I.

Introduction
Site info states, reason for choosing
Menieres disease usually first occurs in people between the age of 20 and 50
years. It affects more than 2.4 million people in the United States. More common in
adults, it has an average age of onset in the 40s, with symptoms usually beginning
between the ages of 20 and 60 years of age. It appears too equally common in both
genders and occurs bilaterally in about 20% of patients. About 50% of the patients
who have the Menieres disease have a positive family history of the disease.
Severe, debilitating attacks alternate with symptom-free periods. Patients often
have certain manifestations before an attack of vertigo such as headaches,
increasing tinnitus, and fullness in affected ear. Patients describe the tinnitus as a
continuous, low-pitched roar or a humming sound, which worsens just before and
during an attack. Hearing loss occur first with the low frequency tones but
progresses to include all levels and with repeated attacks, can become permanent.
The vertigo with periods of whirling may even cause patients to fall. It is so
intense that even while lying down, the patient often holds the bed or ground to keep
from falling. Severe vertigo usually lasts 3 to 4 hours, but he or she may feel dizzy
long after the attack. Nausea and vomiting are common. Other manifestations
include rapid eye movements (nystagmus) and severe headaches.
II. Definition of the disease
Categories and define each
Menieres disease is an abnormal inner ear fluid balance caused by a
malabsorption in the endolymphatic sac or a blockage in the endolymphatic duct.
Endolymphatic hydrops, a dilation in the endolymphatic space, develops, and
either increased pressure in the system or rupture of the inner ear membrane
occurs, producing symptoms Menieres disease.

Menieres disease also known as idiopathic endolymphatic hydrops, is

a disorder of the inner ear resulting in the clinical triad of vertigo, tinnitus, and
hearing loss. Three of the most recognizable indication of Menieres disease
are tinnitus, vertigo, and fluctuating hearing loss. Menieres disease is an inner ear
condition that may trigger disruptions in your balance.
 While there is no known cure for this disorder, there are steps that you can
take to lessen the impact it has on your daily life. A common starting point of these
episodes is a feeling of fullness in the ear that leads to tinnitus and mild hearing
loss. Shortly after these symptoms begin, you may begin to suffer vertigo, a feeling
of dizziness not unlike what you might experience after quickly spinning around
several times. You may feel nauseated and your balance may be impaired.

Episodes vary in length, sometimes ending as quickly as twenty minutes or

lasting for hours. It is common for Menieres disease episodes to appear in clusters,
with individuals enjoying periods of remission between groups of episodes.
Symptoms vary from episode to episode in terms of intensity and duration. If you
notice any of these symptoms, it is important to consult with your doctor to rule out
more serious conditions.

The principle symptoms include:

Vertigo - usually the most striking Meniere's disease symptom, which includes:
o A feeling that you are spinning, even when you are stationary

o Dizziness

o Vomiting

o Nausea

o Irregular heartbeats (palpitations)

o Sweating.

An episode of vertigo may last from a few minutes to a number of hours. As it is

difficult to predict when a vertigo attack may occur, patients should have their vertigo
medication handy at all times. Vertigo can interfere with driving, operating heavy
machinery, climbing ladders/scaffolding, and swimming.
Tinnitus - you sense noise or ringing, buzzing, roaring, whistling or hissing in
your ear, which is generated from inside your body. You will be more aware of it either
during quiet times or when you are tired.
 Hearing loss - hearing loss may fluctuate, especially early on in the course of
the disease. The patient may also be especially sensitive to loud sounds. Eventually,
most people experience some degree of long-term hearing loss.
Three Stages of Menieres Disease
Early stage - sudden and unpredictable episodes of vertigo. Often the patient
will experience nausea, dizziness and vomiting during the episodes. An episode may
last from about 20 minutes to a full 24 hours. During episodes there will be some
hearing loss, which returns to normal after it is over. The ear may feel uncomfortable
and blocked, with a sense of fullness or pressure (aural fullness). Tinnitus is also
common.
Middle stage - vertigo episodes continue, but are usually less severe. Tinnitus
and hearing loss, on the other hand, get worse. Some patients during this stage may
experience periods of complete remission - symptoms just go away and seem to
have gone forever. These periods of remission can last several months.
Late stage - vertigo episodes become even less frequent, and in some cases
never come back. Balance problems, though, continue. Patients will feel especially
unsteady when it is dark and they have less visual input to help maintain balance.
Hearing and tinnitus typically get progressively worse.
The following symptoms are also possible (known as secondary symptoms):
Anxiety, stress, depression - because of Meniere's disease's unpredictability
many patients become, anxious, depressed and stressed. The disease can have a
detrimental impact on the sufferer's work, especially if they have to climb ladders or
operate machinery. As hearing gets progressively worse the patient may find it more
difficult to interact with other people.
Some people cannot drive, further limiting their independence, job prospects,
freedom and access to social contacts. It is important for patients who
experience stress, anxiety and/or depression to tell their doctor.

