Meniere's syndrome

• Ménière's syndrome, also called idiopathic endolymphatic hydrops, or Ménière's disease, is a disorder of the inner ear. Although the cause is unknown, Ménière's syndrome is thought to result from an abnormality in the inner ear fluids.
  About 100,000 individuals per year develop Ménière's syndrome.
• Ménière's syndrome is one of the most common causes of dizziness. In most cases only one ear is involved, but both ears may be affected in about 15% of individuals.
• Ménière's syndrome can cause severe dizziness, a roaring or ringing
  sound in the ears called tinnitus, sporadic or spontaneous hearing loss, and the feeling of ear pressure or pain. Meniere's syndrome causes bilateral hearing loss in 5-20% of individuals
  suffering from the condition.
• Symptoms of Ménière's syndrome
  usually last from 20 minutes to two hours or more. Ménière's syndrome
  typically starts between the ages of 20-50 years. Men and women are affected in equal numbers.
• There is no cure for Ménière's disease. However, individuals may be able to control symptoms by changing the diet (see Treatment) or taking medicine so that the body retains less fluid. Severe cases may require surgery.

• The symptoms of Ménière's syndrome are episodic rotational vertigo (attacks of a spinning sensation), hearing loss, tinnitus (a roaring, buzzing, or ringing sound in the ear), and a sensation of fullness in the affected ear. Tinnitus and fullness of the ear in Ménière's syndrome may come and go with changes in hearing, occur during or just before attacks, or be constant. There may also be an intermittent hearing loss early in the disease, especially in the low pitches, but a fixed hearing loss involving tones of all pitches commonly develops in time. Loud sounds may be uncomfortable and seem distorted in the affected ear.
• Ménière's syndrome generally occurs in only one ear. In rare cases, both ears can be affected. As the disease progresses, hearing loss may be more pronounced and less likely to fluctuate with attacks, and tinnitus and ear fullness may be stronger and more constant. The vertigo (dizziness) attacks may subside over time.
• Vertigo is usually the most troublesome of all the symptoms of Ménière's syndrome. Vertigo is commonly produced by disorders of the inner ear, but may also occur in central nervous system disorders. Vertigo may last for 20 minutes to two hours or longer.
• During attacks, patients are usually unable to perform activities normal to their work or home life. Sleepiness may follow for several hours, and the off-balance sensation may last for days. The symptoms of Ménière's syndrome may be only a minor nuisance, or can be disabling, especially if the attacks of vertigo are severe, frequent, and occur without warning.

• The American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) has proposed diagnosis criteria for Ménière's syndrome. According to AAO-HNS guidelines, a definite diagnosis of Ménière's syndrome requires: two spontaneous episodes of vertigo
  each lasting 20 minutes or longer (with no time frame); ringing in the ear (tinnitus) or feeling of fullness in the ear; and documented hearing loss on a hearing test. Vertigo must be present and at least one of the other symptoms for a diagnosis of Ménière's syndrome.
• A doctor will take a history of the frequency, duration, severity, and character of attacks, the duration of hearing loss or whether it has been changing, and whether the individual has experienced tinnitus or fullness in either or both ears. The individual may be asked whether there is history of syphilis, mumps, or other serious infections in the past, inflammations of the eye, an autoimmune disorder or allergy, or ear surgery in the past. The individual may be asked questions about their general health, such as whether diabetes, high blood pressure, high blood cholesterol, thyroid, or neurologic or emotional disorders are present. Tests may be ordered to look for these conditions. When the history has been completed, diagnostic tests will check hearing and balance functions.
• For hearing: An audiometric examination (hearing test) typically indicates a sensory type of hearing loss in the affected ear. Speech discrimination (the individual's ability to distinguish between words like "sit" and "fit") is often diminished in the affected ear.
• For balance: An ENG (electronystagmograph) may be performed to evaluate balance function. In a darkened room, recording electrodes are placed near the eyes. Warm and cool water or air is gently introduced into each ear canal. Since the eyes and ears work in coordination through the nervous system, measurement of eye movements can be used to test the balance system. In about 50% of individuals, the balance function is reduced in the affected ear. Rotational testing or balance platform may also be performed to evaluate the balance system.
• Electrocochleography: An electrocochleograph (ECoG) measures the electrical potentials generated in the inner ear as a response to sound. An ECoG may indicate increased inner ear fluid pressure in some cases of Ménière's syndrome.
• Auditory brain stem response: The auditory brain stem response (ABR), a computerized test of the hearing nerves and brain pathways, computed tomography (CT), or magnetic resonance imaging (MRI) may be needed to rule out a tumor occurring on the hearing and balance nerve. Such tumors are rare, but they can cause symptoms similar to Ménière's syndrome.
• Magnetic resonance imaging (MRI): An MRI uses a magnetic field and radio waves to create cross-sectional images of the head and body. A doctor can use these detailed, clear images to identify and diagnose a wide range of conditions. MRI may be performed to rule out central nervous system disorders that can imitate Ménière's syndrome, such as acoustic neuroma (a noncancerous brain tumor of the acoustic nerve, which carries sound from the inner ear to the brain), Arnold-Chiari malformation, and multiple sclerosis.

