Recent Publications on Meniere’s

J. Nevoux, et al. 2018. International consensus (ICON) on treatment of Meniere’s disease. OBJECTIVE: To present the international consensus for recommendations for Meniere’s disease (MD) treatment. METHODS: Based on a literature review and report of 4 experts from 4 continents, the recommendations have been presented during the 21st IFOS congress in Paris, in June 2017 and are presented in this work. RESULTS: The recommendation is to change the lifestyle, to use the vestibular rehabilitation in the intercritic period and to propose psychotherapy. As a conservative medical treatment of first line, the authors recommend to use diuretics and Betahistine or local pressure therapy. When medical treatment fails, the recommendation is to use a second line treatment, which consists in the intratympanic injection of steroids. Then as a third line treatment, depending on the hearing function, could be either the endolymphatic sac surgery (when hearing is worth being preserved) or the intratympanic injection of gentamicin (with higher risks of hearing loss). The very last option is the destructive surgical treatment labyrinthectomy, associated or not to cochlear implantation or vestibular nerve section (when hearing is worth being preserved), which is the most frequent option., 135, S29.

A. Attye, et al. 2018. In vivo imaging of saccular hydrops in humans reflects sensorineural hearing loss rather than Meniere’s disease symptoms. OBJECTIVES: A case-controlled imaging study demonstrated that saccular hydrops was specific to Meniere’s disease (MD), but only present in a subset of patients. Here, we compared patients with definite MD, vertigo and sensorineural hearing loss (SNHL) to elucidate the relationship between saccular hydrops and extent of SNHL. METHODS: In this prospective study, we performed 3D-FLAIR sequences between 4.5 and 5.5 h after contrast media injection in patients with MD (n=20), SNHL (n=20), vertigo (n=20) and 30 healthy subjects. Two radiologists independently graded saccular hydrops. ROC analysis was performed to determine the hearing loss threshold to differentiate patients with saccular hydrops. RESULTS: Saccular hydrops was found in 11 of 20 MD patients, 10 of 20 SNHL patients and in none of the vertigo patients and healthy subjects. In SNHL patients, 45 dB was the threshold above which there was a significant association with saccular hydrops, with sensitivity of 100 % and specificity of 90 %. In MD patients, 40 dB was the threshold above which there was a significant association with saccular hydrops, with sensitivity of 100 % and specificity of 44 %. CONCLUSIONS: Our results indicate saccular hydrops as a feature of worse than moderate SNHL rather than MD itself. KEY POINTS: * MRI helps clinicians to assess patients with isolated low-tone sensorineural hearing loss. * Saccular hydrops correlates with sensorineural hearing loss at levels above 40 dB. * Vertigo patients without sensorineural hearing loss do not have saccular hydrops. * Saccular hydrops is described in patients without clinical diagnosis of Meniere’s disease.

S. Caruso, et al. 2018. Effects of combined oral contraception containing drospirenone on premenstrual exacerbation of Meniere’s disease: Preliminary study. OBJECTIVES: Meniere’s disease is caused by an augmented endolymph pressure in the inner ear; symptoms are vertigo, fluctuating hearing loss and tinnitus. Exacerbations has been noted during premenstrual phase. The study aims to evaluate the effects of a 20mum Ethinylestradiol (EE) and 3mg Drospirenone (DRSP) oral contraceptive (20mumEE/3mgDRSP) in continuous regimen, associated with rehabilitation therapy on Meniere’s disease. STUDY DESIGN: This non-randomized controlled study was performed from October 2015 to October 2017. Forty-two premenopausal women affected by MD with severe distress in the premenstrual phase were enrolled. Sixteen women constituted the study group (Group A), and twenty women constituted the control group (Group B). Group A underwent EE/DRSP therapy and rehabilitation and Group B underwent rehabilitation therapy alone. Stabilometry and the Dizziness Handicap Inventory questionnaire were used to measure vestibular function and distress related to the disease, respectively, at baseline (T0), 3 months (T1) and 6 months (T2). RESULTS: At T0, both groups had large, similar areas of stabilometric ellipses (p=NS) that reduced more in Group A than in Group B, at T1 and T2 (p<0.001). High scores of the DHI (cut-off </=54) were observed at T0 in both groups (A 66.8+/-2.8 vs B 65.5+/-3.6; p=NS). At T1, a gradual improvement in both groups was observed, manly in Group A (A 45.1+/-3.6 vs B 62.4+/-4.1; p<0.001). At T2, the DHI scores were significantly lower in Group A (39.2+/-3.8) compared to Group B (68.8+/-3.6) (p<0.001). CONCLUSIONS: DRSP could be effective in reducing the fluid overload typical of the premenstrual phase, improving symptoms of MD. The results support the efficacy of EE/DRSP usage associated with rehabilitation therapy on premenstrual exacerbation of MD., 224, 102.

