Management of Meniere’s disease :Meniere’s Disease (Endolymphatic hydrops) :It is an inner ear disease with distention of membranous labyrinth .

It is due to either excessive formation of endolymph (by stira vascularis ) or lack of its drainage (by endolymphatic sac ).It is usually sudden unilateral , bilateral meniere has been observed in 5 to 10 % of studied cases . It happens around the age of 50 yearsMeniere’s disease is considered as a chronic condition with no cure.  It can be treated by a variety of treatments to reduce the symptoms. The treatments range from medication to surgery for the most severe cases. A multidisciplinary team which contains (GP , ENT, PT,OT, Neurologist, Audiologist, Psychologist..

) will work with the patient to provide the best management for the symptoms: these treatments may include:§  Medications such as :                        -Motion sickness medications: such as meclizine or diazepam (Valium) to reduce vertigo and help control nausea and vomiting.       -Anti-nausea medication: such as promethazine to control  nausea and vomiting during vertigo. – Diuretics: such as triamterene to reduce the amount of  fluid pressure in the inner ear, high Na?² which helps to prevent attacks, should be used with caution because of ototoxicity potential. – Middle ear injections: Medications injected into the middle ear and is absorbed into the inner ear , can help improve vertigo symptoms:        ü  Gentamicin: an antibiotic injected into the inner ear to reduce frequency and severity of vertigo attacks. However, there is a risk of increasing hearing loss.ü  Steroids: such as dexamethasone, it may help control vertigo attacks and may be less effective than Gentamicin.

 §  Noninvasive therapies :          – Vestibular rehabilitation exercises: can be taught by a physical therapist and occupational therapist. It is performed by repetitive balance exercises. Those exercises help patients to habituate to their vestibular loss  helping them compensate for the effects of the inner ear disorder. vestibular therapy is not considered useful as a primary treatment. In fact, vestibular rehabilitation is highly recommended in those who have undergone, labyrinthectomy, or vestibular nerve section. It can help in teaching patients to cope with vertigo and imbalance.           -Hearing aids: A hearing aid is fitted in the affected ear  to improve hearing. An audiologist will give  the patient what hearing aid options would be the best .

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              – Cochlear implant:  a patient with severe unilateral deafness and vertigo attacks, both labyrinthectomy and cochlear implantation are effective in relieving vertigo attacks and improving the auditory function.  The cochlear implant can restore auditory function of the deafened ear and improves binaural sound localization for most patients.                                 – Meniett device :  when it is hard to treat vertigo , there is a device  called a   Meniett pulse generator applies pulses of pressure to the ear canal through a ventilation tube to improve fluid exchange.  Initial reports on the Meniett device show improvement in symptoms of vertigo, tinnitus and aural pressure.          §  Dietary advice:  changing diet may help in reducing the amount of fluids in the inner ear.

Here are some  dietary agents to avoid  which  consider as triggers for the attacks:              – salt           -caffeine           -chocolate           -alcohol          -It’s also important to drink six to eight glasses of water per day, so your body isn’t  retaining fluid.  §  Lifestyle adjustments include: -Resting during  and after vertigo attacks. – Sit or lie down when you feel dizzy.                          -Be aware you might lose your balance: if the patient has chronic balance problems , he should  use a cane for stability when he walks and uses good lightning in the night. Because falling could lead to serious injuries.

– Avoid driving a car or operating heavy machinery. -Eating regularly (to help regulate fluids in your body). -Managing anxiety and stress through psychotherapy or medication. -It’s also important to quit smoking and to avoid any allergens, as both nicotine -and allergies can make the symptoms of Meniere’s disease worse.   §  Surgery: is used when a patient has severe attacks and has not had success with other treatment options.

Procedures include:   –   Endolymphatic sac Decompression or Shunt procedure:  The endolymphatic sac regulates inner ear fluids. This procedure may decrease fluid production or increase fluid absorption which may alleviate vertigo. In endolymphatic sac decompression,  the surgeon removes a small portion of bone is from over the endolymphatic sac. This procedure, in some cases is coupled with the placement of a shunt, a tube which drains excess fluid from your inner ear.    -Selective vestibular neurectomy :   This procedure cuts the nerve that connects the ear to the brain when there is balance nerve problem which reduces vertigo while preserving hearing in the affected ear.     – Labyrinthectomy :  This procedure is done when there are hearing and balance problems. This surgery removes the entire inner ear, which removes the balance and hearing function from the affected ear.

(i.e. control vertigo attack). If the patient has near-total or total hearing loss in the affected ear, this procedure is performed.      https://www.

mayoclinic.org/diseases-conditions/menieres-disease/diagnosis-treatment/drc-20374916                            https://emedicine.medscape.com/article/1159069-treatment#d13  Management of BPPV:*In a research it has been hypothesized that BPPV is secondary to Meniere’s disease, and this applies to the case presented . The reaserch proposed that the  destruction of the maculae of the utricle and saccule is dueto the presence of endolymphatic hydrops,  through compromise of the vascular supply or through detachment of otoconia into the endolymph. Moreover,  it  suggested that BPPV may be induced  by changes in endolymphatic fluid,  also by structural alterations of the vestibular aqueduct.

The detachment of otoconia through macular fibrosis  may be enhanced by a prolonged course of Meniere’s  disease. An increased rate of BPPV in patients with advanced Meniere’s disease should be expected. Also, it presented that  higher percentage of patients with  BPPV associated with Meniere’s disease  are females. In order to treat BPPV , the patient at first should wait for it to go away and do nothing.

Because sometimes symptoms go away by itself within six months. Medications can be helpful during the waiting period to control the severe symptoms  such as  the whirling ,vertigo sensation and the nausea and vomiting that may occur .Those medication are the same medication used with Meniere’s disease to control vertigo and nausea symptoms such as meclizine and promethazine. But medication do not cure BPPV.  Treatment of BPPV  consists of head exercises .

These exercises(when the head is firmly moved into different positions) will move the calcium particles out of the semicircular canals of the inner ear to a place where they will not cause vertigo. They are done by a doctor or physical therapist usually in 10- to 15-minute session.  Over time,  compensation will occur  and  as the brain may react less and less to the confusing signals triggered by the particles in the inner ear. If the patient continue normal head movements even if those movements cause the vertigo sensation.

   Semont maneuver exercises will be useful to the case presented of  posterior BPPV especially with neck pain. It alleviates sympyoms in about  80%  of the patients.   The remaining 20% a second treatment ( Brandt-Daroff exercise) may be done beside the maneuver to speed the compensation process.  The maneuver can be performed  in the doctor’s office with medication such as diazepam to help control nausea during the exercises. The Semont maneuver  is performed as follows:-The patient is seated, and the doctor turns his head as to be halfway between looking straight ahead and looking away from the  affected side that causes the worst vertigo.- Then the doctor lowers the patient quickly to the affected side. The patient looking  up at the ceiling ,when his head on the table.

 The doctor holds the patient in this position for 30 seconds.-The doctor then quickly moves the patient to the other side of the table with continuing the upright position.  The patient now looking down at the table, when his head on the table. The doctor holds the patient in this position for 30 seconds.-Then the doctor will help the patient to sit back up .

There are some instructions for the patient to follow after clinic treatment by Semont maneuver. This instruction will minimize the apportumity for otoconia to return to the semisircular canal of the inner ear and reduce the recurrence of dizziness. The instructions are:Ø   Patient should wait for 10 minutes after the maneuver before going home. This is to avoid the brief  bursts of vertigo after the maneuver.Ø   After the following two days: The patient should sleepwith the headbetween flat and upright at  an angle of 45 degree. This is done by  sleeping wih pollows arranged on a couch.Ø  During the following weeks : There are some steps the patient with BPPV can do at home to reduce the rotatory or spinning sensation of vertigo, those steps are:                – At night, use two or more pillows when you sleep.

              –  Avoid sleeping on the side with the ear that’s causing the problem.              – In the morning, get up slowly and sit on the bed edge before standing.              –  Be careful about reclining, like when your hair washed at a hair salon.             – Avoid tipping your head far back to look up or when to pick things up. And avoid head –forward positions like toe touches.            – Be careful when playing sports that demand turning your head or lie flat on the back.

The patient should wait one week after the clinic treatment in order to test the effectiveness of the treatment. Ø  Brandt-Daroff exercise at home:It is performend when the Semont menuver fails, when a case is mild or when the involved side is not determined. It is used  to speed up the compensation process and stop the symptoms of vertigo .It takes longer to work than the clinical treatments, but it succed in 95% of the patients. The patient can  do it only if he is instructed  to do so by the clincian .

Also, the patient must wait one week after the treatment before doing the Brandt-Daroff exercise.   To do the exercise:            -Should be done on a flat –surface.-Start in an upright, seated position on the edge of the bed.- Then Move into the lying position on one side with the  nose pointed up at about a 45-degree angle.

-Remain in the previous position for about 30 seconds  or until the vertigo become less intense , whichever is longer . Then move back to the seated position.- Repeat the previous steps on the other side.

 It takes 10 minutes to do and should be performed for two weeks, three sets each day. Complete relief from the symptoms is obtained after about 10 days. 30% of patients In the case that the symptoms persist for a year and more, it means that the maneuver or exercise do not help in controlling the symptoms pf BPPV. At this case, surgical treatment  may be recommended. The most common surgery is  posterior semicircular canal  plugging or occlusion.

In this surgery , the surgeon occlude most of the posterior canal’s function but without affecting the other canals or parts of the affected ear. This surgery may have a small risk of hearing loss. It has been showed that it is effective in about 90% of the patients.  There is another surgery called singular neuroctomy. This is done by a section of the ampullary nerve.

This nerve job is to send impulses from the posterior semicircular canal to the balance part in the brain. It has been reported that the suregert has high efficiency but with a significant risk to cause sensorineural hearing loss. Therefore,  it  has been replaced by the posterior semicircular canal occlusion as  it is more simple as it demands less technology