• Complications of Ménière's syndrome may include: an increased risk of falling; an increased risk of an accident while driving a car or operating heavy machinery; permanent, partial, or total hearing loss in the affected ear; and an increased risk of depression or anxiety in dealing with the disease.

• The goal of treatment for Ménière's syndrome is to manage signs and symptoms, such as dizziness, and prevent or decrease the number of attacks. Prescription drugs, over-the-counter (OTC) medicines, and lifestyle changes (such as diet and exercise) may help decrease the number and severity of Ménière's syndrome attacks.
• A low salt diet and a prescription diuretic, or water pill, (such as hydrochlorothiazide), may reduce the frequency of attacks of Ménière's syndrome in some individuals. Because diuretic medications cause the individual to urinate more frequently, their body may become depleted of certain minerals, such as potassium. Healthcare providers may recommend taking a potassium supplement or eating three or four extra servings of potassium-rich foods a week, such as bananas when taking diuretic medications that may cause potassium to be lost, including furosemide (Lasix®).
• Anti-vertigo medications, such as meclizine (Antivert®) may provide temporary relief. Anti-nausea medication is sometimes prescribed, such as prochlorperazine (Compazine®). Anti-anxiety drugs may also be used, such as alprazolam (Xanax®). Anti-vertigo, anti-nausea, and anti-anxiety medications may cause drowsiness. Alprazolam is in a class of drugs called benzodiazepines. These medications may cause physical and psychological addiction.
• Lifestyle changes: Healthcare professionals recommend that individuals with Ménière's disease: avoid caffeine, smoking, and alcohol; get regular sleep; eat a healthy diet, including fresh fruits and vegetables and limiting meats and fatty foods; and avoid foods that contain MSG or monosodium glutamate. Prepackaged food products and Chinese food include MSG, which contains sodium. MSG can contribute to fluid retention and worsen symptoms; and limit stress. Stress may aggravate the vertigo and tinnitus of Ménière's syndrome. Stress avoidance or counseling may be advised.
• If vertigo appears without warning, the individual should not drive. Failure to control the vehicle may be hazardous to the individual and others. It is also best to avoid ladders, scaffolds, and swimming.
• Middle ear injections: A middle ear injection consists of a healthcare professional injecting gentamicin (Garamycin®) in the inner ear, through the eardrum, and into the inner ear. Injecting gentamycin into the ear destroys the balance nerve endings in the inner ear, sparing the hearing nerve endings. This reduces the balancing function of the individual's ear, and their other ear assumes responsibility for balance. The procedure, which can be performed with local anesthesia in a doctor's office, often reduces the frequency and severity of vertigo attacks. Gentamycin is also effectively used as an antibiotic for certain infections. Side effects of middle ear injections are further hearing loss. Middle ear injections are not commonly used.
• Injections with a steroid, such as dexamethasone (Decadron®), may also help control vertigo attacks in some individuals. Although dexamethasone injections may be slightly less effective than gentamicin, dexamethasone is less likely than gentamicin to cause further hearing loss.
• Surgery: If the vertigo attacks associated with Ménière's syndrome are severe and debilitating and medical treatments do not help, surgery may be an option.
• Endolymphatic sac procedures: Endolymphatic sac procedures are surgical procedures that reduce the swelling caused by endolymph (an inner ear fluid) buildup. In endolymphatic sac decompression, some of the bone surrounding the inner ear is removed. In some cases, endolymphatic sac decompression is coupled with the placement of an endolymphatic shunt, a tube that drains excess fluid from the inner ear. Another surgical approach, called a sacculotomy, involves implanting a permanent, tack-like device that allows endolymph to drain out of the inner ear whenever pressure builds up.
• Labyrinthectomy: A labyrinthectomy removes the entire inner ear sense organ (vestibular labyrinth). The operation may be an option if antibiotic injections do not help and the individual has near-total or total hearing loss in the affected ear.
• Vestibular neurectomy: A vestibular neurectomy involves cutting the nerve that controls balance (vestibular nerve). When hearing loss is severe or Ménière's syndrome involves intense vertigo, a vestibular neurectomy may be done to surgically destroy the entire inner ear. The individual's other ear then takes over the balance function.
• Rehabilitation: If the individual experiences problems with balance between attacks, they may benefit from vestibular rehabilitation therapy. The goal of this therapy, which may include exercises and activities performed during therapy sessions and at home, is to help the body and brain regain the ability to process information correctly.