K. Feil, et al. 2018. Predictive Capability of an iPad-Based Medical Device (medx) for the Diagnosis of Vertigo and Dizziness. Background: Making the correct diagnosis of patients presenting with vertigo and dizziness in clinical practice is often challenging. Objective: In this study we examined the performance of the iPad based program medx in the prediction of different clinical vertigo and dizziness diagnoses and as a diagnostic tool to distinguish between them. Patients and methods: The data collection was done in the outpatient clinic of the German Center of Vertigo and Balance Disorders. The “gold standard diagnosis” was defined as the clinical diagnosis of the specialist during the visit of the patient based on standardized history and clinical examination. Another independent and blinded physician finalized each patient’s case in the constellatory diagnostic system of medx based on an algorithm using all available clinical information. These diagnoses were compared to the “gold standard” by retrospective review of the charts of the patients. The accuracy provided by medx was defined as the number of correctly classified diagnoses. In addition, the probability of being test positive when a disease was present (sensitivity), of being test negative when a disease was absent (specificity), of having the disease when the test is positive (positive predictive value) and of not having the disease when the test is negative (negative predictive value) for the most common diagnoses were reported. Sixteen possible different vertigo and dizziness diagnoses could be provided by medx. Results: A total of 610 patients (mean age 58.1 +/- 16.3 years, 51.2% female) were included. The accuracy for the most common diagnoses was between 82.1 and 96.6% with a sensitivity of 40 to 80.5% and a specificity of more than 80%. When analyzing the quality of medx in a multiclass problem for the six most common clinical diagnoses, the sensitivity, specificity, positive and negative predictive values were as follows: Bilateral vestibulopathy (81.6, 97.1, 71.1, and 97.5%), Meniere’s disease (77.8, 97.6, 87.0, and 95.3%), benign paroxysmal positional vertigo (61.7, 98.3, 86.6, and 93.4%), downbeat nystagmus syndrome (69.6, 97.7, 71.1, and 97.5%), vestibular migraine (34.7, 97.8, 76.1, and 88.3%), and phobic postural vertigo (80.5, 82.5, 52.5, and 94.6%). Conclusion: This study demonstrates that medx is a new and easy approach to screen for different diagnoses. With the high specificity and negative predictive value, the system helps to rule out differential diagnoses and can therefore also lead to a cost reduction in the health care system. However, the sensitivity was unexpectedly low, especially for vestibular migraine. All in all, this device can only be a complementary tool, in particular for non-experts in the field., 9, 29.

W. H. Flatz, et al. 2018. In Vivo Morphometric Analysis of Human Cranial Nerves Using Magnetic Resonance Imaging in Meniere’s Disease Ears and Normal Hearing Ears. Analysis of neural structures in Meniere’s Disease (MD) is of importance, since a loss of such structures has previously been proposed for this patient group but has yet to be confirmed. This protocol describes a method of in vivo evaluation of neural changes especially well suitable for cranial nerve analysis using magnetic resonance imaging (MRI). MD-patients and normal hearing persons were examined in a 3-T MR-scanner using a scan protocol including strongly T2-weighted 3D gradient-echo-sequence (3D-CISS). In the patient group, MD was additionally confirmed using MRI-based assessment of endolymphatic hydrops. Morphometric analysis was performed using a freeware DICOM viewer. Evaluation of cranial nerves included measurements of cross-sectional areas (CSAs) of the nerves at different levels as well as orthogonal diametric measurements.

S. Hellstrom 2018. Thomsen J et al. – The non-specific effect of endolymphatic sac surgery in treatment of Meniere’s disease: A prospective, randomized controlled study comparing “classic” endolymphatic sac surgery with the insertion of a ventilating tube in tympanic membrane. Acta Oto-Laryngol 1998: 118: 769-773. 138, 304.

