Stages

Stages of Meniere’s disease

Three stages

Meniere’s disease generally progresses through three distinct stages of symptoms. However you can’t predict the timing of stages and severity of symptoms at each stage for a particular individual – these vary from person to person. This can make diagnosis of Meniere’s disease complex.

Symptom-free periods (remission) may also occur naturally. As well as making diagnosis difficult, all these variations make it difficult to judge the effectiveness of treatments in controlling symptoms.

Stage 1

Vertigo is a form of dizziness where your surroundings appear to ‘spin’. Vertigo is usually the main symptom at this stage and may be accompanied by severe vomiting. Vertigo attacks can last for hours – sometimes days – tending to occur in clusters. Balance returns after each attack but you can feel ‘washed out’ for days after.

Often, by the time you present for diagnostic tests, the ear has returned to normal. But because life style and dietary changes (eg reduced salt and caffeine intake) can lessen the long-term effects of Meniere’s disease, it is important to get an accurate diagnosis as soon as possible.

Patient history is one of the most important factors in making a diagnosis of Meniere’s disease. However, often the vertigo is so distressing that you can fail to notice other symptoms such as changes in hearing or tinnitus (ringing noise in the ear). You need an astute doctor asking the right questions!

Around half the people who are affected with this stage of Meniere’s may experience a remission of symptoms – that is, symptoms will ‘disappear’. This remission may last weeks, months or many years. Remission can occur even though you have experienced several attacks.

Stage 2

It is easier to diagnose Meniere’s disease during this stage, as the symptoms are ‘classical’:

  • Attacks of vertigo continue.
  • Tinnitus increases with attacks of vertigo and becomes continuous.
  • The feeling of pressure or fullness in the ear may be worse before and during a vertigo attack.
  • Hearing fluctuates, but never returns to normal levels.

Stage 3

This stage is often referred to as “burnt out Meniere’s”. Your hearing loss may be severe at all frequency levels to the point where it is difficult to recognise speech. There is no longer fluctuation in hearing levels as the hair cells of the inner ear have been destroyed. Although you may feel that your hearing is useless, it is rare for an ear to become completely deaf.

The tinnitus (noise in the ears) remains but may seem less of a problem because you’ve got used to it.

Attacks of vertigo (dizziness) occur much less frequently and eventually cease. Usually you no longer vomit and the nausea and dizziness is mild. Unfortunately when the ear has lost 50% of its balancing function, a persistent feeling of unsteadiness may replace attacks of vertigo. This lack of balance is more noticeable in the dark or where you cannot use your vision to orient yourself.

A few people may experience ‘drop attacks’ (Tumarkin’s crises) in which balance is lost for a few seconds and you fall to the ground – a particular concern for the elderly. Drop attacks occur without warning and with minimal vertigo. It’s unusual for these attacks to continue happening for longer than one year.

Diagnosis

Diagnosis of Meniere’s disease

Self-diagnosis checklist

Early diagnosis of Meniere’s is important so that you can begin treatments that may help reduce the long-term effects of the disease. If you suspect you have symptoms of Meniere’s disease complete the following checklist.

Professional medical diagnosis

If you have a typical history of ‘classic’ Meniere’s symptoms most doctors can diagnose Meniere’s without any special tests. However tests are recommended to confirm the diagnosis and assess the severity of your condition. Typical tests include:

  • blood tests, a CT scan (CAT scan) or an MRI scan to exclude other conditions that have similar symptoms to Meniere’s e.g. acoustic neuroma (tumour)
  • a physical examination of the ears, head and neck, and the part of the nervous system related to balance
  • a full investigation of hearing and balance function to confirm the diagnosis of Meniere’s and to assess its severity.

Hearing tests

Hearing tests may include:

  • assessment of hearing in both ears using pure tone and speech discrimination tests
  • electrophysiological tests to examine the function of the inner ear and the hearing nerves
  • electrocochleography – an ‘evoked response’ audiometry test that measures the response of the inner ear to sound stimuli introduced to the external auditory canal or middle ear
  • dehydration tests – drugs are used to reduce fluid in the ear and any resultant changes in hearing are measured

Balance tests

Balance tests are used to:

  • determine which ear is affected
  • assess the level of balance lost
  • assess the brain’s compensation for the damage in the ear

These tests make use of the connection between your inner ear and eyes in order to assess how well your balance mechanisms are working. They record and assess eye movement in response to head movement, body movement, rotation or temperature stimulation of the ears. For example:

  • harmonic acceleration tests involve sitting in a rotating chair with the lights turned off and checking to see if your inner ear is detecting the rotation.
  • caloric testing involves stimulating the horizontal semicircular canal in the inner ear by introducing warm or cold water (or air) into the outer ear canal and recording the resulting eye movements.

