Ménière's disease is a condition characterized by recurrent vertigo (dizziness), hearing loss, and tinnitus (a roaring, buzzing, or ringing sound in the ears).
Description
Ménière's disease was named for the French physician Prosper Ménière, who first described the illness in 1861. It is an abnormality within the inner ear. A fluid called endolymph moves in the membranous labyrinth or semicircular canals within the bony labyrinth inside the inner ear. When the head or body moves, the endolymph moves, causing nerve receptors in the membranous labyrinth to send signals to the brain about the body's motion. A change in the volume of the endolymph fluid, or swelling or rupture of the membranous labyrinth is thought to result in Ménière's disease symptoms.
Causes
The cause of Ménière's disease is unknown as of 2002; however, scientists are studying several possible causes, including noise pollution, viral infections, or alterations in the patterns of blood flow in the structures of the inner ear. Since Ménière's disease sometimes runs in families, researchers are also looking into genetic factors as possible causes of the disorder.
One area of research that shows promise is the possible relationship between Ménière's disease and migraine headache. Dr. Ménière himself suggested the possibility of a link, but early studies yielded conflicting results. A rigorous German study published in late 2002 reported that the lifetime prevalence of migraine was 56% in patients diagnosed with Ménière's disease as compared to 25% for controls. The researchers noted that further work is necessary to determine the exact nature of the relationship between the two disorders.
A study published in late 2002 reported that there is a significant increase in the number of CD4 cells in the blood of patients having an acute attack of Ménière's disease. CD4 cells are a subtype of T cells, which are produced in the thymus gland and regulate the immune system's response to infected or malignant cells. Further research is needed to clarify the role of these cells in Ménière's disease.
Another possible factor in the development of Ménière's disease is the loss of myelin from the cells surrounding the vestibular nerve fibers. Myelin is a whitish fatty material in the cell membrane of the Schwann cells that form a sheath around certain nerve cells. It acts like an electrical insulator. A team of researchers at the University of Virginia reported in 2002 that the vestibular nerve cells in patients with unilateral Ménière's disease are demyelinated; that is, they have lost their protective "insulation." The researchers are investigating the possibility that a viral disease or disorder of the immune system is responsible for the demyelination of the vestibular nerve cells.
Symptoms
The symptoms of Ménière's disease are associated with a change in fluid volume within the labyrinth of the inner ear. Symptoms include severe dizziness or vertigo, tinnitus, hearing loss, and the sensation of pain or pressure in the affected ear. Symptoms appear suddenly, last up to several hours, and can occur as often as daily to as infrequently as once a year. A typical attack includes vertigo, tinnitus, and hearing loss; however, some individuals with Ménière's disease may experience a single symptom, like an occasional bout of slight dizziness or periodic, intense ringing in the ear. Attacks of severe vertigo can force the sufferer to have to sit or lie down, and may be accompanied by headache, nausea, vomiting, or diarrhea. Hearing tends to recover between attacks, but becomes progressively worse over time.
Ménière's disease usually starts between the ages of 20 and 50 years; however, it is not uncommon for elderly people to develop the disease without a previous history of symptoms. Ménière's disease affects men and women in equal numbers. In most patients only one ear is affected but in about 15% both ears are involved.
Diagnosis
An estimated three to five million people in the United States have Ménière's disease, and almost 100,000 new cases are diagnosed each year. Diagnosis is based on medical history, physical examination, hearing and balance tests, and medical imaging with magnetic resonance imaging (MRI).
In patients with Ménière's disease, audiometric tests (hearing tests) usually indicate a sensory type of hearing loss in the affected ear. Speech discrimination, or the ability to distinguish between words that sound alike, is often diminished. In about 50% of patients, the balance function is reduced in the affected ear. An electronystagnograph (ENG) may be used to evaluate balance. Since the eyes and ears work together through the nervous system to coordinate balance, measurement of eye movements can be used to test the balance system. For this test, the patient is seated in a darkened room and recording electrodes, similar to those used with a heart monitor, are placed near the eyes. Warm and cool water or air are gently introduced into each ear canal and eye movements are recorded.
Another test that may be used is an electrocochleograph (EcoG), which can measure increased inner ear fluid pressure.
Treatment
Because there is no cure for Ménière's disease, most treatments are aimed at reducing its symptoms, especially tinnitus. General measures to mask the tinnitus include playing a radio or tape of white noise (low, constant sound). Exercising to improve blood circulation
and reducing the intake of salt, alcohol, aspirin, caffeine, and nicotine may relieve Ménière's disease symptoms.