Note
: There is currently a lack of clinical studies that support the use of integrative medicine in Ménière's disease. However, studies do support treatment for related conditions, such as hearing loss and dizziness.

B

Good scientific evidence

• Iodine
  : Chronic iodine deficiency can lead to numerous health problems in children and adults, including hearing loss. Auditory disturbances may be present in iodine deficient children, and continuous iodine supplementation may improve the auditory thresholds.
• There have been reports of severe and even fatal reactions to iodine. Avoid iodine-based products if allergic to iodine. Do not use for more than 14 days. Avoid lugol solution and the saturated solution of potassium iodide (SSKI, PIMA) with high amounts of potassium in the blood, fluid in the lungs, bronchitis, or tuberculosis. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction. Iodine is safe in recommended doses for pregnant or breastfeeding women.

C

Unclear or conflicting scientific evidence

• Acupuncture
  : The practice of acupuncture originated in China 5,000 years ago. Today, it is widely used throughout the world and is one of the main pillars of Chinese medicine. Early evidence suggests that acupuncture may be effective in treating hearing loss and vertigo. Better-designed trials are needed to reach a firm conclusion.
• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with a history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers due to possible interference with the device.
• Applied kinesiology
  : Applied Kinesiology (AK) uses muscle strength testing to identify nutritional deficiencies and health problems. Those that practice applied kinesiology believe that weakness in certain muscles corresponds to specific diseases or body imbalances. Early research suggests that symptoms of vertigo associated with Meniere's disease may improve with rotational exercises. Further evidence is needed before a clear recommendation can be made.
• Applied kinesiology techniques in themselves are harmless. However, medical conditions should not be treated with applied kinesiology alone. Applied kinesiology should not delay appropriate medical treatment.
• Art therapy
  : Art therapy involves many forms of art to treat anxiety, depression, and other mental and emotional problems. An art therapist helps a patient use many different types of artistic expression during art therapy. Drawing, painting, and sculpting are just a few examples of techniques that are used. Art therapy is practiced in hospitals, clinics, public and community agencies, wellness centers, educational institutions, businesses, and private practices. There is limited evidence suggesting that art therapy may be a beneficial treatment for phonological disorders in children. However, more studies are needed to determine the meaning of these findings.
• Because art therapy may stir up distressing thoughts or feelings, it should be used under the guidance of a qualified art therapist or mental health professional. Related materials, such as turpentine or mineral spirits, should be used in areas with good ventilation because they release potentially toxic fumes.
• Chiropractic
  : There is currently insufficient evidence to recommend chiropractic manipulative therapy for the treatment of vertigo. Additional research is needed in this area.
• Avoid with vertebrobasilar vascular insufficiency, aneurysms, arteritis, or unstable spondylolisthesis. Avoid use on post-surgical areas of para-spinal tissue. Use cautiously with acute arthritis, brittle bone disease, conditions that cause decreased bone mineralization, bleeding disorders, migraines, or if at risk of tumors or metastasis of the spine. Use extra caution during cervical adjustments. Avoid if pregnant or breastfeeding due to a lack of scientific data.
• Coenzyme Q10
  : More research is needed in patients with tinnitus with low levels of CoQ10 before a conclusion can be made.
• Allergy associated with coenzyme Q10 supplements has not been reported in the available literature, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners), antiplatelet drugs (like aspirin, warfarin, clopidogrel (like Plavix®), or blood pressure, blood sugar, cholesterol or thyroid drugs. Avoid if pregnant or breastfeeding.
• Danshen
  : Danshen (Salvia miltiorrhiza) is widely used in traditional Chinese medicine (TCM), often in combination with other herbs. Limited evidence suggests that danshen in combination with other herbs and supplements may be a less effective treatment for tinnitus than acupuncture. Additional research is needed to fully understand danshen's effects on tinnitus.
