Editing Ménière's disease (section)

== Management ==
No cure for Ménière's disease is known, but medications, diet, physical therapy, counseling, and some surgical approaches can be used to manage it.<ref name=See2016/> More than 85% of patients with Ménière's disease get better from changes in lifestyle, medical treatment, or minimally invasive surgical procedures. Those procedures include intratympanic steroid therapy, intratympanic gentamicin therapy or [[endolymphatic sac|endolymphatic sac surgery]].<ref name="pmid18675691">{{cite journal |vauthors=Sajjadi H, Paparella MM |title=Meniere's disease |journal=Lancet |volume=372 |issue=9636 |pages=406–414 |date=August 2008 |pmid=18675691 |doi=10.1016/S0140-6736(08)61161-7 |s2cid=20845192 |url=https://pubmed.ncbi.nlm.nih.gov/18675691/ |access-date=15 December 2022 |archive-date=15 December 2022 |archive-url=https://web.archive.org/web/20221215183344/https://pubmed.ncbi.nlm.nih.gov/18675691/ |url-status=live }}</ref>

=== Medications ===
During MD episodes, [[antiemetics|medications to reduce nausea]] are used, as are [[anxiolytics|drugs to reduce the anxiety]] caused by vertigo.<ref name=See2016/><ref name=Foster2015rev/> For longer-term treatment to stop progression, the evidence base is weak for all treatments.<ref name=See2016/> Although a causal relation between allergy and Ménière's disease is uncertain, [[Allergy#Management|medication to control allergies]] may be helpful.<ref name="Allergy2014rev">{{Cite journal|last1=Weinreich|first1=Heather M.| last2= Agrawal|first2=Yuri|date=June 2014|title=The Link Between Allergy and Menière's Disease|journal=Current Opinion in Otolaryngology & Head and Neck Surgery |volume= 22 |issue= 3|pages=227–230|doi=10.1097/MOO.0000000000000041|issn=1068-9508|pmc=4549154|pmid=24573125}}</ref> To assist with vertigo and balance problems, [[glycopyrrolate]] has been found to be a useful vestibular suppressant in patients with Ménière's disease.<ref name= storper108-10>{{Cite journal |pmid = 9778280|year = 1998|last1 = Storper|first1 = Ian S.|last2 = Spitzer|first2 = Jaclyn B.|last3 = Scanlan|first3 = Mark |title = Use of glycopyrrolate in the treatment of Meniere's disease|journal = The Laryngoscope|volume = 108|issue = 10|pages = 1442–1445|doi = 10.1097/00005537-199810000-00004|s2cid = 39137575}}</ref>

[[Diuretics]], such as the thiazide-like diuretic [[chlortalidone]], are widely used to manage MD on the theory that it reduces fluid buildup (pressure) in the ear.<ref>{{Cite journal|last1=Thirlwall|first1=A. S.|last2=Kundu|first2=S.|date=2006-07-19|title=Diuretics for Ménière's disease or syndrome|journal=The Cochrane Database of Systematic Reviews|volume=2010 |issue=3|pages=CD003599|doi=10.1002/14651858.CD003599.pub2|issn=1469-493X|pmid=16856015|pmc=9007146 }}</ref> Based on evidence from multiple but small clinical trials, diuretics appear to be useful for reducing the frequency of episodes of dizziness but do not seem to prevent hearing loss.<ref>{{Cite journal|last1=Crowson|first1=Matthew G. |last2= Patki |first2= Aniruddha |last3= Tucci| first3=Debara L.|date=May 2016|title=A Systematic Review of Diuretics in the Medical Management of Ménière's Disease|journal=Otolaryngology–Head and Neck Surgery|volume=154|issue=5|pages=824–834|doi=10.1177/0194599816630733|issn=1097-6817|pmid=26932948|s2cid=24741244}}</ref><ref name="pmid31046134">{{cite journal| author=Stern Shavit S, Lalwani AK| title=Are diuretics useful in the treatment of meniere disease? | journal=Laryngoscope | year= 2019 | volume= 129 | issue= 10 | pages= 2206–2207 | pmid=31046134 | doi=10.1002/lary.28040 | doi-access=free }}</ref>

