Meniere's disease: new treatments

New Treatments for Meniere's Disease

Timothy C. Hain, MD Page last modified: November 30, 2011

In general, it is best to be skeptical about new treatments for Meniere's. Because the disease fluctuates, very large numbers are needed to prove that a treatment is effective. In other words, one can easily by chance have a sequence of patients who do well on any particular regimen, medication or device, which is actually a placebo. Considerable data supporting this idea has been put forth by Torok (1977) and Ruckenstein (Ruckenstein et al. 1991). There is very little evidence that any currently available treatment, whether it be medical or surgical, changes hearing. (Am J Otol 18:67-73, 1997) There is good evidence, though, that certain destructive treatments (such as gentamicin) alleviate dizziness. Comments are in italics.

Hyperbaric oxygen. Fattori et al, Audiology 35(6):322-34, 1996. These authors report the results of treatment for 15 days with 90 min. sessions of a pressure chamber. They report better hearing results in the treated patients. Comment: lacking a reasonable mechanism and also considering the general problems with placebo responses in Menieres (see the classic paper entitled Old and New in Menieres, by N. Torok), this treatment remains unsubstantiated.
Labyrinth anesthesia. (Adunka, Moustaklis et al. 2003) In this treatment, lidocaine and Kinetin are instilled into the middle ear using transtympanic injection. A remission was reported in 66% of patients. It is difficult to see why a local anesthetic that is gone in hours at most should cause a long lasting remission. Kinetin is a plant growth factor, pesticide, and an ingredient in skin preparations. Perhaps Kinetin has a positive effect on Meniere's disease.
Latanoprost. Rask-Andersen et al. (Otol HNS 2005, 133, 441-443). These authors report injections of this drug through the ear drum once/daily for 3 days. 9 patients were studied. They report improvements in vertigo (30%) and hearing. This drug, used for treatment of glaucoma, has been here tried in the ear. The apparent rationale is reduction of hydrops. This small study shows that it is feasible to use this drug. It is too small to say if it is truly useful.
Meniett. This device, which is sold in the US by Medtronics, is claimed to improve Meniere's disease by means of low pressure. Surgery is required to use this device, and the device itself is expensive (about $3000), and presently not covered by insurance. According to the manufacturors web site (see link), less than 100 patients have been used in studies which suggest its effectiveness. A recent study by Gates et al (2004) suggested that the device is helpful (based on 66 more patients). However, there are some potential problems with the study in that it may not be possible to "blind" people to use of an active device. It is also difficult to see any reason why this device might work, especially considering contemporary autoimmune based theories of the etiology of Menieres. Nevertheless, our position at the moment is cautiously hopeful.
Lupron. Price et al (Arch Otol HNS 120:209-11, 1994) reported a case where Lupron alleviated the symptoms of Menieres. Comment: Lupron is a drug which shuts down natural production of sex hormones. Our assessment at this writing is that the cost/benefit ratio of this drug is not reasonable.
Nimodipine. Lassen and others, Am J Otology 17(4):577-80, 1996. Comment: Nimodipine is a calcium channel blocker. It is mainly used for control of blood vessal spasm in patients with aneurysmal bleeding. They reported successful control or improvement of vertigo and hearing in seven of 12 patients. Our assessment of this drug is that, at least in the USA, this drug is too expensive to use routinely. However we sometimes do use a related drug in our own practice.
Neurontin (Gabapentin). Comment: This drug which is indicated for treatment of seizures also may be helpful in patients with vestibular disorders. No studies are available regarding this use. We have had encouraging results in patients with ongoing nystagmus.
Transtympanic steroids. Shea and Ge (Otol Clin NA, 1996, 29:353-8, also Am J Otol,18:4,1997). Comment: These authors reported positive effects from use of steroids injected into the middle ear, combined with intravenous steroids.However, a double blind study found no significant difference between dexamethasone inner ear perfusion and placebo (Silverstein H, Isaacson JE, Olds MJ, Rowan PT, Rosenberg S; Am J Otol 19:2:1998, 196-201) It is our opinion as well as that of the consensus (See Blakely, Am J Otol, 18:4, 1997), that this treatment is presently investigational, and that a firm scientific basis for its use is lacking. We are particularly concerned that the positive effects, if present, are transient. To us, drops administered via a ventilation tube over a longer period seem more likely to be effective. At this writing (2006), we rarely recommend intratympanic steroids.
Treatment in general. Several authors from the Cleveland clinic (Am J Otol 18:67-73, 1997) surveyed long term hearing results and quality of life in patients with Menieres. They concluded that no statistically significant results was detected in long-term hearing in medically or surgically treated patients compared to untreated patients. Comment: this study adds more support to the general opinion that there is no effective treatment that prevents hearing loss in Menieres. However, nearly everyone agrees that treatment does influence dizziness.
Water. In an amazing report, Naganuma and others from Japan (2006) studied 29 people and reported that large amounts of water intake taken over 2 years (35 ml/Kg -- or about 2.5 liters for a 70 kilo person), "dramatically relieved vertigo" and significantly improved hearing in the last 6 months. In our opinion, this study is underpowered (not enough subjects to prove their point), and also dangerous in that it may lead people to become water intoxicated. We see no reason why there should be good results only in the last 6 months, and also we don't think that a total of 29 patients is anywhere near enough.
New diagnostic modalities:
Intratympanic gadolinium. Louza et al reported that intratympanic gadolinium had no short term effect on hearing. This study allows for the possibilty of imaging the labyrinth using MRI.

References:

Adunka, O., E. Moustaklis, et al. (2003). "Labyrinth Anesthesia - A Forgotten but Practical Treatment Option in Meniere's Disease." ORL J Otorhinolaryngol Relat Spec 65(2): 84-90.
Gates GA and others. The effects of transtympanic micropressure treatment in people with unilateral Meniere's disease. Arch Otol HNS 2004:130;718-725
Louza JP, Flatz W, Krause E, Gürkov R.Short-term audiologic effect of intratympanic gadolinium contrast agent application in patients with Ménière disease. Am J Otolaryngol. 2012 Feb 6. [Epub ahead of print]
Naganuma H, Kawahara K, Tokumasu K, Okamoto M. Laryngoscope.Water may cure patients with meniere disease. 2006 Aug;116(8):1455-60.
Rask-Andersen et al. Effects of intratympanic injection of latanoprost in Meniere's disease: a randomized placebo-controlled, double-blind, pilot study. Otol HNS 2005, 133, 441-443
Ruckenstein MJ, Rutka JA and Hawke M (1991). "The treatment of Meniere's disease: Torok revisited." Laryngoscope 101(2): 211-8.
Torok N (1977). "Old and new in Meniere disease." Laryngoscope 87(11): 1870-7.