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Ménière's Disease

Ménière's disease typically causes attacks of vertigo, hearing loss, and tinnitus (noises in the ear). The 'attacks' can vary in severity, and in how often they occur. Permanent hearing loss and/or permanent tinnitus may eventually develop in some cases. There is no cure, but treatment can help to ease and prevent symptoms. If you are a driver, you must stop driving if Ménière's disease is diagnosed. The DVLA will permit driving again if there is good control of symptoms.

What is Ménière's disease?

Ménière's disease is a condition of the inner ear. About 1 in a 1000 people develop Ménière's disease. It can affect anyone at any age, but it most commonly begins between the ages of 20 and 50. Generally, this condition starts in one ear only. The other ear is also affected at some stage in about 4 in 10 cases. The disease is named after a French doctor called Prosper Ménière who first described the disease in the 1860s.

• Dulled hearing in the affected ear(s). The degree of hearing loss varies.
• Vertigo. This is dizziness with a spinning sensation. It can be quite severe and make you feel sick or vomit. Vertigo can develop with little or no warning. You may feel very dizzy and ill. You may need to go to bed until it passes.
• Tinnitus. This is a ringing, roaring, or buzzing noise which you can hear from inside the affected ear.
• Ear pressure. You may get a sense of fullness or pressure inside the ear.
• Loud noises may seem unpleasant and distorted.

An attack of Ménière's disease may last from 20 minutes to several hours. The average is 2-4 hours. Many people feel quite sleepy after an attack. Slight unsteadiness may last a day or so after an attack - sometimes longer.

The symptoms can vary from person to person, and from time to time in the same person. A typical attack is of vertigo, hearing loss, and tinnitus which lasts a few hours. However, some people only have the vertigo without the hearing loss. Attacks of hearing loss without vertigo are uncommon.

Some people just have slight vertigo during an attack. Others are severely affected and vomit for several hours. Attacks may be frequent, or occur only every few months or longer. Sometimes they come in 'clusters' of several attacks in quick succession. For example, you may have an attack every couple of days or so for a week or so. Some attacks may be so close together that it may seem that one attack lasts for several days.

An uncommon symptom is to have sudden unexplained falls (drop attacks). These are falls without losing consciousness. Drop attacks last just a short time with little associated vertigo. They occur in about 1 in 25 people with Ménière's disease. So, although uncommon, drop attacks can be alarming and potentially dangerous if, for example, you are driving or up a ladder when one occurs.

You may have long periods of time (months or years) between attacks (or clusters of attacks) when you have no symptoms. In about 7 in 10 people with Ménière's disease, the attacks stop altogether within 5-10 years of them starting.

Symptoms that may become permanent

If permanent symptoms develop, they usually take months or years to develop.

• Hearing loss. During each 'attack' the hearing loss is temporary at first. In the early stages of the disease the hearing usually reverts back to normal when an attack is over. In time, some permanent hearing loss may develop. In some people this becomes worse and leads to deafness in the affected ear. If you have Ménière's disease for several years, the vertigo attacks may become less, but the deafness may become the most serious symptom. This is particularly so if both ears are affected.
• Tinnitus. Like hearing loss, tinnitus is often temporary at first during each attack. Again, like hearing loss, it eventually becomes permanent in some cases.

The inner ear includes the cochlea and semicircular canals. These are small 'shell-like' structures in which there is a system of narrow fluid-filled channels called the labyrinth. The semicircular canals sense movement of your head and help to control balance and posture. The cochlea is concerned with hearing. Messages of balance and sound are sent down nerves (the vestibular nerve and the cochlear nerve) to the brain.

It is thought that a build up of fluid in the labyrinth from time to time causes the symptoms. The build up of fluid may increase the pressure and cause swelling of the labyrinth. Also, fluid may leak between different parts of the labyrinth. These effects may cause the inner ear to send abnormal messages to the brain, which causes the dizziness and vomiting.

An increased pressure of fluid on the hearing cells which line the labyrinth is probably why they do not work so well and leads to dulled hearing. As the pressure eases, the cells work better again, and hearing returns to normal. However, repeated bouts of increased pressure may eventually damage the hearing cells. This is why hearing loss may become permanent.

