Tuesday, February 5, 2013

Ménière's Syndrome

Ménière's Syndrome
Ménière's disease is a disease that affects the inner ear, and affects hearing and balance to a different degree. The disease is characterized by incidents of vertigo, hearing loss and low pitched tinnitus. The nature of the hearing loss is fluctuating then permanent. This means that it the symptom comes and goes. The person suffering from the disorder can hear for some time and them losses the hearing ability completely. The disease gets it name from Prosper Ménière, a French physician. He in an article that was published in 1861 reported that inner ear disorders caused vertigo. This disorder affects people in a different way; it ranges from a mild irritation to a permanent chronic disorder (Haybach, 1998, p. 55). Even though the disorder was recognized in the 19th century, no conclusive cause has been identified.
Ménière's syndrome is idiopathic. However, it is argued that it is related to endolymphatic hydrops, which is excessive fluid in the inner ear (Lempert and Neuhauser, p. 333). Haybach (1998, p. 8) endolymphatic fluid flows from its usual channels in the ear to other parts. This “hydrops” cause the damage. A membrane system in the ear known as the membranous labyrinth holds a fluid, endolymph. These membranes can be dilated incase pressure rises, thus blocking drainage. This may be linked to puffing up of the endolymphatic sac. Other tissues in the ear that are responsible for maintaining balance can also swell. In other cases, a blockage of the endolymphatic duct by scar tissue can occur. The duct can also be narrow from birth in other cases. In some other cases the stria vascularis can secrete excessive fluid. The symptoms of the disease can happen because of an infection in the middle ear, infection on the upper respiratory track, or a head trauma. Other causes can be use of aspirin, drinking alcohol or smoking cigarettes. In some people, the problem can be augmented by excessive use of salt. Shichinohe (1999: 71-72) propose that the disorder in various patients is as a result of the harmful implications of a herpes virus. Herpesviridae are normally present in various hosts but in a dormant state. The author goes further to argue that the virus becomes reactive in case of depression to the immune system like an infection, trauma or surgery.
A diagnosis is established on patients with complaints and those with medical history. Nevertheless detailed examination, otolaryngological examination, as well as audiometry and head MRI scan are performed to rule out a superior canal dehiscence or a vestibular schwannoma, such are other disorders that can cause similar symptoms. Haybach (1998, p. 9) argues that there is no definitive examination for disorder. It is only diagnosed when other diseases with similar symptoms are excluded.  Incase any cause has been identified, this would rule out the disorder. This is because by it very definition as a completely idiopathic disorder, there is no known cause.
Ménière's syndrome has been known as early as the 1860s. However, the disease was comparatively indistinct and general at the time of its discovery. The American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium (AAO HNS CHE) developed criteria for the diagnosis of the disorder. The organization also defined two sub-groups of the disorder: cochlear (without vertigo) and vestibular (without deafness) (Beasley and Jones, p. 111).
A criterion for the diagnosis of Ménière’s disease was developed in 1972 by the academy:
“Fluctuating, progressive, sensorineural deafness” (Beasley and Jones, p. 111).
“Episodic, characteristic definitive spells of vertigo lasting 20 minutes to 24 hours with no unconsciousness, vestibular nystagmus always present” (Beasley and Jones, p. 111).
“Usually tinnitus” (Beasley and Jones, p. 111).
“Attacks are characterized by periods of remission and exacerbation” (Beasley and Jones, p. 111).
The list however changed in the year 1985 change words like “deafness” to “hearing loss associated with tinnitus, characteristically of low frequencies” as well as necessitating more than just a single vertigo attack to diagnose (Beasley and Jones, p. 111). The list was again altered to account for degrees of the disorder:
    “Certain - Definite disease with histopathological confirmation”
    “Definite - Requires two or more definitive episodes of vertigo with hearing loss plus tinnitus and/or aural fullness”
   “Probable - Only one definitive episode of vertigo and the other symptoms and signs”
    “Possible - Definitive vertigo with no associated hearing loss” (Beasley and Jones, p. 111).
Treatment and management
Various dietary and environmental changes are believed to lower the incidence or severity of Ménière’s disease symptom outbreaks. It is suggested that given the fact that excessive intake of salt cause water retention, it can cause an increase (or avert the decrease) of the fluid in the inner ear. However, there is no conclusive explanation of the relationship between excessive intake of salt and the inner ear. High intake of salt is believed to change the amounts of fluid in the ear. This means that the episodes of the disease can be increased by high intake of salts. It is recommended that a person should take one to two grams of salt in a day. To facilitate low salt diets, diuretics have conventionally been prescribed. However, there is no sufficient evidence to support this argument (Greenberg and Nedzelski, p. 1081). Individuals diagnosed with the disease may be required to stop taking alcohol, caffeine and smoking tobacco. This is because all these are elements that can increase the symptoms of the disorder. Some patients diagnosed with the disorder may require allergy testing in order to find out whether they qualify for allergy desensitization. This is because some allergies have been recognized to increase the symptoms of the disorder
Medicine has been used in the treatment and management of Ménière’s syndrome. Prescription and over-the-counter drugs are utilized in the efforts to lessen vomiting and nausea during episodes. Some of the medicines that are used include antihistamines like “meclozine or dimenhydrinate, trimethobenzamide and other antiemetics, betahistine, diazepam, or ginger root” (Haybach, 1998, p. 198). Betahistine particularly has been proposed as a drug capable of preventing the symptoms of the disorder. This is because of the drug’s vasodilation impact on the inner ear (Greenberg and Nedzelski, p. 1081). The antiherpes virus medicine acyclovir has also been utilized with some effectiveness in the treatment and management of the disorder.