Treatment

Treatment of Meniere’s disease

Although there is no cure for Meniere’s disease you can manage and minimise the symptoms and secondary effects through a careful combination of lifestyle choices, medication and other treatments:

Get advice firstModify your dietInform yourself about Meniere’sManage your stress levelsTake medication if necessaryTry balance therapyTry ‘complementary’, ‘alternative’ or ‘natural’ therapiesAs a last resort you may need surgery

Get advice first

The best treatment for Meniere’s depends on what stage of the condition you are currently experiencing. It’s important to seek qualified medical advice from an appropriate health professional before beginning any treatment.

Modify your diet

Low salt diet

Meniere’s symptoms generally result from having excess fluid within your inner ear. This condition is called ‘endolymphatic hydrops’. Eating too much salt (sodium) increases this fluid, making your symptoms worse and even causing vertigo attacks.

Cutting back on salt in your diet is a key strategy in managing Meniere’s. This includes the salt found in many processed foods – often you are not aware it is there and need to check the food labelling. See our recommended links section for more information. Remember to inform your doctor before commencing a low salt diet especially if you are taking prescribed medications, eg. diuretics.

An acceptable level of sodium is no more than 120mg per 100g of food. Nearly all fresh foods are naturally low in salt. Many processed foods are not low in salt. Over 75% of our salt intake comes from the salt (or other forms of sodium such as baking powder) that is added to processed foods.

Download the following guidelines (pdf documents) for choosing low salt foods. These documents were produced to help you understand the importance of a low salt diet for all Australians and especially for people with Meniere’s who want to control their vertigo.

    • Quick Guide (53KB) – shows you how to tell which foods are low in salt
    • Bread and Iodine (23KB) – looks at the importance of low salt bread in controlling salt intake and recommends ways to avoid iodine deficiency. It has copyright information and contact details for the author.
    • Shopping List 1 (394KB) – pictures and information on over 50 low salt processed foods.
  • Shopping List 2 (504KB) – pictures and information on more low salt processed foods.

See our catalogue for more information resources that can help you plan a low salt diet.

As reducing salt intake is a key strategy in managing Meniere’s, MA have joined AWASH (Australian Division of World Action on Salt and Health). AWASH issue a newsletter called “Drop The Salt Campaign Bulletin”. To find out more about AWASH or to join visit their website www.awash.org.au.

Low caffeine diet

It is thought that the caffeine found in tea, coffee and cola drinks can constrict blood vessels and make tinnitus (ringing noise in the ears) worse. Cutting back on your caffeine intake can be an effective strategy in managing Meniere’s. Foods that contain caffeine – like chocolate – are also best taken in moderation.

Avoid excess alcohol

Alcohol affects blood vessels and fluid balance in the body. Excess alcohol intake may make Meniere’s symptoms worse.

Inform yourself about Meniere’s

Your first step in managing Meniere’s is to learn as much as you can about the disease and the various ways you can manage it. The information below provides a starting point.

Medical professionals can provide you with more detailed medical information about the nature and likely progression of the disease. They can also advise you on suitable management strategies and medication options.

Talking to other people with Meniere’s can help answer many questions. Contacting and joining support groups such as Meniere’s Australia can help put you in touch with others in the same boat.

There is also a lot of information available in the form of pamphlets, brochures, books and videos. See our on-line Catalogue section.

Manage your stress levels

Emotional or physical stress can result in fluid retention in your body. This can make Meniere’s symptoms worse or act as a trigger for attacks of vertigo. It’s vital that you manage your stress levels.

Members are able to access MA’s library at the Meniere’s Resource and Information Centre or via phone or mail order. We have lots of resources that can help you with stress management.