In cases where hearing loss and continuing severe episodes of vertigo occur, a [[chemical labyrinthectomy]], in which a medication such as [[gentamicin]] is injected into the middle ear and kills parts of the vestibular apparatus, may be prescribed.<ref name=See2016/><ref name=Pul2011>{{cite journal |last1=Pullens |first1=B |last2=van Benthem |first2=PP |title= Intratympanic gentamicin for Ménière's disease or syndrome. |journal=The Cochrane Database of Systematic Reviews |date=16 March 2011 |issue=3 |pages=CD008234 |doi= 10.1002/14651858.CD008234.pub2 |pmid=21412917}}</ref><ref name="PMID22699980">{{Cite journal|last1=Huon|first1=Leh-Kiong|last2=Fang|first2=Te-Yung|last3=Wang|first3=Pa-Chun |date= July 2012| title=Outcomes of intratympanic gentamicin injection to treat Ménière's disease|journal=Otology & Neurotology |volume=33|issue=5|pages=706–714 |doi= 10.1097/MAO.0b013e318259b3b1| pmid= 22699980 |s2cid= 32209105}}</ref> This treatment has the risk of worsening hearing loss.<ref name=Pul2011/>

===Diet===
People with MD are often advised to reduce their sodium intake.<ref name="Foster2015rev">{{Cite journal|last=Foster|first=Carol A.|date=2015|title=Optimal management of Ménière's disease|journal=Therapeutics and Clinical Risk Management|volume=11|pages=301–307|doi=10.2147/TCRM.S59023|issn=1176-6336|pmc=4348125|pmid=25750534 |doi-access=free }}</ref><ref name=Esp2016>{{cite book |last1=Espinosa-Sanchez |first1=JM |last2=Lopez-Escamez |first2=JA |chapter=Menière's disease |title=Neuro-Otology |series= [[Handbook of Clinical Neurology]] |date=2016 |volume=137 |pages=257–277 |doi=10.1016/B978-0-444-63437-5.00019-4 |pmid=27638077|isbn=978-0-444-63437-5 }}</ref> Reducing salt intake, however, has not been well studied.<ref name=Esp2016/><!-- Quote = Patients are advised to eliminate the use of salt at the table and limit its use during cooking... These recommendations are based on expert opinions, but evidence is lacking. --> Based on the assumption that MD is similar in nature to a migraine, some advise eliminating "migraine triggers" such as caffeine, but the evidence for this is weak.<ref name= Foster2015rev/> There is no high-quality evidence that changing diet by restricting salt, caffeine or alcohol improves symptoms.<ref>{{Cite journal |last1= Hussain |first1= Kiran |last2= Murdin|first2=Louisa|last3=Schilder|first3=Anne GM|date=31 December 2018|title=Restriction of salt, caffeine and alcohol intake for the treatment of Ménière's disease or syndrome |journal=Cochrane Database of Systematic Reviews|volume=2018|issue= 12 |pages=CD012173|doi=10.1002/14651858.CD012173.pub2|issn=1469-493X|pmid=30596397|pmc=6516805}}</ref>

===Physical therapy===
While use of physical therapy early after the onset of MD is probably not useful due to the fluctuating disease course, physical therapy to help retraining of the balance system appears to be useful to reduce both subjective and objective deficits in balance over the longer term.<ref name=See2016/><ref name="PMID9386249">{{Cite journal| last1= Clendaniel |first1= R. A.|last2=Tucci|first2=D. L.|date=December 1997|title=Vestibular rehabilitation strategies in Meniere's disease|journal=Otolaryngologic Clinics of North America| volume= 30 |issue= 6|pages=1145–1158|doi=10.1016/S0030-6665(20)30155-9|issn=0030-6665|pmid=9386249}}</ref>

=== Counseling ===
The psychological distress caused by the vertigo and hearing loss may worsen the condition in some people.<ref>{{Cite journal|last=Orji|first=Ft|date=2014|title=The Influence of Psychological Factors in Meniere's Disease|journal=Annals of Medical and Health Sciences Research|volume=4|issue=1|pages=3–7|doi=10.4103/2141-9248.126601|doi-broken-date=1 November 2024 |issn=2141-9248| pmc= 3952292 |pmid= 24669323 |doi-access=free }}</ref> Counseling may be useful to manage the distress,<ref name=See2016/> as may education and [[relaxation techniques]].<ref name="Greenberg2010">{{Cite journal|last1=Greenberg|first1=Simon L.|last2=Nedzelski|first2=Julian M.|date=October 2010|title=Medical and noninvasive therapy for Meniere's disease|journal=Otolaryngologic Clinics of North America|volume=43|issue=5|pages=1081–1090|doi=10.1016/j.otc.2010.05.005|issn=1557-8259|pmid=20713246}}</ref>

