Meniere’s Disease: Experts Discuss Diagnosis and Treatment

From its sometimes confusing overlap with migraine to limited evidence for systemic treatments, Ménière’s disease poses challenges to clinicians. Expert panelists offered their insights into managing the disorder at the Triological Society Combined Sections Meeting.

Yuri Agrawal, MD, associate professor of otolaryngology–head and neck surgery at Johns Hopkins School of Medicine in Baltimore, said that while an audiogram is the only testing required to make a diagnosis of Meniere’s, other tests could play a role in certain situations. Caloric testing, she noted, is the most sensitive in correctly identifying the affected ear, followed by cervical vestibular-evoked myogenic potential (cVEMP).

MRI and cVEMP, she said, could help with further management. “It might be useful, for example, when contemplating an ablative procedure for an index ear … to know what might be the
status of the contralateral ear,” she said. “If you do see evidence of hydrops in MRI of the contralateral ear, or altered cVEMP, that might suggest that an ablative therapy might be in store for the other ear, too, and may change your management accordingly.”

Other panelists said they typically only obtain an audiogram in suspected cases of Ménière’s, but, if further treatment is needed, they would be inclined to get an electronystagmogram (ENG) or other tests. Brian Blakley, MD, PhD, professor of otologic and neurotologic surgery at the University of Manitoba, said he tends to order MRI regularly to rule out acoustic neuroma.

Similarities with Vestibular Migraine

Hamid Djalilian, MD, professor of neurotology and skull base surgery at the University of California in Irvine, said his group started, approximately nine years ago, treating patients with Ménière’s disease as they do migraine patients. Researchers have repeatedly found similarities between patients with Ménière’s and those with vestibular migraine, in symptoms and test results, and have suggested that a link in physiology could account for this.

In a study of 37 patients with definite Ménière’s disease at his center, 49% of whom met the International Headache Society (IHS) criteria for migraine, the overlap with migraine was even greater than it seemed. One hundred percent of the patients with Ménière’s experienced three sensitivities associated with migraine, a family history of migraine, or two migraine-related symptoms  (Laryngoscope. 2016;126:163–168).

“There’s a population of Ménière’s disease that doesn’t qualify for the IHS criteria for migraine, but they have a lot of the migraine-related symptoms,” Dr. Djalilian said.

At his center, among a cohort of 25 Ménière’s patients with long-term follow-up who didn’t qualify for a vestibular migraine diagnosis but were treated with a migraine regimen, 92% experienced significant improvement in quality of life. “When you look at our success rate, it’s really on par with vestibular nerve section,” a procedure meant to eliminate vertigo attacks.