Ménière's disease
Ménière's disease | |
---|---|
Other names | Ménière's syndrome, idiopathic |
Prognosis | After ~10 years hearing loss and chronic ringing[5] |
Frequency | 0.3–1.9 per 1,000[1] |
Ménière's disease (MD) is a disease of the inner ear that is characterized by potentially severe and incapacitating episodes of vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear.[3][4] Typically, only one ear is affected initially, but over time, both ears may become involved.[3] Episodes generally last from 20 minutes to a few hours.[5] The time between episodes varies.[3] The hearing loss and ringing in the ears can become constant over time.[4]
The cause of Ménière's disease is
No cure is known.
Ménière's disease was identified in the early 1800s by Prosper Menière.[5] It affects between 0.3 and 1.9 per 1,000 people.[1] It typically starts in people 40 to 60 years old.[3][6] Females are more commonly affected than males.[1] After 5 to 15 years of symptoms, the episodes of the world spinning sometimes stop and the person is left with loss of balance, poor hearing in the affected ear, and ringing or other sounds in the affected ear or ears.[5]
Signs and symptoms
Ménière's is characterized by recurrent episodes of vertigo, fluctuating hearing loss, and tinnitus; episodes may be preceded by a headache and a feeling of fullness in the ears.
Causes
The cause of Ménière's disease is unclear, but likely involves both genetic and environmental factors.[1][3][7] A number of theories exist including constrictions in blood vessels, viral infections, and autoimmune reactions.[3]
Mechanism
The initial triggers of Ménière's disease are not fully understood, with a variety of potential inflammatory causes that lead to endolymphatic hydrops, a distension of the endolymphatic spaces in the inner ear. Endolymphatic hydrops is strongly associated with developing Ménière's disease,[1] but not everyone with EH develops Ménière's disease: "The relationship between endolymphatic hydrops and Meniere's disease is not a simple, ideal correlation."[8]
Additionally, in fully developed Ménière's disease, the balance system (vestibular system) and the hearing system (cochlea) of the inner ear are affected, but some cases occur where EH affects only one of the two systems enough to cause symptoms. The corresponding subtypes of the disease are called vestibular Ménière's disease, showing symptoms of vertigo, and cochlear Ménière's disease, showing symptoms of hearing loss and tinnitus.[9][10][11][12]
The mechanism of Ménière's disease is not fully explained by EH, but fully developed EH may mechanically and chemically interfere with the sensory cells for balance and hearing, which can lead to temporary dysfunction and even to death of the sensory cells, which in turn can cause the typical symptoms of MD – vertigo, hearing loss, and tinnitus.[8][10]
An estimated 30% of people with Ménière's disease have Eustachian tube dysfunction.[13]
Diagnosis
The diagnostic criteria as of 2015 define definite MD and probable MD as:[1][4]
Definite
- Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours
- Audiometrically documented low- to medium-frequency sensorineural hearing loss in the affected ear on at least one occasion before, during, or after one of the episodes of vertigo
- Fluctuating aural symptoms (hearing, tinnitus, or fullness) in the affected ear
- Not better accounted for by another vestibular diagnosis
Probable
- Two or more episodes of vertigo or dizziness, each lasting 20 minutes to 24 hours
- Fluctuating aural symptoms (hearing, tinnitus, or fullness) in the reported ear
- Not better accounted for by another vestibular diagnosis
A common and important symptom of MD is hypersensitivity to sounds.[15] This hypersensitivity is easily diagnosed by measuring the loudness discomfort levels (LDLs).[16]
Symptoms of MD overlap with migraine-associated vertigo (MAV) in many ways, but when hearing loss develops in MAV, it is usually in both ears, and this is rare in MD, and hearing loss generally does not progress in MAV as it does in MD.[1]
People who have had a transient ischemic attack (TIA) or stroke can present with symptoms similar to MD, and in people at risk magnetic resonance imaging should be conducted to exclude TIA or stroke.[1]
Other vestibular conditions that should be excluded include vestibular paroxysmia, recurrent unilateral vestibulopathy, vestibular schwannoma, or a tumor of the endolymphatic sac.[1]
Management
No cure for Ménière's disease is known, but medications, diet, physical therapy, and counseling, and some surgical approaches can be used to manage it.[4] More than 85% of patients with Ménière's disease get better from changes in lifestyle, medical treatment, or minimally invasive surgical procedures. Those procedures include intratympanic steroid therapy, intratympanic gentamicin therapy or endolymphatic sac surgery.[17]
Medications
During MD episodes,
In cases where hearing loss and continuing severe episodes of vertigo occur, a
Diet
People with MD are often advised to reduce their sodium intake.[18][26] Reducing salt intake, however, has not been well studied.[26] Based on the assumption that MD is similar in nature to a migraine, some advise eliminating "migraine triggers" such as caffeine, but the evidence for this is weak.[18] There is no high-quality evidence that changing diet by restricting salt, caffeine or alcohol improves symptoms.[27]
Physical therapy
While use of physical therapy early after the onset of MD is probably not useful due to the fluctuating disease course, physical therapy to help retraining of the balance system appears to be useful to reduce both subjective and objective deficits in balance over the longer term.[4][28]
Counseling
The psychological distress caused by the vertigo and hearing loss may worsen the condition in some people.