=== Surgery ===
If symptoms do not improve with less invasive approaches and for cases where the condition is uncontrolled or persistent and affecting both ears, surgery may be considered.<ref name=See2016/><ref name="Foster2015rev" /><ref name=":0">{{Cite journal |last1=Lee |first1=Ambrose |last2=Webster |first2=Katie E |last3=George |first3=Ben |last4=Harrington-Benton |first4=Natasha A |last5=Judd |first5=Owen |last6=Kaski |first6=Diego |last7=Maarsingh |first7=Otto R |last8=MacKeith |first8=Samuel |last9=Ray |first9=Jaydip |last10=Van Vugt |first10=Vincent A |last11=Burton |first11=Martin J |date=2023-02-24 |editor-last=Cochrane ENT Group |title=Surgical interventions for Ménière's disease |journal=Cochrane Database of Systematic Reviews |language=en |volume=2023 |issue=2 |pages=CD015249 |doi=10.1002/14651858.CD015249.pub2 |pmc=9955726 |pmid=36825750}}</ref> 

==== Endolymphatic sac surgery ====
Surgery to decompress the [[endolymphatic sac]] is one surgical approach that is sometimes suggested. Three methods of surgical endolymphatic sac decompression are sometimes suggested – simple decompression, insertion of a shunt, or removal of the sac.<ref name="Lim" /> There is some very weak evidence that all three methods may be useful for reducing dizziness, but that the level of evidence supporting these surgical procedures is low with further higher quality investigations being suggested.<ref name="Lim">{{Cite journal|display-authors= 3| last1=Lim|first1=Ming Yann|last2=Zhang|first2=Margaret|last3=Yuen|first3=Heng Wai|last4=Leong|first4=Jern-Lin|date=November 2015|title=Current evidence for endolymphatic sac surgery in the treatment of Meniere's disease: a systematic review|journal= [[Singapore Medical Journal]] |volume=56|issue=11|pages=593–598 |doi= 10.11622/smedj.2015166| issn= 0037-5675 |pmc= 4656865 |pmid= 26668402}}</ref> There is a risk in these types of surgical procedures that the shunts used in these surgeries are at risk of becoming displaced or misplaced.<ref name="Foster2015rev" /> For those with severe cases who are eligible for endolymphatic sac decompression, a 2014 systematic review reported that in at least 75% of people, EL sac decompression was effective at controlling vertigo in the short term (>1 year of follow-up) and long term (>24 months).<ref name="PMID24751747">{{Cite journal|last1=Sood|first1=Amit Justin |last2= Lambert |first2= Paul R. |last3=Nguyen|first3=Shaun A.|last4=Meyer|first4=Ted A. |display-authors= 3| date=July 2014|title=Endolymphatic sac surgery for Ménière's disease: a systematic review and meta-analysis |journal= [[Otology & Neurotology]] |volume=35|issue=6|pages=1033–1045|doi=10.1097/MAO.0000000000000324|issn=1537-4505|pmid=24751747|s2cid=31381271}}</ref>

==== Ventilation tubes ====
Surgical implantation of eustachian tubes (ventilation tubes) is not strongly supported by medical studies. There are some tentative evidence of benefit from [[tympanostomy tubes]] for improvement in the unsteadiness associated with the disease,<ref name="Walther2005Rev" /> conclusions about how effective this surgery is and the potential for side effects and harms is not clear.<ref name="Har2014" /><ref name=":0" />

==== Other surgical interventions ====
Destructive surgeries such as vestibular nerve [[labyrinthectomy]] are irreversible and involve removing entire functionality of most, if not all, of the affected ear; as of 2013, almost no evidence existed with which to judge whether these surgeries are effective.<ref name="Cochrane2013surgery">{{Cite journal|last1=Pullens|first1=Bas|last2=Verschuur|first2=Hendrik P.|last3=van Benthem|first3=Peter Paul|date=2013|title=Surgery for Ménière's disease|journal=The Cochrane Database of Systematic Reviews|volume=2013 |issue=2|pages=CD005395|doi=10.1002/14651858.CD005395.pub3|issn=1469-493X|pmid=23450562|pmc=7389445}}</ref> The inner ear itself can be surgically removed via labyrinthectomy, although hearing is always completely lost in the affected ear with this operation.<ref name="Cochrane2013surgery" /> The surgeon can also cut the nerve to the balance portion of the inner ear in a [[Vestibular nerve|vestibular]] [[neurectomy]]. The hearing is often mostly preserved; however, the surgery involves cutting open into the lining of the brain, and a hospital stay of a few days for monitoring is required.<ref name="Cochrane2013surgery" />

