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'''Ménière's disease''' {{IPAc-en|m|eɪ|n|ˈ|j|ɛər|z}},<ref>''[http://dictionary.reference.com/browse/meniere%27s%20syndrome Dictionary.com Unabridged]'' (v 1.1). Random House, Inc. Accessed on 9 September 2008</ref> is a disorder of the [[inner ear]] that usually affects both [[Hearing (sense)|hearing]] and [[balance (ability)|balance]]. It is characterized by episodes of [[vertigo]] and by fluctuating or permanent [[tinnitus]] and [[hearing loss]]. The condition affects people differently. It can range in intensity from being a mild annoyance to a disabling disease. It is similar to many other conditions so a [[differential diagnosis]] is important.<ref name=2015DiagConsensus>Lopez-Escamez JA, Carey J, Chung WH, et al. Diagnostic criteria for Ménière's disease. J Vest Res 2015;25(1):1–7. PMID 25882471 [http://content.iospress.com/download/journal-of-vestibular-research/ves00549?id=journal-of-vestibular-research%2Fves00549 Free full text]</ref>
'''Ménière's disease''' {{IPAc-en|m|eɪ|n|ˈ|j|ɛər|z}},<ref>''[http://dictionary.reference.com/browse/meniere%27s%20syndrome Dictionary.com Unabridged]'' (v 1.1). Random House, Inc. Accessed on 9 September 2008</ref> is a disorder of the [[inner ear]] that usually affects both [[Hearing (sense)|hearing]] and [[balance (ability)|balance]]. It is characterized by episodes of [[vertigo]] and by fluctuating or permanent [[tinnitus]] and [[hearing loss]]. The condition affects people differently. It can range in intensity from being a mild annoyance to a disabling disease. It is similar to many other conditions so a [[differential diagnosis]] is important.<ref name="2015DiagConsensus">{{Cite journal|last=Lopez-Escamez|first=Jose A.|last2=Carey|first2=John|last3=Chung|first3=Won-Ho|last4=Goebel|first4=Joel A.|last5=Magnusson|first5=Måns|last6=Mandalà|first6=Marco|last7=Newman-Toker|first7=David E.|last8=Strupp|first8=Michael|last9=Suzuki|first9=Mamoru|date=2015|title=Diagnostic criteria for Menière's disease|journal=Journal of Vestibular Research: Equilibrium & Orientation|volume=25|issue=1|pages=1–7|doi=10.3233/VES-150549|issn=1878-6464|pmid=25882471}}</ref>


The immediate cause of Ménière's disease is unknown; the field was formerly centered on [[endolymphatic hydrops]], an excess of fluid in the inner ear, but in the 2000s other causes, like genetic susceptibility, infection, electrolyte imbalances, allergy, and autoimmune disease have been thought to be possible causes.<ref name=Seemungal2016>Seemungal B, Kaski D, Lopez-Escamez JA. Early Diagnosis and Management of Acute Vertigo from Vestibular Migraine and Ménière's Disease. Neurol Clin. 2015 Aug;33(3):619-28, 2. Review. PMID 26231275</ref>
The immediate cause of Ménière's disease is unknown; the field was formerly centered on [[endolymphatic hydrops]], an excess of fluid in the inner ear, but in the 2000s other causes, like genetic susceptibility, infection, electrolyte imbalances, allergy, and autoimmune disease have been thought to be possible causes.<ref name="Seemungal2016">{{Cite journal|last=Seemungal|first=Barry|last2=Kaski|first2=Diego|last3=Lopez-Escamez|first3=Jose Antonio|date=August 2015|title=Early Diagnosis and Management of Acute Vertigo from Vestibular Migraine and Ménière's Disease|journal=Neurologic Clinics|volume=33|issue=3|pages=619–628, ix|doi=10.1016/j.ncl.2015.04.008|issn=1557-9875|pmid=26231275}}</ref>


Evidence for all treatments is weak; they include use of drugs to manage the nausea and anxiety caused by vertigo, diuretics and changes in diet, and steroids. Physical therapy may help manage the loss of sense of balance, and therapy or relaxation techniques may be useful to help manage the distress caused by the condition. Surgical treatments to reduce pressure inside the ear, or to remove portions of the ear, may be used.
Evidence for all treatments is weak; they include use of drugs to manage the nausea and anxiety caused by vertigo, diuretics and changes in diet, and steroids. Physical therapy may help manage the loss of sense of balance, and therapy or relaxation techniques may be useful to help manage the distress caused by the condition. Surgical treatments to reduce pressure inside the ear, or to remove portions of the ear, may be used.
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Prior to the 2000s it was thought that MD was caused by [[endolymphatic hydrops]] (EH), an excess of fluid in the inner ear, where the [[vestibular system]] that controls spatial orientation resides. The [[membranous labyrinth]], a system of channels in the inner ear drained by the [[endolymphatic sac]], contains a fluid called [[endolymph]]; these channels and the sac swell when pressure increases, which can be caused by drainage from the sac being blocked.<ref name=Hain2012>Hain, TC [http://american-hearing.org/disorders/menieres-disease/ Meniere's Disease] at the American Hearing Research Foundation. Page last modified: 10/2012</ref>
Prior to the 2000s it was thought that MD was caused by [[endolymphatic hydrops]] (EH), an excess of fluid in the inner ear, where the [[vestibular system]] that controls spatial orientation resides. The [[membranous labyrinth]], a system of channels in the inner ear drained by the [[endolymphatic sac]], contains a fluid called [[endolymph]]; these channels and the sac swell when pressure increases, which can be caused by drainage from the sac being blocked.<ref name=Hain2012>Hain, TC [http://american-hearing.org/disorders/menieres-disease/ Meniere's Disease] at the American Hearing Research Foundation. Page last modified: 10/2012</ref>


That theory has come into question, since many people with healthy hearing and balance have high pressure in their inner ear and EH.<ref name=Hain2012/><ref name=IshiyamaRev>Ishiyama G, Lopez IA, Sepahdari AR, Ishiyama A. Meniere's disease: histopathology, cytochemistry, and imaging Ann N Y Acad Sci. 2015 Apr;1343:49-57. Review. PMID 25766597</ref> More recent theories have looked at possible [[autoimmune disease|dysfunction of the immune system]], since the endolymph is part of the immune system and there is a correlation between MD and other autoimmune disorders.<ref name=Hain2012/> As around 9% of cases appear to be genetic, researchers have looked for mutations that might lead to susceptibility to MD.<ref name=Hain2012/> In particular investigators suspect mutations in [[DTNA]] and [[FAM136A]].<ref name=2015DiagConsensus/>
That theory has come into question, since many people with healthy hearing and balance have high pressure in their inner ear and EH.<ref name=Hain2012/><ref name="IshiyamaRev">{{Cite journal|last=Ishiyama|first=Gail|last2=Lopez|first2=Ivan A.|last3=Sepahdari|first3=Ali R.|last4=Ishiyama|first4=Akira|date=April 2015|title=Meniere's disease: histopathology, cytochemistry, and imaging|journal=Annals of the New York Academy of Sciences|volume=1343|pages=49–57|doi=10.1111/nyas.12699|issn=1749-6632|pmid=25766597}}</ref> More recent theories have looked at possible [[autoimmune disease|dysfunction of the immune system]], since the endolymph is part of the immune system and there is a correlation between MD and other autoimmune disorders.<ref name=Hain2012/> As around 9% of cases appear to be genetic, researchers have looked for mutations that might lead to susceptibility to MD.<ref name=Hain2012/> In particular investigators suspect mutations in [[DTNA]] and [[FAM136A]].<ref name=2015DiagConsensus/>


