Prevention of Meniere’s Disease Attacks

The other main area of medical therapy for Meniere’s disease is the use of medications to prevent the attacks of endolymphatic hydrops, or to cut down on their frequency or severity.

Sodium Restriction

The main approach that has been used for years is a marked salt restriction (1500-mg low-sodium diet). The theory is that the sodium in regular salt (sodium chloride) builds up in the body, making bodily fluids (such as endolymph and perilymph) too concentrated, so the body retains fluid (water retention). This may cause too much fluid to stay in the tissues (called edema, often seen as swelling of the ankles), increased pressure (such as high blood pressure), or, in this case, endolymph hydrops. Many people with Meniere’s disease find that a large amount of salt or salty foods may trigger an attack. Although there is certainly more to it than this, it has been known that marked salt restriction does seem to prevent attacks of Meniere’s. Most doctors recommend limiting salt to 1500 mg of sodium a day, which is a very difficult task (much stricter than the 3000 mg of sodium a day restriction recommended for people with high blood pressure). It may be necessary to see a dietician to find out how to eat foods that are very low in salt.

Diuretic Therapy

In addition to minimizing the ingestion of salt, many doctors recommend using a diuretic, which is a medication that tends to increase the production of urine, leading to loss of salt and water from the body (a "water pill"). Diuretics may also change the amount of sodium in the endolymph or cut down on the amount of this fluid, and thereby prevent hydrops.

The most commonly used medications for this purpose are the thiazide diuretics, of which hydrochlorothiazide (HydroDIURIL®, Microzide®) are the most commonly used. Another medication is a combination of hydrochlorothiazide and triamterene (Dyazide®). These medications are also commonly used to treat high blood pressure. They must be taken daily for very long periods of time to control these medical conditions. Some reports have shown that the regular use of a diuretic, along with salt restriction, can control Meniere’s vertigo symptoms in about 50%-75% of patients.

Remission Induction

As mentioned previously, some doctors have found that an intensive treatment with medications such as the steroids dexamethasone or prednisone, a vasodilator in combination with an anticholinergic, or prolonged use of betahistine may induce Meniere’s disease to go into a remission phase, when there may be no symptoms for a period of time, ranging from weeks to years. In some cases, very good results have been reported with a combination of a low-salt diet, vasodilators, and anticholinergic medications. One approach uses papaverine (Pavabid®) 150 mg every 8 to 12 hours along with glycopyrrolate (Robinul®) 1mg every 8 hours. Visible improvements have been seen in 1 to 2 weeks in about half of patients.

Surgery

There are some effective surgeries that can prevent the symptoms of vertigo, but these often are major surgeries that may damage some hearing or other ear functions. These surgeries are usually reserved for patients who cannot get any relief from the disabling vertigo by any other method. The most common operations include endolymphatic sac surgery, vestibular neurectomy, and labyrinthectomy. These procedures are usually performed by only a few otolaryngologists (ENT doctors) or neurosurgeons and involve delicate surgery at the base of the skull, next to the brain. The various forms of endolymphatic sac surgery try to increase the resorption of endolymph from the sac that drains the endolymphatic duct and semicircular canals and may involve inserting a small valve or tube to carry the fluid elsewhere. Surgical labyrinthectomy destroys the cochlea as well as the balance organs, so it is only done when the vertigo is disabling and there is no effective hearing left in the involved ear. It can sometimes be done more easily by injection of ototoxic drugs. Vestibular neurectomy or vestibular nerve section is an operation in which the nerve from the balance organs, the vestibular nerve, is surgically cut before it gets into the brain, thereby blocking off the flow of balance information to the brain from that ear. There are different methods for cutting this nerve, and some may damage the hearing nerves as well. Only by consulting with physicians who regularly perform these special surgeries can patients determine if any given operation is best for them.

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