Ménière's disease: damaged hearing but reduced vertigo
Authors: Steven D Rauch
Journal: The Lancet (2016)

Current thinking is that Ménière's disease (or, more accurately, Ménière's syndrome) is a phenotype of unstable or erratic inner ear hearing and vestibular function that arises from failure of one or more of the many inner ear homoeostatic systems that regulate endolymph and perilymph, afferent and efferent nerve signalling, and blood flow.1Merchant SN Adams JC Nadol Jr, JB Pathophysiology of Meniere's syndrome: are symptoms caused by endolymphatic hydrops?.Otol Neurotol. 2005; 26: 74-81Crossref PubMed Scopus (387) Google Scholar Clinically, the fluctuating and progressive sensorineural hearing loss tends to be relatively resistant to treatment (ie, progressive), but the episodic vertigo is usually quite responsive to treatment. The combination of diet and lifestyle adjustments to avoid stressing fragile homoeostatic systems plus diuretic medication to aid with inner ear ionic gradient management can control or eliminate Ménière's vertigo attacks in over 90% of patients.2Rauch SD Clinical hints and precipitating factors in patients suffering from Meniere's disease.Otolaryngol Clin N Am. 2010; 43: 1011-1017Summary Full Text Full Text PDF PubMed Scopus (58) Google Scholar However, a troublesome group remains: 5–10% of all patients with Ménière's disease are not responsive to these conservative and medical interventions and need more aggressive treatment. Nowadays, this most often means intratympanic drug treatment. In The Lancet, Mitesh Patel and colleagues3Patel M Agarwal K Arshad Q et al.Intratympanic methylprednisolone versus gentamicin in patients with unilateral Ménière's disease: a randomised, double-blind, comparative effectiveness trial.Lancet. 2016; (published online Nov 16.)http://dx.doi.org/10.1016/S0140-6736(16)31461-1Google Scholar present results of a double-blind comparative effectiveness trial of intratympanic methylprednisolone (n=30) versus intratympanic gentamicin (n=30) on intractable vertigo attacks in patients with unilateral Ménière's disease. The two treatments were equally effective at reducing vertigo attacks; the mean number of vertigo attacks in the final 6 months compared with the 6 months before the first injection (primary outcome) decreased from 19·9 (SD 16·7) to 2·5 (5·8; 87% reduction) in the gentamicin group and from 16·4 (12·5) to 1·6 (3·4; 90% reduction) in the methylprednisolone group (difference −0·9, 95% CI −3·4 to 1·6). Secondary outcomes related to other vestibular symptoms and hearing loss (all p>0·05) were also similar between groups, as was the occurrence of adverse events (three in each group). Intratympanic corticosteroid treatment for Ménière's disease is based on the supposition that Ménière's disease symptoms arise from an inflammatory or other reversible mechanism that could be favourably altered by administration of corticosteroid. Tens or hundreds of inner ear proteins have steroid-binding capability. In fact, it would be startling if administration of corticosteroid to the inner ear didn't have an effect of some kind. But what is the likelihood that application of such a so-called blunt instrument would do more good than harm? We have learned empirically over the past 30 years that intratympanic corticosteroid is safe, producing few side-effects and virtually no hearing loss or vestibular damage. It won't hurt and it might help, so it has become a popular treatment despite the absence of strong evidence of efficacy. By contrast, gentamicin is a hair cell ototoxin. It is preferentially vestibulotoxic, typically causing much more vestibular than auditory damage. Administration of intratympanic gentamicin to patients with Ménière's disease is based on the notion that the patient's vestibular symptoms are due to the damaged and distorted vestibular signals emanating from their damaged ear and that they are better off with no signal than with a damaged and distorted signal. The objective of intratympanic gentamicin is to weaken vestibular signals in the Ménière's ear to the point at which they are no longer strong enough to generate a vertigo attack. This objective is achieved in about 90% of treated patients. However, there is a price to pay in the form of 1–2 months of, and possibly permanent, disequilibrium and about 20% risk of further hearing loss in the treated ear. Patel and colleagues' study,3Patel M Agarwal K Arshad Q et al.Intratympanic methylprednisolone versus gentamicin in patients with unilateral Ménière's disease: a randomised, double-blind, comparative effectiveness trial.Lancet. 2016; (published online Nov 16.)http://dx.doi.org/10.1016/S0140-6736(16)31461-1Google Scholar by adhering to stringent methods, offers robust evidence that both of these treatments have substantial efficacy, with each achieving about 90% reduction of vertigo attacks. There was no placebo control group to provide greater certainty that the treatment effects were not just the natural course of this relapsing–remitting disease. However, the data showed a dramatic drop in vertigo frequency soon after treatment and no reactivation over 24 months of follow-up, which is persuasive evidence of a true treatment effect. One treatment aims to modulate an underlying, and unknown, disease process and the other treatment is ablative, aiming to weaken or eliminate abnormal function in the damaged ear. The equivalence of outcome of these two treatments has shed no new light on the underlying mechanisms of Ménière's disease, but will still have important clinical impact. Since we now know that either intratympanic corticosteroid or intratympanic gentamicin can be used to achieve vertigo control, the actual decision of which to use will be based on doctor and patient consideration of auditory and vestibular side-effects, status of the contralateral ear, general health factors, and patient preference. Although most patients with Ménière's disease gradually go deaf in their affected ear, the best news for patients is that some combination of diet and lifestyle adjustments, diuretics, and intratympanic drug treatment can control or eliminate vertigo in 99% of cases. And there is always the surgical option of labyrinthectomy for patients who do not respond to intratympanic gentamicin. I declare no competing interests. Intratympanic methylprednisolone versus gentamicin in patients with unilateral Ménière's disease: a randomised, double-blind, comparative effectiveness trialMethylprednisolone injections are a non-ablative, effective treatment for refractory Ménière's disease. The choice between methylprednisolone and gentamicin should be made based on clinical knowledge and patient circumstances. Full-Text PDF Open Access