As of 2015 doctors were divided into two camps; those who view MD as an ear disorder caused by EH, and those who view it more like migraine.<ref name=Foster2015rev/>
As of 2015 doctors were divided into two camps; those who view MD as an ear disorder caused by EH, and those who view it more like migraine.<ref name=Foster2015rev/>
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For longer term treatment to stop progression, the evidence base is weak for all treatments.<ref name=Seemungal2016/>
For longer term treatment to stop progression, the evidence base is weak for all treatments.<ref name=Seemungal2016/>


Although a causal relation between allergy and Menière's disease is uncertain, [[Allergy#Management|medication to control allergy]] may be helpful.<ref name=Allergy2014rev>{{Cite journal|pmc=4549154|year=2014|author1=Weinreich|first1=H. M.|title=The Link Between Allergy and Menière's Disease|journal=Current Opinion in Otolaryngology & Head and Neck Surgery|volume=22|issue=3|pages=227–230|last2=Agrawal|first2=Y|doi=10.1097/MOO.0000000000000041}} (Review).</ref>
Although a causal relation between allergy and Menière's disease is uncertain, [[Allergy#Management|medication to control allergy]] may be helpful.<ref name="Allergy2014rev">{{Cite journal|last=Weinreich|first=Heather M.|last2=Agrawal|first2=Yuri|date=June 2014|title=The Link Between Allergy and Menière's Disease|url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549154/|journal=Current opinion in otolaryngology & head and neck surgery|volume=22|issue=3|pages=227–230|doi=10.1097/MOO.0000000000000041|issn=1068-9508|pmc=4549154|pmid=24573125}}</ref>


[[Diuretics]] are widely used to manage Ménière's on theory that it will reduce fluid buildup in the ear; based on evidence from multiple but small clinical trials, diuretics appear to be useful for reducing the frequency of episodes of dizziness, but do not seem to prevent hearing loss.<ref>Crowson MG et al. A Systematic Review of Diuretics in the Medical Management of Ménière's Disease. Otolaryngol Head Neck Surg. 2016 May;154(5):824-34. PMID 26932948</ref>
[[Diuretics]] are widely used to manage Ménière's on theory that it will reduce fluid buildup in the ear; based on evidence from multiple but small clinical trials, diuretics appear to be useful for reducing the frequency of episodes of dizziness, but do not seem to prevent hearing loss.<ref>{{Cite journal|last=Crowson|first=Matthew G.|last2=Patki|first2=Aniruddha|last3=Tucci|first3=Debara L.|date=May 2016|title=A Systematic Review of Diuretics in the Medical Management of Ménière's Disease|journal=Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery|volume=154|issue=5|pages=824–834|doi=10.1177/0194599816630733|issn=1097-6817|pmid=26932948}}</ref>


In cases where there is significant hearing loss and continuing severe episodes of vertigo, a chemical labyrinthectomy, in which a drug (such as [[gentamicin]]) that "kills" parts or most of the vestibular apparatus is injected into the middle ear.<ref name=Seemungal2016/><ref name="PMID21412917">{{Cite book|pmid= 21412917|year= 2011|author1= Pullens|first1= B|title= Cochrane Database of Systematic Reviews|journal= The Cochrane database of systematic reviews|issue= 3|pages= CD008234|last2= Van Benthem|first2= P. P.|doi= 10.1002/14651858.CD008234.pub2|chapter= Intratympanic gentamicin for Ménière's disease or syndrome}} (Review).</ref><ref name="PMID22699980">{{Cite journal|pmid= 22699980|year= 2012|author1= Huon|first1= L. K.|title= Outcomes of intratympanic gentamicin injection to treat Ménière's disease|journal= Otology & Neurotology|volume= 33|issue= 5|pages= 706–14|last2= Fang|first2= T. Y.|last3= Wang|first3= P. C.|doi= 10.1097/MAO.0b013e318259b3b1}} (Review).</ref>
In cases where there is significant hearing loss and continuing severe episodes of vertigo, a chemical labyrinthectomy, in which a drug (such as [[gentamicin]]) that "kills" parts or most of the vestibular apparatus is injected into the middle ear.<ref name=Seemungal2016/><ref name="PMID21412917">{{Cite book|url=http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008234.pub2/abstract|title=Intratympanic gentamicin for Ménière's disease or syndrome|last=Pullens|first=Bas|last2=van Benthem|first2=Peter Paul|date=2011-03-16|publisher=John Wiley & Sons, Ltd|isbn=14651858|language=en|doi=10.1002/14651858.cd008234.pub2}}</ref><ref name="PMID22699980">{{Cite journal|last=Huon|first=Leh-Kiong|last2=Fang|first2=Te-Yung|last3=Wang|first3=Pa-Chun|date=July 2012|title=Outcomes of intratympanic gentamicin injection to treat Ménière's disease|journal=Otology & Neurotology: Official Publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology|volume=33|issue=5|pages=706–714|doi=10.1097/MAO.0b013e318259b3b1|issn=1537-4505|pmid=22699980}}</ref>


===Diet===
===Diet===
People with MD are often advised to reduce their salt intake for similar reasons, but the evidence for this is very poor.<ref name=Foster2015rev>Foster CA. Optimal management of Ménière's disease. Ther Clin Risk Manag. 2015 Feb 25;11:301-7 . Review. PMID 25750534 PMC 4348125 [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4348125/pdf/tcrm-11-301.pdf Free full text]</ref>
People with MD are often advised to reduce their salt intake for similar reasons, but the evidence for this is very poor.<ref name="Foster2015rev">{{Cite journal|last=Foster|first=Carol A.|date=2015|title=Optimal management of Ménière's disease|journal=Therapeutics and Clinical Risk Management|volume=11|pages=301–307|doi=10.2147/TCRM.S59023|issn=1176-6336|pmc=4348125|pmid=25750534}}</ref>