It is not clear why a build up of fluid occurs in the labyrinth. There may be some fault where the amount of fluid that you make is more than the amount drained. A variety of factors may cause this. For example, slight abnormalities of the bones around the middle ear may be a factor. Inheritance may play some part. (About 8 in 100 close relatives of affected people develop Ménière's disease compared to 1 in a 1000 of the general population.) Other theories include: virus infections of the ear, salt imbalance in the labyrinth fluid, diet, a faulty immune system.

Note: side-effects from some medicines can cause symptoms similar to Ménière's disease, or make symptoms of Ménière's disease worse. For example, some anticonvulsants, antidepressants, antihistamines, antipsychotics, and sedatives. Tell your doctor if you think that a medicine that you are taking may be causing symptoms, or making them worse.

The diagnosis is usually based on the typical symptoms. Ideally, a formal hearing test during an attack would help to clarify the diagnosis as hearing is reduced. However, this is often impractical as attacks usually come 'out of the blue' and can make you feel quite ill. The diagnosis may only become clear over time as the typical pattern of recurring attacks develops.

Other conditions can cause similar symptoms to Ménière's. For example: injury, infection, or tumours in the inner ear or nerve may cause deafness, tinnitus, or vertigo. However, Ménière's disease is the likely cause if the symptoms are intermittent (that is, they come and go as 'attacks'). Ear tests and scans may be advised in some cases to rule out other conditions. In particular, a scan will normally be needed if you have persistent symptoms of vertigo and/or hearing loss.

What are the treatment options for Ménière's disease?

Understanding the cause of the symptoms is often helpful in itself. Although Ménière's disease can be unpleasant, it is not due to cancer, or to a brain or nerve disorder. There is no cure for Ménière's disease, but symptoms can be helped.

Treating attacks of vertigo

A short course of a medicine such as prochlorperazine or cinnarizine may ease the dizziness and vomiting when attacks of these symptoms occur. These medicines work by calming the nerve messages which are sent from the ear to the brain. Many people have a warning feeling or 'aura' just before an attack begins. If possible, take your medicine at this stage to prevent the attack becoming worse, or to lessen its severity. Stop taking the medicine when the attack of symptoms has gone.

Tablets may not be absorbed from the gut so well if you vomit. The absorption may be helped by:

• using a medicine which is absorbed from within the mouth and gums straight into the bloodstream, or
• using a medicine in suppository form, or
• using a soluble form of medicine which may be absorbed quickly into the bloodstream.

The aim is to get the medicine into the body as soon as possible after symptoms begin. If one type of medicine does not help, see a doctor as another type may be more suitable. Sometimes an injection is needed to help stop severe dizziness and vomiting.

Preventing attacks of vertigo

If you have mild or infrequent attacks then you may not need or want any treatment to prevent the attacks. You may just prefer to treat each attack as it arises with one of the medicines mentioned above. If needed, treatments which can help to prevent attacks include the following:

• Betahistine is a medicine that is thought to increase the blood flow around the inner ear. This may reduce the amount of fluid inside the labyrinth and prevent symptoms from developing. If you take betahistine every day it is unlikely to stop all attacks, but it may reduce the number and/or severity of attacks. It does not work in all cases. A trial for 6-12 months of taking betahistine may be advised to see if it helps to reduce symptoms. If it does, it can be continued.
• Other medicines are sometimes tried on the advice of a specialist. For example, diuretics or beta-blockers may help in some cases.
• Intratympanic gentamicin. This treatment involves injecting a drug called gentamycin through the eardrum into the middle ear. This gives a very high concentration of the drug next to the affected inner ear. This drug works by damaging the nerve endings that send signals of balance down the vestibular nerve. It is a relatively new technique and is not a 'routine' treatment. It is only considered if you are greatly troubled with vertigo and other treatments have not helped. However, research studies suggest that it works quite well in most cases. Also, in most cases this treatment does not have any bad effect on the hearing ability of the inner ear.
• Surgery to the inner ear. There are various operations. They are considered a 'last resort' for people who have severe or frequently recurring attacks of vertigo that have not been helped by other treatments. Operations that may be considered include:
• • Saccus decompression. This is an operation to reduce the pressure of the fluid in the labyrinth.
  • Vestibular nerve section. This means that the nerve of balance is cut - which stops the abnormal signals of balance being sent to the brain.
  • Labyrinthectomy. This means totally destroying the inner ear. The big disadvantage of this is that the hearing part of the ear is destroyed in addition to the balance part. So, you will be totally deaf in the operated ear.