The possibility for success in the treatment of the disorder is found to depend on the duration of the infection. The success is found to decrease with increased duration of the disorder. This is possibly due to the fact that viral suppression does not affect the damage in a reverse manner. In patients suffering from the disorder, Morphological alterations to the inner ear have been identified. This is probably because of infections by the herpes simplex virus. It was thus suggested that long-term treatment using acyclovir (more than half a year) would be necessary to render a favorable effect on the symptoms of the disorder. By use a process referred to as HHV Latency Associated Transcript, the virus has the capability of staying inactive in the nerve cells. Ongoing use of acyclovir works in preventing reactivation of this virus and also enable for the probability of an improvement in terms of the symptoms. Another perspective is that various strain of this virus can show varying traits. This can cause differences in the exact implications of the virus. This is further evidence that the drug can have positive effects on the symptoms of the disorder (Haybach, 1998, p. 198).  
Researches carried out as far as the utilization of transtympanic micropressure pulses is concerned have showed promise with sufferers of the disease who had not in the past been treated by surgery or by gentamicin or surgery. Other researches show less clear findings and suggest that micropressure procedures are basically placebos (Haybach, 1998 p. 198-200).
Some of the health ways of reducing stress and anxiety in individuals with the disease include “aromatherapy, yoga, t'ai chi, and meditation” (Haybach, 1998 p. 198-200). Greenberg and Nedzelski (2010) suggest education to deal with depression and helplessness.
Surgery can be considered in cases that fail to respond to typical treatment. However, because of the functioning of the ear, there are few surgeries that ca guarantee success without loss of hearing. Nondestructive surgeries are those that aim at improving the working of the ear, without removing any functionality. Intratympanic steroid treatments entail injection of steroids such as dexamethasone in the middle ear. This is aimed at reducing inflammation and change circulation in the inner ear. For temporal relief of symptoms Surgery aimed at decompressing the endolymphatic sac are used. Destructive surgeries on the other hand cannot be reversed and entail complete removal of functionality of the ear which is affected. Labyrinthectomy removes the inner ear itself and can cause complete loss of hearing (Haybach, 1998 p.212). However, a chemical labyrinthectomy, where drug like gentamicin is put into the middle ear to kill the vestibular apparatus can have the same results without affecting hearing. In a vestibular neurectomy, the nerve of the balance part of the ear can be cut.
This plays a major part in the management of Meniere’s syndrome. Professionals utilize interventions in vestibular rehabilitation that aim at stabilizing gaze, lowering dizziness, and enhancing balance. Once a vestibular evaluation is carried out, the professional customizes the management plan to the particular needs of the sufferer (Haybach, 1998 p.215). Due to the plastic nature of the central nervous system, it can be re-trained. In vestibular rehabilitation, experts take advantage of the elastic nature of the central nervous system by inciting symptoms of lack of balance or dizziness with head movement, while letting the visual, vestibular and somatosensory systems to perform interpretation of the information. The process causes an ongoing decrease of the symptoms. Even if a lot of research has been carried out in regards to the use of regarding vestibular rehabilitation in other diseases, not much as been carried out particularly on Meniere’s syndrome. However, it is accepted as a best practice in its management.
Ménière's disorder begins restricted to one ear, but with time it might extend to the second ear. The number of individuals who suffer from bilaterial Ménière’s is not certain. Haybach (1998, p. 10) gives a range spanning from 17% to 75%. Some patients suffering from this disorder, in serious cases, can end up losing their jobs because of the loss of functionality. They can also be in disability up to the time when the disorder burns out (Haybach, 1998, p. 224). Nevertheless, a majority, between 60 and 80 percent, of the patients will not require permanent disability. They can also get well with or without medical attention.  In the early stages of the disorder hearing loss normally fluctuates and goes on to become more permanent as the diseases progresses. However, hearing aids as well as cochlear implants can assist in remedying the damage.  Tough sufferers get used to tinnitus over time, it can be unpredictable (Haybach, 1998, p. 223).
Due to its unpredictable nature, the disease has a variable prognosis. Attacks resulting from the disorder can be more frequent and more severe, less frequent and less severe, and any place in between. Nevertheless, the disorder is known to “burn out.” This happens when the vestibular functioning is destroyed to a level where there is ceasing of vertigo attacks. Researches carried out on both left and right ear patients reveal that those who are affected in the right ear tend to suffer more as far as cognitive performance is concerned (Theilgaard, Laursen, Kjaerby, et al. p. 103). Generally there was no effect on intelligence, and a conclusion was made that decreasing performance depended on the length of time that the patient has been suffering from the disorder.

Work cited
Beasley NJ, Jones NS Menière's disease: evolution of a definition. J Laryngol Otol 110 (12):
(December 1996). 1107–13.
Greenberg, Simon; Julian Nedzelski, Medical and Noninvasive Therapy for Meniere's Disease.
The Otolaryngologic clinics of North America 43 (5): (October 2010).  1081–1090.
Haybach, P. J. Meniere's Disease: What You Need to Know. Portland, OR: Vestibular Disorders
Association (1998).
Lempert, T.; Neuhauser, H. Epidemiology of vertigo, migraine and vestibular
migraine. Journal of Neurology 256 (3): (November 2008).  333–338.
Shichinohe, Mitsuo Effectiveness of Acyclovir on Meniere's Syndrome III Observation of
Clinical Symptoms in 301 cases. Sapporo Medical Journal 68 (4/6): (December 1999).  71–77.
Theilgaard A, Laursen P, Kjaerby O, et al Menière's disease. II. A neuropsychological study.
ORL J. Otorhinolaryngol. Relat. Spec. 40 (3): (1978). 139–46