D. Huppert, et al. 2018. Dizziness and vertigo syndromes viewed with a historical eye. Seasickness, fear of heights, and adverse effects of alcohol were the major areas where descriptions of vertigo and dizziness were found in Roman, Greek, and Chinese texts from about 730 BC-600 AD. A few detailed accounts were suggestive of specific vestibular disorders such as Meniere’s attacks (Huangdi Neijing, the Yellow Thearch’s Classic of Internal Medicine) or vestibular migraine (Aretaeus of Cappadocia). Further, the etymological and metaphorical meanings of the terms and their symptoms provide fascinating historical insights, e.g. Vespasian’s feelings of dizzy exultations when becoming Emperor (69 AD) after Nero’s suicide or the figurative meaning of German “Schwindel” (vertigo) derived from English “swindle” to express “financial fraud” in the Eighteenth century. The growth of knowledge of the vestibular system and its functions began primarily in the Nineteenth century. Erasmus Darwin, however, was ahead of his times. His work Zoonomia, or The Laws of Organic Life in 1794 described new dizziness syndromes and concepts of sensorimotor control including the mechanism of fear of heights as well as made early observations on positional alcohol vertigo. The latter is beautifully illustrated by the German poet and cartoonist Wilhelm Busch (1832-1908) who also documented the alleviating effect of the “morning after drink”. The mechanism underlying positional alcohol vertigo, i.e., the differential gravities of alcohol and endolymph, was discovered later in the Nineteenth century. The first textbook on neurology (Lehrbuch der Nervenkrankheiten des Menschen, 1840) by Moritz Romberg contained general descriptions of signs and symptoms of various conditions having the key symptom of vertigo, but no definition of vestibular disorders. Our current knowledge of vestibular function and disorders dates back to the seminal work of a group of Nineteenth century scientists, e.g., Jan Evangelista Purkinje, Ernst Mach, Josef Breuer, Hermann Helmholtz, and Alexander Crum-Brown.

D. Huppert, et al. 2018. Dizziness in Europe: from licensed fitness to drive to licence without fitness to drive. A common European Community driving licence was established in 1980. However, there are major differences among the countries as regards medical conditions that legally affect driving ability. This article discusses various assessment guidelines for dizzy patients. These range from a total absence of specified binding requirements in Finland or regulations open to clinical interpretation in Switzerland, to inappropriately strict regulations in Germany. We focus on requirements for patients with vestibular disorders in Germany which have been in force since 2014. These guidelines stipulate that for group 1 driving licence (private cars < 3.5 t, motorbikes): (1) patients with Meniere’s disease (attacks without prodromes) must have had no attacks for 2 years before it is possible to drive again. (2) Patients with vestibular migraine without prodromes must not have had any attacks for 3 years. For a group 1 and group 2 driving licence (“professional driver”): (3) patients with bilateral vestibulopathy as a rule are considered to have a driving disability. Similarly, strict restrictions have been formulated for ocular motor disorders such as downbeat and upbeat nystagmus and for patients with functional (psychosomatic) forms of dizziness such as phobic postural vertigo. The authors represent a working group of the European Dizzynet focusing on the topic “fitness to drive with vertigo and balance disorders”. They agree that European guidelines must be revised and harmonized, for some are too strict and the required dizziness-free intervals are too long; others must be revised, for they are too lax. A common European standard is needed.

S. K. Kim, et al. 2018. Relationship between sleep quality and dizziness. OBJECTIVE: Poor sleep quality has a number of significant negative effects on daytime function. However, few studies have examined sleep quality in patients with dizziness. Here, we investigated the potential association between sleep quality and various types of dizziness. SUBJECTS AND METHODS: We examined dizziness and sleep disturbance in 237 patients experiencing dizziness using Korean versions of the Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), and Dizziness Handicap Inventory (DHI). All participants were classified as having benign paroxysmal positional vertigo (BPPV), Meniere’s disease (MD), vestibular neuritis (VN), vestibular migraine (VM), psychogenic dizziness (PD), or Other. RESULTS: The mean PSQI and ISI scores were highest in the PD group. The rate of sleep disturbance was highest in the Other group when the cut-off score for each questionnaire was set differently, except ISI >/= 15. The correlation between DHI and sleep disturbance indices was highest in the VM group. Multivariate regression showed that PSQI score and DHI-E score were significantly related to the PD and Other groups, while the Other group was significantly related to the ISI score. CONCLUSION: The findings of this study strongly suggest that there are associations between sleep quality and some disease subtypes associated with dizziness. Therefore, it is important to consider sleep disturbance in patients with psychogenic dizziness, such as phobic postural vertigo and chronic subjective dizziness, or nonspecific dizziness., 13, e0192705.