On the theory that MD is like migraine, some doctors advise eliminating "migraine triggers" like caffeine, but the evidence for this is weak.<ref name=Foster2015rev/>
On the theory that MD is like migraine, some doctors advise eliminating "migraine triggers" like caffeine, but the evidence for this is weak.<ref name=Foster2015rev/>


===Physical therapy===
===Physical therapy===
While use of physical therapy early after the onset of MD is probably not useful due to the fluctuating disease course, physical therapy to help retraining of the balance system appears to be useful to reduce both subjective and objective deficits in balance over the longer term.<ref name=Seemungal2016/><ref name="PMID9386249">{{Cite journal|pmid= 9386249|year= 1997|author1= Clendaniel|first1= R. A.|title= Vestibular rehabilitation strategies in Meniere's disease|journal= Otolaryngologic clinics of North America|volume= 30|issue= 6|pages= 1145–58|last2= Tucci|first2= D. L.}} (Review).</ref>
While use of physical therapy early after the onset of MD is probably not useful due to the fluctuating disease course, physical therapy to help retraining of the balance system appears to be useful to reduce both subjective and objective deficits in balance over the longer term.<ref name=Seemungal2016/><ref name="PMID9386249">{{Cite journal|last=Clendaniel|first=R. A.|last2=Tucci|first2=D. L.|date=December 1997|title=Vestibular rehabilitation strategies in Meniere's disease|journal=Otolaryngologic Clinics of North America|volume=30|issue=6|pages=1145–1158|issn=0030-6665|pmid=9386249}}</ref>


=== Coping ===
=== Coping ===
There appears to be vicious circle in MD for some people, as psychological distress caused by the vertigo and hearing loss appears to worsen the condition.<ref>Orji F. The Influence of Psychological Factors in Meniere's Disease. Ann Med Health Sci Res. 2014 Jan;4(1):3-7. Review. PMID 24669323 PMC 3952292 [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3952292/ Free full text]</ref> Psychiatric care or counseling may be useful to manage the distress,<ref name=Seemungal2016/> as may education and [[relaxation techniques]].<ref name=Greenberg2010>Greenberg SL, Nedzelski JM. Medical and noninvasive therapy for Meniere's disease. Otolaryngol Clin North Am. 2010 Oct;43(5):1081-90. PMID 20713246</ref>
There appears to be vicious circle in MD for some people, as psychological distress caused by the vertigo and hearing loss appears to worsen the condition.<ref>{{Cite journal|last=Orji|first=Ft|date=2014|title=The Influence of Psychological Factors in Meniere's Disease|journal=Annals of Medical and Health Sciences Research|volume=4|issue=1|pages=3–7|doi=10.4103/2141-9248.126601|issn=2141-9248|pmc=3952292|pmid=24669323}}</ref> Psychiatric care or counseling may be useful to manage the distress,<ref name=Seemungal2016/> as may education and [[relaxation techniques]].<ref name="Greenberg2010">{{Cite journal|last=Greenberg|first=Simon L.|last2=Nedzelski|first2=Julian M.|date=October 2010|title=Medical and noninvasive therapy for Meniere's disease|journal=Otolaryngologic Clinics of North America|volume=43|issue=5|pages=1081–1090|doi=10.1016/j.otc.2010.05.005|issn=1557-8259|pmid=20713246}}</ref>


=== Surgery ===
=== Surgery ===
If symptoms do not improve with typical treatment, more permanent surgery is considered.<ref name=Seemungal2016/> Surgery to decompress the [[endolymphatic sac]] is one option. A [[systematic review]] from 2015 found that three methods of decompression have been used: simple decompression, insertion of a shunt; and removal of the sac.<ref name=Lim/> It found some evidence that all three methods were useful for reducing dizziness, but that the level of evidence was low, as trials were not blinded nor were there placebo controls.<ref name=Lim>Lim MY, Zhang M, Yuen HW, Leong JL. Current evidence for endolymphatic sac surgery in the treatment of Meniere's disease: a systematic review. Singapore Med J. 2015 Nov;56(11):593-8. Review. PMID 26668402 [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4656865/ PMC 4656865]</ref> Another 2015 review found that shunts used in these surgeries often turn out to be displaced or misplaced in autopsies, and recommended their use only in cases where the condition is uncontrolled and affecting both ears.<ref name=Foster2015rev/>
If symptoms do not improve with typical treatment, more permanent surgery is considered.<ref name=Seemungal2016/> Surgery to decompress the [[endolymphatic sac]] is one option. A [[systematic review]] from 2015 found that three methods of decompression have been used: simple decompression, insertion of a shunt; and removal of the sac.<ref name=Lim/> It found some evidence that all three methods were useful for reducing dizziness, but that the level of evidence was low, as trials were not blinded nor were there placebo controls.<ref name="Lim">{{Cite journal|last=Lim|first=Ming Yann|last2=Zhang|first2=Margaret|last3=Yuen|first3=Heng Wai|last4=Leong|first4=Jern-Lin|date=November 2015|title=Current evidence for endolymphatic sac surgery in the treatment of Meniere’s disease: a systematic review|journal=Singapore Medical Journal|volume=56|issue=11|pages=593–598|doi=10.11622/smedj.2015166|issn=0037-5675|pmc=4656865|pmid=26668402}}</ref> Another 2015 review found that shunts used in these surgeries often turn out to be displaced or misplaced in autopsies, and recommended their use only in cases where the condition is uncontrolled and affecting both ears.<ref name=Foster2015rev/>
A systematic review and [[meta-analysis]] from 2014 found that in at least 75% of patients with Ménière's disease EL sac decompression was effective at controlling vertigo in the short term (>1 year of follow-up) and long term (>24 months).<ref name="PMID24751747">{{Cite journal|pmid= 24751747|year= 2014|author1= Sood|first1= A. J.|title= Endolymphatic sac surgery for Ménière's disease: A systematic review and meta-analysis|journal= Otology & Neurotology|volume= 35|issue= 6|pages= 1033–45|last2= Lambert|first2= P. R.|last3= Nguyen|first3= S. A.|last4= Meyer|first4= T. A.|doi= 10.1097/MAO.0000000000000324}} (Review).</ref>
A systematic review and [[meta-analysis]] from 2014 found that in at least 75% of patients with Ménière's disease EL sac decompression was effective at controlling vertigo in the short term (>1 year of follow-up) and long term (>24 months).<ref name="PMID24751747">{{Cite journal|last=Sood|first=Amit Justin|last2=Lambert|first2=Paul R.|last3=Nguyen|first3=Shaun A.|last4=Meyer|first4=Ted A.|date=July 2014|title=Endolymphatic sac surgery for Ménière's disease: a systematic review and meta-analysis|journal=Otology & Neurotology: Official Publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology|volume=35|issue=6|pages=1033–1045|doi=10.1097/MAO.0000000000000324|issn=1537-4505|pmid=24751747}}</ref>


