Meniere’s disease

Introduction
Meniere’s disease is a hearing disorder that affects the inner ear leading to dizzy spells referred to as vertigo. Meniere’s disease affects only one ear in most cases and could lead to hearing loss. The inner year is basically the center of balance and hearing, during an attack by the disease, a person experiences the vertigo effect, which causes a sensation that they or the world surrounding them is moving. It causes dizziness and a feeling of sickness to the victim because the hearing is dominated by hissing and roaring sounds that cause the ear or both ears, though not often for both ears, to feel full to a busting point, an effect that is referred to as the tinnitus effect.
It is named after a French doctor, Prosper Meniere, who was the first to identify the disease in the 1800s. It is a disease that develops gradually over time with gradual loss of hearing and sudden vertigo attacks that lasts from ten minutes to several hours. After the attack, the victims may experience mild deafness in the ear(s), and at times, they may feel unsure about their footing. As the disease progresses through the stages, vertigo episodes become less frequent, and deafness becomes severe.
Meniere’s disease can occur at any stage in life. However, it is commonly known to start between young and middle-aged adulthood life stages, especially to people in the 40s and 50s.

Causes of the disease
The exact or specific causes of the disease have not been identified yet, but the symptoms of the disease appear to be as a result of an abnormal amount of the endolymph fluid and increased pressure in the inner year which is caused by a variety of factors. The inner ear has a series of canals that are filled with fluid. These canals are angled differently in a way that when the head moves, the rolling of the fluid in the canals is passed along to the brain through the balance nerve called the vestibular. There is another snail-shaped organ in the inner ear called the cochlea, which is also filled with the endolymph fluid, which also moves in response to sounds (National Institute on Deafness & Communication Disorders, n.d.). The message is passed along the hearing nerve to the brain, which communicates what you are hearing.
The build-up of this fluid is associated with Meniere’s disease, which interrupts the messages to the brain from both the hearing nerves and the balance. This disturbs the hearing nerve endings that cause fluctuations and may cause permanent damage eventually(Ears-Meniere’s disease, 1999). The imbalance in the fluid is caused and triggered by a number of factors, including;

Improper drainage of the fluid due to blockage and anatomic abnormality.

This causes imbalanced pressures of the fluid, which triggers the infection of the disease.

Viral infections and Respiratory infections.

From the research done by various physicians, the antibodies of the Herpes virus (HSV) have been commonly found in patients with Meniere’s disease. Other viral infections have also been identified as the trigger, such as the Epstein Barr viruses and cytomegalovirus founded by the Japanese researchers.

Head injuries and migraines

There have been cases of post-traumatic Meniere’s syndrome and head injury cases attributed to the hydrodynamic changes that are caused by scarring from bleedings into the internal ear. Exposure to much noise that causes migraine have also been observed to affect the inner ear, which triggers the Meniere’s disease.

Low spinal fluid pressure.

The inner ear fluid is connected to the spinal fluid through various channels, and therefore, low spinal fluid pressure may be a source of hydrops that may cause lead to the disease.

Various allergic conditions

A research conducted by a physician by the name of Derebury in 1966 showed that 30% of the Meniere’s disease patients had different food-related allergies. Allergies may contribute to the disease in three common ways, the first being the deposition of the circulating immune complex which might produce an inflammation that may interfere with the sac’s filtering capabilities, the second is the condition where the sac might be the target organ of the allergic depositions and reactions, and lastly, a predisposing viral infection may interact with the allergies and cause the endolymphatic sac of the ear to decompensate resulting in endolymphatic hydrops.

Abnormal immune responses

A significant number of patients with Meniere's disease have been observed to have autoimmune disorders and thyroiditis, which causes an abnormal response to the balances of the fluid. This may cause imbalances that trigger the infection of the disease.

Side effects from certain medications.

Some medications may have side effects that affect the ear, especially the middle or the inner ear triggering the infection of the disease.

Stressful conditions, fatigue, and anxiety.

Genetic predisposition in a family with a history of the disease.

A significant number of researches show that one out of three patients with the disease has a first-degree relative who has had the disease. The hereditary predisposition is related to the differences in the anatomy of the fluid channels within the ear and differences in the immune responses that exist among the relatives.

