5. menier's disease

Meniere’s Disease

DR. RS MEHTA, BPKIHS

• The disease is named after a
French doctor - Prosper Ménière who described the condition as
being characterised by sudden
attacks of
dizziness, nausea, vomiting, loss
of hearing and a buzzing in the
ears (tinnitus).

Meniers disease is a disorder of inner
ear where the endolymphatic system is
distended.
It is chracterised by
i. Virtigo
ii. Sensorial hearing loss
iii. Tinnitus and
iv. Aural fullness


Function of ear
• Hearing: Sound conduction and transmission
• Balance and equilibrium


Anatomy of ear
It consists of:
• Outer ear
• Middle ear
• Inner ear


Inner ear
 Bony labyrinth:
 Vestibule
 Semicircular canals
 Cochlea

 Membranous labyrinth
Cochlear duct
Utricle and saccules
Semi-circular ducts
Endolymphatic duct

Definition
• Meniere’s disease is a disorder of inner ear in
which the endolymphatic system is distended.
• It is also called endolymphatic hydrops.


Incidence
•
•
•
•

Male are affected more than female.
Disease is mainly unilateral.
It is more common in age group 35-60 years
About 50,000 - 100,000 people of world
develop Meniere's disease in a year.
• About 50 % of the patients who have
Meniere's disease have a positive family
history of this disease.

Etiology
•
•
•
•
•
•
•
•
•

The exact cause of Meniere’s disease is unknown.
Possible causes include:
Defective absorption by endolymphatic sac
Allergies
Sodium and water retention
Hypothyroidism
Autoimmune and viral aetiologies
Mumps
Syphilis
Head trauma
Previous infection

• Hormonal (Pregnant females are more prone)

Risk factors
•
•
•
•
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Smoking
Alcohol use
Fatigue
Respiratory infection
Stress
Use of certain medications, including aspirin
Genetics may also play a role


Pathophysiology
Obstruction of endolymphatic duct/sac

Alteration in production and absorption of endolymph

Distension of endolymphatic sac

Increased in pressure and rupture of inner membranes

Vertigo, tinnitus, hearing loss( Meniere’s)

Normal membranous labyrinth

Dilated membranous labyrinth in
Meniere's disease (Hydrops)


Clinical features
Cardinal symptoms of Miniere’s disease are:
• Episodic vertigo
 Sudden onset
 Feeling of rotation of himself/environment

• Fluctuating hearing loss
Following /accompanying vertigo
 Deterioration in hearing with each attack

Cont
• Tinnitus
 Low pitch roaring type
• Sense of aural fullness:
Accompany/ preceed
vertigo


Other features
•
•
•
•

Headache
Pain or discomfort in the abdomen
Nausea and vomiting
Uncontrollable eye movements


Physical Examination
•
•
•

During an acute attack, the patient
has severe vertigo.
Patients are sometimes diaphoretic
and pale.
Vital signs may show elevated blood
pressure, pulse, and respiration.


• The Weber tuning fork test usually lateralized to the better
ear.
• The Rinne test is positive absolute bone conduction is
reduced in the affected ear

Weber Test:
Normal: equal hearing both sides of same type
Abnormal – Tone louder in on one side
=Conductive loss – tone louder on affected side
=SNHL – tone louder on contralateral side

Rinne test:
Normal: AC > BC
Abnormal
Negative Rinne – louder on mastoid process
Positive Rinne – Bilateral SNHL

Investigations
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Otoscopy
Audiometry
Electrocochleography
Caloric test: reduced respond on the affected
site


Imaging Studies
• Magnetic resonance imaging:
Brain scan should be done to rule out
abnormal anatomy or mass lesions.
• CT scans reveal dehiscent superior
semicircular canals and/or widened
cochlear and vestibular aqueducts


Transtympanic
electrocochleography

• Transtympanic electrocochleography
(ECOG) specifically detects
distortion of the neural membranes
of the inner ear.


Electronystagmography (ENG)
• Electronystagmography (ENG) is a test
of the inner ear function (particularly the
semicircular canals).


Management
General measures:

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Reassurance: psychological support
Cessation of smoking
Low salt diet
Avoid excessive intake of water
Life style modification


Cont..
Management of acute attack
• Reassurance
• Bed rest
• Vestibular sedatives:
prochlorperazine,diazepam
• Vasodilators: adenosine triphosphate


Cont…
Management of chronic phase
• Vestibular sedatives: prochlorperazine,
• Vasodilators: nicotinic acid, betahistine
• Diuretics: furesemide
• Avoid allergen
• Chemical labyrinthectomy:
intratympanic gentamicin therapy

Cont..
Surgical management
• Conservative procedure:
Endolymphatic decmpression
Endolymphatic shunt operation
Ultrasonic destruction of vestibular labyrinth

• Destructive measure:
Labyrinthectomy

Rx: summary
1. Atropine: stop attack for 20-30 Minutes
2. Bed rest in quite environment
3. Labyrinthine sedative like: Prochlorperazine (stemetil),
Idmenhydrinate (Dramamine) to control giddiness and
N/V
4. Vasodilators: Nicotinic acid, betahistamine to control
vasospasm
5. Tranquilizer and anti-depressant to relieve anxiety
6. Prphylactic antihistamine or mild sedative:
Phenobarbitone, diazepam may be helpful.
7. Steroid to reduce inflamation
8. Antibiotics: esp. Aminoglycocise groups

Nursing management
• Assess the severity and frequency of attack,
any associated ear symptoms (hear loss,
tinnitus).
• Help patient prevent from aura, so patient has
time to prepare for an attack.
• Encourage patient to lie down during attack in
safe place.
• Put side rails in the bed if patient is in bed
• Place pillow to restrict movement.

Cont..
• Administer or teach anti-vertiginous
medication and sedation medication as
prescribed
• Avoid noises and glary bright light which may
initiate attack.
• Advise patient to avoid food that cause allergy.
• Assist with ambulation when indicated.
• Provide comfort measures and avoid stress
producing activities.

Post operative instructions:
• Antibiotic and other medication are to be taken
as prescribed.
• Nose blowing to be avoided (few weeks).
• Sneezing and coughing should be done with the
mouth open for a few weeks after surgery.
• Heavy lifting, straining, and bending are to be
avoided for a few weeks after surgery.
• Minor discomfort is expected can relief by
analgesic, excessive pain should be reported to
surgeon.

• Some slightly bloody or serosanganious drainage
from the ear is normal after surgery.
• Excessive or purulent drainage should be
reported to the surgeon.
• The cotton ball in the ear can be changed as
needed but not to touch or remove any packing
from the external auditory canal.
• Post auricular suture line should be cleaned and
antibiotic oint. Applied twice daily.
• The surgeon should consult for regular air travel.
• Getting water in the operated ear must be
avoided for 2 weeks after surgery.

•
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Dressing first open-3rd day
Suture removal 10th day
Head up 300 (3-10 days)
Avoid: Chewing, sneezing, coughing etc
Prevent water in ear: 6 weeks
Never put oil in ear
Hearing may be impaired for few months RT
edema, blood, fluid
• Observe complications: Facial nerve palsy (VII),
brain abscess, meningitis etc
• Avoid flying in air for 2 months
• BIPP dressing (bismuth icthymol parafin paste)
while doning mastoid surgery

Complications
• Inability to walk or function due to
uncontrollable vertigo.
• Hearing loss on the affected side.
• Possible of injury due to imbalance.


Prognosis
• The outcome varies. Meniere's disease can
often be controlled with treatment.
• The condition may get better on its own
sometimes.
• Meniere's may be chronic disabling causing
permanent hearing loss.


Thank You


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