Destructive surgeries are irreversible and involve removing entire functionality of most, if not all, of the affected ear; as of 2013 there was almost no evidence with which to judge whether these surgeries are effective.<ref name=Cochrane2013surgery>Pullens B, Verschuur HP, van Benthem PP. Surgery for Ménière's disease. Cochrane Database Syst Rev. 2013 Feb 28;(2):CD005395. Review. PMID 23450562</ref> The inner ear itself can be surgically removed via labyrinthectomy although hearing is always completely lost in the affected ear with this operation.<ref name=Cochrane2013surgery/> The surgeon can also cut the nerve to the balance portion of the inner ear in a [[Vestibular nerve|vestibular]] [[neurectomy]]. Hearing is often mostly preserved, however the surgery involves cutting open into the lining of the brain, and a hospital stay of a few days for monitoring would be required.<ref name=Cochrane2013surgery/>
Destructive surgeries are irreversible and involve removing entire functionality of most, if not all, of the affected ear; as of 2013 there was almost no evidence with which to judge whether these surgeries are effective.<ref name="Cochrane2013surgery">{{Cite journal|last=Pullens|first=Bas|last2=Verschuur|first2=Hendrik P.|last3=van Benthem|first3=Peter Paul|date=2013|title=Surgery for Ménière's disease|journal=The Cochrane Database of Systematic Reviews|issue=2|pages=CD005395|doi=10.1002/14651858.CD005395.pub3|issn=1469-493X|pmid=23450562}}</ref> The inner ear itself can be surgically removed via labyrinthectomy although hearing is always completely lost in the affected ear with this operation.<ref name=Cochrane2013surgery/> The surgeon can also cut the nerve to the balance portion of the inner ear in a [[Vestibular nerve|vestibular]] [[neurectomy]]. Hearing is often mostly preserved, however the surgery involves cutting open into the lining of the brain, and a hospital stay of a few days for monitoring would be required.<ref name=Cochrane2013surgery/>


=== Applications without sufficient evidence of positive effect ===
=== Applications without sufficient evidence of positive effect ===
* As of 2014 many doctors trialed people with MD on [[betahistine]] as it cheap and very safe;<ref name=Harcourt2014/> however it was investigated in both a [[systematic review]] and a large-scale [[Placebo-controlled study|placebo-controlled]] [[longitudinal study]] that published in 2016. Neither found evidence to justify its use in Ménière's disease.<ref name="PMID11279734">{{Cite book|pmid=11279734|year=2001|author1=James|first1=A. L.|title=Betahistine for Menière's disease or syndrome|journal=The Cochrane database of systematic reviews|issue=1|pages=CD001873|last2=Burton|first2=M. J.|doi=10.1002/14651858.CD001873|chapter=Betahistine for Ménière's disease or syndrome}} (Review).</ref><ref name="PMID26797774">{{Cite journal|pmc=4721211|year=2016|author1=Adrion|first1=C|title=Efficacy and safety of betahistine treatment in patients with Meniere's disease: Primary results of a long term, multicentre, double blind, randomised, placebo controlled, dose defining trial (BEMED trial)|journal=BMJ|volume=352|pages=h6816|last2=Fischer|first2=C. S.|last3=Wagner|first3=J|last4=Gürkov|first4=R|last5=Mansmann|first5=U|last6=Strupp|first6=M|last7=Bemed Study|first7=Group|doi=10.1136/bmj.h6816|pmid=26797774}}</ref>
* As of 2014 many doctors trialed people with MD on [[betahistine]] as it cheap and very safe;<ref name=Harcourt2014/> however it was investigated in both a [[systematic review]] and a large-scale [[Placebo-controlled study|placebo-controlled]] [[longitudinal study]] that published in 2016. Neither found evidence to justify its use in Ménière's disease.<ref name="PMID11279734">{{Cite journal|last=James|first=A. L.|last2=Burton|first2=M. J.|date=2001|title=Betahistine for Menière's disease or syndrome|journal=The Cochrane Database of Systematic Reviews|issue=1|pages=CD001873|doi=10.1002/14651858.CD001873|issn=1469-493X|pmid=11279734}}</ref><ref name="PMID26797774">{{Cite journal|pmc=4721211|year=2016|author1=Adrion|first1=C|title=Efficacy and safety of betahistine treatment in patients with Meniere's disease: Primary results of a long term, multicentre, double blind, randomised, placebo controlled, dose defining trial (BEMED trial)|journal=BMJ|volume=352|pages=h6816|last2=Fischer|first2=C. S.|last3=Wagner|first3=J|last4=Gürkov|first4=R|last5=Mansmann|first5=U|last6=Strupp|first6=M|last7=Bemed Study|first7=Group|doi=10.1136/bmj.h6816|pmid=26797774}}</ref>
* Transtympanic micropressure pulses were investigated in two systematic reviews. Neither found evidence to justify this technique.<ref name="PMID25756795">{{Cite book|doi=10.1002/14651858.CD008419.pub2|chapter=Positive pressure therapy for Ménière's disease or syndrome|title=Cochrane Database of Systematic Reviews|year=2015|last1=Van Sonsbeek|first1=Sanne|last2=Pullens|first2=Bas|last3=Van Benthem|first3=Peter Paul}} (Review).</ref><ref name="PMID25346252">{{Cite journal|pmid= 25346252|year= 2015|author1= Syed|first1= M. I.|title= Positive pressure therapy for Meniere's syndrome/disease with a Meniett device: A systematic review of randomised controlled trials|journal= Clinical Otolaryngology|volume= 40|issue= 3|pages= 197–207|last2= Rutka|first2= J. A.|last3= Hendry|first3= J|last4= Browning|first4= G. G.|doi= 10.1111/coa.12344}} (Review).</ref>
* Transtympanic micropressure pulses were investigated in two systematic reviews. Neither found evidence to justify this technique.<ref name="PMID25756795">{{Cite book|url=http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008419.pub2/abstract|title=Positive pressure therapy for Ménière's disease or syndrome|last=van Sonsbeek|first=Sanne|last2=Pullens|first2=Bas|last3=van Benthem|first3=Peter Paul|date=2015-03-10|publisher=John Wiley & Sons, Ltd|isbn=14651858|language=en|doi=10.1002/14651858.cd008419.pub2}}</ref><ref name="PMID25346252">{{Cite journal|last2=Rutka|first2=J. A.|last3=Hendry|first3=J|last4=Browning|first4=G. G.|year=2015|title=Positive pressure therapy for Meniere's syndrome/disease with a Meniett device: A systematic review of randomised controlled trials|journal=Clinical Otolaryngology|volume=40|issue=3|pages=197–207|doi=10.1111/coa.12344|pmid=25346252|author1=Syed|first1=M. I.}}</ref>
* Intratympanic [[steroid]]s were investigated in two systematic reviews of clinical trials. It was concluded that the data were insufficient to decide if this therapy has positive effects.<ref name="PMID19923807">{{Cite journal|pmid= 19923807|year= 2009|author1= Hu|first1= A|title= Intratympanic steroids for inner ear disorders: A review|journal= Audiology and Neurotology|volume= 14|issue= 6|pages= 373–82|last2= Parnes|first2= L. S.|doi= 10.1159/000241894}} (Review).</ref><ref name="pmid25215266">{{cite journal | vauthors = Miller MW, Agrawal Y | title = Intratympanic Therapies for Menière's disease | journal = Current Otorhinolaryngology Reports | volume = 2 | issue = 3 | pages = 137–143 | year = 2014 | pmid = 25215266 | pmc = 4157672 | doi = 10.1007/s40136-014-0055-8 | url = }} (Review).</ref>
* Intratympanic [[steroid]]s were investigated in two systematic reviews of clinical trials. It was concluded that the data were insufficient to decide if this therapy has positive effects.<ref name="PMID19923807">{{Cite journal|last2=Parnes|first2=L. S.|year=2009|title=Intratympanic steroids for inner ear disorders: A review|journal=Audiology and Neurotology|volume=14|issue=6|pages=373–82|doi=10.1159/000241894|pmid=19923807|author1=Hu|first1=A}}</ref><ref name="pmid25215266">{{cite journal|year=2014|title=Intratympanic Therapies for Menière's disease|url=|journal=Current Otorhinolaryngology Reports|volume=2|issue=3|pages=137–143|doi=10.1007/s40136-014-0055-8|pmc=4157672|pmid=25215266|vauthors=Miller MW, Agrawal Y}}</ref>