Signs and symptoms
Meniere’s disease is characterized by a variety of symptoms that the victims and patients experience from time to time, depending on the stage of the disease. These symptoms include the following:

Repeated episodes of the vertigo effect (loss of balance).

The patient may feel a spinning sensation that starts and stops from time to time. The vertigo episodes occur without any signs or warnings to the patients and can last from for 20 minutes to several hours, but not more than a day (24 hours). Severe episodes of vertigo also cause nausea.

Hearing loss

The patients may also experience a hearing loss that comes from time to time and then ends abruptly. The hearing loss becomes permanent eventually for most victims.

Tinnitus effect (Ringing in the ear).

This is the perception of a buzzing, ringing, whistling, roaring, or hissing sound in the ear.

Sensitivity to noise. Some noise may hurt the ear while others might be silent with a pitch that brings about a sensation of pain to the ear.

Feeling full and pressure in the ear. People with this disease also feel pressure and aural fullness in the affected ear or ears, which is more often as the stages develop.

Sudden dizzy spells that cause a feeling of sickness to the patients with Meniere’s disease.

Often, some symptoms might appear more than others. The symptoms vary from one person to another, and some may experience more attacks over long periods, while others may have isolated attacks once from time to time.
The signs usually begin with a feeling of pressure in the ear(s), which is followed by the tinnitus effect, then the hearing loss, and finally, the experiences of vertigo. However, this is not the particular order of the symptoms. Patients of Meniere's disease generally experience the episodes in clusters with more extended periods of remissions. It is advisable that whenever you experience an episode of the disease, it is better to lie down and focus on one, non-moving object. This has been observed to make the patients feel better. However, the doctor, specialist, or a physician should be consulted to help in managing the condition.

Stages of Meniere’s disease
The stages of Meniere’s disease are identified as three distinct stages.

The early-stage

It is the first stage where the disease causes the most episodes. The flare-ups are usually unpredictable and are always striking at the worst possible moments. It is the stage during which the person experiences sudden and often out-of-blue episodes of the vertigo effect that lasts from 20 minutes to 24 hours. The diagnosis for most patients happens at this stage because the disease makes itself known through the means of the symptoms.
The most common symptom is severe vertigo. Other symptoms include congestions in the ear, tinnitus, fluctuating hearing loss, feelings of nausea and vomiting, cold sweat, and feelings of anxiety.

The middle stage

In this stage, the symptoms of vertigo tend to become less severe. The hearing loss and tinnitus, however, increases severely. The patient may also experience long term remission for several months where the disease may seem to go away.

Late-stage

This is the final stage of the disease where the vertigo episodes become fewer and occur in rare intervals. Some patients may not experience the vertigo symptoms again after hitting this stage. However, the tinnitus and hearing loss might probably get worse, and the patient is likely to experience unsteady regular balances, and therefore, most people at this stage may feel unstable, especially in dark conditions.
Most people do not reach this stage due to the effective care of the disease in the early and middle stages. However, those who hit this stage are usually at risk of bigger health problems such as total deafness and other side effects.
It is, therefore, advisable to seek the best care as soon as possible during the early and middle stages as soon as the symptoms have been experienced.

Diagnosis
The diagnosis for Meniere's disease includes diagnosing the vertigo symptoms, hearing loss symptoms, feelings of pressure, and tinnitus effects. This is because other conditions can also cause many of the other symptoms of this disease, and therefore, the diagnosis of the disease often involves ruling out other medical possibilities first.
There are no specific tests for Meniere’s disease; it involves conducting a range of tests to diagnose the disorder, which includes:

Hearing tests. Checks whether the hearing loss is specific to the inner ear.

The Electronystagmography (ENG) test. This measures the involuntary movement of the eye while your balance is put under stress.

The Magnetic resonance imaging (MRI) test. It is a test that can be used to rule out the disorders of the central nervous system that may be confused with Meniere’s disease, such as Arnold-Chiari malformation, acoustic neuroma, and multiple sclerosis (MS).

Requirements for the diagnosis

A diagnosis of the disease requires the following elements of the symptoms:

Two distinct episodes of vertigo, where each lasts for 20 minutes or longer, mot longer than 24 hours.

