Don’t let the drawing of the spinning Go-Gos throw you off,
but it is a good prelude to a discussion about dizziness. I drew this back in my youth when they first
came out, and I cannot recall why I arranged them in a circle, but it makes for
fun if you spin the drawing on its center axis.
Attribute this to a young guy’s sense of creativity and being a huge fan
of the group.
Meniere's
Disease is a mysterious, sometimes frightening disease that
has affected millions of people. The cause of Meniere's is really not known. Meniere’s Disease typically involves a triad
of symptoms: episodic dizziness (mainly vertigo or motion-sensation), fluctuating
hearing loss usually in one ear, and fluctuating tinnitus (ear noises or ear-ringing),
also usually in one ear.
There
are two major organs of the inner ear: 1. The cochlea which is
responsible for hearing, and 2. The vestibule, which is responsible for
balance. There is a liquid which flows
through the chambers and canals of the inner ear and bathes the receptor cells
in both the cochlea and vestibule. The
receptor cells connect to a single nerve cell (a neuron) which then
travel from the inner ear to the brain.
Those neurons from the cochlea collectively form the cochlear nerve
and those from the vestibule form the vestibular nerve (do you see the
crafty logic behind medical terminology?).
The
vestibular nerve sends signals or messages to the brain indicating the latest
position of the body. The eyes, muscles
and joints also send positional messages to the brain. Thus, the inner ear is only one part of a
system that helps with the body’s balance.
The brain interprets these messages, and then sends out instructions to
the body so that it can adjust and balance itself. The cochlear nerve sends signals generated
from sound stimuli to the ear. The brain
then interprets the meaning of these sounds.
Note:
the “fluid” we are talking about is within the dense bony chambers of the inner
ear. Fluid in the middle ear (the
space between the ear drum (tympanic membrane) and the that bony inner
ear) is entirely a different problem.
Middle ear fluid occurs more commonly and is a cause of otitis
media. Middle ear
fluid also is a result of eustachian
tube dysfunction.
If
the volume of liquid in the chambers and canals increases, the fluid pressure
also increases, sending an incorrect message to the brain. This affects both the cochlea and
vestibule. The fluid normally drains
into the endolymphatic sac located in the mastoid bone which then
absorbs and removes any excess fluid. In
Meniere's disease, increased fluid pressure causes the symptoms of this disease. It
is thought the production of the fluid is greater than the ability of the inner
ear to drain it through the endolymphatic sac.
Common symptoms are: vertigo (spinning or a sensation of movement when
the body is stationary), nausea and vomiting (a reaction to the vertigo),
hearing loss (or “muffled” sense of hearing), tinnitus
(ear ringing, usually of a lower frequency, much like the sound of a seashell
held to your ear), and a sense of ear stuffiness or ear fullness (due to the
hearing loss).
Meclizine
can alleviate and shorten the effects of the acute episode, but this should be
used sparingly given its side-effects of sedation. It is
a known as a vestibular sedative. There
are other medications (i.e., ondansetron,
phenergan) which can help control nausea and vomiting. Diuretics (i.e., hydrochlorothiazide and
triamterene, usually started at a low dose) are used to reduce the inner
ear fluid and often prescribed to prevent or reduce the dizzy episodes. Antihistamines are sometimes used as there
might be an allergy component to this.
To reduce production of inner ear fluid, it is important to decrease salt in the diet; sodium
intake should not exceed 2,000mg per day.
I’ll admit this can be very bland, but the typical American diet is way
too high in sodium. Many patients find
it helpful to record daily sodium intake in a diary, since one can easily
surpass 2,000mg. Also eliminate or
reduce caffeine and alcohol intake, and do not smoke. Stress relief can also help. It is also important to stay well-hydrated,
drink plenty of fluids, which sounds counter-intuitive, but it is believed it’s
the excess dietary sodium that causes the fluid retention, not the oral intake
of more water or fluids.
More
invasive forms of therapy include a technique called intratympanic injection
of either gentamycin or a steroid. This
technique actually is trans-tympanic (across the tympanic membrane). Gentamycin is a strong antibiotic but
has an ototoxic (“ear-toxic”) side-effect where it can kill off the receptor
cells in the inner ear. It is thus
considered an ablative therapy, utilizing the ototoxic properties of the
drug. A small needle is placed through
the tympanic membrane (after it has been anesthetized) and the gentamycin is
injected into the middle ear space. It
then gets absorbed through the round window (a membranous window within
the bone of the cochlea) and enters the fluid within the inner ear. For some reason, gentamycin selectively kills
the receptor cells more so in the vestibule rather than the cochlea, but a
minority of patients can have toxic effects in the cochlea, and thus one of the
risks of this treatment is permanent hearing loss. A steroid such as dexamethasone can
also be delivered in the same way.
Steroids are anti-inflammatory medications, and it is theorized there is
an inflammatory reaction during acute episodes of Meniere’s. There is less of a risk for hearing loss; in
fact, the other indication for intratympanic steroid injections is for the
treatment of sudden-onset hearing loss.
There
are other more involved surgical approaches for Meniere’s disease if these
measures are unsuccessful. Candidates
for surgery would often be referred to an otology subspecialist, one who has
additional fellowship training beyond ENT residency and who specializes in more
complex ear surgery.
Surprisingly, some of the nonmedical therapies work well,
such as reducing dietary salt. I’ve had
testimonials from a few patients stating this, especially when they were
diligent in the sodium restriction and recorded their salt intake. They actually had better results than medical
therapy.
Most of us know that a sensible diet, proper exercise,
avoidance of too much salt and sugar are good for you. It’s putting this into practice that’s
difficult. As with many things in life
that are beneficial, it’s a matter of willpower, the sheer audacity to take
control of your physiology and mental weakness to do what’s right and proper
for your body, your mind, and ultimately your overall well-being. To help you through this and perhaps provide
some motivation, think beyond yourself; think about those who rely on you, are
dependent on you for their well-being and existence. And I’m going to get a bit preachy here by saying
that no matter who you are, you are important to someone else. We--along with every other human being on
this planet--are all vital parts of a collective whole. Anyway, that’s my sermon. But I am of the mind to always try the most
conservative approach first (i.e., diet and lifestyle changes), then move to
pharmaceutical treatments and reserving invasive procedures and surgery for
last. So for Meniere’s sufferers, there
are a variety of options out there to help with this problem.
©Randall S. Fong, M.D.
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