Take medication if necessary

Caution: Seek your doctor’s advice first. Commonly used medications include:

  • Diuretics – increase the excretion of water from your body
  • Urea – quickly reduces fluid in the body and therefore the inner ear
  • Anti-emetics (eg Stemetil) – suppress vomiting and reduce nausea
  • Vestibular sedatives (eg Valium) – suppress neural output, the confusing messages that the affected ear(s) are sending to the brain
  • Vasodilators (eg Serc) – improve blood supply to the inner ear

Remember to inform your doctor if you are taking any ‘over-the-counter’ or natural therapies as these could interact negatively with prescribed medications.

Try balance therapy

Chronic vertigo or dizziness is a major symptom in the later stages of Meniere’s as the body’s balancing (vestibular) mechanism becomes damaged (see Stages of Meniere’s).

Through a series of graded exercises you can re-train your body to balance effectively by re-training the balance mechanism and/or by using alternative techniques like visual cues.

Try ‘complementary’, ‘alternative’ or ‘natural’ therapies

There are many ‘alternative’ therapies you can try to help manage the symptoms of Meniere’s. We strongly recommend that you inform your GP or specialist about any ‘alternative’ therapies or techniques you are using to manage Meniere’s.

Common ‘alternative’ therapies include the following:

  • Psychological therapies
  • Dietary measures
  • Energy therapies
  • Physical therapies
  • Traditional medicine

As a last resort you may need surgery

When Meniere’s symptoms cannot be managed by a combination of life style measures and medication, surgery may be considered. The following sections describe the two types of surgery available – destructive and non-destructive.

When considering surgery it’s wise to research the available options. If necessary seek further opinions.

Non destructive Surgery

These procedures attempt to alter the course of Meniere’s disease.

Endolymphatic sac surgery aims to improve or alter the function of the endolymphatic sac, which is thought to control either the production or absorption of the endolymphatic fluid. Long-term studies have shown that these operations are successful in approximately half to two thirds of patients.

Destructive Surgery

These procedures destroy the balance mechanism in order to gain control of vertigo. Only a very small percentage (around 5%) of people with Meniere’s will require surgical intervention for control of vertigo. Usually as Meniere’s disease progresses the acute disabling attacks of vertigo cease.

Chemical Ablation involves injecting the middle ear with antibiotics (eg Gentamicin, Streptomycin). The drugs are absorbed through the membranes between the middle and inner ear and are toxic to balance and hearing nerve endings. This treatment aims to reduce or destroy the vestibular function of that ear, helping to relieve symptoms of vertigo.

The following procedures are only considered when all other measures to control vertigo have failed.

Vestibular nerve section involves cutting the balance nerve of the affected ear to stop the incorrect signals reaching the brain. Hopefully the hearing nerve is spared.

A vestibular neurectomy aims to destroy the inner ear and is usually only considered if there is no useable hearing in the ear.

Psychology

Psychological impact of Meniere’s disease

Meniere’s disease doesn’t only affect you physically. The symptoms of this condition can affect all facets of your life including employment, family relationships, sporting and social activities.This in turn can undermine your psychological well-being – your confidence, self-esteem and sense of independence.

Most people diagnosed with Meniere’s experience a prolonged process of psychological adjustment before coming to terms with their condition. The various phases in this process are outlined below.

Phase One: Denial

This may be the longest phase if attacks of symptoms are infrequent. During this early phase you may:

  • deny – to yourself and others (excuses) – difficulties caused by Meniere’s
  • harbour fearful thoughts
  • lose confidence and self esteem

Phase 2: Anger

As the disease progresses you may:

  • experience feelings of anger, resentment and frustration – ‘why me?’
  • acknowledge but not yet accept the diagnosis of Meniere’s
  • blame others and doubt their ability to help
  • feel overwhelmed and confused

Professional and family support is vital during this phase.

Phase 3: Bargaining

During this phase you may still not accept the impact of Meniere’s on your life:

  • You may make bargains with yourself to ‘fix’ the condition so life will return to normal e.g. stop smoking, lose weight, change your diet, try alternative treatments.
  • When these actions have no major effect your reactions may alternate between anger and more bargaining.

