Ménière’s Disease: Treatment Options, Dietary Restrictions, and Lifestyle Modifications

Abstract

This review aims to review treatments and studies for Ménière’s disease (MD) and the impact of dietary restrictions and lifestyle changes on MD symptoms.

INTRODUCTION

Ménière’s disease (MD) is a rare and chronic inner ear disorder characterized by hearing loss, tinnitus, and vertigo. It affects about 615,000 people in the United States with approximately 46,000 new cases diagnosed yearly. In most cases, the condition progresses gradually and significantly impacts an individual’s social functioning. The economic burden is substantial, affecting patients, their loved ones and healthcare systems due to decreased productivity, increased sick leaves, and more frequent medical consultations and testing.[1]

While the exact cause of MD remains unclear, symptoms can be managed through various treatments, including medication, surgery, hearing aids, and vestibular rehabilitation. Additionally, lifestyle modifications are often believed to provide some benefit. These include dietary changes, physical activity adjustments, regular exercise, sleep patterns, and stress management.[2]

Among dietary recommendations, salt and dairy restriction, and increased water intake are commonly advised, along with reducing caffeine and alcohol intake. More recently, the potential benefits of specially processed cereals and gluten-free diets have been explored for clinical efficacy. However, there is currently no consensus on the most effective nonsurgical approach for managing this condition.

TREATMENT OPTIONS

Ancient therapies

• Cupping therapy is an ancient practice that continues to be widely used, particularly in the Middle East, Africa, and the United Kingdom. This method involves creating suction inside cups placed on specific areas of the skin to enhance blood circulation. Studies and case reports published in the Cureus Medical Journal, a case report on a 54-year-old man and a 48-year-old MD patient with long-standing Ménière’s disease who did not respond to routine treatments and were reluctant to undergo surgery. As an alternative, they underwent monthly cupping therapy sessions for two years. Over time, both patients experienced a gradual reduction in symptom intensity and frequency, along with improvements in hearing loss. While cupping therapy has been practiced for centuries, there remains a lack of extensive clinical research, comprehensive data, and standardized medical protocols for its use in treating Ménière’s disease.[3]

Pharmacological options

• Pharmacological betahistine is a commonly prescribed medication for patients diagnosed with Ménière’s disease (MD) worldwide. A clinical study of betahistine drug usage and clinical outcomes investigated the use of betahistine in 78 patients with 96 affected ears diagnosed with cochlear MD, who received treatment for over six months. The study assessed hearing status, the frequency of acute hearing loss episodes, and disease progression.[4] Clinical factors, including age, sex, affected ear side, betahistine, trichlormethiazide treatment duration, and pretreatment hearing levels, were recorded from medical charts. Results indicated that the independent factors influencing hearing status included the four-tone average (P = 0.01) and low-tone average (P = 0.03). Patients who received an average of at least 277 days of betahistine treatment per year showed better odds of hearing improvement, particularly in low- and medium-frequency ranges. For patients with cochlear MD, consistent and long-term betahistine treatment may improve hearing outcomes in these frequency ranges. In another clinical study of betahistine for symptoms of Vertigo involving 17 studies and 1,025 participants, betahistine was evaluated for its effectiveness in treating vertigo. Twelve of these studies (567 patients) were published, while five were unpublished (458 patients). Sixteen studies, including 953 participants, compared betahistine with a placebo. Low-quality evidence suggested that betahistine may help reduce vertigo symptoms in patients with various causes of the condition.[5] Betahistine was generally well tolerated, with a low risk of adverse events. However, future research on vertigo management should employ more rigorous methodologies and focus on outcomes that are meaningful to patients and their families. Betahistine remains unapproved by the FDA due to the need for additional clinical studies differing from Europe and others around the world.