Pathophysiology:

III. Risk factors with rationales

 Modifiable and Non-Modifiable
Associated with aging
Middle-ear infection
Head trauma

IV. Clinical manifestations with rationales

S&Sx with ratio
Symptoms of Menieres disease include fluctuating progressive sensorineural hearing
loss; tinnitus or a roaring sound feeling of pressure or fullness in the ear; and episodic,
incapacitating vertigo, often accompanied by nausea and vomiting. These symptoms
range in severity from a minor nuisance to extreme disability, especially if the attacks of
vertigo are severe. At the onset of the disease, perhaps only one or two of the
symptoms are manifested.

1. Episodic vertigo rotatory in nature

2. Ipsilateral hearing loss
3. Aural fullness
4. Roaring tinnitus
5. Diplacusis
SYMPTOMS
Sudden onset
Preceded by aural fullness
Feeling of to and fro or up and down movement- Ship wrecked in storm
feeling
Episodic- lasting from 20 mins to 24 hrs
Associated vomiting, anxiety
Tullio phenomenon
Tumarkin drop attacks
SIGNS
Nystagmus - depending on phase
Associated Documentable hearing loss
Spontaneous complete recovery
Absence of loss of consciousness, neurological deficits, persistant
imbalance after the episode

Sudden episodes of severe whirling vertigo, with an inability to stand or walk; episode
may last up to several hours
Buzzing tinnitus (worsens before and during an episode)
Nausea, vomiting, and diaphoresis
Possibly, brief loss of consciousness with nystagmus

V. Medical management with description

Most patient can be successfully treated with diet and medication. Many patients
can control their symptoms by adhering to a low-sodium (200mg/day) diet. The
amount of sodium is one of the many factors that regulate the balance of fluid within
the body. Sodium and fluid retention disrupts the delicate balance between
endolymph and perilymph in the inner ear. Psychological evaluation may be
indicated if a patient is anxious, uncertain, fearful or depressed.
IVF, Drugs, Diet & Activity Given to the patient
Non-Surgical Management
Teach patients to move the head slowly to prevent worsening of the vertigo.
Nutrition and lifestyle changes can reduce the amount of endolymphatic
fluid. Encourage the patients to stop smoking because of the blood vessels
constricting effects.

Although there is no cure, there is treatment that can help the patient manage
some of the symptoms of Meniere's disease.

Medications for vertigo - the individual may be prescribed medication to be taken

during an episode of vertigo to reduce the intensity of an attack. These may include:
Motion sickness drugs - examples include meclizine (Antivert) or diazepam
(Valium). They may help with the spinning sensation, as well as nausea and vomiting.
Drugs for nausea - prochlorperazine has been shown to be effective in the
treatment of nausea during a vertigo episode.
Diuretics - a combination of triamterene and hydrochlorothiazide (Dyazide, Maxzide)
will reduce fluid retention. By reducing the amount of fluid the body retains the patient's
fluid volume and pressure in the inner ear may improve, resulting in less severe and
less frequent Meniere's disease symptoms.
Long-term diuretic medication may deplete body levels of minerals, such as potassium.
Patients should supplement their diet with potassium-rich foods, such as bananas,
cantaloupe, spinach, sweet potatoes and oranges.
Dietary changes - there are some dietary changes which can help reduce fluid
retention. Generally, the less fluid retention a patient has the less severe and frequent
his/her symptoms Meniere's disease symptoms will be.

These measures are known to help:

Many smaller meals evenly distributed throughout the day helps regulate body
fluids. Rather than three large meals a day, try to go for six smaller ones.

Eat less salt - the less salt you consume the less fluid your body will retain. Do
not add any salt to your meals. Cut out most junk foods.

Cut out MSG (monosodium glutamate) - any foods with MSG added should be
struck off your shopping list.

1. Nutrition Therapy
Dietary changes - there are some dietary changes which can help reduce fluid
retention. Generally, the less fluid retention a patient has the less severe and
frequent his/her symptoms Meniere's disease symptoms will be.

These measures are known to help:

Many smaller meals evenly distributed throughout the day helps regulate
body fluids. Rather than three large meals a day, try to go for six smaller
ones.

Eat less salt - the less salt you consume the less fluid your body will
retain. Do not add any salt to your meals. Cut out most junk foods.

Cut out MSG (monosodium glutamate) - any foods with MSG added
should be struck off your shopping list.
 Caffeine - caffeine has been shown to make tinnitus louder. If you avoid
caffeine completely you may find symptoms improve.
Smoking - a significant number of patients report improved symptoms
after they give up smoking.
Stress, anxiety - experts are not sure whether stress/anxiety cause
symptoms or whether they are caused by the disease. However, some
studies indicate that good stress and anxiety management may help
lessen the intensity of symptoms.