Phase 4: Depression

This is generally the lowest point in the process of adjustment. Internalised anger can lead you to:

  • withdraw from life
  • suffer disrupted sleep and eating patterns
  • experience emotional disturbances
  • focus on loss and feel negative
  • feel that life is not worth living

Phase 5: Resolution and acceptance

Gradually, through a process of self-questioning, feelings of anger, frustration and denial are resolved and you become more hopeful and positive:

  • You begin to accept the diagnosis and understand what living with Meniere’s entails.
  • You recognise and accept your own limitations, understand what triggers vertigo attacks etc.
  • You realise that YOU must take control ie. make decisions and follow through with action.
  • You implement coping strategies eg wear a hearing aid, join a support group, undertake balance rehabilitation, seek out more information.
  • You re-evaluate priorities so that you take care of yourself.
  • You understand and meet your own needs.
  • You regain independence, strength and the ability to lead a fulfilling life.

Research

Current research related to Meniere’s disease

Meniere’s/Vertigo/BPPV Diagnostic Tool

More volunteers needed – Alfred Hospital-Monash University
Monash University (Australia) researchers believe they have developed a new diagnostic tool for assisting in the early detection of Meniere’s/Vertigo/BPPV disease and subsequently for measuring the effectiveness of drug therapies applied to their treatments.

Research has progressed well (see below). To complete the next stage of the project the team are now looking for more volunteers with diagnosed Meniere’s or BPPV or non specific Vertigo to participate. The test involves placing a cotton bud like electrode in the ear and voluntarily tilting the head forward and back. The test lasts about 1-1.5 hours. Meniere’s Australia Committee Member Lynn Polson OAM participated and found it to be a very interesting experience.

For more information email Bria Lithgow.

Progress report – May 2013
The research into the uses of ElectroVesibulography (EVestG) as a tool for detecting and monitoring Vestibular disorders is progressing well thanks to the volunteers who have participated in the study.

In 2010 EVestG won the ABC New Inventor’s Invention of the year.

A second EVestG clinical facility is now operational at the Riverview Hospital Winnipeg Canada [associated with the University of Manitoba]. This facility is working on Balance disorders, as well as mild traumatic brain injury (concussion) and early detection of Alzheimer’s Disease (Dementia), both conditions affecting balance.

The Researchers have just completed a pilot blind trial of separating a number of vertiginous pathologies including BPPV, Meniere’s, Acoustic Neuroma with a >84% accuracy. These results have encouraged us to expand this blind trial. A journal on these results is currently being prepared.

Example Publications:

  1. “ElectroVestibuloGram (EVestG): The separation of Benign Paroxysmal Positional Vertigo and Meniere’s Disease” by B. Lithgow, M. Shoushtarian, and D. Heibert. MedSip2006, Glasgow, UK. CD Rom 4 pgs.
  2. “Electrovestibulography (EvestG): The “DC” potential used to separate Meniere’s Disease and BPPV” (2007) by A .Garrett, D.Heibert and B. Lithgow, Annual International Conference of the IEEE EMBS, Lyon France 4 pages.
  3. “EVestG signals: Feature selection.” B. J. Lithgow, D. Heibert. NER2009, Ankalya, Turkey. 4pgs.
  4. “Computer Models of the Vestibular Head Tilt Response, and their relationship to EVestG and Meniere’s Disease”, Heibert,D.,Lithgow, B.and Hourigan, K., Tokyo May 2010 International Conference on Cognitive and Neural Systems Engineering. 10pgs
  5. “A methodology for detecting field potentials from the external ear canal: NEER and EVestG”, (2012) Brian J. Lithgow, Annals of Biomedical Engineering, 40(8) 1835-1850. DOI:10.1007/s10439-012-0526-3.

Australian Meniere’s Research Fund Inc. (MRFI)

Australian Daniel Brown MSc (Hons) was awarded the first MRF Postdoctoral Research Fellowship for research into Meniere’s disease. Daniel worked with Professor Alec N Salt at the University of Washington USA. The research involved studies of the activity of hair cells within the inner ear that could reveal new insights into Meniere’s disease.

Funds for the Fellowship were donated by members of the Meniere’s Support Groups of Victoria and NSW, Australian corporations and individuals.

For more information about Dr Daniel Brown and the work that the Meniere’s Research Fund is currently undertaking visit the Meniere’s Research Fund Inc website.