Vestibular Rehab Blog Series: 6 of 12
So, let's talk a little bit about Meniere's disease or endolymphatic hydrops. So, in the acute or the real severe spells, it's typically meds to alleviate the severity of the vertigo and nausea. Meclizine and valium are probably the most common for the vertigo and Zofran or Phenergan for the nausea. Phenergan has more of a sedative effect and sometimes with an acute spell of Meniere's, patients prefer the Phenergan.
Now long term, what starts before even pharmaceutical management is conservative lifestyle changes: exercise regularly, a healthy diet, drinking plenty of water, reducing stress, adequate sleep, managing allergies. Medications may be a diuretic. If it's a diuretic like hydrochlorothiazide or HCTZ, they might need a potassium supplement with that and or there may be a combination of betahistine. Now, here in the States, a diuretic is probably the most common treatment for Meniere’s, and the purpose of that is using the diuretic to stabilize the fluid problem of the inner ear. Remember, it's suspected in Meniere’s, that there's a retention of fluid where the sodium levels may be higher than the potassium levels. So that diuretic pulls off the excess sodium in an effort to stabilize the inner ear. HCTZ is commonly used, but it depletes potassium. So, patients that are receiving HCTZ may need to be on a matching potassium supplement, whereas betahistine is probably the more common treatment in other countries.
Again, patient education is key. You will hear differences on low salt diet. If you were to go Google low salt diet, you may get something less than 10000 milligrams. Some people say less than twenty five hundred. Our average is typically less than two thousand if appropriate. And when I say if appropriate, we just can't put people in a box. You may have patients who seem like they're a great candidate for a diuretic and a low salt diet, but they already have low blood pressure. So, the doctor would likely be talking to them about other alternatives, such as betahistine. You also want to talk to your patients about the impact of alcohol, caffeine, sugar, and the effects of smoking. Allergies may also be a factor. So vestibular rehab can be very, very beneficial if the Meniere’s disease is not active or the inner ear is stable. Now keep in mind, some patients will have Meniere’s attacks and they completely recover within the attacks. And the attacks could be years apart. It could be months apart, but they don't have any symptoms in between the spells. If that's the case, they likely don't need vestibular rehab because they're making a complete recovery after the spell. What the priority always is, is stabilizing that inner ear. Now, many patients in between the spells, they feel off. They feel unsteady. They can benefit from the vestibular rehab because they're not making a complete recovery after a spell.
Now, more aggressive treatments for non-controllable Meniere’s, that would include gentamicin injections and I say injections because there's almost always more than one. That is an in-office procedure done by the ear, nose, and throat doctor. Or they receive an injection of gentamicin in the ear. Remember, gentamicin is toxic to the hair cells of the inner ear. So, it's literally trying to destroy the receptor cells of the inner ear that are sending those bad messages to the brain, resulting in a vertigo attack. So that is a much more conservative treatment than surgery. Surgery for like a labyrinthectomy that is much, much more aggressive.
Now, you may have heard about a surgery like an endolymphatic shunt. Typically, can work very well. But overall, the benefits are typically short term where patients have the surgery many times. So, you see this movement away from an endolymphatic shunt. Certainly, people are doing more gentamicin injections. I think one of the concerns I see with gentamicin injections, I've actually seen physicians do that when the patients had less than five spells and that just seems a little early to destroy that nerve. It's a low chance that they'll get it in both ears, but it's a risk that later they could develop it in the other ear. So, this is just a brief overview of treatment options.
And remember, Meniere’s disease is not considered curable, but it's often successfully managed, especially with a team approach. And, you know, your patients are on the Internet. Oftentimes, they're diagnosing themselves with Meniere’s. Certainly, Meniere’s was more of a go to diagnosis years ago. And so a lot of people out there have the diagnosis but don't truly have Meniere’s. And remember, that low frequency hearing loss is a key indicator. So, a lot of patient education needs around it.
Click here to progress to the next blog in this series: Clinical Tests to Treatment: Migraine Associated Vertigo (MAV)