If your levels of anxiety, stress, and possibly depression are affecting your
life, or if you would like to have better control, talk to your doctor.
Professional psychotherapy, as well as some medications have been
known to help many patients with Meniere's disease.

A hydrops diet may stabilize body fluid levels to prevent excess endolymph
accumulation.
The basic structure of this diet involves:
1.a. Limit foods high in salt or sugar. Beware of foods with hidden salts
and sugars.

1.b. Eat meals and snacks at regular intervals to stay hydrated. Missing
meals or snacks may alter the fluid level in the inner ear.

1.c. Eat fresh fruits, vegetables, and whole grains. Limit the amount of
canned, frozen or processed foods with high sodium content.

1.d. Drink plenty of fluids. Water, milk, and low-sugar fruit juices are
recommended. Limit intake of coffee, tea, and soft drinks. Avoid
caffeine because of its diuretic effect.

1.e. Limit alcohol intake. Alcohol may change the volume and
concentration of the inner ear fluid and may worsen symptoms.

1.f. Avoid monosodium glutamate (MSG), which may increase symptoms.

 1.g Avoid Aspirin and aspirin-containing medications. Aspirin may increase
tinnitus and dizziness.

Summary:

a. Avoiding monosodium glutamate (MSG).

b. Drinking adequate amounts of fluids daily.
c. Avoiding caffeine-containing fluids and foods.
d. Limiting alcohol intake to one serving per day.
e. Avoiding foods or fluids with a high salt content.
f. Distributing food and fluid intake evenly throughout the day and
from day to day.
Coordinate with a dietician for more information about diet therapy for reduction
of Menieres manifestation.
2. Drug Therapy

Although there is no cure, there is treatment that can help the patient manage some of
the symptoms of Meniere's disease.

Medications for vertigo - the individual may be prescribed medication to be taken

during an episode of vertigo to reduce the intensity of an attack. These may include:
Motion sickness drugs - examples include meclizine (Antivert) or diazepam
(Valium). They may help with the spinning sensation, as well as nausea and vomiting.
Drugs for nausea - prochlorperazine has been shown to be effective in the
treatment of nausea during a vertigo episode.
Diuretics - a combination of triamterene and hydrochlorothiazide (Dyazide,
Maxzide) will reduce fluid retention. By reducing the amount of fluid the body
retains the patient's fluid volume and pressure in the inner ear may improve,
resulting in less severe and less frequent Meniere's disease symptoms.
Long-term diuretic medication may deplete body levels of minerals, such as potassium.
Patients should supplement their diet with potassium-rich foods, such as bananas,
cantaloupe, spinach, sweet potatoes and oranges.
 May reduce the vertigo, vomiting and restore normal balance of what?.
Mild diuretics are prescribed to decrease endolymph volume, which
reduces vertigo, hearing loss, tinnitus, and aural fullness.
a. Nicotonic Acid
b. Antihistamines such as diphenhydramine hydrochloride (Benadryl,
Allerdryl) and dimenhydrinate (Dramamine, Gravol) and antivertiginous
drugs, such as meclizine (Antivert, Bonamine) help reduce the severity
of or stop an acute attack.
c. Antiemetics, such as chlorpromazine hydrochloride (Thorazine, Novo-
Chlorpromazine), droperidol (Inapsine), promethazine (Phenergan),
and ondansetron (Zofran), help reduce the nausea and vomiting.
Diazepam (Valium, Apo-Diazepam) calms the patient to rest quietly
during an attack. Intratympanic therapy with gentamycin and steroids
can prevent manifestations; however, this therapy results in some
hearing loss.
3. Pressure Pulse Treatments
Meniett device, which use a tympnostomy tube to apply low-
pressure micro pulses to the inner ear several times daily, have helped
reduce episodes in some patients with Menieres disease (National
Institute on Deafness and other Communication Disorders or NIDCD),
2010. This action displaces inner ear fluid and prevents o relieves
manifestations.