• Avoid if allergic or hypersensitive to danshen. Use cautiously with altered immune states, arrhythmia, compromised liver function or a history of glaucoma, stroke, or ulcers. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if taking blood thinners (anticoagulants), digoxin, or hypotensives including ACE inhibitors such as captopri, or Sophora subprostrata root or herba serissae. Avoid with bleeding disorders, low blood pressure, and following cerebal ischemia. Avoid if pregnant or breastfeeding.
• Folate
  : Folate and folic acid are forms of a water-soluble B vitamin. Folate occurs naturally in food and folic acid is the synthetic form of this vitamin. Folic acid supplementation was shown to slow the decline in hearing of speech frequencies associated with aging in a population from a country without folic acid fortification of food. The effect of folate on hearing loss requires confirmation, especially in populations from countries with folic acid fortification programs.
• Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents and with anemia and seizure disorders. It is recommended that pregnant women consume 400 micrograms of folate daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.
• Ginkgo
  :
  Ginkgo biloba has been used medicinally for thousands of years. Early research has been conducted on the effect of ginkgo in chronic cochleovestibular (relating to parts of the ear) disorders. Further research is needed before a conclusion can be made on the effectiveness of ginkgo for cochlear deafness. Ginkgo has also been studied as a possible treatment for tinnitus and vertigo. Additional well-designed research is needed to make a conclusion.
• Avoid if allergic or hypersensitive to members of the Ginkgoaceae
  family.
  If allergic to mango rind, poison sumac, poison ivy, poison oak, or cashews, then allergy to ginkgo is possible. Avoid if taking anticoagulants due to an increased risk of bleeding. Ginkgo should be stopped two to three weeks before surgical procedures. Use cautiously with seizures or in children. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Do not use ginkgo in supplemental doses if pregnant or breastfeeding. There is conflicting research regarding the use of ginkgo for tinnitus. Additional well-designed research is needed in order to resolve this controversy.
• Hypnotherapy, hypnosis
  : Hypnosis is a trance-like state in which a person becomes more aware and focused and is more open to suggestion. Hypnotherapy has been used to treat health conditions and to change behaviors. It remains unknown if hypnotherapy can effectively treat tinnitus. Study results are conflicting and additional well-designed research is needed.
• Use cautiously with mental illnesses (e.g. psychosis/schizophrenia, manic depression, multiple personality disorder, or dissociative disorders) or seizure disorders.
• Kudzu
  : Kudzu has been traditionally used in China to treat alcoholism, diabetes, gastroenteritis, and deafness. Kudzu was used in clinical study to treat sudden nerve deafness. Additional evidence is needed to confirm these results.
• Avoid if allergic to kudzu, its constituents, or members of the Fabaceae/Leguminosae family. Avoid if taking methotrexate. Use cautiously if taking blood thinners, drugs that treat diabetes, benzodiazepines, bisphosphonates, mecamylamine, neurologic agents, drugs that have estrogenic activity, drugs that lower blood pressure, or drugs that are broken down by the liver. Avoid if pregnant or breastfeeding, due to a lack of safety evidence.
• Magnet therapy
  : The use of magnets to treat illness has been described historically in many civilizations. In modern times, magnetic fields play an important role in Western medicine, including use for magnetic resonance imaging (MRI), pulsed electromagnetic fields, and experimental magnetic stimulatory techniques. There are several small studies that have investigated the use of electromagnetic stimulation for tinnitus. Some trials reported no benefits, while other study reported significant improvements in symptom severity. Most research in this area has not been well designed or reported, and it remains unclear if magnet therapy is useful for this condition.
• Avoid with implantable medical devices, such as heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions, and it should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.
• Music therapy
  : Specially designed music therapy may help improve symptoms of tinnitus. More research is needed. Music therapy is generally known to be safe.
• Noni
  : Noni (Morinda citrifolia) is a traditional folk medicinal plant that has been used for more than 2,000 years in Polynesia. Noni juice has been used for many years for a wide variety of indications in Southeast Asia, and noni juice may improve hearing in patients with hearing loss. Although results are promising, additional research is warranted in this area.
