Treatment of Meniere's disease

The main goal of treatment for Meniere's disease is to stop attacks of systemic dizziness and damage to the hearing organ.

Treatment of Meniere's disease is mainly symptomatic and only in some cases can it be considered conditionally pathogenetic, for example, when using dehydration therapy and inhalation of gas mixtures. The surgical treatment used is also certainly symptomatic. Often, even the most radical surgical interventions do not relieve the patient from the painful attacks of Meniere's disease. This is confirmed by the statement of B. M. Sagalovich and V. T. Palchun (2000): "... there is no particular need to emphasize the difficulties of developing a treatment for Meniere's disease. Rather, the lack of a system of scientific principles and justifications in the approach to this problem can be considered explainable. Contradictions in the clinical outline, classification, etiology and pathogenesis of the disease doom the search for its treatment mainly to empiricism, and this is fraught with not only their futility, the occurrence of side effects, but also the danger of treatment in relation to various organs and systems." Such a pessimistic view of the problem of treating Meniere's disease, expressed by leading scientists, should not, however, affect the efforts undertaken to find the most effective treatment. These searches, in our opinion, should be based on the following principles:

1. since Meniere's disease is largely related to the so-called associative diseases, the treatment strategy requires the principle of identifying concomitant diseases that may be etiologically and pathogenetically associated with Meniere's disease;
2. when implementing the first principle, it is necessary to proceed from the fact that the most probable causes of Meniere's disease are various forms of cerebrovascular accidents, primarily in the vertebrobasilar arterial system, as well as autonomic and endocrine dysfunctions, allergies;
3. since the course of Meniere's disease goes through a number of specific clinical phases, which are characterized by certain morphofunctional changes both in the ear labyrinth and in the labyrinth-dependent structures of the central nervous system, treatment must be built taking into account these phases, i.e. taking into account the state of the systems and their elements involved in the formation of the labyrinthine syndrome; this principle is based on the position that Meniere's disease cannot be attributed entirely to a peripheral syndrome, since it is an integral pathological process, the final (possibly secondary) stage of which is hydrops of the labyrinthine, in which not only specific auditory and vestibular organs participate, but also, above all, other systems that selectively determine the trophic and barrier functions of the inner ear;
4. treatment of Meniere's disease should be comprehensive, i.e. it should be carried out simultaneously in relation to all identified active pathological foci that can, to one degree or another, influence the course of the underlying disease;
5. Treatment of Meniere's disease should be systematic - urgent during an attack and planned in the inter-attack period; special attention should be paid to planned treatment, since it, in combination with health-improving preventive measures, helps to optimize the long-term prognosis in relation to labyrinthine functions, reduces the severity of future attacks and leads to their less frequent occurrence;
6. Treatment of Meniere's disease should be preventive, especially if the periodicity of attacks is known; in this case, it is necessary to carry out preventive treatment, which can reduce the severity of the upcoming attack or even completely eliminate it; an indication for such treatment may be precursors of a crisis, which many patients feel well.

Indications for hospitalization

Depending on the severity of attacks, hospitalization may be required; in this case, rest, sedatives, antiemetics, and vestibular suppressants are prescribed. Hospitalization is necessary for surgical intervention for Meniere's disease and selection of an adequate course of conservative therapy, as well as for a comprehensive examination of the patient.

Treatment of Meniere's disease is divided into non-surgical and surgical. Non-surgical treatment, according to the classification of I.B. Soldatov et al. (1980), includes: carbogen or oxygen therapy, HBO (if oxygen therapy is indicated), drug treatment (sedative, analgesic, dehydrating, etc.), X-ray therapy (irradiation of the autonomic brain centers and cervical sympathetic ganglia), reflexology, physical therapy and exercise therapy, etc. (before any drug treatment, it is necessary to familiarize yourself with the contraindications to the use of a particular drug and its side effects).

Treatment of an acute attack of Meniere's disease is based on blocking pathological impulses emanating from the ear labyrinth affected by hydrops, reducing the sensitivity of specific vestibular and cochlear centers to these impulses, as well as non-specific centers of the autonomic nervous system. For this purpose, inhalation and dehydration therapy, minor tranquilizers, antidepressants are used, and gentle conditions are created for the patient. In the acute period, with vomiting, medications are administered parenterally and in suppositories. With concomitant migraine, analgesics, sleeping pills and antihistamines are prescribed. At the same time, the patient is prescribed a salt-free diet, drinking is limited and antiemetics are prescribed.