• Intratympanic gentamicin drug is widely used for treatment of MD symptoms. A study was conducted to evaluate the effectiveness of intratympanic gentamicin (ITG) injections as a treatment for Ménière’s disease (MD) in 71 patients with unilateral MD who had been unresponsive to medical therapy for at least one year, following the 1995 American Academy of Otolaryngology-Head and Neck Surgery guidelines. The patients received weekly intratympanic injections of gentamicin at a concentration of 27 mg/mL until symptoms indicating vestibular hypofunction developed in the treated ear. The primary outcome measures used were the 1995 AAO-HNS criteria for MD treatment outcomes, which included control of vertigo, disability status (evaluated by the Dizziness Handicap Inventory and UCLA Dizziness Questionnaire), hearing levels, and vestibular function measurements. Results showed that 83.1% of the patients achieved control of vertigo. In 17 patients, vertigo recurred after initial control, but 13 of them were successfully treated with additional gentamicin injections. Functional status and self-reported disability were significantly improved in patients who had control of their vertigo. Although the pure-tone hearing level remained unchanged two years posttreatment, hearing loss occurred in 23 patients at the end of the treatment, and in 9 and 11 patients at three months and two years, respectively. Vestibular function was maintained or only mildly reduced in 49.3% of patients, while vestibular areflexia was observed in the remainder. Control of vertigo was independent of the extent of vestibular damage. The study concluded that ending weekly intratympanic gentamicin injections when clinical signs of vestibular deafferentation appear can effectively control vertigo in most patients. It is a valuable treatment option, alongside other surgical methods, for patients with Ménière’s disease who do not respond to medical therapy.[6]

• Intratympanic corticosteroids (ITC), methylprednisolone—Intratympanic methylprednisolone (ITMP) corticosteroid injection has emerged as a non-ablative alternative to gentamicin in the management of refractory Ménière’s disease. Studies on methylprednisolone corticosteroids have shown improvements in controlling the MD symptoms, and in some patients reporting a complete cessation of vertigo attacks. A comparative study between gentamicin and methylprednisolone injections found that both treatments yielded positive results. However, intratympanic gentamicin injections were more effective in controlling MD symptoms than ITMP.[7]

• Intratympanic corticosteroids (ITC), dexamethasone—Intratympanic dexamethasone corticosteroid Transtympanic dexamethasone perfusion using the Silverstein MicroWick™ is another corticosteroid treatment for patients with Ménière’s disease.[8] A study involving 40 participants divided them into two groups: Group 1 (n = 34), who did not require further procedures, and Group 2 (n = 6), who needed additional treatments for their condition. In Group 1, 50% reported subjective improvement in tinnitus, 59% in aural fullness, 79% in vertigo, and 21% in hearing loss following MicroWick™ treatment. Statistical analysis revealed that improvements in aural fullness (P = 0.03) and vertigo (P = 0.002) were statistically significant. In Group 2, no significant symptom changes were observed. Audiological data showed no significant alterations in the pure-tone average or word recognition score posttreatment. These results suggest that the MicroWick™ method is particularly effective in reducing aural fullness and vertigo in patients with Ménière’s disease.[9] Similarly, another study conducted proven positive results with MD symptoms. Even though these studies on dexamethasone corticosteroids emerge as alternatives for gentamicin aminoglycoside antibiotics, the potential is a successful management option for these patients.[10]

A review comparing intratympanic gentamicin (ITG) and intratympanic corticosteroids (ITC) found that ITG offers some advantages in subjective outcomes but shows no significant difference in objective outcomes or complication rates. However, this advantage is relatively minor. Both treatments are effective and safe for managing acute episodes of Ménière’s disease.[11]

Surgical interventions

• Endolymphatic sac decompression (ESD)—The use of ESD has been widely adopted by the international neurotological community due to the high vertigo control rate. A statistical review concluded that there is a significant improvement in both aural fullness and tinnitus for patients undergoing ESD with no negative effect on audiological status. ESD is a viable option for the treatment of Ménière’s disease with vertigo, aural fullness, and tinnitus relief. Future prospective studies are needed to further improve the evidence of ESD’s effect on secondary symptoms of Ménière’s disease.[12]

