Treatment of Meniere's Disease

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

Treatment of Ménière's disease is mostly symptomatic and only in some cases it can be considered conditionally pathogenic, for example, with the use of 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 of the painful seizures of Meniere's disease. This is confirmed by the statement of B.М. Sagalovich and V.T. Palchouna (2000): "... There is no special need to stress the difficulties of developing treatment for Meniere's disease. Rather, it can be considered explainable the lack of a system of scientific principles and justifications in approaching this problem. Contradictions in the clinical outline, classification, etiology and pathogenesis of the disease doom the search for treatment of its predominantly empiricism, and this is fraught not only with 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 Ménière's disease, expressed by prominent scientists, however, should not affect the efforts made in the search for the most effective treatment. These searches, in our opinion, should be based on the following principles:

1. since Ménière's disease in many respects refers to so-called associative diseases, the strategy of treatment requires the principle of identifying co-morbid diseases that can be etiologically and pathogenetically associated with Meniere's diseases;
2. when implementing the first principle, it must be assumed that the most likely causes of Meniere's disease are various forms of cerebral circulation, mainly in the vertebral-basilar arterial system, as well as vegetative and endocrine dysfunctions, allergies;
3. since the course of Meniere's disease passes through a number of specific clinical phases characterized by certain morphofunctional changes both in the ears labyrinth and in 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 a labyrinthine syndrome; this principle is based on the proposition that Meniere's disease can not be attributed entirely to peripheral syndrome, since it is a holistic pathological process, the final (possibly, secondary) stage of which is the labyrinth hydrophyx, in which not only specific auditory and vestibular organs, but also, above all, other systems that selectively determine the trophic and barrier functions of the inner ear;
4. Treatment of Ménière's disease should be complex, that is, carried out simultaneously in relation to all identified active pathological foci, which may in some way influence the course of the underlying disease;
5. treatment of Meniere's disease should be systematic - urgent in the period of attack and planned in the interictal period; planned treatment should be given special attention, since it, combined with preventive health interventions, optimizes the long-term prognosis for labyrinth functions, reduces the severity of future seizures and leads to their more rare occurrence;
6. Treatment of Meniere's disease should be prophylactic, especially if the frequency of seizures is known; in this case it is necessary to carry out pre-emptive treatment, which can reduce the severity of the impending attack or even completely exclude it; Indication of this treatment may be precursors of the crisis, which many patients are well-experienced.

Indications for hospitalization

Depending on their severity, attacks may require hospitalization; while prescribing rest, sedatives, antiemetics, vestibular suppressants. Hospitalization is necessary for surgical intervention for Meniere's disease and the selection of a course for adequate conservative therapy, as well as for a comprehensive examination of the patient.

Treatment for Meniere's disease is divided into nonoperative and surgical. Non-surgical treatment, according to IBSoldatov's classification (1980), includes: carbogen or oxygen therapy, HBO (with indications to oxygen therapy), drug treatment (sedative, analgesic, dehydration, etc.), X-ray therapy (irradiation vegetative cerebral centers and cervical sympathetic nodes), reflexotherapy, FTL and exercise therapy, etc. (before any medication should be familiar with the contraindications to the use of a drug and its side effects).

Treatment of an acute attack of Meniere's disease is based on blockade of pathological impulses emanating from the affected labyrinth of the hydrops, reducing the sensitivity to these impulses of specific vestibular and cochlear centers, as well as nonspecific centers of the autonomic nervous system. To do this, use inhalation and dehydration therapy, small tranquilizers, antidepressants, create sparing conditions for the patient. In acute period during vomiting, drugs are injected parenterally and in candles. With concomitant migraine, analgesics, sleeping pills and antihistamines are prescribed. At the same time, the patient is prescribed a salt-free diet, restricts drinking and prescribes antiemetics.

Emergency care should begin with interventions that stop the attack (subcutaneous injection of 3 ml of 1% adrenoblocker pyrroxane and after 6 hours another 3 ml of 1% solution intramuscularly). The effectiveness of pyrroxane is enhanced when it is combined with cholinolytics (scopolamine, platyphylline, spasmolytin) and antihistamine drugs (diphenhydramine, diprazine, suprastin, diazolin, tavegil, betaserk). When vomiting is prescribed antiemetic drugs of central action, mainly thiethylperazine (tourekan), - intramuscularly 1-2 ml or in suppositories, 1 suppository (6.5 mg) morning and evening.

Simultaneously with the use of drug therapy, a BTE meatotimpanal Novocaine blockade (5 ml of a 2% solution of novocaine) is performed so that the drug reaches the plexus plexus. To do this, the solution of novocaine is introduced along the posterior bone wall of the external auditory canal, by sliding a needle along its surface, achieving complete blanching of the skin. The effectiveness of the procedure is assessed by a rapid (up to 30 min) significant improvement in the patient's condition. After novocaine blockade, dehydration therapy is carried out - bufenox, veroshpiron, hypothiazide, diacarb, furosemide (lasix), etc. In cases where intravenous administration of a diuretic, for example furosemide, is possible, it is first applied in this way, with a subsequent transfer to intramuscular and oral (percutaneous) administration. For example, furosemide intravenously injected slowly in a dose of 20-40 mg 1-2 times a day until the end of the attack.

