Meniere's Disease

Prepared by:Laurice Grace Z. Bael, RN

• Dr. Prosper Meniere , in 1861• also called endolymphatic hydrops

•  characterized by an episodic sudden onset of vertigo, low-frequency hearing loss (in the early stages of the disorder), tinnitus, and sensation of fullness in the affected ear.

more common in adults an average age of onset in the 40s with symptoms usually beginning

between the ages of 20 and 60 years

common in both genders the right and left ears are affected

with equal frequency

Normal Dilated

Anatomy of the Ear

Outer ear

• Pinna- collects and directs sound waves

• External auditory canal- short narrow chamber, lined with ceruminous gland that produces the cerumen.

• Tympanic membrane- vibrates when sounds hit

Middle ear

• Small, air-filled cavity with in the temporal bone

• Eustachian tube - a tube that connects the middle ear to the back of the nose; it equalizes the pressure between the middle ear and the air outside and drains drainage to the nasopharynx.

• 3 bones/ ossicles:• Hammer • Anvil• Stirrups

Inner ear• Cochlea-responsible for converting

sounds which enter the ear canal, from mechanical vibrations into electrical signals called transduction

• Organ of Corti- contains auditory sensory cells or "hair cells“, It contains between 15,000-20,000 auditory nerve receptors. Each receptor has its own hair cell.

• Vestibule- central part of the osseous labyrinth. contains the utricle and saccule, which are crucial in ensuring that your head and body maintain normal balance and positioning as you move about.

• Semicircular Canals - These are fluid-filled loops, attached to the cochlea and help in maintaining the balance.

• Auditory Nerve - the electrical impulses, generated by the nerve cells, are then passed to the brain.

• Utricle and saccule- are both organs for static equilibrium, which maintains the stability of the head and body when they are motionless or during linear (straight) movements. They are sensitive to gravity and linear acceleration.

Fluids• Endolymph-(high in K, low

in Na). • fluid waves in the

endolymph of the cochlear duct stimulate the receptor cells, which in turn translate their movement into nerve impulses that the brain perceives as sound.

• Perilymph- is the fluid contained within the osseus labyrinth, surrounding and protecting the membranous labyrinth.

Pathophysiology

• Otolithic crisis of Tumarkin- these are attributed to sudden mechanical deformation of the otolith organs (utricle and saccule), causing a sudden activation of vestibular reflexes. Patients suddenly feel that they are tilted or falling (although they may be straight), and bring about much of the rapid repositioning themselves. This is a very disabling symptom as it occurs without warning and can result in severe injury.

ASSESSMENT

• A careful history is taken to determine the frequency, duration, severity, and character of the vertigo attacks.

• Patients are sometimes diaphoretic and pale.

• Vital signs may show elevated blood pressure, pulse, and respiration.

• Spontaneous nystagmus directed toward affected ear is typical during an acute attack.

• The Romberg test generally shows significant instability and worsening when the eyes are closed.

• The Rinne test usually indicates that air conduction remains better than bone conduction.

• The Weber tuning fork test usually lateralizes away from the affected ear.

• No lab studies are specific for Meniere disease.• A CBC, urinalysis, chemistry panel, and alcohol

and drug screening may be helpful if other causes are considered.

• If an infectious cause is suspected, consider blood cultures, urine culture, and a cerebral spinal fluid (CSF) examination.

Diagnostic Findings

• Magnetic resonance imaging- Brain scan should be done to rule

out abnormal anatomy or mass lesions.

• CT scans reveal dehiscent superior semicircular canals and/or widened cochlear and vestibular aqueducts

• Audiometry is particularly helpful to document present hearing acuity and to detect future change.-The patient may not notice a loss at specific frequencies. Low-frequency or mixed low- and high-frequency insufficiency may be observed.- Typically, the lower frequencies are affected more severely. This is due to preferential sensitivity of the apex to the hydrops.

• pure-tone air and bone conduction with masking -is the basic measurement of hearing sensitivity and the integrity of the entire auditory receptive pathway. Air-conduction thresholds are measured under headphones or with insert earphones. Bone measurements attempt to by-pass the outer and middle ear and test the function of the cochlea and the auditory nerve.

Normal Results• The ability to hear a whisper, normal

speech, and a ticking watch is normal.• The ability to hear a tuning fork through

air and bone is normal.• In detailed audiometry, hearing is normal

if you can hear tones from 250 Hz - 8,000 Hz at 25 dB or lower.

• Result:unilateral sensorineural hearing loss; usually low-frequency hearing loss is present in early stages of MD and during or before attacks; as disease progresses, middle and high frequencies are affected

• Electronystagmography (ENG) is a test of the inner ear function.