Surgery
If symptoms do not improve with less invasive approaches and for cases where the condition is uncontrolled or persistent and affecting both ears, surgery may be considered.[4][18][31]
Endolymphatic sac surgery
Surgery to decompress the endolymphatic sac is one surgical approach that is sometimes suggested. Three methods of surgical endolymphatic sac decompression are sometimes suggested – simple decompression, insertion of a shunt, or removal of the sac.[32] There is some very weak evidence that all three methods may be useful for reducing dizziness, but that the level of evidence supporting these surgical procedures is low with further higher quality investigations being suggested.[32] There is a risk in these types of surgical procedures that the shunts used in these surgeries are at risk of becoming displaced or misplaced.[18] For those with severe cases who are eligible for endolymphatic sac decompression, a 2014 systematic review reported that in at least 75% of people, EL sac decompression was effective at controlling vertigo in the short term (>1 year of follow-up) and long term (>24 months).[33]
Ventilation tubes
Surgical implantation of eustachian tubes (ventilation tubes) is not strongly supported by medical studies. There are some tentative evidence of benefit from
Other surgical interventions
Destructive surgeries such as vestibular nerve labyrinthectomy are irreversible and involve removing entire functionality of most, if not all, of the affected ear; as of 2013, almost no evidence existed with which to judge whether these surgeries are effective.[34] The inner ear itself can be surgically removed via labyrinthectomy, although hearing is always completely lost in the affected ear with this operation.[34] The surgeon can also cut the nerve to the balance portion of the inner ear in a vestibular neurectomy. The hearing is often mostly preserved; however, the surgery involves cutting open into the lining of the brain, and a hospital stay of a few days for monitoring is required.[34]
Poorly supported
- As of 2014, betahistine is often used as it is inexpensive and safe;[5] but evidence does not justify its use in Ménière's disease.[35][36]
- Transtympanic micropressure pulses were investigated in two systematic reviews. Neither found evidence to justify this technique.[37][38]
- Intratympanic steroids were investigated in three systematic reviews. The data were found to be insufficient to decide if this therapy has positive effects.[39][40][41]
- Evidence does not support the use of alternative medicine such as acupuncture or herbal supplements.[3]
Prognosis
Ménière's disease usually starts confined to one ear; it extends to both ears in about 30% of cases.[5] People may start out with only one symptom, but in Ménière's disease all three appear with time.[5] Hearing loss usually fluctuates in the beginning stages and becomes more permanent in later stages. Ménière's disease has a course of 5–15 years, and people generally end up with mild disequilibrium, tinnitus, and moderate hearing loss in one ear.[5] As of 2020, there has been no recent major breakthrough in the pathogenesis research of Ménière's disease.[42]
Epidemiology
From 3 to 11% of diagnosed dizziness in neuro-otological clinics are due to Ménière's disease.[43] The annual incidence rate is estimated to be about 15 cases per 100,000 people and the prevalence rate is about 218 per 100,000, and around 15% of people with Ménière's disease are older than 65.[43] In around 9% of cases, a relative also had Ménière's disease, indicating a genetic predisposition in some cases.[4]
The odds of Ménière's disease are greater for people of white ethnicity, with severe obesity, and women.[1] Several conditions are often comorbid with Ménière's disease, including arthritis, psoriasis, gastroesophageal reflux disease, irritable bowel syndrome, and migraine.[1]
History
The condition is named after the French physician Prosper Menière, who in an 1861 article described the main symptoms and was the first to suggest a single disorder for all of the symptoms, in the combined organ of balance and hearing in the inner ear.[44][45]
The
In 1972, the academy defined criteria for diagnosing MD as:[46]
- Fluctuating, progressive, sensorineural deafness
- Episodic, characteristic definitive spells of vertigo lasting 20 minutes to 24 hours with no unconsciousness, vestibular nystagmusalways present.
- Tinnitus (ringing in the ears, from mild to severe) is accompanied often by ear pain and a feeling of fullness in the affected ear; usually, the tinnitus is more severe before a spell of vertigo and lessens after the vertigo attack.
- Attacks are characterized by periods of remission and exacerbation.
In 1985, this list changed to alter wording, such as changing "deafness" to "hearing loss associated with tinnitus, characteristically of low frequencies" and requiring more than one attack of vertigo to diagnose.[46] Finally in 1995, the list was again altered to allow for degrees of the disease:[46]
- Certain – Definite disease with histopathological confirmation
- Definite – Requires two or more definitive episodes of vertigo with hearing loss plus tinnitus and/or aural fullness
- Probable – Only one definitive episode of vertigo and the other symptoms and signs
- Possible – Definitive vertigo with no associated hearing loss
In 2015, the International Classification for Vestibular Disorders Committee of the Barany Society published consensus diagnostic criteria in collaboration with the American Academy of Otolaryngology–Head and Neck Surgery, the European Academy of Otology and Neurootology, the Japan Society for Equilibrium Research, and the Korean Balance Society.[1][4]
References
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- ^ a b c d e f g h i j k l m n o p q r s "Ménière's Disease". NIDCD. 1 June 2016. Archived from the original on 27 July 2016. Retrieved 18 July 2016.
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- Ménière P (1861). "Sur une forme de surdité grave dépendant d'une lésion de l'oreille interne" [On a form of severe deafness dependent on a lesion of the inner ear]. Bulletin de l'Académie Impériale de Médecine (in French). 26. republished online at gallica.bnf.fr: 241. Archived from the originalon 16 February 2016.
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External links
- Basura GJ, Adams ME, Monfared A, et al. (8 April 2020). "Clinical Practice Guideline: Ménière's Disease". Otolaryngology–Head and Neck Surgery. 162 (2 suppl): S1–S55. PMID 32267799.
- Menière's Disease, Stanford Ear Institute.