Diet and lifestyle

There is little research evidence to prove that diet and lifestyle can help. However, some people claim their symptoms improve by one or more of the following:

• A low salt diet. This may help to reduce the fluid build up in the inner ear.
• Regular exercise and methods to combat stress.
• Stopping smoking if you are a smoker.
• Food triggers. There seems to be a link between migraine and Ménière's disease. Food triggers are known to cause migraine attacks in some people. A similar trigger may contribute to some attacks of Ménière's disease. For example, cutting out caffeine (found in tea, coffee, cola, and chocolate) and alcohol may be worth trying.

Other treatments are sometimes advised

For example:

• If you develop permanent hearing loss, you may benefit from a hearing aid.
• If you develop permanent tinnitus then various strategies may be advised. For example, an audiologist or hearing therapist may advise on sound therapy. This is often a CD or tape which plays soothing and relaxing sounds which helps to distract you from the sound of tinnitus. Some people have found 'coping strategies', relaxation training, counselling, and other such techniques useful to combat tinnitus. See separate leaflet called 'Tinnitus'.
• A physiotherapist may be involved if your balance becomes permanently affected (in severe cases).
• If loud sounds become distressing then an audiologist or hearing therapist can provide advice on compression hearing aids which may help to ease this symptom.

Some important safety points

If you are prone to sudden attacks of vertigo with little or no warning then:

• It is sensible to always carry some medication in case it is needed.
• Avoid heights, ladders, etc, and do not go swimming alone.

Make your home safe in case you fall whilst dizzy. In particular, if you have vertigo you are likely to go to bed until it eases. The trip to the bathroom may pass open stairs. It may be sensible to block the top of the stairs in case you fall.

If you are a driver, you must stop driving if Ménière's disease is diagnosed and you must tell the Driver and Vehicle Licensing Agency (DVLA). This is because you may have sudden attacks of vertigo, or even drop attacks, with little warning. The DVLA will permit driving again if there is good control of symptoms. See the DVLA website for details - http://www.dvla.gov.uk/ - and click Medical Rules.

What is the outlook (prognosis)?

The way Ménière's disease affects people can vary greatly. At the outset of the disease, it is not possible to predict how badly it will affect an individual in the coming years. In many cases, months or years go by between attacks. In some cases the attacks are more frequent. Some attacks are minor and don't last long. Some attacks can be very distressing with severe vomiting and dizziness. However, treatments that can ease symptoms have improved in recent years.

There is a good chance that after a while (typically after 5-10 years) the attacks stop occurring altogether. However, you may have developed some permanent hearing loss or permanent tinnitus in the affected ear or ears by this time. This may be only a minor degree of hearing loss, but some people become deaf in the affected ear or ears.

Further help and information

The Ménière's Society

The Rookery, Surrey Hills Business Park, Wotton, Dorking, Surrey, RH5 6QT
Helpline: 0845 120 2975 Web: http://www.menieres.org.uk/

British Tinnitus Association

Ground Floor, Unit 5, Acorn Business Park, Woodseats Close, Sheffield, S8 0TB
Tel (Freephone): 0800 018 0527 Web: http://www.tinnitus.org.uk/

RNID Tinnitus Helpline

19-23 Featherstone Street, London, EC1Y 8SL
Helpline: 0808 808 6666 (voice) 0808 808 0007 (text) Web: http://www.rnid.org.uk/

References

Ménière's Disease; Ménière's disease, Clinical Knowledge Summaries (2007)

Saeed SR, Fortnightly review: Diagnosis and treatment of Ménière's disease; BMJ January 1998

Lorenzo N, Ménière's disease. eMedicine. Article dated July 2006

Assimakopoulos D, Patrikakos G; Treatment of Meniere's disease by intratympanic gentamicin application. J Laryngol Otol. 2003 Jan;117(1):10-6. [abstract]

Minor LB, Schessel DA, Carey JP; Meniere's disease. Curr Opin Neurol. 2004 Feb;17(1):9-16. [abstract]

Comprehensive patient resources are available at http://www.patient.co.uk/
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS and PiP have used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions