AUTHOR Michael John Pritchard, ENG, DipHE, BA with ENB Higher Award, RGN, is advanced nurse practitioner in general surgery, breast, urology and orthopaedics, Wirral University Teaching Hospital NHS Foundation Trust.
ABSTRACT Pritchard, M.J. (2007) Understanding Ménière’s disease 2: treatment options. Nursing Times; 103: 46, 30–31.
Keywords: Meniere’s Disease, Tinnitus, Management
1. Know about some of the treatments available to a patient with Ménière’s disease and tinnitus.
2. Be aware of other sources of help and advice that a person with Ménière’s disease could obtain.
This is the second part of a two-part unit on Ménière’s disease and tinnitus. Part 1 explored the incidence, causes, risk factors and diagnosis of Ménière’s. This part examines the treatments available, including medication, surgery, lifestyle changes and psychological support. It also highlights the unpredictability of the disease and the difficulties healthcare professionals face in trying to understand and treat the condition.
Medication such as antihistamines, anticholinergics and diuretics may ease the vertigo, dizziness and vomiting that characterise Ménière’s for some patients but they do not work for all. They may calm the nerve messages that are sent from the ear to the brain or, in the case of diuretics, reduce blood pressure and as a result the pressure in the inner ear. Medication should not be taken continually, only when patients have an attack.
A number of other treatments have been tried. In trials, lidocaine stopped tinnitus in a small number of patients and this raised hopes that other anti-arrhythmic drugs would be effective. However, lidocaine had to be given in high IV doses to give only a brief respite. It exacerbated tinnitus in a larger number of patients and has serious side-effects (den Hartigh et al, 1993).
Trials of flecainide and mexiletine proved unsuccessful because of adverse side-effects and high drop-out rates among participants (Dobie, 1999).
Benzodiazepines were also unsuccessful because tinnitus may recur after the treatment ends and can then cause a greater level of distress (Lechtenberg and Shulman, 1984).
Antidepressants such as tricyclics have shown some benefit, because depression is relatively common among patients with tinnitus. Female patients with diagnosed depression who have insomnia appear to benefit most, with an improvement in Ménière’s symptoms (Dobie et al, 1993).
Surgical procedures may be recommended if the vertigo attacks are so frequent, severe or disabling that medication can no longer offer any relief. The most common surgical treatment is to insert a small tube or shunt to drain some of the fluid from the emicircular canals. This preserves hearing and controls vertigo in about one-half to two-thirds of cases. However, it is not a permanent cure in all cases.
Another surgical procedure is vestibular neurectomy. In this procedure, the vestibular nerve is cut so the distorted impulse causing dizziness no longer reaches the brain. This permanently cures the majority of patients and hearing is preserved in most. However, there is a small risk that hearing and the facial muscles will be affected by the surgery.
A procedure known as chemical labyrinthectomy destroys the balance and possibly the hearing mechanism of the inner ear on the affected side. This is considered when the patient’s hearing is already poor in the affected ear, or the symptoms are so severe that the condition is affecting the patient’s ability to live a normal life. The procedure is simple: the inner ear is punctured and gentamicin is injected. The patient is then given ear drops of gentamicin to be taken three times a day for two weeks to complete the procedure and allow the body to get used to having only one balance organ.
This method has the highest rate of control of vertigo attacks (90% effective). However, it can also cause complete deafness in the affected ear (National Library of Medicine, 2007). It is therefore seen as a last resort and can only be carried out once. If the patient goes on to develop the symptoms in the other ear – which is very rare – this method could not be used again as it would render the patient completely deaf.
Another option is a cochlear implant/electrical stimulation. This procedure has two components. In the first an electrode array is threaded into the cochlea and in the second a receiver is implanted just beneath the skin behind the ear. The array sends electrical sound signals from the ear to the brain. The technique is used in deaf or near-deaf patients only, because there is a risk of destroying whatever hearing remains, although the treatment aims to restore hearing. It only works in 50% of cases. It is also possible it may help with tinnitus in suitable patients.
Various treatment strategies use sound to treat tinnitus. They work by helping the brain to become accustomed to the sound, and hence filter it out. By desensitising the auditory system, tinnitus noises should also recede. Sound therapies include wearable devices similar to hearing aids and non-wearable devices such as table-top sound machines. Once again, the effectiveness of these strategies is very variable.
Some other options are available but their value is unproven. They are mentioned below because some patients have found them beneficial.
TRANSCRANIAL MAGNETIC STIMULATION
This was developed in the 1990s and involves placing a powerful electromagnet against the head. The magnetic field can be strong enough to change activity in the brain.
However, its effectiveness depends critically on the frequency and strength of the field. Initial results have been interesting. Nonetheless, before it can be considered a treatment for tinnitus, further research is needed into its safety and whether there are any effects on other brain activity (De Ridder et al, 2005; Kleinjung et al, 2005).
Some patients with tinnitus have found minerals such as magnesium or zinc, herbal preparations such as ginkgo biloba, homeopathic remedies and B vitamins helpful. Others have tried acupuncture, cranio-sacral therapy, magnets, hyperbaric oxygen and hypnosis. A few of these therapies have been researched but to date the results have been inconclusive.
Another option is a change in lifestyle. Eating a low-salt diet, stopping smoking and/or drinking and taking regular exercise have proved to be beneficial for some people. Others have found that avoiding certain high-caffeine foods and drinks reduces the number of attacks (American Academy of Family Physicians, 2007).
Stress can also affect the condition and therefore controlling a patient’s stress levels could decrease the frequency and severity of attacks. Biofeedback is a relaxation technique that teaches people to control certain autonomic body functions, such as pulse, muscle tension and skin temperature. The goal of this technique is to help people manage stress in their lives, not by reducing the stress itself but by changing the body’s reaction to it. Many people have noticed a reduction in tinnitus when they have learnt how to modify their reaction to stress.
If stress levels cannot be managed, another option is a change in occupation. This may affect the patient’s financial situation so indirectly increase stress and make the condition worse. Therefore any change in career would need to be carefully discussed before making a decision.
Psychological support can have a beneficial effect for patients whose lives are greatly affected by Ménière’s disease. Research indicates that for many people counselling may reduce the perceived level of tinnitus – with the use of a noise generator to tune out the tinnitus. This works by gradually reducing its severity by resetting auditory filters so they are not transmitting tinnitus messages to the conscious part of the brain (Jastreboff and Jastreboff, 2000; Jastreboff and Hazell, 1993).
It is not a cure and some experts have argued that the use of a noise generator is an integral part of the success of the process, while others maintain that counselling is the key. However it works, it is a long process lasting between 18 months and two years.
Organisations such as the Ménière’s Society and the British Tinnitus Association offer practical help and support to patients and their families.
A form of physiotherapy known as vestibular rehabilitation can play a role in treatment. The patient is taught head and body exercises to help improve their sense of balance (Dix, 1979). However, the technique does not work for every patient.
The aim of most treatments is to alleviate symptoms. None of the treatments offers a cure – but many offer some relief. The problem is the nature of the disease process itself, as it can be insidious and have a chronic or disabling effect. Many patients are suffering unnecessarily because they do not realise they have Ménière’s disease as they have not been diagnosed.
The important thing is to try to stop patients from becoming disheartened. Just because the present treatment is not effective does not mean that another treatment will not offer some relief.
Possibly the most important thing nurses can do is to offer support by listening to patients. This simple gesture can make all the difference to a person’s life. Nurses can help to reduce patients’ feelings of isolation and loneliness by putting them in touch with organisations such as the Ménière’s Society or the British Tinnitus Association, which can offer practical advice and support.
American Academy of Family Physicians (2007) Meniere’s Disease. http://familydoctor.org/online/famdocen/home/articles/096.html
De Ridder, D. et al (2005) Transcranial magnetic stimulation for tinnitus:
influences of tinnitus duration on stimulation parameter choice and maximal tinnitus suppression. Otology & Neurotology;
Jastreboff, P.J., Jastreboff, M.M. (2000) Tinnitus retraining therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. Journal of the American Academy of Audiology; 11: 3, 162–177.
Kleinjung, T. et al (2005) Long-term effects of repetitive transcranial magnetic stimulation (rTMS) in patients with chronic tinnitus. Otolaryngology – Head and Neck Surgery; 132: 4, 566–569.
National Library of Medicine (2007) Ménière’s disease. www.nlm.nih.gov/medlineplus/menieresdisease.html
The full reference list for this part of the unit is available in Portfolio Pages on nursingtimes.net