Treatment of Ménière's Disease

Initial Conservative Management

The American Academy of Otolaryngology-Head and Neck Surgery recommends starting all patients with conservative management, including a low-sodium diet, avoidance of caffeine and alcohol, and consideration of a diuretic as first-line therapy, reserving more invasive interventions for those who fail conservative measures after several months 1, 2
Patients should begin with lifestyle and dietary modifications as the foundation of treatment, including sodium restriction to 1500-2300 mg daily to reduce endolymphatic fluid accumulation 1, 2, 3, 4, 5
Eliminate or significantly reduce caffeine intake, as it can trigger attacks in susceptible patients 1, 2, 5
Limit alcohol consumption, which may precipitate vertigo episodes 1, 2, 5
Identify and manage allergies, as they contribute to symptoms in up to 30% of patients 2
Stress management through relaxation techniques, regular exercise, and adequate sleep is recommended 2
Maintain a symptom diary to identify personal triggers 2

Diuretics are recommended as first-line pharmacologic maintenance therapy to modify electrolyte balance in the endolymph and reduce its volume, based on moderate-quality evidence from observational studies and Cochrane reviews 1, 2
Betahistine cannot be definitively recommended due to questionable efficacy, with the BEMED trial finding no significant difference between betahistine and placebo in reducing vertigo attacks 2

Offer intratympanic steroid injections to patients with active Ménière's disease not responsive to conservative measures, providing 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy 1, 2, 5
Reserve intratympanic gentamicin for patients with persistent vertigo who have failed conservative and steroid therapies, achieving complete vertigo control in approximately 73.6% of patients 2

Consider non-ablative procedures to preserve auditory function in patients with usable hearing, including endolymphatic sac decompression and vestibular nerve section 1, 5
Offer labyrinthectomy to patients who have failed less definitive therapy and have non-usable hearing, providing vertigo control but sacrificing remaining hearing 1, 2, 5

Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy, improving symptom control and reducing fall risk 2

Conventional hearing aids are recommended for patients with usable hearing, while CROS hearing aids are recommended for patients with severely compromised speech discrimination 1, 5
Bone-anchored devices and cochlear implants are options for patients with severe to profound hearing loss 1, 5

Obtain audiometry at diagnosis and regularly during follow-up to document characteristic low-to-mid-frequency sensorineural hearing loss and monitor progression 1, 2, 5
Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment 1, 2, 5
Assess quality of life impact using validated instruments 1, 5