• Triple Semicircular Canal Occlusion (TSCO) with Cochlear Implantation—A study on TSCO with Cochlear Implantation involved three patients—two men and one woman—aged between 45 and 61 years. Among them, two patients with unilateral Ménière’s disease achieved Class A vertigo control, while the patient with bilateral disease achieved Class B control. Hearing outcomes varied; two patients experienced minimal to no hearing loss on the treated side, whereas one patient had a 30 dB hearing loss postoperatively. These findings suggest that TSCO offers potential benefits as a treatment for intractable Ménière’s disease, providing an effective alternative to vestibular neurectomy with reduced morbidity and long-term stability. Although technically complex, the procedure is promising and warrants further investigation due to its advantages in vertigo control and hearing preservation.[13]

• Labyrinthectomy procedures—A study included 72 patients with a mean age of 56.7 years (SD 10.7), all with unilateral Ménière’s disease. Drop attacks were reported in 43 patients (59.7%), and 62 patients (86.1%) had previously failed symptom control with gentamicin injections. Preoperative word recognition scores averaged 36.4% (SD 23.7) in the affected ear, compared to 95.1% (SD 8.5) in the contralateral ear. The pure-tone average (PTA) before surgery was 65.5 dB (SD 18.0) in the affected ear, versus 16.2 dB (SD 13.5) in the unaffected ear. The average hospital stay was 2.0 days (SD 0.87, range 1–5 days). Three patients (4.2%) experienced prolonged postoperative vertigo. The findings highlight that drop attacks were common, and the hospital stay was generally short.[14]

• Vestibular neurectomy (VN)—As noted in the article, VN has been a standard surgical treatment for Ménière’s disease (MD) in leading institutions, such as Johns Hopkins Hospital. This procedure has been used for many years as a historical approach to managing MD surgically. A review of 73 patients who underwent VN demonstrated effective vertigo control, confirming its proven efficacy in managing Ménière’s disease symptoms.[15]

Dietary restrictions and lifestyle changes

It has been a holistic approach with limiting salt, caffeine, and alcohol intake and increasing intake of water. It has been the oldest recommendation to limit the salt intake for MD treatment. In the article “The relationship between nutrition and Ménière’s disease,” the clinical results showed that there are benefits of limiting salt, caffeine, alcohol, and processed cereals that have helped MD symptoms, depending on the patient’s compliance.[16]

In the statistical review, the article collected data from multiple articles, the author concluded that there is no evidence from randomized controlled trials to support or refute the restriction of salt, caffeine, or alcohol intake in patients with Ménière’s disease or syndrome. In a study conducted using standard Cochrane methods, with a study, 51 participants in Sweden were exposed to a dietary modification of receiving processed cereals, and the second included 233 individuals to received abundant water intake (35 mL/kg/day), or slept in darkness (in an unlit room for six to seven hours per night), or to receive no intervention. The duration of follow-up was two years. The outcomes assessed were “improvement in vertigo” and hearing. As these studies considered different interventions, we were unable to carry out any meta-analysis, and for almost all outcomes the certainty of the evidence was very low. We are unable to draw meaningful conclusions from the numerical results. The author concluded that the evidence of dietary interventions for Ménière’s disease is very uncertain.[17]

CONCLUSION

Despite numerous clinical studies aimed at understanding the cause of Ménière’s disease (MD), a clear diagnosis of its origin remains elusive, and there is no permanent cure at this time. According to the review of articles, some studies have shown slight improvements in MD symptoms with dietary restrictions and lifestyle changes, such as sleeping in a dark environment for extended hours, but the results are inconclusive regarding their effectiveness in addressing MD symptoms.

Pharmacological treatments, including betahistine, intratympanic gentamicin, intratympanic corticosteroids (ITC), methylprednisolone, and dexamethasone, have been shown to help control MD symptoms. Often, increasing the dosage or combining these medications is necessary to achieve symptom control.

In addition to pharmacological treatments, surgical options, such as endolymphatic sac decompression, triple semicircular canal occlusion, labyrinthectomy procedures, and vestibular neurectomy are available to manage MD symptoms, equally effective with side effects. It is common practice to use either pharmacological treatments, surgical interventions, or a combination of both, depending on the severity of MD symptoms.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.