Meniere's disease

ENT

1. Meniere’s Disease Mr. Binu Babu M.Sc. Nursing Mrs. Jincy Ealias M.Sc. Nursing

2. Introduction First described by Prosper Meniere in 1861 . Ménière’s disease is a balance disorder.

3. Definition Meniere’s disease is an abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolymphatic duct . It is also called endolymphatic hydrops.  It occurs bilaterally in about 20 % of patients.

4. Etiology Unknown. Common in adults Age : between 40 and 60 years of age Equally common in men and women Family history: 50% of the patients have a positive family history Hypersecretion or hypoabsorption of endolymph or both Deficit membrane permeability Allergy Viral infection Hormonal Imbalance Mental stress.

5. Pathophysiology  Obstruction of endolymphatic duct/sac Hypersecretion or hypoabsorption of endolymph or both Excessive accumulation of endolymph Distension of membranous labyrinth & endolymphatic sac Increased in pressure and rupture of inner membranes Loss of auditory and vestibular function Vertigo , tinnitus, hearing loss

6. Clinical features

7. Clinical Manifestations Fluctuating, progressive sensorineural hearing loss Tinnitus Vertigo Accompanied by nausea and vomiting and nystagmus. Vertigo lasts 2 to 4 hours . And followed by dizziness and unsteadiness .

8. Warning signs Headache A feeling of pressure or fullness in the ear Behavioral changes Irritability Depression Withdrawal

9. Types Two subtypes Cochlear Meniere's disease Vestibular Meniere's disease

10. Cochlear Meniere's disease is recognized as a fluctuating, progressive sensorineural hearing loss associated with tinnitus and aural pressure in the absence of vestibular symptoms. Vestibular Meniere's disease is characterized as the occurrence of episodic vertigo associated with aural pressure but no cochlear symptoms.

11. Diagnostic measures History collection Physical examination Audiogram : identify the type and magnitude of the hearing loss . CT or MRI: Electronystagmogram : to evaluate the oculomotor and vestibular systems to differentiate the cause of vertigo, tinnitus, and hearing loss of unknown origin.

12. Management Medical Management Pharmacologic therapy Dietary management

13. Pharmacologic therapy Antihistamine : to suppress the vestibular system. Eg : meclizine Tranquilizers : to control vertigo. Eg : diazepam Antiemetic : eg . promethazine (Phenergan ). To control the nausea and vomiting and the vertigo because of their antihistamine effect .

14. Diuretic : relieve symptoms by lowering the pressure in the endolymphatic system. Eg : hydrochlorothiazide, triamterene Vasodilators : eg : papaverine hydrochloride Avoid aspirin and aspirin-containing medications. Aspirin may increase tinnitus and dizziness.

15. If not responding to drugs; Ablation therapy Intratympanic injection of gentamicin is being used to cause ablation of the vestibular hair cells.

16. Dietary management Low-sodium ( 1000 to 1500 mg/day or less) diet . The amount of sodium is a factor that regulate the balance of fluid within the body. Sodium and fluid retention disrupts the delicate balance between endolymph and perilymph in the inner ear.

17. Limit foods high in salt or sugar . Eat meals and snacks at regular intervals to stay hydrated. Missing meals or snacks may alter the fluid level in the inner ear. Limit intake of coffee, tea, and soft drinks. Avoid caffeine because of its diuretic effect. Limit alcohol intake. Alcohol may change the volume and concentration of the inner ear fluid and may worsen symptoms. Avoid monosodium glutamate (MSG), which may increase symptoms .

18. Surgical Management The surgical treatment of Meniere's disease is aimed at eliminating the attacks of vertigo, so hearing loss , tinnitus, and aural fullness may continue. The surgical procedures are: Endolymphatic sac procedures Vestibular nerve section.

19. Endolymphatic Sac Decompression First-line surgical approach to treat the vertigo of Meniere's disease as it is simple, safe and can be performed on an outpatient basis. Through a postauricular incision, a shunt or drain is inserted in the endolymphatic sac and fluid is drained into subarachnoid space . Thus release of pressure on the endolymphatic system in the labyrinth

20. Vestibular Nerve Sectioning Performed by a translabyrinthine approach or in a manner that can conserve hearing ( ie , suboccipital or middle cranial fossa ), depending on the degree of hearing loss . Cutting the nerve prevents the brain from receiving input from the semicircular canals.

21. Nursing management Assess the severity and frequency of attack, any associated ear symptoms (hear loss, tinnitus ). Acute vertigo: provide bedrest , sedation, antiemetics Encourage patient to lie down during attack in safe place . Advise patient to avoid food that cause allergy . Maintain the prescribed low-salt diet

22. Impaired comfort related to impairment in auditory function or vestibular function. Impaired auditory sensory perception related to altered state of the ear. Risk for deficient fluid volume related to increase fluid output, altered intake. Risk for injury related to impaired equilibrium Anxiety related to threat to changes health status.