== Prognosis ==
== Prognosis ==
Line 105: Line 105:


==Epidemiology==
==Epidemiology==
From 3% to 11% of diagnosed dizziness in neuro-otological clinics are due to Meniere's.<ref name=Iwasaki>Iwasaki S, Yamasoba T Dizziness and Imbalance in the Elderly: Age-related Decline in the Vestibular System. Aging Dis. 2014 Feb 9;6(1):38-47. doi: 10.14336/AD.2014.0128. eCollection 2015. PMID 25657851 PMC 4306472 [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306472/ Free full text]</ref> The annual incidence rate is estimated to be 15/100,000 and 218/100,000, respectively, in the general population, and around 15% of people with Meniere's disease are older than 65.<ref name=Iwasaki/> In around 9% of cases a relative also had MD, signalling that there may be a genetic predisposition in some cases.<ref name=Seemungal2016/>
From 3% to 11% of diagnosed dizziness in neuro-otological clinics are due to Meniere's.<ref name="Iwasaki">{{Cite journal|last=Iwasaki|first=Shinichi|last2=Yamasoba|first2=Tatsuya|date=February 2015|title=Dizziness and Imbalance in the Elderly: Age-related Decline in the Vestibular System|journal=Aging and Disease|volume=6|issue=1|pages=38–47|doi=10.14336/AD.2014.0128|issn=2152-5250|pmc=4306472|pmid=25657851}}</ref> The annual incidence rate is estimated to be 15/100,000 and 218/100,000, respectively, in the general population, and around 15% of people with Meniere's disease are older than 65.<ref name=Iwasaki/> In around 9% of cases a relative also had MD, signalling that there may be a genetic predisposition in some cases.<ref name=Seemungal2016/>


The odds of MD are greater for people of white ethnicity, with severe obesity, and women.<ref name=2015DiagConsensus/> Several conditions are often comorbid with MD, including arthritis, psoriasis, gastroesophageal reflux disease, irritable bowel syndrome, and migraine.<ref name=2015DiagConsensus/>
The odds of MD are greater for people of white ethnicity, with severe obesity, and women.<ref name=2015DiagConsensus/> Several conditions are often comorbid with MD, including arthritis, psoriasis, gastroesophageal reflux disease, irritable bowel syndrome, and migraine.<ref name=2015DiagConsensus/>

Revision as of 01:54, 20 June 2016

Not to be confused with Ménétrier's disease.

Ménière's disease
SpecialtyOtorhinolaryngology Edit this on Wikidata
Frequency0.19%

Ménière's disease /meɪnˈjɛərz/,[1] is a disorder of the inner ear that usually affects both hearing and balance. It is characterized by episodes of vertigo and by fluctuating or permanent tinnitus and hearing loss. The condition affects people differently. It can range in intensity from being a mild annoyance to a disabling disease. It is similar to many other conditions so a differential diagnosis is important.[2]

The immediate cause of Ménière's disease is unknown; the field was formerly centered on endolymphatic hydrops, an excess of fluid in the inner ear, but in the 2000s other causes, like genetic susceptibility, infection, electrolyte imbalances, allergy, and autoimmune disease have been thought to be possible causes.[3]

Evidence for all treatments is weak; they include use of drugs to manage the nausea and anxiety caused by vertigo, diuretics and changes in diet, and steroids. Physical therapy may help manage the loss of sense of balance, and therapy or relaxation techniques may be useful to help manage the distress caused by the condition. Surgical treatments to reduce pressure inside the ear, or to remove portions of the ear, may be used.

In most people, MD subsides after 5 – 15 years, at the end of which the person has mild loss of balance, moderate hearing loss in one ear, and tinnitus; in about 30% of people both ears are affected.[4] The affected person is able to get up again immediately afterwards.[4]

Signs and symptoms

Audiograms illustrating normal hearing (left) and unilateral low-pitch hearing loss associated with Ménière's disease (right).

Ménière's is characterized by recurrent episodes of vertigo, hearing loss and tinnitus; episodes may be accompanies by headache and a feeling of fullness in the ears.[3]

People may also experience additional symptoms related to irregular reactions of the autonomic nervous system. These symptoms are not symptoms of Meniere's disease per se, but rather are side effects resulting from failure of the organ of hearing and balance, and include nausea, vomiting, and sweating—which are typically symptoms of vertigo, and not of Ménière's.[2] This includes a sensation of being pushed sharply to the floor from behind.[4]

Sudden falls without loss of consciousness (drop attacks) may be experienced by some people.[2]

Cause

The cause of MD is uncertain. It is often attributed to viral infections of the inner ear, head injury, a hereditary predisposition, allergies,[5] and water/ion homeostasis.[6]

Prior to the 2000s it was thought that MD was caused by endolymphatic hydrops (EH), an excess of fluid in the inner ear, where the vestibular system that controls spatial orientation resides. The membranous labyrinth, a system of channels in the inner ear drained by the endolymphatic sac, contains a fluid called endolymph; these channels and the sac swell when pressure increases, which can be caused by drainage from the sac being blocked.[5]