=== Poorly supported ===
* As of 2014, [[betahistine]] is often used as it is inexpensive and safe;<ref name=Har2014/> but evidence does not justify its use in Ménière's disease.<ref name="PMID11279734">{{Cite journal|last1=James|first1=A. L.|last2=Burton|first2=M. J.|date=2001|title=Betahistine for Menière's disease or syndrome|journal=The Cochrane Database of Systematic Reviews |volume=2020 |issue= 1|pages=CD001873|doi=10.1002/14651858.CD001873|issn=1469-493X|pmid=11279734|pmc=6769057}}</ref><ref name="PMID26797774">{{Cite journal| pmc= 4721211 |year= 2016 |last1= Adrion |first1=C|title=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)|journal=BMJ|volume=352|pages=h6816|last2=Fischer|first2=C. S.| last3= Wagner |first3= J |last4= Gürkov |first4= R |last5= Mansmann |first5= U|last6=Strupp| first6=M |display-authors= 3| doi=10.1136/bmj.h6816|pmid=26797774}}</ref> However, recent [[pharmacokinetic]] experiments have shown that combination therapy with [[Monoamine oxidase inhibitor|Monoamine oxidase inhibitors]] can drastically increase the bioavailability of betahistine in humans,<ref name="DOI10.3389/fneur.2023.1271640">Michael Strupp, Grant C. Churchill, Ivonne Naumann, Ulrich Mansmann, Amani Al Tawil, Anastasia Golentsova, Nicolina Goldschagg: ''Examination of betahistine bioavailability in combination with the monoamine oxidase B inhibitor, selegiline, in humans—a non-randomized, single-sequence, two-period titration, open label single-center phase 1 study (PK-BeST).'' In: ''Frontiers in Neurology.'' 2023, Band 14 {{doi|10.3389/fneur.2023.1271640}}.</ref> and improve cochlear blood flow in [[guinea pigs]].<ref name="DOI10.1177/00034894221098803">Benedikt Kloos, Mattis Bertlich, Jennifer L. Spiegel, Saskia Freytag, Susanne K. Lauer, Martin Canis, Bernhard G. Weiss, Friedrich Ihler: ''Low Dose Betahistine in Combination With Selegiline Increases Cochlear Blood Flow in Guinea Pigs.'' In: ''Annals of Otology Rhinology & Laryngology.'' 2022, Band 132, Nummer 5, S.&nbsp;519–526 {{doi|10.1177/00034894221098803}}.</ref>
* Transtympanic micropressure pulses were investigated in two systematic reviews. Neither found evidence to justify this technique.<ref name="PMID25756795">{{cite journal | pmid = 25756795 | doi=10.1002/14651858.CD008419.pub2 | issue=3 | title=Positive pressure therapy for Ménière's disease or syndrome | year=2015 | journal=Cochrane Database Syst Rev | page=CD008419 | author=van Sonsbeek S, Pullens B, van Benthem PP| volume=2015 | pmc=11026870 }}</ref><ref name="PMID25346252">{{Cite journal|last2=Rutka|first2=J. A. |last3= Hendry |first3= J |last4= Browning |first4= G. G.|display-authors= 3| year=2015|title=Positive pressure therapy for Meniere's syndrome/disease with a Meniett device: A systematic review of randomised controlled trials|journal=Clinical Otolaryngology|volume=40|issue=3|pages=197–207|doi=10.1111/coa.12344|pmid=25346252|last1=Syed|first1=M. I.|s2cid=1025535 }}</ref>
* Intratympanic [[steroid]]s were investigated in three systematic reviews. The data were found to be insufficient to decide if this therapy has positive effects.<ref name="PMID19923807">{{Cite journal|last2=Parnes|first2=L. S.|year=2009|title=Intratympanic steroids for inner ear disorders: A review|journal=Audiology and Neurotology |volume= 14 |issue= 6|pages=373–382|doi=10.1159/000241894|pmid=19923807|last1=Hu|first1=A|s2cid=38726308}}</ref><ref name="pmid25215266">{{cite journal|year=2014|title=Intratympanic Therapies for Menière's disease|journal=Current Otorhinolaryngology Reports|volume=2|issue=3|pages=137–143|doi=10.1007/s40136-014-0055-8|pmc=4157672|pmid=25215266|vauthors=Miller MW, Agrawal Y}}</ref><ref>{{Cite journal|last1=Phillips|first1=John S.|last2=Westerberg|first2=Brian|date=2011-07-06|title=Intratympanic steroids for Ménière's disease or syndrome |journal= The Cochrane Database of Systematic Reviews|issue=7|pages=CD008514|doi=10.1002/14651858.CD008514.pub2|issn=1469-493X|pmid=21735432}}</ref>
* Evidence does not support the use of alternative medicine such as [[acupuncture]] or herbal supplements.<ref name=NIH2016/>