Hearing loss verified by a hearing test

Tinnitus feeling in the year (feeling of fullness).

Exclusion of other cases that might be known to cause these problems.

The hearing assessment or tests.

A hearing test referred to as audiometry helps to assess how well a person detects sounds at different pitches and various volumes, and how well the person is able to distinguish between words that sound similar.
People with Meniere's disease are observed to have problems hearing low frequencies or those with combined high and low frequencies with normal hearing in the frequencies at midrange.

Balance tests and assessment.

Between the episodes of vertigo, a sense of balance returns to normal for most people with Meniere's disease. The patient might, however, have some ongoing balance problems. Various tests that assess the function of the inner ear have therefore been established, which include:
The Videonystagmography (VNG) test. This test evaluates the balance function by assessing the movement of the eye. Sensors that are balance-related in the inner ear are linked to the muscles that control the movement of the eye. This connection enables the patient to move the head while keeping your eyes focused on a point at the same time.
Rotary-chair testing. Just like a Videonystagmography, VNG test, this test measures the inner ear function based on the movement of the eye. The patient sits in a rotating chair that is computer-controlled, which stimulates the inner ear.
The Vestibular Evoked Myogenic Potentials (VEMP) test. This test diagnoses and also monitors Meniere's disease. It shows the various characteristic changes in the affected ears of the people with Meniere's disease.
Posturography test. This is a computerized test that reveals the part of the balance system, which might be the inner ear function, vision, or sensations from the skin, joints, tendons, and muscles. The patient relies on most parts that may cause problems. The patient stands in bare feet on a given platform and keeps the balance under various conditions while wearing a safety harness.
The Video Head Impulse Test (VHIT). This is a newer test that uses video to measure the reactions of the eye to abrupt movement. While focusing on a point, the head of the patient is turned unpredictably and quickly. If the eyes move off the target when the head is turned, the patient is said to have an abnormal reflex.
Electrocochleography (ECoG) test. It is a test that looks at the inner ear’s response to various sounds. This is considered helpful in determining if there is an abnormal buildup of the fluid in the inner ear, but it is not specific for Meniere's disease.

Tests to rule out other conditions

Various blood tests and imaging scans, such as an MRI, may be used to rule out disorders that can cause problems that are similar to those of Meniere's disease, such as multiple sclerosis, and a tumor in the brain.

Treatment and management
Treatment of the disease
Meniere’s disease is considered to be a chronic condition with no identified cure for the disease. However, a number of treatments have been identified that helps to reduce the severity and frequencies of the occurrence of vertigo episodes. The treatments can be non-surgical or surgical. The non-surgical treatments include the following (“Meniere’s disease - Symptoms and causes - Mayo Clinic,” n.d.).

Medications for the vertigo symptoms.

The doctor may prescribe various medications to take during a vertigo episode to reduce and lessen the severity of an attack. This may include the following medications;

Motion sickness, these are medications such as diazepam (Valium) and meclizine, which may reduce the spinning sensation and help control vomiting and feelings of nausea.

Anti-nausea medications. They include medications such as promethazine, which also helps to control vomiting and nausea during vertigo episodes.

Long-term medication use

Medications may also be prescribed to reduce fluid retention, diuretic, and also make other suggestions, such as limiting salt intake. For some people, this combination may help to control the frequency and severity of Meniere's disease signs and symptoms.

Noninvasive therapies and procedures

People with this disease may benefit from other noninvasive therapies and processes such as.

Rehabilitation therapy and procedure. If a patient might have balance problems between the episodes of vertigo, then a vestibular rehabilitation therapy might help to improve their balance.

Use of a hearing aid. A hearing aid put in the ear that is affected by Meniere's disease might help to improve the hearing. The doctor can refer the patient to an audiologist to examine and discuss what hearing aid options that would be best for the patient.

A positive pressure therapy. For episodes of vertigo that is hard to treat, the positive pressure therapy involves applying some pressure into the middle ear to lessen the fluid buildup. It is done by use of a device called a Meniett pulse generator that applies pulses of pressure to the canal of the ear via a ventilation tube. This treatment is done at home, mainly three times per day for 5 minutes at a time.

