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Mnires Disease
A Lifelong Merry-Go-Round
Tamera Pearson, PhD, ACNP, FNP
Mnires disease is a complex disorder of intermittent vertigo, tinnitus, and hearing loss whose
symptoms usually manifest between ages 20 and 60. Although this disorder is uncommon,
its impact on a persons quality of life can be significant. Here are the symptoms, criteria for
diagnosis, and appropriate treatment or referrals for Mnires disease.
CE/CME INFORMATION
Earn credit by reading this article and
successfully completing the posttest
at www.clinicianreviews.com/cecme/
cecme.html. Successful completion is
defined as a cumulative score of at
least 70% correct.
This program has been reviewed and is
approved for a maximum of 1.0 hour
of American Academy of Physician
Assistants (AAPA) Category I CME
credit by the Physician Assistant Review
Panel. [NPs: Both ANCC and the AANP
Certification Program recognize AAPA
as an approved provider of Category 1
credit.] Approval is valid for one year
from the issue date of October 2013.
LEARNING OBJECTIVES
D
escribe the pathophysiology of
Mnires disease, as it is currently
understood.
D
iscuss the triad of symptoms
that should prompt suspicion for
Mnires disease in a primary care
patient.
L ist the diagnostic criteria for
definite Mnires disease, as
defined by the American Academy
of OtolaryngologyHead and Neck
Surgery.
R
eview pharmacologic management,
intratympanic injection and other
nonoperative therapies, and surgical
treatment for Mnires disease.
Pinna
Malleus
Incus
Stapes
INNER
EAR
Ear
canal
Cochlea
Tympanic
membrane
Middle ear
Eustachian
tube
DIAGNOSIS
Establishing the diagnosis of Mnires disease can be
difficult and time-consuming because the symptoms
of the disorder are nonspecific and variable. Mnires
disease is a clinical diagnosis, and thus the clinician
must conduct a thorough physical exam and elicit a
very specific history, including a detailed description of
vertigo incidents and associated symptoms. Often, the
greatest challenge is encouraging patients to articulate
CE/CME
TABLE 1
Symptom
Criteria
Certain
Mnires Disease
Probable
Mnires Disease
Possible
Mnires Disease
Spontaneous vertigo
Hearing loss
Audiometrically
documented on
at least 1 occasion
Audiometrically
documented on
at least 1 occasion
Present
Present
Not present
Other causes
Excluded
Excluded
Excluded
Triggers of Vertigo
Selected triggers of vertigo that must be considered are
benign paroxysmal positional vertigo (BPPV), labyrinthitis, acoustic neuroma, migraine with vertigo, and cerebral vascular events.6 Diagnostic tests are indicated to
rule out certain problems, such as MRI to exclude a tumor or an acoustic neuroma. Distinct differences noted
during a complete assessment may help eliminate certain disorders. BPPV is triggered by a change in physical position and usually lasts less than one minute; the
diagnosis can be confirmed by the Dix-Hallpike maneuver.4 Labyrinthitis is characterized by acute vertigo
associated with continuing imbalance, while instability with walking resolves completely between vertigo
episodes in Mnires disease.4 If abnormal neurologic
manifestations are noted during the exam or reported
in a patients account of a vertigo episode, then a transient ischemic attack or stroke must be ruled out by
more detailed diagnostic testing.
TREATMENT OPTIONS
Presently, no evidence-based guidelines exist for the
treatment of Mnires disease, and the evidence supporting the efficacy of currently used therapies is inconsistent. However, several medicines and treatments
are useful in relieving symptoms and improving a patients quality of life.
Primary care clinicians can initiate treatment for
Mnires disease through lifestyle recommendations
and prescription of specific medications. Everyday
adjustments that incorporate dietary changes, stress
reduction, adequate sleep, and regular exercise have
been shown to improve vertigo symptoms in 60% of
patients with Mnires disease.5,9
Lifestyle Changes
Dietary changes. Patients diagnosed with Mnires
disease may benefit from following a low-sodium diet,
limiting their daily sodium intake to between 1,000 and
2,000 mg.2,7,11 A low-sodium diet is believed to have a
positive impact on inner ear fluid homeostasis by decreasing fluid retention and reducing the endolymphatic hydrops.2,7,11 Decreasing alcohol and caffeine
consumption is also routinely recommended as part of
the treatment of Mnires disease.2,5
Researchers have recently suggested a different approach to dietary changes for Mnires disease that
reflects the underlying loss of ability to regulate fluid in
the inner ear. This alternate method of dietary regulation aims to maintain fluid homeostasis by avoiding
variations in the daily intake of sodium, caffeine, or al-
CE/CME
ety associated with an acute episode of vertigo.6,11 Benzodiazepines should be started at the lowest dose and
increased as needed to the maximum recommended
for individual medications based on symptom relief
and side effects.6 Although caution needs to be used
when prescribing benzodiazepines, studies show that
they can be effective for persons with Menieres disease.11
Other antiemetic medications, such as promethazine or ondansetron, may be needed to treat severe
nausea, but these agents should be used cautiously
with other medications due a potential side effect of
sedation.