Emergency care should begin with measures to stop the attack (subcutaneous injection of 3 ml of 1% alpha-adrenoblocker pyrroxane and after 6 hours another 3 ml of 1% solution intramuscularly). The effectiveness of pyrroxane is enhanced by its combination with anticholinergics (scopolamine, platifillin, spasmolytin) and antihistamines (diphenhydramine, diprazine, suprastin, diazolin, tavegil, betaserk). In case of vomiting, antiemetic drugs of central action are prescribed, mainly thiethylperazine (torekan) - intramuscularly 1-2 ml or in suppositories, 1 suppository (6.5 mg) in the morning and evening.

Simultaneously with the use of drug therapy, a behind-the-ear meatotympanic novocaine block is performed (5 ml of a 2% solution of novocaine) so that the drug reaches the tympanic plexus. For this, the novocaine solution is injected along the posterior bone wall of the external auditory canal, sliding the needle along its surface, achieving complete blanching of the skin. The effectiveness of the procedure is assessed by a rapid (up to 30 minutes) significant improvement in the patient's condition. After the novocaine block, dehydration therapy is performed - bufenox, veroshpiron, hypothiazide, diacarb, furosemide (lasix), etc. In cases where intravenous administration of a diuretic is possible, for example, furosemide, it is used primarily in this way, followed by a transfer to intramuscular and oral (rectal) administration. For example, furosemide is administered intravenously slowly by jet stream in a dose of 20-40 mg 1-2 times a day until the attack stops.

Author's schemes for the treatment of an acute attack of Meniere's disease

Scheme by I.B. Soldatov and N.S. Khrappo (1977). Intravenously 20 ml of 40% glucose solution; intramuscularly 2 ml of 2.5% pipolfen solution or 1 ml of 10% sodium caffeine benzoate solution; mustard plasters on the cervical-occipital region, a heating pad on the legs, in case of concomitant hypertensive crisis - intravenously 20 ml of 25% magnesium sulfate solution (slowly!), after 30 min - intravenously 20 ml of 40% glucose solution + 5 ml of 0.5% novocaine solution (slowly, over 3 min!). If after 30-40 min there is no effect, then it is advisable to administer 3 ml of 1% pyrroxane solution subcutaneously and after 6 hours another 3 ml of this drug intramuscularly.

Scheme of V.T. Palchun and N.A. Preobrazhensky (1978). Subcutaneously 1 ml of 0.1% solution of atropine sulfate; intravenously 10 ml of 0.5% solution of novocaine; 10 ml of 40% glucose solution. If the effect is low - 1-2 ml of 2.5% solution of aminazine intramuscularly. After 3-4 hours, atropine, aminazine and novocaine are administered again. In severe attacks - subcutaneously 1 ml of 1% solution of pantopon. In case of arterial hypotension, the use of aminazine is contraindicated, in such cases a lytic mixture is prescribed in the form of a powder of the following composition: atropine sulfate 0.00025 g; pure caffeine 0.01 g; phenobarbital 0.2 g; sodium bicarbonate 0.25 g - 1 powder 3 times a day.

Method of T. Hasegawa (1960). 150-200 ml of 7% sodium bicarbonate solution, prepared ex tempore, is administered intravenously at a rate of 120 drops/min; 50 ml is administered beforehand to determine the tolerability of the drug. If the first infusion produces a positive effect, a course of 10-15 infusions is administered daily or every other day. The solution should be administered no later than 1 hour after preparation.

Treatment in the immediate post-attack period should consist of a set of measures aimed at consolidating the effect achieved from emergency therapy (appropriate diet, regimen, normalization of sleep, drug treatment with drugs used during the attack, with a gradual reduction in their dosage, identification of concomitant diseases.

Treatment in the interictal period should be active, systematic and comprehensive. Drug treatment should include the use of complex vitamin preparations with a set of microelements, sedatives and sleeping pills, if indicated, diet (moderate consumption of meat, spicy and salty dishes), exclusion of smoking and excessive consumption of alcoholic beverages, rational balance of work and rest, exclusion of sharp loads on the VA and the organ of hearing (occupational hazards), treatment of concomitant diseases.

The use of plasma-substituting solutions and parenteral nutrition solutions is promising in relation to the treatment of BM at its various stages, especially during an attack (polyglucin, rheopolyglucin with glucose, rheogluman, hemodez, gelatinol). These drugs have the ability to improve hemodynamics and microcirculation both in the body as a whole and in the inner ear, are effective anti-shock and detoxifying agents that normalize the electrolyte balance in the body's fluids and acid-base balance.

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Non-drug treatment of Meniere's disease

Treatment should not be aimed at rehabilitation of vestibular and auditory function. The following strategic directions should be considered:

• preventive measures - informing the patient, psychological and social counseling;
• nutritional recommendations that help balance metabolic processes in the body;
• promoting adaptation and compensation - timely discontinuation of drugs that suppress vestibular function and are used to relieve attacks of dizziness, and physical exercises aimed at training the vestibular apparatus and improving spatial coordination.