• Electrodes are placed at locations above and below the eye to record electrical activity. By measuring the changes in the electrical field within the eye, ENG can detect nystagmus in response to various stimuli. If nystagmus does not occur upon stimulation, a problem may exist within the ear, nerves that supply the ear, or certain parts of the brain.

• Oculomotor evaluation

• Positioning/positio-nal testing

• Caloric stimulation of the vestibular system

• Gaze nystagmus test-involves staring at a fixed light placed either to the center or side as you are seated or lying down.

• water caloric test-involves introducing warm or cool water into the ear canal with a syringe so that it touches the tympanic membrane. If no problem exists, your eyes will move involuntarily to this stimulus.

• Typically, Meniere disease causes a reduced vestibular response in the affected ear, although response may be increased secondary to an irritative lesion.

Pharmacologic therapy

1. Antihistamines2. Tranquilizers3. Antiemetics 4. Diuretic5. Vasodilators

• class

•    Tranquilizers and antihistamines such as meclizine (Antivert) to control vertigo and to suppress the vestibular system.

• Diazepam also alleviates the anxiety associated with this disorder. Usual dose is 5 mg administered orally every 3 hours. The initial dose may also be administered intravenously.

• Antihistamines:• Meclizine:This drug is one of the most

useful to prevent / treat nausea and vomiting associated with vertigo of vestibular origin. It has a slower onset and a longer duration of action (24 hours). usual dose administered in adults is 25 - 100 mg daily in divided doses. Side effects of this drug include:blurred vision, drowsiness.

• .•  Diuretics to lower pressure in the endolymphatic system,alter the fluid balance of inner ear, leading to a depletion of endolymph and a correction of hydrops.•    Vasodilators are often used in conjunction with other therapies

• antiemetics for nausea and vomiting

• Aminoglycosides: Streptomycin and gentamycin are predominantly vestibulotoxic.

• daily dose is 1 g of streptomycin intramuscularly 5 days a week until vestibular ablation occurs .Intratympanic injections of these drugs have also been used with success.

Drug Considerations

• Aspirin can cause tinnitus. Nonsteroidal anti-inflammatory agents such as ibuprofen or naproxen should also be avoided.

• Dietary  Management•    Low sodium (2,000 mg/day)•    Avoidance of alcohol, nicotine and caffeine

Surgical management Indications

• failure to respond to 3-6 months of medical therapy

• Severe vertigo attacks

Contraindications

• Otitis media and mastoiditis

• Bilateral vestibular disease -risk of complete loss of inner ear function

• Hypersensitivity or allergy to the target medication

• Endolymphatic Sac Decompressionequalizes the pressure in the endolymphatic space by removing petrous bone that encases the endolymph reservoir, some insert a drain or valve from the endolymphatic space to the mastoid or subarachnoid space to reduce pressure further.The risk of hearing loss and facial nerve damage is minimal. Severe postoperative pain is unusual, and the recovery period is usually short and uneventful.

Anesthesia: GeneralSurgical Time: 45-60 minutesHospital Admission: Outpatient or overnight observationSurgical Procedure: An incision is made behind the ear and a mastoidectomy is performed. Bone overlying the endolymphatic sac is removed, then stented open into the mastoid. This allows stabilization of the inner ear fluids.

• Middle and Inner Ear Perfusion

used to decrease vestibular function and decrease vertigo

ototoxic medications, such as streptomycin or gentamicin, can be given to patients by infusion into the middle and inner ear.

• Intratympanic Gentamicin Anesthesia: TopicalSurgical Time: 30 minutes

An incision is made in the eardrum and gentamicin is placed into the middle ear. The patient is positioned one side for 30 minutes as the medication perfuses through the membranes of the inner ear. The eardrum heals on its own in a few days.

• Vestibular Nerve Section

provides the greatest success rate (approximately 98%) in eliminating the attacks of vertigo

cutting the nerve prevents the brain from receiving input from the semicircular canals.

highest risk of CSF complications and increases the risk of damage to the facial and cochlear nerves

• By cutting the balance nerve, abnormal signals coming from the inner ear may be eliminated. Balance compensation occurs by allowing the brain to use normal information from the opposite ear, unhindered by the diseased ear. This allows preservation of hearing in the diseased ear in the vast majority of patients.

• Labyrinthectomy -has the advantage of a high cure rate (>95%)

• involves ablation of the diseased inner-ear organs but does not require entry into the cranial cavity.

• less invasive ,Craniotomy is not required; the risk of CSF leakage and meningitis is reduced. Patients typically require a few days of inpatient care. Adaptation to the surgical loss of 1 vestibular apparatus usually takes weeks to months. Vestibular rehabilitation during this period is also helpful.