Surgical Management
1. Endolymphatic Decompression with drainage and a shunt
The effectiveness of this procedure varies. The endolymphatic sac
is drained, and a tube is inserted for continued fluid drainage. Some
patients report relief of vertigo with retention of their hearing. Vertigo is
present immediately after surgery from movement of the vestibules of the
inner ear during surgery. Reassure the patient that the vertigo is a
temporary result of the surgical procedure, not the disease.
Middle ear injections - some middle ear injections (injected into the middle ear) may
improve symptoms of vertigo. They include:
 Gentamicin - this is an antibiotic that reduces the balancing function of the ear
so that the other ear takes over the body's balance. Gentamicin may reduce the
severity and frequency of vertigo attacks. There is a risk of further hearing loss.
Steroids - some patients report better control over vertigo attacks with such
steroids as dexamethasone. Dexamethasone is less effective than gentamicin, but
has a much lower risk of causing further hearing loss.
Surgery - this may be an option if the patient did not respond to other treatments, or if
symptoms are very severe. Surgery options include:
Endolymphatic sac decompression - a small portion of bone is removed from
over the endolymphatic sac. Occasionally, a shunt is placed (a tube that drains
excess fluid from the inner ear).
Labyrinthectomy - a portion of the inner ear is surgically removed. This takes
away both the hearing and balance function of the affected ear. This procedure is
only done if the patient is either totally, or almost totally deaf in that ear.
Vestibular nerve section - the vestibular nerve is cut. This nerve connects the
balance and movement sensors in the inner ear to the brain. A vestibular nerve
section is aimed at preserving hearing in the affected ear, while addressing the
problems with vertigo.
Vestibular rehabilitation therapy - patients who have problems with their balance
between episodes of vertigo may benefit from exercises and activities aimed at helping
the body and the brain regain the ability to process balance data properly.
Hearing aid - a patient with Meniere's disease who has suffered hearing loss from the
affected ear may benefit from a hearing aid. A hearing aid is an instrument to help in
hearing.

Audiogram - this exam determines the extent of hearing loss caused by the disease.
An audiometer produces tones of varying loudness and pitch. The patient listens with
headphones and indicates when he/she hears a sound, or when a sound is no longer
present. The test only works if the patient has normal hearing in one ear - the specialist
can then make a comparison. An audiogram may not be so effective during the early
stage because hearing loss is usually temporary. The test may also determine whether
the hearing problem is in the inner ear or the nerve that connects the inner ear to the
brain (auditory nerve).

Balance Assessment

Many people with Meniere's disease have some degree of ongoing balance
problems, even when their sense of balance appears to return to normal between
episodes of vertigo.

Electronystagmography (ENG) - this assesses eye movement to evaluate

balance function. Muscles that control eye movement are linked to balance-related
sensors in the inner ear - it is this link that allows people to turn their head while
focusing their eyes steadily on a single point.
Electrodes are placed on the skin near the eyes and on the patient's forehead. Warm
and cool water or air is introduced into the ear canal. Involuntary eye movements in
response to this simulation are measured. Abnormalities may indicate an inner ear
problem.
Rotary-chair testing - this test also measures inner ear movement by assessing
eye movement. It is usually better tolerated than the ENG. The patient sits in a chair
in a small, dark booth. Electrodes are placed near the eyes and a computer-guided
chair rotates gently back and forth at varying speeds. The movement stimulates the
inner balance system and causes nystagmus (eye movements) that are recorded by
a computer and monitored with an infrared camera.
Rotary chair testing does not provide specific diagnostic information about each ear
individually - unlike the ENG.
VEMP (vestibular evoked myogenic potentials) testing - this test measures
the function of the sensors in the vestibule of the inner ear that detects acceleration
movement. These sensors are slightly sensitive to sound. When exposed to sound
the neck muscles contract at varying degrees. VEMP testing can indirectly measure
inner ear function.
Post-urography - this test determines which part of the balance system the
patient relies on the most, and which may cause problems. The patient wears a
 safety harness, stands barefoot on a special platform and has to keep his/her
balance under various conditions. We rely on various senses for balance, including
vision, inner ear, or sensations in our skin, muscles, tendons and joints.
A doctor may wish to rule out other possible diseases and conditions, such as
a brain tumor or multiple sclerosis. In order to do so, the following tests may be
ordered:
MRI (magnetic resonance imaging) scan - a magnetic field and radio waves
created a 3-D image of the brain on a computer screen (monitor)
CT (computerized tomography) scan - many X-ray images produce cross-
sectional images of internal structures of the body
Auditory brainstem response audiometry - a computerized measure of
auditory function using responses produced by the auditory nerve at the brainstem.
This test is also known as brainstem evoked response audiometry. This test can
determine whether a tumor is disrupting the function of the auditory nerves.
VI. Nursing management with description
Handling the situation the patient
Risk for injury related to altered mobility because of gait disturbed and vertigo.
Impaired adjustment related to disability requiring change in lifestyle because of
unpredictability of vertigo.

References

Books:

Medical-Surgical Nursing Elevent Edition by Brunner & Suddarths

pages 2112-2125 (volume 2)
Medical-Surgical Nursing Eight Edition(Patient-Centered Collaborative
Care)
pages 892-902
Introductory Medical-Surgical Nursing Tenth Edition by Timby & Smith
pages 1008-1016
Sites:

http://www.medicalnewstoday.com/articles/163888.php
https://www.welcomecure.com/diseases/menieres-disease/risk-factors