Ayurveda
Ayurvedic practitioners believe that tinnitus is a vata disorder. (Vata is one of three doshas, or body/mental types.) The patient can drink a tea prepared from 1 tsp of a mixture of comfrey, cinnamon, and chamomile two to three times a day. Yogaraj guggulu in warm water can be taken two or three times a day. Gentle massage of the mastoid bone (behind the ear) with warm sesame oil may help relieve tinnitus. Placing three drops of garlic oil into the affected ear at night may also be effective.
Homeopathy
Homeopathic remedies are chosen based on each patients specific set of symptoms. Salicylic acidum is indicated for patients who experience a roaring sound, deafness, and giddiness. Bryonia is recommended for patients with headache, a buzzing or roaring sound in the ear, and dizziness that is worsened by motion. Cocculus is indicated for those who experience dizziness and nausea. Conium is chosen for the patient who experiences light sensitivity and dizziness that is worsened by lying down. Carbonium sulphuratum is recommended for patients
who experience a roaring with a tingling sensation and clogged ears. Kali iodatum is chosen for patients who have long-term ringing in the ears and no other symptoms. Theridion is indicated for patients who experience sensitivity to noise and dizziness with nausea and vomiting that is worsened by the slightest motion.
Other remedies
Other alternative medicine disciplines which have treatments to help relieve symptoms of Ménière's disease are:
Acupuncture. The acupuncture ear points neurogate, kidney, sympathetic, occiput, heart, and adrenal may relieve dizziness associated with Ménière's disease. Chronic cases may be treated at the body points on the spleen, triple warmer, and kidney meridians. The World Health Organization (WHO) lists Ménière's disease as one of 104 conditions that can be treated effectively with acupuncture.
Aromatherapy. The essential oils of geranium, lavender, and sandalwood may be added to bath water. Lavender or German chamomile oils may be used as massage oils.
Body adjustments. Chiropractors or osteopaths may adjust the head, jaw, and neck to relieve movement restrictions that could affect the inner ear. Craniosacral therapists may gently move bones of the skull to relieve pressure on the head.
Herbals. Ginkgo (Ginkgo biloba) improves circulation which may improve tinnitus and Ménière's disease. Ginkgo is a powerful antioxidant and blood thinner. Ginkgo relieves tinnitus in about half of the patients who use it. Fenugreek (Trigonella foenum-graecum) tea (steeped in cold water) stops cricket noises and ringing in the ears. Chamomile (Matricaria recutita) promotes relaxation and may help the patient to sleep.
Reflexology. Working the cervical spine, ear, and neck points on the hands and feet and the points on the bottoms and sides of the big toes may relieve tinnitus.
Relaxation techniques. Biofeedback, yoga, massage, and other stress-reduction techniques can promote relaxation and divert the patient's attention away from tinnitus. Stress can worsen tinnitus and bring on an attack of Ménière's disease so relaxation techniques can be beneficial.
Supplements. Magnesium deficiency may cause tinnitus. Magnesium supplementation may relieve the tinnitus associated with Ménière's disease and protect the ears from damage resulting from loud sounds. Vitamin B12 supplementation has improved tinnitus in patients deficient in this vitamin. Other supplements recommended for the treatment of Ménière's disease include vitamins C, B1, B2, and B6 and zinc.
TENS. Transcutaneous electrical nerve stimulation reduced tinnitus in 60% of the Ménière's disease patients in a study of tinnitus sufferers. Patients received six to 10 treatments biweekly. A few of the study patients reported temporary or permanent worsening of tinnitus, however, the cause of the tinnitus in these patients was not specified.
Allopathic treatment
There is no cure for Ménière's disease, but medication, surgery, and dietary and behavioral changes can help control or improve the symptoms.
A special hearing aid is available which makes a soft noise to mask the ringing and other noises associated with Ménière's disease. This device does not interfere with hearing or speech.
Medications
Symptoms of Ménière's disease may be treated with a variety of oral medicine or through injections. Antihistamines, like diphenhydramine, meclizine, and cyclizine can be prescribed to sedate the vestibular system. A barbiturate medication like pentobarbital may be used to completely sedate the patient and relieve the vertigo. Anticholinergic drugs, like atropine or scopolamine, can help minimize nausea and vomiting. Diazepam has been found to be particularly effective for relief of vertigo and nausea in Ménière's disease. There have been some reports of successful control of vertigo after antibiotics (gentamicin or streptomycin) or a steroid medication (dexamethasone) are injected directly into the inner ear. Some researchers have found that gentamicin is effective in relieving tinnitus as well as vertigo.
