’s disease. Intra-Tympanic steroid injections may provide some short term benefit to those dealing with frequent episodes of vertigo. Intra-Tympanic gentamicin, and surgical ablative procedures such as vestibular nerve section or labrynthectomy, are quite effective at stopping the episodes of vertigo associated with Meniere’s disease, but carry the risk of hearing damage, and leaving the treated ear non-functional with a roughly 30% chance that the patient will eventually develop Meniere’s disease in the other ear.
The decision process to move forward with these invasive procedures is based on a number of variables: some known, some unknown, and some impossible to predict. The “knowns” are the onset (when it started), the frequency (how often the episodes occur), and the impact on quality of life. The “unknowns” often include lack of a clear diagnosis, lack of clear understanding of the physiology behind the episodes, and most distressing, an unpredictable progression or resolution of symptoms. Most people considering an invasive treatment for Meniere’s disease do so because the symptoms are frequent, have been going on for a while, and have not responded to conservative treatment. Meniere’s disease does not last a lifetime, and the frequency of vertigo episodes diminishes over time. We can look at averages, but we can never know how that might apply to a specific patient. If a patient could wait for a year or two before considering an invasive treatment, what is the likelihood things might improve?
Like most issues involving Meniere’s disease, this is not an easy question to answer. One must pick bits and pieces of available information to get a cloudy picture of the typical course of Meniere’s disease.
In a 2016 study, which essentially demonstrated that Betahistine did not significantly alter the course of Meniere’s episodes, we learned a bit about the natural progression of untreated Meniere’s disease from their placebo group. A significant reduction in the frequency of attacks over a nine month period following onset of the disease was noted in the placebo group.
In Herb Silverstein’s classic study on the benefits (or lack thereof) of endolymphatic sac surgery, we learned something about the natural course of the disease from those patients that chose NOT to undergo surgery. They report, “Of the non-operated group, 57% had complete control of vertigo episodes at two years; 71% had complete control after an average of 8.3 years. After the ELS (endolymphatic sac surgery) 40% of patients had complete control of vertigo after two years; 70% had complete control after and average of 8.7 years.” So, we learned that the patients in this study did not have better long term or short term results from the surgery, and that about ½ of patients see improvement in vertigo episodes within 2 years.
A 2008 study out of Spain found that, after 3 years, the frequency of episodes of vertigo decreased by two thirds when compared to the frequency in the first two years. In other words, if you have 3 episodes a month in the first year, by the third year they reduced to one episode per month (at least in this group.)
On the other hand, many patients with Meniere’s disease continue to suffer from episodes of vertigo for years. Approximately 10% continue to have episodes for more than ten years, but in this small group, the continued episodes are likely to be the result of developing Meniere’s disease in the opposite ear.
The available evidence suggests a period of frequent episodes in the one to two years following onset. After that two year period, episodes will most likely decrease in frequency and may actually (about a 50/50 chance) resolve or reduce enough that invasive procedures may not be necessary.