L. R. Lucinda, et al. 2018. COMMENT ON “MASTOID AND INNER EAR MEASUREMENTS IN PATIENTS WITH MENIERE’S DISEASE”.

J. F. Peneda, et al. 2018. Immune-Mediated Inner Ear Disease: Diagnostic and therapeutic approaches. INTRODUCTION: Immune Mediated Inner Ear Disease (IMIED) is a rare form of sensorineural bilateral hearing loss, usually progressing in weeks to months and responsive to immunosuppressive treatment. Despite recent advances, there is no consensus on diagnosis and optimal treatment. METHODS: A review of articles on IMIED from the last 10 years was conducted using PubMed((R)) database. RESULTS: IMIED is a rare disease, mostly affecting middle aged women. It may be a primary ear disease or secondary to autoimmune systemic disease. A dual immune response (both cellular and humoral) seems to be involved. Cochlin may be the inner ear protein targeted in this disease. Distinction from other (core common) forms of neurosensory hearing loss is a challenge. Physical examination is mandatory for exclusion of other causes of hearing loss; audiometry identifies characteristic hearing curves. Laboratory and imaging studies are controversial since no diagnostic marker is available. CONCLUSION: Despite recent research, IMIED diagnosis remains exclusive. Steroids are the mainstay treatment; other therapies need further investigation. For refractory cases, cochlear implantation is an option and with good relative outcome.

F. Sbeih, et al. 2018. Newly Diagnosed Meniere’s Disease: Clinical Course With Initiation of Noninvasive Treatment Including an Accounting of Vestibular Migraine. OBJECTIVE: To describe the course of Meniere’s disease with noninvasive treatment during the first few years after initial diagnosis. METHODS: A retrospective review of consecutive patients with newly diagnosed definite Meniere’s disease between 2013 and 2016 and a minimum follow-up of 1 year. Patients received a written plan for low sodium, water therapy, and treatment with a diuretic and/or betahistine. Subjects were screened and treated for vestibular migraine as needed. Vertigo control and hearing status at most recent follow-up were assessed. RESULTS: Forty-four subjects had an average follow up of 24.3 months. Thirty-four percent had Meniere’s disease and vestibular migraine, and 84% had unilateral Meniere’s disease. Seventy-five percent had vertigo well controlled at most recent follow-up, with only noninvasive treatments. Age, gender, body mass index, presence of vestibular migraine, bilateral disease, and duration of follow-up did not predict noninvasive treatment failure. Worse hearing threshold at 250 Hz and lower pure tone average (PTA) at the time of diagnosis did predict failure. Fifty-two percent of ears had improved PTA at most recent visit, 20% had no change, and 28% were worse Conclusions: Encountering excellent vertigo control and stable hearing after a new diagnosis of Meniere’s disease is possible with noninvasive treatments. Worse hearing status at diagnosis predicted treatment failure., 3489418763224.

D. P. Schoo, et al. 2017. Intratympanic (IT) Therapies for Meniere’s Disease: Some Consensus Among the Confusion. Purpose of Review: Aminoglycosides and corticosteroids are commonly used to treat Meniere’s disease. Intratympanic (IT) administration of these medications allows high inner ear concentrations without significant adverse systemic effects. As a direct result, IT therapy has grown in popularity. Recent studies have compared patient outcomes between IT aminoglycosides and corticosteroids. This review summarizes these findings. Recent Findings: Trials comparing IT corticosteroids to IT placebo or oral therapy have had conflicting results. Most recently, Lambert et al. investigated the effect of IT dexamethasone in a sustained-release formulation compared to placebo. Their findings demonstrated improvement in some secondary measures of vertigo with the sustained-release formulation.IT gentamicin is known to be effective in controlling vertigo in Meniere’s disease. In a recent study from 2016, Patel et al compared IT gentamicin and IT methylprednisolone in a double-blind, randomized controlled trial and identified no significant differences between the two in vertigo control. Summary: IT injections of aminoglycosides and corticosteroids can improve vertigo control. Hearing and vestibular loss however may result with IT aminoglycosides. Corticosteroids demonstrate limited hearing loss but may not have the same efficacy in controlling vertigo. Further investigation in the etiology of Meniere’s disease is needed to tailor the proposed treatment to suit the disease mechanism., 5, 132.

