Guideline for Ménière's disease offers 16 key action statements for diagnosis, treatment

An updated guideline for Ménière's disease offers criteria for diagnosis and recommendations on testing, treatment, and patient education.

The guideline from the American Academy of Otolaryngology—Head and Neck Surgery is meant to improve on one issued 20 years ago to improve timely, accurate diagnosis of Ménière's disease for optimal symptom control and patient outcomes. It is intended for clinicians in primary care, emergency medicine, otolaryngology, neurology, audiology, and physical/vestibular therapy and was published online April 8 by Otolaryngology–Head and Neck Surgery.

The guideline offers 16 key action statements. Among other steps, clinicians should:

• diagnose definite or probable disease in patients presenting with two or more episodes of vertigo lasting 20 minutes to 12 hours (definite) or up to 24 hours (probable) and fluctuating or nonfluctuating sensorineural hearing loss, tinnitus, or pressure in the affected ear;
• determine if patients meet the diagnostic criteria for vestibular migraine;
• get an audiogram as part of making the diagnosis;
• educate patients about the natural history of the disease, measures for symptom control, treatment options, and outcomes, as well as dietary and lifestyle modifications that may reduce or prevent symptoms; and
• offer a limited course of vestibular suppressants to patients with Ménière's disease for management of vertigo only during attacks, as well as diuretics and/or betahistine for maintenance therapy to reduce symptoms or prevent them.

The guideline also said that clinicians should not prescribe positive pressure therapy. They may offer MRI of the internal auditory canal and posterior fossa to patients with possible Ménière's and audiometrically verified asymmetric sensorineural hearing loss but should not routinely order vestibular function testing or electrocochleography to make the diagnosis. They may also offer intratympanic (IT) steroids to patients with active Ménière's disease not responsive to noninvasive treatment, IT gentamicin to patients with active disease not responsive to nonablative therapy, or labyrinthectomy in patients with active disease and nonusable hearing in whom less definitive therapy has failed.

The guideline emphasized that physicians should clinically distinguish Ménière's disease from other causes of vertigo that may mimic it, such as otosyphilis, vestibular neuritis, or acute labyrinthitis. In addition, because of the variety of clinical presentations in patients with definite and probable Ménière's disease, a full and accurate diagnosis may take months to attain.

“This is an important consideration since this speaks to the natural history and variable clinical presentation of Ménière's disease that the panelists on this clinical practice guideline felt should be highlighted,” the guideline stated. “This can directly affect clinical decision making and subsequent treatment recommendations.”

Treatment goals are to prevent or at least reduce the severity and frequency of vertigo attacks. In addition, treatment approaches aim to relieve or prevent hearing loss, tinnitus, and aural fullness and improve overall quality of life, the guideline said.