• Postoperative Care Patients undergoing destructive surgery

can expect severe vertigo and imbalance for the first few days. Liberally dispense medications to alleviate nausea and vomiting during this time. Early vestibular rehabilitation is helpful in achieving rapid compensation for loss of unilateral vestibular input.

Complications

hearing loss, tinnitus, dizziness, facial paralysis, hematoma, bleeding, cerebrospinal fluid (CSF) leakage, taste disturbance, and mouth dryness are possible.

Vestibular Rehabilitation Therapy

• physical therapy designed to habituate symptoms, and promote adaptation to deficits of balance disorders.

• improve balance• Minimize falls• Decrease subjective sensations of dizziness• Improve stability during locomotion• Improve neuromuscular coordination• Decrease anxiety and somatization due to

vestibular disorientation

• Candidates: have stable central or peripheral vestibular deficits and intact cognitive, cerebellar, visual, and proprioceptive systems.

• focus on gaze stability and gait stability

• Meniett device -is a handheld device that delivers intermittent pressure pulses through the ear canal and is self-administered 3 times per day. A tympanostomy tube is placed in the tympanic membrane and should be kept patent throughout the treatment.

Nursing Diagnosis

• Activity intolerance related to altered mobility secondary to vertigo

• Monitor vital/ cognitive signs, watch for changes in vital signs and presence of confusion

• Adjust activities as tolerated • Provide positive atmosphere,

while acknowledging difficulty of the situation.  

• Administer prescribed medications, which may include antihistamines, antiemetics, and possibly, mild diuretics

• Recommend that patient keep eyes open and stare straight ahead when lying down and experiencing vertigo.

• Risk for injury related to altered mobility secondary to gait disturbance and vertigo.

• Identify needed interventions and safety devices

• Provide side rails in bed• Evaluate clients cognitive

status• Let client enroll in

vestibular rehabilitation• Place pillow on each side

of head to restrict movement.

• Encourage patient to sit down when dizzy

• Mobility, impaired physical r/t perceptual and cognitive impairment

• Assessment:• Postural instability

when performing ADL• Uncoordinated

movement

• Implement ROM exercises. This prevents muscle atrophy.

• Ensure pt. comfort by padding extremities prone to skin breakdown

• Encourage active movement by assistive devices- increase muscle tone and pt. self-esteem

• Turn to sides every 2 hrs

•     Risk for fluid volume deficit related to increased fluid output, altered intake, and medications.

1.Monitor intake and output.

2.Assess indicators of dehydration (e.g. pulse, skin turgor, blood pressure, mucous membranes).

3.Encourage oral fluids as tolerated; discourage beverages containing caffeine.

•     Impaired adjustment related to disability requiring change in lifestyle because of unpredictability of vertigo.

• •    Anxiety related to threat of, or change in, health status and disabling effects of vertigo.•    Ineffective coping related to personal vulnerability and unmet expectations secondary to vertigo.•    Feeding, bathing/hygiene, dressing/grooming, and toileting self-care deficits related to labyrinth dysfunction and episodes of vertigo.

Nursing Management

• Instruct the client on self-care instructions to control the number of acute attacks.

• Avoid eating foods or fluids that have a high salt content.

• Drink adequate amounts of fluid daily. This should include water, milk and low-sugar fruit juices.

• Avoid caffeine-containing fluids and foods (such as coffee, tea and chocolate.

• Avoid cigarettes. The nicotine present in cigarettes constricts blood vessels and can decrease the blood supply to the inner ear, making your symptoms worse.

• Some attacks may occur during the night, so be sure to have a night light on

• make sure that the path to the bathroom is free of throw rugs, furniture or other obstructions.

• It may be necessary to take antidepressants or anti-anxiety drugs, under the supervision of an appropriate health care professional.

During attacks • lay down on a firm surface. Stay as

motionless as possible, with your eyes open and fixed on a stationary object. Do not try to drink or sip water immediately, as you'd be very likely to vomit. Stay like this until the severe vertigo (spinning) passes, then get up SLOWLY. After the attack subsides, you'll probably feel very tired and need to sleep for several hours.

• Provide nursing care during acute attack.•    Provide a safe, quiet, dimly lit environment and enforce bed rest•    Provide emotional support and reassurance to alleviate anxiety•    Administer prescribed medications, which may include antihistamines, antiemetics, and possibly, mild diuretics

• Rest is crucial during severe episodes• It is important not to participate in

hazardous activities such as driving, operating heavy machinery, climbing, and similar activities until one week after symptoms disappear. During the attacks, avoid bright lights, TV, or reading, as they may make symptoms worse

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