That theory has come into question, since many people with healthy hearing and balance have high pressure in their inner ear and EH.[5][6] More recent theories have looked at possible dysfunction of the immune system, since the endolymph is part of the immune system and there is a correlation between MD and other autoimmune disorders.[5] As around 9% of cases appear to be genetic, researchers have looked for mutations that might lead to susceptibility to MD.[5] In particular investigators suspect mutations in DTNA and FAM136A.[2]

As of 2015 doctors were divided into two camps; those who view MD as an ear disorder caused by EH, and those who view it more like migraine.[7]

Diagnosis

The diagnostic criteria as of 2015 define definite MD and probable MD as follows:[2][3]

Definite

  1. Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours
  2. Audiometrically documented low- to medium-frequency sensorineural hearing loss in the affected ear on at least 1 occasion before, during, or after one of the episodes of vertigo
  3. Fluctuating aural symptoms (hearing, tinnitus, or fullness) in the affected ear
  4. Not better accounted for by another vestibular diagnosis

Probable

  1. Two or more episodes of vertigo or dizziness, each lasting 20 minutes to 24 hours
  2. Fluctuating aural symptoms (hearing, tinnitus, or fullness) in the reported ear
  3. Not better accounted for by another vestibular diagnosis

Symptoms of MD overlap with migraine-associated vertigo (MAV) in many ways, but when hearing loss develops in MAV is usually in both ears, and this is rare in MD, and hearing loss generally doesn't progress in MAV as it does in MD.[2]

People who have had a transient ischemic attack (TIA) and stroke can present with symptoms similar to MD, and in people at risk for stroke magnetic resonance imaging (MRI) should be conducted to exclude TIA or stroke, and as TIA is often a precursor to stroke, that risk should be managed.[2]

Other vestibular conditions that should be excluded include vestibular paroxysmia, recurrent unilateral vestibulopathy, vestibular schwannoma, or a tumor of the endolymphatic sac.[2]

Management

There is no cure for Ménière's disease but drugs, diet, physical therapy and counseling, and some surgical approaches can be used to manage it.[3]

Medications

During MD episodes, drugs to reduce nausea are used, as are drugs to reduce the anxiety caused by vertigo.[3][7]

For longer term treatment to stop progression, the evidence base is weak for all treatments.[3]

Although a causal relation between allergy and Menière's disease is uncertain, medication to control allergy may be helpful.[8]

Diuretics are widely used to manage Ménière's on theory that it will reduce fluid buildup in the ear; based on evidence from multiple but small clinical trials, diuretics appear to be useful for reducing the frequency of episodes of dizziness, but do not seem to prevent hearing loss.[9]

In cases where there is significant hearing loss and continuing severe episodes of vertigo, a chemical labyrinthectomy, in which a drug (such as gentamicin) that "kills" parts or most of the vestibular apparatus is injected into the middle ear.[3][10][11]

Diet

People with MD are often advised to reduce their salt intake for similar reasons, but the evidence for this is very poor.[7]

On the theory that MD is like migraine, some doctors advise eliminating "migraine triggers" like caffeine, but the evidence for this is weak.[7]

Physical therapy

While use of physical therapy early after the onset of MD is probably not useful due to the fluctuating disease course, physical therapy to help retraining of the balance system appears to be useful to reduce both subjective and objective deficits in balance over the longer term.[3][12]

Coping

There appears to be vicious circle in MD for some people, as psychological distress caused by the vertigo and hearing loss appears to worsen the condition.[13] Psychiatric care or counseling may be useful to manage the distress,[3] as may education and relaxation techniques.[14]

Surgery

If symptoms do not improve with typical treatment, more permanent surgery is considered.[3] Surgery to decompress the endolymphatic sac is one option. A systematic review from 2015 found that three methods of decompression have been used: simple decompression, insertion of a shunt; and removal of the sac.[15] It found some evidence that all three methods were useful for reducing dizziness, but that the level of evidence was low, as trials were not blinded nor were there placebo controls.[15] Another 2015 review found that shunts used in these surgeries often turn out to be displaced or misplaced in autopsies, and recommended their use only in cases where the condition is uncontrolled and affecting both ears.[7] A systematic review and meta-analysis from 2014 found that in at least 75% of patients with Ménière's disease EL sac decompression was effective at controlling vertigo in the short term (>1 year of follow-up) and long term (>24 months).[16]

Destructive surgeries are irreversible and involve removing entire functionality of most, if not all, of the affected ear; as of 2013 there was almost no evidence with which to judge whether these surgeries are effective.[17] The inner ear itself can be surgically removed via labyrinthectomy although hearing is always completely lost in the affected ear with this operation.[17] The surgeon can also cut the nerve to the balance portion of the inner ear in a vestibular neurectomy. Hearing is often mostly preserved, however the surgery involves cutting open into the lining of the brain, and a hospital stay of a few days for monitoring would be required.[17]

Applications without sufficient evidence of positive effect

  • As of 2014 many doctors trialed people with MD on betahistine as it cheap and very safe;[4] however it was investigated in both a systematic review and a large-scale placebo-controlled longitudinal study that published in 2016. Neither found evidence to justify its use in Ménière's disease.[18][19]
  • Transtympanic micropressure pulses were investigated in two systematic reviews. Neither found evidence to justify this technique.[20][21]
  • Intratympanic steroids were investigated in two systematic reviews of clinical trials. It was concluded that the data were insufficient to decide if this therapy has positive effects.[22][23]

Prognosis

Ménière's disease usually starts confined to one ear; it appears that it extends to both ears in about 30% of cases.[4]

People may start out with only one symptom, but in MD all three appear with time.[4] Hearing loss usually fluctuates in the beginning stages and becomes more permanent in later stages. MD has a course of 5 – 15 years, and people generally end up with mild disequilibrium, tinnitus, and moderate hearing loss in one ear.[4]

Epidemiology

From 3% to 11% of diagnosed dizziness in neuro-otological clinics are due to Meniere's.[24] The annual incidence rate is estimated to be 15/100,000 and 218/100,000, respectively, in the general population, and around 15% of people with Meniere's disease are older than 65.[24] In around 9% of cases a relative also had MD, signalling that there may be a genetic predisposition in some cases.[3]

The odds of MD are greater for people of white ethnicity, with severe obesity, and women.[2] Several conditions are often comorbid with MD, including arthritis, psoriasis, gastroesophageal reflux disease, irritable bowel syndrome, and migraine.[2]

History

The condition is named after the French physician Prosper Ménière, who in an article from 1861 described the main symptoms and was the first to suggest a single disorder for all of the symptoms, in the combined organ of balance and hearing in the inner ear.[25]

The American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium (AAO HNS CHE) set criteria for diagnosing Ménière's, as well as defining two sub categories of Ménière's: cochlear (without vertigo) and vestibular (without deafness).[26]

In 1972, the academy defined criteria for diagnosing Ménière's disease as:[26]

  1. Fluctuating, progressive, sensorineural deafness.
  2. Episodic, characteristic definitive spells of vertigo lasting 20 minutes to 24 hours with no unconsciousness, vestibular nystagmus always present.
  3. Tinnitus (ringing in the ears, from mild to severe) Often the tinnitus is accompanied by ear pain and a feeling of fullness in the affected ear. Usually the tinnitus is more severe before a spell of vertigo and lessens after the vertigo attack.
  4. Attacks are characterized by periods of remission and exacerbation.