A newer medication that appears to be effective in treating the vertigo associated with Ménière's disease is flunarizine, which is sold under the trade name Sibelium. Flunarizine is a calcium channel blocker and anticonvulsant that is presently used to treat Parkinson's disease, migraine headache, and other circulatory disorders that affect the brain.
Surgical procedures
Surgical procedures may be recommended if the vertigo attacks are frequent, severe, or disabling and cannot be controlled by other treatments. The most common surgical treatment is insertion of a small tube or shunt to drain some of the fluid from the canal. This treatment usually preserves hearing and controls vertigo in about one-half to two-thirds of cases, but it is not a permanent cure in all patients.
The vestibular nerve leads from the inner ear to the brain and is responsible for conducting nerve impulses related to balance. A vestibular neurectomy is a procedure where this nerve is cut so the distorted impulses causing dizziness no longer reach the brain. This procedure permanently cures the majority of patients and hearing is preserved in most cases. There is a slight risk that hearing or facial muscle control will be affected.
A labyrinthectomy is a surgical procedure in which the balance and hearing mechanism in the inner ear are destroyed on one side. This procedure is considered when the patient has poor hearing in the affected ear. Labyrinthectomy results in the highest rates of control of vertigo attacks, however, it also causes complete deafness in the affected ear.
Expected results
Ménière's disease is a complex and unpredictable condition for which there is no cure. The vertigo associated with the disease can generally be managed or eliminated with medications and surgery. Hearing tends to become worse over time, and some of the surgical procedures recommended, in fact, cause deafness.
Prevention
Because the cause of Ménière's disease is not definitely known as of 2002, there are no proven strategies for its prevention. Stress reduction and relaxation may prevent attacks of Ménière's disease. Wearing earplugs while exposed to loud sounds will help to prevent hearing damage and worsening of tinnitus.
BOOKS
"Ménière's Disease." The Alternate Advisor: The Complete Guide to Natural Therapies and Alternative Treatments. Edited by Robert. Richmond, VA: Time-Life Books, 1997.
The Merck Manual of Diagnosis and Therapy. 17th ed., edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Ménière's Disease." New York: Simon & Schuster, 2002.
PERIODICALS
Ballester, M., P. Liard, D. Vibert, and R. Hausler. "Ménière's Disease in the Elderly." Otology and Neurotology 23 (January 2002): 73–78.
Corvera, J., G. Corvera-Behar, V. Lapilover, and A. Ysunza. "Objective Evaluation of the Effect of Flunarizine on Vestibular Neuritis." Otology and Neurotology 23 (November 2002): 933–937.
Driscoll, C. L., et al. "Low-Dose Gentamicin and the Treatment of Ménière's Disease: Preliminary Results." Laryngoscope 107 (January 1997): 83–89.
Friberg, U., and H. Rask-Andersen. "Vascular Occlusion in the Endolymphatic Sac in Ménière's Disease." Annals of Otology, Rhinology, and Laryngology 111 (March 2002): 237–245.
Fung, K., Y. Xie, S. F. Hall, et al. "Genetic Basis of Familial Ménière's Disease." Journal of Otolaryngology 31 (February 2002): 1–4.
Ghosh, S., A. K. Gupta, and S. S. Mann. "Can Electro-cochleography in Ménière's Disease Be Noninvasive?" Journal of Otolaryngology 31 (December 2002): 371–375.
Mamikoglu, B., R. J. Wiet, T. Hain, and I. J. Check. "Increased CD4+ T cells During Acute Attack of Ménière's Disease." Acta Otolaryngologica 122 (December 2002): 857–860.
Radtke, A., T. Lempert, M. A. Gresty, et al. "Migraine and Ménière's Disease: Is There a Link?" Neurology 59 (December 10, 2002): 1700–1704.
Saeed, Shakeel R. "Diagnosis and Treatment of Ménière's Disease." British Medical Journal 316 (January 1998): 368.
Spencer, R. F., A. Sismanis, J. K. Kilpatrick, and W. T. Shaia. "Demyelination of Vestibular Nerve Axons in Unilateral Ménière's Disease." Ear, Nose and Throat Journal 81 (November 2002): 785–789.
Steenerson, Ronald L., and Gaye W. Cronin. "Treatment of Tinnitus with Electrical Stimulation. Otolaryngology-Head and Neck Surgery 121 (November 1999): 511–513.
Yetiser, S., and M. Kertmen. "Intratympanic Gentamicin in Ménière's Disease: The Impact on Tinnitus." International Journal of Audiology 41 (September 2002): 363–370.
ORGANIZATIONS
American Academy of Otolaryngology-Head and Neck Surgery. One Prince Street, Alexandria, VA 22314. (703) 836-4444. <http://www.entnet.org>.