Intratympanic Medication
Patients who do not respond well to the previously described management should be referred to a specialist
for additional treatment options. An otolaryngology
specialist may administer intratympanic medications
to patients with Mnires disease who have not responded to primary medical therapy.
Patients in the US who have not responded positively to lifestyle or diuretic medication are commonly
offered treatment with intratympanic dexamethasone.
The primary goal of this therapy is to improve vertigo
Acupuncture
A traditional Chinese medical approach, acupuncture is one complementary and alternative medicine
therapy that has been studied as a treatment option
for Mnires disease. Studies on the use of acupuncture to treat vertigo demonstrate a beneficial effect for
persons with this disease. While the optimal number
and frequency of treatments has not been determined,
all types of acupuncture studied showed benefit. Acupuncture has a positive effect in both acute episodes
of vertigo in those without Mnires disease and in
patients who have had Mnires disease for many
years.13
Vestibular Rehabilitation
An additional adjunctive treatment option to consider for patients with residual disequilibrium is
vestibular rehabilitation. Vestibular rehabilitation is
designed to desensitize or retrain the balance system
response through a series of exercises and activities
supervised by a physical or occupational therapist.
This rehabilitation may improve balance in patients
with Mnires disease who have undergone medical or surgical intervention used to treat vertigo. Patients who have significant balance problems occurring between acute vertigo episodes may also benefit
from vestibular rehabilitation.6
Surgical Treatment
Surgical intervention should be the last resort to treat
Mnires disease due to the higher risk involved with
any surgical procedure and the potential adverse effect
on hearing. Endolymphatic sac decompression surgery involves removing a portion of the mastoid bone,
resulting in decompression of the sac adjacent to the
sigmoid sinus. This procedure has been used for more
than 40 years to control vertigo and has the advantage
of preserving hearing.7,9 However, the benefit of this
procedure is now somewhat controversial and possibly related to a placebo effect.6 Researchers also report
positive results with the use of tenotomy surgery, which
involves severing tendons to the stapedius and tensor
tympani muscles in the middle ear.14
No surgical procedure should be considered without the recommendation of an otolaryngology specialist. The decision should be made based on the severity of the disease and its effect on the patient, weighed
against the risks involved in such an invasive treatment
option.
CONCLUSION
Mnires disease is a complex disorder that can significantly alter a persons quality of life. While neither the exact cause nor pathophysiology underlying
Mnires disease is well understood, several solid
theories are being investigated and contribute to the
current understanding of treatment options. Primary
care clinicians can help determine this clinical diagnosis based on a detailed history and comprehensive
assessment of recurrent vertigo with tinnitus, hearing
loss, and possibly a sensation of aural fullness. Establishing the diagnosis of Mnires disease requires ruling out other possible causes of vertigo.
Lifestyle changes that improve the consistency
of dietary intake of sodium, caffeine, and alcohol as
well as reduction of stress are ongoing recommendations for patients with Mnires disease. Oral medications from a range of drug categories may be used
to improve acute and chronic symptoms, including
antiemetics, anticholinergics, antihistamines, benzodiazepines, and mild diuretics. Additionally, a compounded substance with vasodilator and histaminereceptorantagonist properties (betahistine) can be
used for treatment of Menieres.
Patients who do not respond well to conservative
therapy should be referred to an otolaryngologist for
possible intratympanic medications, ventilation tube
placement with a prescription for pulse pressure
therapy (ie, Meniett device), or surgical intervention.
Primary care clinicians can initiate treatment for Mnires disease by recommending lifestyle changes,
prescribing oral medications, providing patient education, and recognizing indications for referral. CR
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