In 1985, this list changed to alter wording, such as changing "deafness" to "hearing loss associated with tinnitus, characteristically of low frequencies" and requiring more than one attack of vertigo to diagnose.[26] Finally in 1995, the list was again altered to allow for degrees of the disease:[26]

  1. Certain – Definite disease with histopathological confirmation
  2. Definite – Requires two or more definitive episodes of vertigo with hearing loss plus tinnitus and/or aural fullness
  3. Probable – Only one definitive episode of vertigo and the other symptoms and signs
  4. Possible – Definitive vertigo with no associated hearing loss

In 2015 the The International Classification for Vestibular Disorders Committee of the Barany Society published consensus diagnostic criteria in collaboration with the American Academy of Otolaryngology – Head and Neck Surgery, the European Academy of Otology & Neuro-Otology, the Japan Society for Equilibrium Research, and the Korean Balance Society.[2][3]

Notable cases

  • Ryan Adams, an American musician, had to take a two-year break from music due to severe symptoms of the disease and his resulting psychological distress.[27]
  • Kristin Chenoweth, Broadway, film, TV actress, and singer.[28][29]
  • Brent Crosswell, former Australian Rules football player.[30]
  • Mamie Eisenhower, wife of Dwight D. Eisenhower, 34th President of the United States.[31]
  • Doc Hammer, painter and co-creator of The Venture Bros. He has stated repeatedly that he has Ménière's disease.[32]
  • Varlam Shalamov, a Russian writer, was affected.[33]
  • Alan B. Shepard, the first American astronaut and fifth man on the Moon, was diagnosed with Ménière's disease in 1964, grounding him after only one brief spaceflight. Several years later, an endolymphatic shunt surgery (which was then at the experimental stage) was performed, allowing Shepard to fly to the Moon on Apollo 14.[34]
  • Jonathan Swift, Anglo-Irish satirist, poet, and cleric, is known to have suffered from Ménière's disease.[35]
  • Dana White, president and minority owner of the Ultimate Fighting Championship (UFC). White had surgery on the condition but the procedure was a failure.[36] After the failed surgery White had another procedure involving the use of stem cells, this time the procedure was successful.[37]