The goal of vestibular rehabilitation is to improve the patient's ability to maintain balance and movement, and reduce the manifestation of disease symptoms. It is important to note that in case of damage to the inner ear, rehabilitation of both vestibular and auditory functions is necessary. In case of bilateral hearing damage, social adaptation with rehabilitation of the lost auditory function is necessary - patients are recommended to wear hearing aids.

Drug treatment of Meniere's disease

The peculiarity of conservative treatment of this disease is the low level of evidence of the effectiveness of the treatment, which is associated with a number of factors: the etiology of the disease is not known for certain, there is a high percentage of placebo-positive treatment results, and the severity of pathological symptoms decreases with the course of the disease. Treatment measures for Meniere's disease are mainly empirical.

There are two stages of treatment for Meniere's disease: stopping attacks and long-term treatment,

To stop an attack in a hospital setting, intramuscular injection of atropine and platifillin solutions is used: in addition, vestibular blockers of central action and sedatives are used. The symptomatic effect of sedatives in acute dizziness is associated with a general effect, under which the ability of the vestibular nuclei to analyze and interpret impulses coming from the labyrinth is reduced.

In long-term treatment, various drugs are used to prevent the development of the disease. Of great importance in the complex treatment is the patient's adherence to a diet that allows limiting the amount of salt consumed. In addition, the complex of conservative therapy should be individually selected. In the complex treatment, drugs are prescribed that improve microcirculation and permeability of the capillaries of the inner ear. In some cases, they reduce the frequency and intensity of dizziness, reduce noise and ringing in the ears, and improve hearing. Diuretics are also prescribed, although there is data in the literature on the comparability of diuretic therapy with the placebo effect. The point of prescribing diuretics is that, by increasing diuresis and reducing fluid retention, they reduce the volume of endolymph, preventing the formation of hydrops. Some studies have found that diuretics have a positive effect, especially in women during menopause.

Betahistine is widely used at a dose of 24 mg three times a day. There are representative clinical studies confirming the effectiveness of betahistine in stopping dizziness and in reducing noise and stabilizing hearing in patients suffering from cochleovestibular disorders with hydrops of the inner ear, due to the improvement of microcirculation in the vessels of the cochlea. In addition, venotonics and drugs stimulating neuroplasticity are used in complex treatment, in particular, ginkgo biloba leaf extract at a dose of 10 mg three times a day. Drugs stimulating neuroplasticity are of particular importance in patients in complex treatment during vestibular rehabilitation.

Complex conservative therapy is effective in 70-80% of patients - the attack is stopped and a more or less long-term remission occurs,

Surgical treatment of Meniere's disease

Considering the fact that even according to the most favorable prognoses after the positive effect of conservative therapy, a number of patients continue to suffer from severe symptoms of Meniere's disease, the issue of surgical treatment of this disease is very relevant. Over the past decades, various approaches to solving this problem have been developed.

From a modern perspective, surgical treatment of Meniere's disease should be based on three principles:

• improving endolymph drainage;
• increasing the excitability thresholds of vestibular receptors;
• preservation and improvement of hearing.

Surgical treatment of Meniere's disease

Further management

It is necessary to inform the patient. People suffering from Meniere's disease should not work in transport, at height, near moving machinery, or in conditions of pressure drops. Smoking and alcohol consumption should be completely excluded. It is recommended to follow a diet with limited table salt. Patients are also recommended to do physical exercises under the supervision of a specialist to speed up vestibular rehabilitation. Good results are obtained by doing oriental gymnastics, in particular "tai chi". Physical therapy should be done only in the interictal period.

Forecast

For most patients, vertigo, often referred to as a crisis or attack of Ménière's disease, is the most frightening manifestation of the disease and the main cause of their disability, due to the severity and unpredictability of these attacks. As the disease progresses, hearing loss occurs and chronic vestibular dysfunction develops, leading to disability or decreased activity (for example, the inability to walk in a straight line), which in turn prevents most patients from engaging in professional activities.

Approximate periods of disability are determined by the specific course of the disease in a particular patient and the need for conservative and surgical treatment, as well as the possibility of conducting a comprehensive examination on an outpatient basis.

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Prevention of Meniere's disease

The etiology of the disease is unknown, so there are no specific prevention methods. When Meniere's disease develops, preventive measures should be aimed at stopping dizziness attacks, which are usually accompanied by a progressive decrease in hearing function and tinnitus. To achieve this, a set of conservative treatment methods and surgical techniques are used. In addition, preventive measures should include an examination of the patient to determine the psycho-emotional state and further social adaptation and rehabilitation. Elimination of stressful situations is of great importance in disease prevention.