M. Strupp, et al. 2018. Meniere’s disease: combined pharmacotherapy with betahistine and the MAO-B inhibitor selegiline-an observational study. OBJECTIVES: Since oral betahistine has a very high first-pass effect (ca. 99%), metabolized by monoamine oxidases (MAO), the benefits of a high-dosage betahistine monotherapy were compared with those of a lower dosage of betahistine in combination with the MAO-B inhibitor (MAO-B) selegiline on the frequency of acute attacks of vertigo in patients with Meniere’s disease (MD). METHODS: Thirteen adults aged 40-75 years (mean 58.9 years; six females) had initially been treated with a high dosage of betahistine dihydrochloride for at least 1 year. Under this therapy, all of them had </= 1 attack for >/= 3 months prior to the combination pharmacotherapy. Subsequently, they received 5 mg/day selegiline and the dosage of betahistine was reduced to about one tenth and then individually adjusted to the dosage needed to achieve the same treatment response (</= 1 per 3 months, observational period of at least 6 months). RESULTS: The initial dosage for the long-term “titration” of the attacks of vertigo was 9-80 24-mg tablets/day (mean 37.3), i.e. 216-1920 mg/day (mean 895.4 mg/day). After the combination with selegiline, the dosage needed to achieve the same benefit for >/= 3 months was 3-36 24-mg tablets (mean 8.5), i.e., 72-864 mg/day [mean 204.9 mg/day, p < 0.001 (paired t test)]. One patient transiently stopped the treatment with selegiline, another one reduced the dosage to 2.5 mg/day and the attacks re-occurred after 2-4 weeks. Six out of 13 patients reported transient fullness of the head during the combined treatment; in 2 of them this went away when they switched to 2.5 mg bid. In the longer term (> 9 months), one patient had to increase the selegiline dosage to 5 mg bd, one patient stopped the treatment with selegiline. CONCLUSIONS: The achievement of the same clinical effect with a significantly lower (about 1/5) dosage of betahistine can be explained by the inhibition of the MAO-B by selegiline leading to higher serum concentrations of betahistine. This approach is in line with recent developments to bypass the first-pass effect of betahistine by transbuccal or intranasal application. Despite the substantial methodological limitations of such an observational study, this combined pharmacotherapy could be an alternative to a high-dosage monotherapy with betahistine of MD.

E. M. Sugihara, et al. 2018. COMMENT ON “MASTOID AND INNER EAR MEASUREMENTS IN PATIENTS WITH MENIERE’S DISEASE”.

S. Yetiser 2018. Intratympanic Gentamicin for Intractable Meniere’s Disease – A Review and Analysis of Audiovestibular Impact. Introduction Intratympanic gentamicin regulates the symptoms in most patients with incapacitating Meniere’s disease. The treatment protocols have changed over the years from medical labyrinthectomy to preservation of vestibular function. Objectives This study aims to review the audiovestibular response related to the effect of the drug in controlling vertigo. Data Synthesis Articles were identified by means of a search in the PubMed database using the key words Meniere and intratympanic or transtympanic gentamicin . Total 144 articles were reviewed after excluding those that were technical reports, those based on experimental animal studies, those that focused on outcomes other than vertigo (tinnitus or aural fullness), those with delivery methods other than tympanic membrane injection, and those with bilateral cases. If there was more than one article by the same author(s) or institution, only the most recent one matching the aforementioned criteria and those that were not overlapping were included. Conclusion Titration methods or multiple injections on a daily basis can be preferred if the patients have profound or non-serviceable hearing, since these methods have significant incidence of hearing loss. Treatment protocols with a frequency of injection not shorter than once a week, or those with injections on a monthly basis as “needed” provide the same level of vertigo control with better preservation of hearing. Caloric testing is not an ideal tool to analyze the correlation between vertigo control and the effect of gentamicin as compared with gain asymmetry of the vestibulo-ocular reflex. Vestibular-evoked myogenic potentials and the head thrust test are more reliable than other vestibular tests for the follow-up of patients undergoing gentamicin treatment., 22, 190.