Author's schemes of treatment of acute attack of Ménière's disease

The scheme of IBSoldatov and NSKhrappo (1977). Intravenously 20 ml 40% glucose solution; intramuscularly 2 ml of a 2.5% solution of pipolpene or 1 ml of a 10% solution of caffeine-benzoate sodium; mustard on the cervico-occipital region, warmer to the feet, with the accompanying hypertensive crisis - intravenously 20 ml 25% solution of magnesium sulfate (slowly!), after 30 minutes - intravenously 20 ml 40% glucose solution + 5 ml 0.5% solution of novocaine slowly, for 3 minutes!). If after 30-40 minutes of the effect does not occur, it is advisable to administer 3 ml of a 1% solution of pyrroxane 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 a 0.1% solution of atropine sulfate; intravenously 10 ml of 0.5% solution of novocaine; 10 ml 40% glucose solution. At low efficiency - 1-2 ml of a 2.5% solution of aminazine intramuscularly. After 3-4 hours, re-enter atropine, aminazine and novocaine. In severe seizures, subcutaneously 1 ml of a 1% solution of pantopone. With arterial hypotension, the use of aminazine is contraindicated, in such cases, the lytic mixture is administered in the form of a powder of the following composition: atropine sulfate 0.00025 g; caffeine pure 0,01 g; phenobarbital 0.2 g; sodium bicarbonate 0.25 g - 1 powder 3 times a day.

Method T. Hasegawa (1960). Intravenously inject 150-200 ml of a 7% solution of sodium bicarbonate, prepared ex tempore, at a rate of 120 cap / min; 50 ml is first introduced to determine drug tolerance. With a positive effect from the first infusion, a course of 10-15 infusions is administered daily or every other day. The solution should be administered no later than 1 hour from the time of preparation.

Treatment in the immediate after-treatment period should consist of a set of measures aimed at fixing the effect achieved from urgent therapy (appropriate diet, regimen, sleep normalization, drug treatment with drugs used in the seizure period, with a gradual decrease in their dosage, and 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 trace elements, according to indications, sedatives and hypnotics, diet (moderate consumption of meat, sharp and salty foods), the exclusion of tobacco smoking and excessive consumption of alcoholic beverages, the rational balance of labor and recreation, exclusion of sharp loads on VA and hearing organ (profvrednostey), treatment of concomitant diseases.

Promising in the treatment of BM in its various stages is the use of plasma-substituting solutions and solutions for parenteral nutrition, especially in the period of attack (polyglucin, reopolyglucin with glucose, rheoglumane, hemodez, gelatin). 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 body fluids and CBS.

[1], [2], [3]

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;
• recommendations on nutrition, allowing to balance the metabolic processes in the body;
• facilitating adaptation and compensation - timely abolition of vestibular suppressive drugs used to stop dizziness attacks, and physical exercises aimed at training the vestibular apparatus, to improve coordination in space.

The goal of vestibular rehabilitation is to improve the patient's ability to maintain balance and movement, to reduce the manifestation of symptoms of the disease. It is important to note that when the inner ear is damaged, rehabilitation of both vestibular and auditory function is necessary. With bilateral hearing loss, social adaptation is necessary with the rehabilitation of the lost auditory function - the patient is shown hearing.

Medicamentous treatment of Ménière's disease

The peculiarity of conservative treatment of this disease is low 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 results of treatment, the severity of pathological symptoms is observed with the course of the disease. The therapeutic measures for Meniere's disease are mostly empirical in nature.

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

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

With long-term treatment, various drugs are used to prevent the development of the disease. Of great importance in complex treatment is adherence to patients diet, which allows to limit the amount of salt consumed. In addition, the complex of conservative therapy should be individually selected. In complex treatment prescribe drugs 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, improve hearing. Assign also diuretics, although the literature has data on the comparability of diuretic therapy with the placebo effect. The meaning of diuretic prescription is that, by increasing diuresis and reducing fluid retention, they reduce the volume of the endolymph, preventing the formation of a hydrops. Some studies have found that diuretics have a positive effect, especially in women during menopause.

Widely used betahistine in a dose of 24 mg three wounds a day. There are representative clinical studies confirming the efficacy of betahistin in dizzying and with respect to reducing noise and hearing stabilization in patients suffering from cochleostestibular disorders in hydrops of the inner ear, by improving the microcirculation in the vessels of the cochlea. In addition, venotonics and drugs stimulating neuroplasticity are used in complex treatment, in particular ginkgo bilobate leaf extract in a dose of 10 mg three times a day. Of particular importance are drugs that stimulate neuroplasticity in patients with complex treatment for vestibular rehabilitation.

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

Surgical treatment of Ménière's disease

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

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

• improvement of drainage of the endolymph;
• an increase in the thresholds of vestibular receptor excitability;
• preservation and improvement of hearing.

Surgical treatment of Ménière's disease

Further management

It is necessary to inform the patient. Those suffering from Meniere's disease should not work in transport, at altitude, near moving machinery, to conditions of pressure drop. Smoking and drinking should be completely ruled out. Recommend the observance of a diet with restriction of table salt. Patients are also recommended exercise complexes under the supervision of a specialist to accelerate vestibular rehabilitation. Good results are given by oriental gymnastics, in particular "tai chi". Classes of curative physical culture should be conducted only in the inter-attack period.

Forecast

For most patients, dizziness, which is often called a crisis or a bout of Meniere'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. In the course of the development of the disease, hearing impairment develops and chronic vestibular dysfunction develops, which leads to disability or decreased activity (for example, inability to go in a straight line), which, in turn, does not allow for professional activity in most patients.

Approximate terms of incapacity for work 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 survey in outpatient settings.

[4], [5], [6], [7], [8]

Prevention of Meniere's Disease

The etiology of the disease is unknown, so there are no specific prevention methods. With the development of Ménière's disease, preventive measures should be aimed at cessation of dizziness attacks which, as a rule, are accompanied by progressive decrease of auditory function and noise in the ears. To achieve this, a set of conservative methods of treatment and surgical techniques are used. In addition, preventive measures should include examination of the patient to determine the psycho-emotional state and further social adaptation and rehabilitation. The important thing in the prevention of the disease is the elimination of stressful situations.