Ménière’s Disease-Don’t Blame the Patient

There is growing evidence to support Hrobjartsson and Gotzsche’s conclusions. The original work on the placebo effect has been called into question for its scientific validity. The very fact that placebos are completely inert or inactive has also been called into question. As early as 1968, Shapiro made the observation that there is no such thing as placebo in the true sense of the word.4

Outcomes mistakenly attributed to placebo effect can be accounted for by many factors, including natural termination of the disease process, the cyclic nature of Ménière’s disease, errant diagnosis, and temporary improvement confused with cure. We not only have a poor understanding of why Ménière’s disease occurs, but also why it terminates. No one suspects the placebo effect when more than 90% of acute otitis media patients have resolution without antibiotics. They rightfully claim natural termination of the disease process, because we understand the pathophysiology of why an ear infection can resolve on its own.

However, probably the most common confusion of placebo effect and resolution of symptoms from Ménière’s disease has to do with the statistical phenomenon of regression to the mean. Regression to the mean is the phenomenon by which an extreme outcome score will, for purely statistical reasons, be less extreme at a subsequent measurement. Several sports analogies come to mind: the sophomore slump, the Heisman curse, the Sports Illustrated Cover Jinx, and so on. In all these cases, an athlete has an extremely good year-much better than he or she typically can perform. Consequently, the following year, the athlete’s performance is less spectacular.

Similarly, with Ménière’s disease, the patients will seek the most extreme forms of therapy when their symptoms are at their worst. Regardless of the treatment employed, they get better-not because of placebo effect, but because of regression to the mean. As otolaryngologists, we have added to the misery of these patients by emphasizing the placebo effect in Ménière’s disease.

Panic Attacks, Anxiety, and Depression

Considering the incidence of depression and anxiety among patients with chronic medical illnesses, it is not surprising to see a fair amount of this in patients with Ménière’s disease. However, the presence of panic disorder probably bears mentioning. It is an organic disorder with a 5% lifetime prevalence that is very effectively treated with selective serotonin reuptake inhibitors (SSRIs) and psychotherapy. Among patients with panic disorder, situational or environmental triggers are very common.

For some patients with Ménière’s disease, vertigo spells act as a trigger for their panic attacks. This does not imply that their Ménière’s symptoms are fabricated or that they are crazy. It simply means they have two concomitant disorders, with one triggering the other. Referral to the appropriate mental health specialist is just as important for this type of patient as the appropriate referral for any other medical condition.

The Rest of the Story

The patient described at the beginning of this article who had the bilateral atypical Ménière’s syndrome was found on examination to have a mild right-beating nystagmus. Her past medical history was significant for breast cancer, with a bilateral mastectomy performed one year earlier. Review of the reportedly normal MRI revealed bilateral symmetric mildly enhancing masses in the internal auditory canals. The first MRI scan, which had been done a year earlier, revealed no such masses present. A lumbar puncture for cytology was ordered and confirmed the presence of metastatic breast cancer. Believe it or not, although she was distressed by the diagnosis, she was relieved just to have a diagnosis.