Meniere's disease - symptoms, treatment
1) attacks of systemic labyrinthine vertigo attended with nausea and vomiting;
2) unilateral hearing loss;
3) noise in the involved ear. The disease was first described by Prosper Meniere, a French physician, in 1861.
Attacks of vertigo occur amid complete health and are attended by nausea and sometimes vomiting. As a rule, noise in the affected ear intensifies during an attack. The patient feels as if his ear is stuffed or he is deafened. The objective sign of an attack is spontaneous nystagmus which disappears soon after the attack is abated. The patient loses his sense of balance during attacks and tries to assume a horizontal position, often with his eyes closed. Any attempt to change the position impairs the patient's condition and intensifies nausea and vomiting. Attacks can occur at any time of the day, but mostly at night time or in the morning. A physical or psychic overstrain can be the provoking factors. Some patients feel the approaching attack a few hours or even days before the actual onset of the disease. Noise in the ear or slight loss of balance are precursors of the forthcoming attack.
Fluctuation of hearing is a leading diagnostic sign of the auditory disorder: the hearing can improve considerably between attacks against the background of a gradually progressing deafness. During the initial stage of the disease, the hearing function can be restored completely thus indicating the absence of organic changes in the vestibulocochlear nerve during this period.
Meniere's disease occurs mostly in the young. Its onset is characterized by the noise in the ear which is followed (in a few hours or years) by attacks of systemic vertigo and vegetative disorders. An important point is that the auditory, rather than vestibular, disorders are typical for the onset of the disease. When establishing a diagnosis, it is necessary to take into account the periodicity of attacks, their short duration, good subjective condition of the patient during remission, etc.
The disease should first of all be differentiated from the vascular and vestibular syndrome, arachnoiditis, and tumour of the cerebellopontine angle.
Variants of Meniere's disease
Vestibular hydrops: Patient gets typical attacks of episodic vertigo while cochlear functions remain normal. It is only with time that a typical picture of Meniere's disease will develop.
Lermoyez syndrome: Here symptoms of Meniere's disease are in reverse order. First there is progressive deterioration of hearing followed by an attack of vertigo, at which time the hearing recovers.
Secondary Meniere's disease: Endolymphatic hydrops with clinical picture resembling Meniere's disease has been observed in congenital or acquired syphilis, otosclerosis, Paget's disease and post-stapedectomy cases.
Treatment
The polyaetiological origin of the disease accounts for the multitude of methods of treating it.Methods causing reconstruction of the vegetative nervous system are widely used.
These are as follows:
1) Reflex action of novocain block (intranasal block, the block of the stellate ganglion and the cervical sympathetic trunk);
2) Vitamin B, PP, A, and E therapy;
3) Oxygen therapy and habituation (training with controlled increasing strength of rotation);
4) Exposure of the diencephalon (the centre of the vegetative nervous system) and the sympathetic cervical ganglia to X-rays.
Surgical methods of treatment have been widely used in the recent decade (the operation for decompression of endolymphatic sac).
An acute attack of vertigo is eliminated by subcutaneous injection of 1 ml of a 0.1 per cent atropine sulphate solution, intravenous administration of 10 ml of novocain solution and 10 ml of a 40 per cent glucose solution. If this measure is not sufficient, 1-2 ml of a 2.5 per cent aminazine solution should be injected intramuscularly. If the attack fails to be removed completely, administration of atropine, aminazine and novocain should be repeated in 3-4 hours. If vertigo is severe and the mentioned means prove insufficiently effective, 1 ml of a 1 per cent pantopon solution can be administered subcutaneously. The presence of arterial hypotension rules out the use of aminazine.
Antihistaminics, chloropyramine, and diphenhydramine hydrochloride are effective both during and after the attack. One of these preparations is administered in a common dose subcutaneously.
The following mixture should be given during 10 days following the attack:
Rp.: Atropini sulfas 0.003
Papaverini hydrochloridum 0.2
Aq. destill. 20.0
S. 15 drops two times a day after meals
It is recommended to carry out a course of intravenous injections of a 5 per cent sodium bicarbonate solution, 50 ml a day, for 15-30 days. Positive effect is attained with dehydration: salt intake should be restricted to 0.5 g a day; ammonium chloride should be taken in 3-day courses (3 g, 3 times a day), 2 or 3 courses at 3-4-day intervals.
Surgical treatment
It is used only when medical treatment fails.
1. Conservative procedures: They are used in cases when vertigo is disabling hut hearing is still useful and needs to be preserved. They are , decompression of endolymphatic sac. Endolymplwtic shunt operation. A tube is put connecting endolymphatic sac wilh subarachnoid space to drain excess endolymph.
Succulolomy: It is puncturing the saccule with a needle through stapesfootplate. A distended saccule lies close to stapes footplate.
Section of vestibular nerve: The nerve is exposed by middle cranial fossa approach and seieclively sectioned. It controls vertigo hut preserves hearing.
Ultrasonic destruction of vestibular labyrinth. Cochlear function is preserved.
2. Destructive procedures:They totally destroy cochlear and vestibular function and are thus used only when cochlear function is not serviceable.
Labyrinthectomy: Membranous labyrinth is completely destroyed either by opening lateral semicircular canal or through the oval windows.
Patients with Meniere's disease should abstain from work with moving mechanisms or in conditions of vibration and noise exceeding 70 dB. Work at high altitudes is also prohibited.
By: Dr. Sameena Shaik