Ménière’s Disease: A Diagnosis of Exclusion with Controversial Therapies

The disease has certainly captured the hearts and minds of otolaryngologists because of its many controversies. This is good, as it forces us to keep an open mind about alternative therapies and not rely on what we learned 20 to 30 years ago or how we were trained.

The dilemma we face today is that once Ménière’s disease is diagnosed, we know how to control the vertigo, but we don’t know how to stop the decline in hearing, said Dr. Megerian. We need insight now as to the mechanism that causes hearing loss in this disease so that we can develop inhibitors of this process in the future. Unfortunately, we are nowhere close to doing this.

One of the exciting things I see in the future of otolaryngology is being able to administer pharmaceutical agents, through a tympanostomy tube, that either protect or preserve hearing, continued Dr. Megerian. I think in the next five to 10 years, new imaging protocols with high-powered MRI scans will allow us to home in on the inner ear and see the anatomical changes to confirm a diagnosis of Ménière’s disease in living patients with certainty.

AAO-HNS Definitions of Ménière’s Disease

Possible

• Episodic vertigo of the Ménière’s type (>20 minutes, associated with horizontal rotatory nystagmus) without documented hearing loss, or
• Sensorineural hearing loss, fluctuating or fixed, with disequilibrium, but without definitive episodes
• Other causes excluded

Probable

• One definitive episode of vertigo
• Audiometrically documented hearing loss on at least one occasion
• Tinnitus or aural fullness in the treated ear
• Other causes excluded

Definite

• Two or more definitive spontaneous episodes of vertigo 20 minutes or longer
• Audiometrically documented hearing loss on at least one occasion
• Tinnitus or aural fullness in the treated ear
• Other cases excluded

Certain

• Definite Ménière’s disease, plus histopathologic confirmation

AAO-HNS Functional Level Scale

Regarding my current state of overall function, not just during attacks (check the ONE that best applies):

• My dizziness has no effect on my activities at all.
• When I am dizzy I have to stop what I am doing for a while, but it soon passes and I can resume activities. I continue to work, drive, and engage in any activity I choose without restriction. I have not changed any plans or activities to accommodate my dizziness.
• When I am dizzy, I have to stop what I am doing for a while, but it does pass and I can resume activities. I continue to work, drive, and engage in most activities I choose, but I have had to change some plans and make some allowance for my dizziness.
• I am able to work, drive, travel, take care of a family, or engage in most essential activities, but I must exert a great deal of effort to do so. I must constantly make adjustments in my activities and budget my energies. I am barely making it.
• I am unable to work, drive, or take care of a family. I am unable to do most of the active things that I used to. Even essential activities must be limited. I am disabled.
• I have been disabled for 1 year or longer and/or I receive compensation (money) because of my dizziness or balance problem.

References

1. Li JC. Inner Ear, Meniere Disease, Medical Treatment. January 17, 2007. Retrieved November 10, 2007 from eMedicine from WebMD website: www.emedicine.com/ent/TOPIC232.htm .
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2. Hain, TC. Epidemiology of Ménière’s Disease. September 16, 2003. Retrieved November 10, 2007 from Dizziness and Balance website: www.dizziness-and-balance.com/disorders/menieres/men_epi.html .
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3. Rauch SD, Merchant SN, Thedinger BA. Ménière’s syndrome and endolymphatic hydrops. Double-blind temporal bone study. Ann Oto Rhinol Laryngol 1989;98(11):873-83.
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5. Arnold W, Niedermeyer HP. Herpes simplex virus antibodies in the perilymph of patients with Ménière’s disease. Arch Otolaryngol Head Neck Surg 1997;123(1):53-6.
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7. Yazawa Y, Suzuki M, Hanamitsu M, et al. Detection of viral DNA in the endolymphatic sac in Ménière’s disease by in situ hybridization. ORL J Otorhinolaryngol Relat Spec 2003;65(3):162-8.
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8. Stahle J, Friberg U, Svedberg A. Long-term progression of Ménière’s disease. Acta Otolaryngol Suppl 1991: 485:75-83.
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9. Silverstein H, Rosenberg SI. Surgical Techniques of the Temporal Bone and Skull Base. Philadelphia: Lea and Febinger, 1992.
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10. Stapleton E, Mills R. Clinical diagnosis of Ménière’s disease: how useful are the American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium guidelines? J Laryngol Otol 2007;Oct 12:1-7.
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11. Silverstein H, Lewis WB, Jacson LE, et al. Changing trends in the surgical treatment of Ménière’s disease: results of a 10-year survey. Ear Nose Throat J 2003;82(3):185-7, 191-4.
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12. Martin E, Perez N. Hearing loss after intratympanic gentamicin therapy for unilateral Ménière’s disease. Otol Neurotol 2003;24(5):800-6.
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13. Li, JC. Inner Ear, Meniere Disease, Surgical Treatment. January 17, 2007. Retrieved November 10, 2007 from eMedicine from WebMD website; www.emedicine.com/ent/TOPIC233.htm .
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14. Gottshall KR, Hoffer ME, Moore RJ, Balough BJ. The role of vestibular rehabilitation in the treatment of Ménière’s disease. Otolaryngol Head Neck Surg 2005;133(3):326-8.
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Laryngoscope Highlights

Flap Reconstruction in Conjunction with Intraoperative Radiation Therapy

For patients with advanced or recurrent head and neck cancer, major resections combined with complex reconstructions are frequently necessary to obtain locoregional control and restore form and function. These patients may benefit from intraoperative radiation therapy (IORT) because it allows high doses of radiation to be delivered directly to the tumor bed while avoiding adjacent tissues. IORT is especially useful for patients who have received radiation previously or who have tumors near radiation-intolerant tissues. The higher doses, however, raise concerns regarding wound healing, flap survival, and functional outcome. Michael D. Most, MD, and associates present 22 cases (in 21 patients) of head and neck cancer in which IORT was used in conjunction with immediate flap reconstruction.