• Avoid if allergic to noni, its constituents, or any plants in the Rubiaceae family. Use cautiously if taking oral agents, anticoagulants (blood thinners), antivirals, blood pressure-lowering drugs, or immunosuppressants. Use cautiously with injuries, low blood pressure, HIV/AIDS, liver problems, gastrointestinal disorders and obstructions, or kidney problems. Use cautiously after surgery. Avoid if pregnant or breastfeeding.
• Physical therapy
  : The goal of physical therapy is to improve mobility, restore function, reduce pain, and prevent further injury. A variety of techniques, including exercises, stretches, traction, electrical stimulation, and massage, are used during physical therapy sessions. There is limited study on the effects of physical therapy in tinnitus and vertigo. More study is needed in this area.
• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Based on the available literature, physical therapy appears generally safe when practiced by a qualified physical therapist. However, physical therapy may aggravate some pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.
• Relaxation therapy
  : Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation. In preliminary studies, relaxation therapy has been associated with benefits for patients with tinnitus. Further research is needed to confirm these results.
• Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, and then relaxing the muscles) should be used cautiously with illnesses such as heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and it should not delay the time to diagnosis or treatment with more proven techniques.
• Rutin
  : Rutin is a yellow crystalline flavonol glycoside (C27H30O16) that is found in various plants, especially the buckwheat plant, black tea, apple peels, onions, and citrus. Early study results support the use of O-(beta-hydroxyethyl)-rutosides for reduction of symptoms associated with Meniere's syndrome. Additional study is warranted in this area.
• Avoid if allergic/hypersensitive to O-(beta-hydroxyethyl)-rutosides or plants that rutin is commonly found in, such as rue, tobacco, or buckwheat. Use cautiously in elderly patients. Use cautiously with skin conditions. Use cautiously if taking diuretics, anti-coagulants, or medications used to treat edema. Use cautiously if pregnant or breastfeeding.
• Tai chi
  : Early scientific evidence suggests that tai chi may be helpful as an adjunct treatment to regular vestibular rehabilitation programs. Tai chi may improve body stability and footfall stability. More studies are needed on the effects of tai chi for vestibulopathy.
• Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while practicing tai chi may increase the risk of injury.
• Yoga
  : Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. It is unclear whether yoga therapy may improve tinnitus. Although relaxation may theoretically benefit this condition, additional research is needed before a recommendation can be made.
• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Certain yoga breathing techniques should be avoided with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction. However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
• zinc
  : Zinc formulations have been used since ancient Egyptian times to enhance wound healing. Studies on the efficacy of zinc in treating tinnitus have produced conflicting results. Further research is necessary before a conclusion can be drawn.
• Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride because studies have not evaluated its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used because studies cannot rule out the possibility of harm to the fetus.

D

Fair negative scientific evidence

• Acupuncture
  : Scientific evidence suggests that acupuncture is not an effective treatment for tinnitus. Small trials have been conducted and found no benefits over placebo for the treatment of chronic unilateral or bilateral tinnitus. However, non-controlled case series have found possible benefit. Larger studies are needed before a conclusion can be made.
• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, medical conditions of unknown origins, or infections. Acupuncture should not be applied to the chest in patients with lung diseases or on any area that may rely on muscle tone to provide stability. Avoid use in infants, young children, or in patients with needle phobias. Use cautiously with bleeding disorders, neurological disorders, seizure disorders, or diabetes. Use cautiously in elderly or medically compromised patients. Use cautiously in patients who will drive or operate heavy machinery after acupuncture. Use cautiously if taking anticoagulants. Avoid if pregnant.