References

  1. ^ Dictionary.com Unabridged (v 1.1). Random House, Inc. Accessed on 9 September 2008
  2. ^ a b c d e f g h i j k Lopez-Escamez, Jose A.; Carey, John; Chung, Won-Ho; Goebel, Joel A.; Magnusson, Måns; Mandalà, Marco; Newman-Toker, David E.; Strupp, Michael; Suzuki, Mamoru (2015). "Diagnostic criteria for Menière's disease". Journal of Vestibular Research: Equilibrium & Orientation. 25 (1): 1–7. doi:10.3233/VES-150549. ISSN 1878-6464. PMID 25882471.
  3. ^ a b c d e f g h i j k l Seemungal, Barry; Kaski, Diego; Lopez-Escamez, Jose Antonio (August 2015). "Early Diagnosis and Management of Acute Vertigo from Vestibular Migraine and Ménière's Disease". Neurologic Clinics. 33 (3): 619–628, ix. doi:10.1016/j.ncl.2015.04.008. ISSN 1557-9875. PMID 26231275.
  4. ^ a b c d e f g Harcourt J, Barraclough K, Bronstein AM (2014). "Meniere's disease". BMJ (Clinical Research Ed.). 349: g6544. doi:10.1136/bmj.g6544. PMID 25391837.
  5. ^ a b c d e Hain, TC Meniere's Disease at the American Hearing Research Foundation. Page last modified: 10/2012
  6. ^ a b Ishiyama, Gail; Lopez, Ivan A.; Sepahdari, Ali R.; Ishiyama, Akira (April 2015). "Meniere's disease: histopathology, cytochemistry, and imaging". Annals of the New York Academy of Sciences. 1343: 49–57. doi:10.1111/nyas.12699. ISSN 1749-6632. PMID 25766597.
  7. ^ a b c d e Foster, Carol A. (2015). "Optimal management of Ménière's disease". Therapeutics and Clinical Risk Management. 11: 301–307. doi:10.2147/TCRM.S59023. ISSN 1176-6336. PMC 4348125. PMID 25750534.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  8. ^ Weinreich, Heather M.; Agrawal, Yuri (June 2014). "The Link Between Allergy and Menière's Disease". Current opinion in otolaryngology & head and neck surgery. 22 (3): 227–230. doi:10.1097/MOO.0000000000000041. ISSN 1068-9508. PMC 4549154. PMID 24573125.
  9. ^ Crowson, Matthew G.; Patki, Aniruddha; Tucci, Debara L. (May 2016). "A Systematic Review of Diuretics in the Medical Management of Ménière's Disease". Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 154 (5): 824–834. doi:10.1177/0194599816630733. ISSN 1097-6817. PMID 26932948.
  10. ^ Pullens, Bas; van Benthem, Peter Paul (16 March 2011). Intratympanic gentamicin for Ménière's disease or syndrome. John Wiley & Sons, Ltd. doi:10.1002/14651858.cd008234.pub2. ISBN 14651858. {{cite book}}: Check |isbn= value: length (help)
  11. ^ Huon, Leh-Kiong; Fang, Te-Yung; Wang, Pa-Chun (July 2012). "Outcomes of intratympanic gentamicin injection to treat Ménière's disease". Otology & Neurotology: Official Publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 33 (5): 706–714. doi:10.1097/MAO.0b013e318259b3b1. ISSN 1537-4505. PMID 22699980.
  12. ^ Clendaniel, R. A.; Tucci, D. L. (December 1997). "Vestibular rehabilitation strategies in Meniere's disease". Otolaryngologic Clinics of North America. 30 (6): 1145–1158. ISSN 0030-6665. PMID 9386249.
  13. ^ Orji, Ft (2014). "The Influence of Psychological Factors in Meniere's Disease". Annals of Medical and Health Sciences Research. 4 (1): 3–7. doi:10.4103/2141-9248.126601. ISSN 2141-9248. PMC 3952292. PMID 24669323.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  14. ^ Greenberg, Simon L.; Nedzelski, Julian M. (October 2010). "Medical and noninvasive therapy for Meniere's disease". Otolaryngologic Clinics of North America. 43 (5): 1081–1090. doi:10.1016/j.otc.2010.05.005. ISSN 1557-8259. PMID 20713246.
  15. ^ a b Lim, Ming Yann; Zhang, Margaret; Yuen, Heng Wai; Leong, Jern-Lin (November 2015). "Current evidence for endolymphatic sac surgery in the treatment of Meniere's disease: a systematic review". Singapore Medical Journal. 56 (11): 593–598. doi:10.11622/smedj.2015166. ISSN 0037-5675. PMC 4656865. PMID 26668402.
  16. ^ Sood, Amit Justin; Lambert, Paul R.; Nguyen, Shaun A.; Meyer, Ted A. (July 2014). "Endolymphatic sac surgery for Ménière's disease: a systematic review and meta-analysis". Otology & Neurotology: Official Publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 35 (6): 1033–1045. doi:10.1097/MAO.0000000000000324. ISSN 1537-4505. PMID 24751747.
  17. ^ a b c Pullens, Bas; Verschuur, Hendrik P.; van Benthem, Peter Paul (2013). "Surgery for Ménière's disease". The Cochrane Database of Systematic Reviews (2): CD005395. doi:10.1002/14651858.CD005395.pub3. ISSN 1469-493X. PMID 23450562.
  18. ^ James, A. L.; Burton, M. J. (2001). "Betahistine for Menière's disease or syndrome". The Cochrane Database of Systematic Reviews (1): CD001873. doi:10.1002/14651858.CD001873. ISSN 1469-493X. PMID 11279734.
  19. ^ Adrion, C; Fischer, C. S.; Wagner, J; Gürkov, R; Mansmann, U; Strupp, M; Bemed Study, Group (2016). "Efficacy and safety of betahistine treatment in patients with Meniere's disease: Primary results of a long term, multicentre, double blind, randomised, placebo controlled, dose defining trial (BEMED trial)". BMJ. 352: h6816. doi:10.1136/bmj.h6816. PMC 4721211. PMID 26797774. {{cite journal}}: |first7= has generic name (help)
  20. ^ van Sonsbeek, Sanne; Pullens, Bas; van Benthem, Peter Paul (10 March 2015). Positive pressure therapy for Ménière's disease or syndrome. John Wiley & Sons, Ltd. doi:10.1002/14651858.cd008419.pub2. ISBN 14651858. {{cite book}}: Check |isbn= value: length (help)
  21. ^ Syed, M. I.; Rutka, J. A.; Hendry, J; Browning, G. G. (2015). "Positive pressure therapy for Meniere's syndrome/disease with a Meniett device: A systematic review of randomised controlled trials". Clinical Otolaryngology. 40 (3): 197–207. doi:10.1111/coa.12344. PMID 25346252.
  22. ^ Hu, A; Parnes, L. S. (2009). "Intratympanic steroids for inner ear disorders: A review". Audiology and Neurotology. 14 (6): 373–82. doi:10.1159/000241894. PMID 19923807.
  23. ^ Miller MW, Agrawal Y (2014). "Intratympanic Therapies for Menière's disease". Current Otorhinolaryngology Reports. 2 (3): 137–143. doi:10.1007/s40136-014-0055-8. PMC 4157672. PMID 25215266.
  24. ^ a b Iwasaki, Shinichi; Yamasoba, Tatsuya (February 2015). "Dizziness and Imbalance in the Elderly: Age-related Decline in the Vestibular System". Aging and Disease. 6 (1): 38–47. doi:10.14336/AD.2014.0128. ISSN 2152-5250. PMC 4306472. PMID 25657851.
  25. ^ Méniere (1861) "Sur une forme de surdité grave dépendant d’une lésion de l’oreille interne" (On a form of severe deafness dependent on a lesion of the inner ear), Bulletin de l'Académie impériale de médecine, 26 : 241.
  26. ^ a b c d Beasley NJ, Jones NS (December 1996). "Menière's disease: evolution of a definition". J Laryngol Otol. 110 (12): 1107–13. doi:10.1017/S002221510013590X. PMID 9015421.
  27. ^ Drew, Ian (21 October 2011). "Ryan Adams Opens Up About Tragic Ear Disease". US Weekly. Retrieved 25 May 2012. Having your first album of new material immediately break into the Billboard Top 200 albums chart on release week is usually cause for celebration for most rock stars. But Ryan Adams isn't smiling just because his brilliantly subdued new disc, Ashes & Fire, slid right in at #7 this week. That's because the alternative singer, 36, is still grappling with Ménière's disease, a debilitating and incurable inner ear condition that forced him to take a break from music for over two years.
  28. ^ Byron, Ellen. "Kristin Chenoweth: Exclusive Interview With Prevention". Prevention.com. Retrieved 7 March 2013.
  29. ^ "April 16, 2009". Fresh Air.
  30. ^ Tim Lane for The Age. July 8, 2012 Fate stepped in to distinguish between two prodigious talents
  31. ^ Gould, Louis L. (2001). American First Ladies: Their Lives and Their Legacy. Taylor & Francis. p. 315. ISBN 978-0-415-93021-5.
  32. ^ Doc-Hammer (16 May 2005). "50 Questions (from MySpace)". Deviant Art. Retrieved 7 March 2013.
  33. ^ Toker, Leona (2000). Return from the Archipelago: narratives of Gulag survivors. Bloomington: Indiana University Press. p. 149. ISBN 0-253-33787-9. Meanwhile, Shalamov's health kept deteriorating—the Kolyma twig would have but a short time before wilting in Moscow. The body of a Kolyma survivor bore witness of its own: blindness, deafness, frostbitten skin, Ménière's disease, chronic congestion, and apparently also minor strokes, angina pectoris, Parkinson's disease, and incipient dementia. Iulii Shreider found a woman to cook and clean for him, yet eventually Shalamov broke with her too. Unable to take care of himself, in 1979 he was placed in a nursing home (see Isaev 1996).
  34. ^ Gray, Tara. "Alan B. Shepard, Jr". 40th Anniversary of Mercury 7. NASA. Retrieved 25 May 2012.
  35. ^ Crook, Keith (1998). A Preface to Swift. Longman. p. 6. ISBN 978-0-582-28978-9.
  36. ^ Jesse Holland (22 February 2013). "After surgical 'disaster,' Dana White contemplates radical procedure for Meniere's Disease that could leave him unable to walk". MMAmania.com.
  37. ^ Adam Guillen Jr. (18 April 2013). "Dana White Meniere's Disease: A-Rod, German stem cell treatment cure UFC President '100 percent'". MMAmania.com.

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