Update on Meniere Disease

Educational Objectives

The goal of this program is to improve diagnosis and treatment of dizziness. After hearing and assimilating this program, the clinician will be better able to:

1. List recent changes in the diagnostic criteria for Ménière disease.
2. Summarize findings of clinical trials assessing pharmacologic treatments for Ménière disease.

Summary

Diagnostic criteria:

1995 criteria from American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS): recognized 4 groups; diagnosis of certain Meniere disease (MD) required definite MD plus histologic confirmation of hydrops; definite MD required episodes of vertigo, hearing loss, and tinnitus or aural fullness; other categories probable and possible; term may have referred to fluctuating vertigo or sensorineural hearing loss without vertigo (vestibular or cochlear variant of MD)

International Classification of Vestibular Disorders: diagnostic criteria adopted by AAO-HNS in 2015; certain and possible categories eliminated; symptoms must last ≤24 hr; definite MD — criteria similar to those in older definition (hearing loss, tinnitus, and fluctuating aural symptoms); probable MD — diagnosis based on vertigo and fluctuating aural symptoms (fullness or tinnitus) in patient in whom symptoms not better explained by another diagnosis; diagnosis no longer requires audiometrically defined hearing loss; comments — most patients with vertigo and fluctuating aural symptoms have vestibular migraine; 50% of patients with vestibular migraine have tinnitus or aural fullness that changes during episodes; criteria suggest that fluctuating sensorineural hearing loss in 1 ear that does not appear to be autoimmune and yields negative imaging results not consistent with MD; however, this interpretation may be incorrect

Imaging: Nakashima et al found that contrast agents used during magnetic resonance imaging (MRI) diffuse into perilymph but not into endolymph; examiner sees bright perilymph and dark endolymph; contrast given intravenously, followed by imaging after 4 hr; alternatively, contrast given intratympanically (IT), with imaging after 24 hr; in normal patient, dark (endolymphatic) space encompasses <30% of cross-sectional area of vestibule

Implications: ability to image provided new lessons about MD; endolymphatic hydrops (EH) uniformly present in ears with MD; degree of EH correlates with pure tone averages on audiography and saccular function as measured by vestibular evoked myogenic potentials, but not with degree of caloric weakness; early data suggest that EH may correlate with symptomatic improvement; most patients with atypical variants of MD (unexplained, fluctuating sensorineural hearing loss) or vestibular variant have EH; delayed EH refers to MD that develops years after hearing loss; MRI studies reveal EH in such patients; although every patient with MD has EH, EH also seen in patients with other conditions such as stapedectomy, dehiscence of superior semicircular canal, or vestibular schwannoma; imaging may confirm improvement of MD after treatment

Management: salt restriction and diuretics remain standard of care, despite low quality of evidence; clinician may consider betahistine, if patient interested; if steroids ineffective, gentamicin or ablative surgery may help

Clinical trials: difficult to interpret because patients improve with time; BEMED — large trial randomized patients to placebo, low-dose betahistine, or high-dose betahistine (48 mg three times daily); primary endpoint attack rate/30 days, compared with attack rate during lead-in phase; mean rates of vertigo attack improved in every group (from 6 attacks/30 days to 3 attacks/30 days); study criticized mainly because dose considered inadequate (current dose 500–1000 mg/day); gentamicin vs steroids — gentamicin supported by data from animal studies but may impair hearing; blinded trial compared methylprednisolone with gentamicin; although study found no difference in severity of vertigo between groups, steroid group less likely to respond and received more injections; trial provides justification for trying steroids before gentamicin; Otonomy — study compared sustained-release dexamethasone with placebo; primary outcome (vertigo at 3–4 mo) similar in both groups; Meniett device — double-blinded, randomized trial in 97 patients found no difference between groups in number of episodes of vertigo

Conclusions: good evidence shows betahistine (up to 144 mg/day) not helpful for MD; reasonable evidence supports use of IT steroids before gentamicin or ablative therapy; good evidence shows Meniett device ineffective; more data needed

Readings

Adrion C et al: Efficacy and safety of betahistine treatment in patients with Meniere’s disease: primary results of a long term, multicentre, double blind, randomised, placebo controlled, dose defining trial (BEMED trial). BMJ 2016 Jan 21;352:h6816; Goebel JA: 2015 Equilibrium Committee Amendment to the 1995 AAO-HNS guidelines for the definition of Meniere’s disease. Otolaryngol Head Neck Surg 2016 Mar;154(3):403-4; Gürkov R et al: In vivo visualized endolymphatic hydrops and inner ear functions in patients with electrocochleographically confirmed Meniere’s disease. Otol Neurotol 2012 Aug;33(6):1040-5; Katayama N, Ishida IM: Visualization of endolymphatic hydrops in patients with Meniere’s disease. Laryngoscope 2007 Mar;117(3):415-20; Kasai S et al: Endolymphatic space imaging in patients with delayed endolymphatic hydrops. Acta Otolaryngol 2009 Nov;129(11):1169-74; Kato M et al: Endolymphatic hydrops revealed by magnetic resonance imaging in patients with atypical Meniere’s disease. Acta Otolaryngol 2013 Feb;133(2):123-9; Lambert PR et al: Intratympanic sustained-exposure dexamethasone thermosensitive gel for symptoms of Meniere’s disease: randomized phase 2b safety and efficacy trial. Otol Neurotol 2016 Dec;37(10):1669-76; Naganawa S, Nakashima T: Visualization of endolymphatic hydrops with MR imaging in patients with Meniere’s disease and related pathologies: current status of its methods and clinical significance. Jpn J Radiol 2014 Apr;32(4):191-204; Nakashima T et al: Visualization of endolymphatic hydrops in patients with Meniere’s disease. Laryngoscope 2007 Mar;117(3):415-20; Patel M et al: Intratympanic methylprednisolone versus gentamicin in patients with unilateral Meniere’s disease: a randomised, double-blind, comparative effectiveness trial. Lancet 2016 Dec 3;388(10061):2753-62; Russo FY et al: Meniett device in Meniere disease: Randomized, double-blind, placebo-controlled multicenter trial. Laryngoscope 2017 Feb;127(2):470-5; Suga K et al: Changes in endolymphatic hydrops in patients with Meniere’s disease treated conservatively for more than 1 year. Acta Otolaryngol 2015 Sep;135(9):866-70.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Sharon spoke at Otolaryngology Update 2017, presented by the University of California, San Francisco, School of Medicine and held November 2-4, 2017, in San Francisco, CA. To learn about CME opportunities from the University of California, San Francisco, School of Medicine, please visit meded.ucsf.edu/cme. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT511202

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.