In some studies, the positive pressure therapy has indicated improvement in the symptoms of vertigo, aural pressure, and tinnitus. In other studies, these improvements have not been observed, and therefore, its long-term effectiveness has not yet been determined.
In case these non-surgical conservative treatments are not successful, the doctor may recommend some of the various more-aggressive (surgical) treatments, including.

Middle ear injections

Various medications are injected into the middle ear, which is then absorbed into the inner ear that may help to improve the symptoms of vertigo. It is a treatment that is done in the doctor's office using a variety of injections available that include;

It is an antibiotic that is toxic to the inner ear. It reduces the balancing function of the ear affected, and the other ear, in turn, assumes responsibility for the balance. However, using these injections has a risk of further hearing loss.

Various steroids, for instance, dexamethasone, may also help in controlling the vertigo attacks in some patients. Dexamethasone is less likely to cause further hearing loss the gentamicin; however, it might be slightly less effective as compared to gentamicin.

Surgery

In cases where the vertigo attacks resulting from Meniere's disease are severe, and other treatments do not work, surgery is also considered as an option, through the following procedures:

The Endolymphatic sac procedure. The endolymphatic sac in the ear plays an essential role in regulating the inner ear fluid levels. During this procedure, the endolymphatic sac is therefore decompressed, which helps to alleviate excess levels of the fluid. This procedure is combined with the placement of a shunt in some cases, which is a tube that drains the excess fluid from the inner ear.

Labyrinthectomy procedure. It is a procedure that involves the surgeon taking off the balance portion of the inner ear and thereby removing both the hearing and balance functions from the affected ear(s). It is a procedure performed only if the patient has already had a total or near-total hearing loss in the affected ear.

The Vestibular nerve section procedure. It is a procedure that involves cutting the nerve connecting the movement and balance sensors in the inner ear to the vestibular nerve of the brain. It is a procedure that usually corrects problems with vertigo and attempts to preserve hearing for the affected ear. It needs general anesthesia and an overnight stay in the hospital.

Treatment also involves lifestyle changes, which consist of stress and anxiety management, diet changes, especially taking of low salt diets, quitting smoking, and avoiding excessive consumption of alcohol.

Management of the disease
The doctor can help in managing the symptoms of Meniere’s disease to help reduce the severity and frequency of the attacks associated with the disease. Some of the suggestion for management of the disease includes the following.

Recognizing the warning signs of an attack, after which you should sit or lie down as soon as you feel dizzy. You should also continue resting after the attacks for some time before resuming to regular activities.

When balance problems are experienced between attacks, one might benefit from doing some exercises and activities that help the brain and body to regain its ability to process the balance information correctly, which is referred to as vestibular

Avoid triggers that might make the symptoms worse, such as sudden movement, watching, and bright lights.

Avoid driving and operating heavy machinery in cases of frequent episodes of vertigo. This could lead to an injury and accident.

Consider joining a support group. This can offer understanding and information that may help to live with the condition and also manage the disease.

Conclusion
Meniere's disease is an ear disorder that leads to dizzy spells called vertigo. Meniere's disease could lead to hearing loss and mostly affects one ear, which commonly occurs to people between young and middle-aged adulthood life stages. It is a situation that is caused by an imbalance in the endolymph fluid in the inner ear due to a variety of factors such as improper fluid drainage due to blockage or anatomic abnormality, abnormal immune response, genetic predisposition and viral infections. Meniere's disease occurs in three stages being the early stage, middle stage and the late stage. It is characterized by vertigo, hearing loss, tinnitus effects, and feeling of fullness (aural fullness) and pressure in the ear.
Upon experience of any of these symptoms, it is advisable and recommended to visit a doctor or a specialist in this field to help in managing the situation.
References
Ears-Meniere’s disease. (1999). Retrieved from www.betterhealth.vic.gov.au
Meniere’s disease - Symptoms and causes - Mayo Clinic. (n.d.). Retrieved January 18, 2020, from https://www.mayoclinic.org/diseases-conditions/menieres-disease/symptoms-causes/syc-20374910
National Institute on Deafness, T., & Communication Disorders, O. (n.d.). NIDCD...Improving the lives of people with communication disorders.