Ménière’s disease patients in the acute stage

Meniere’s Disease (MD) is an idiopathic inner ear disorder characterized by spinning dizziness (lasting from 20’ to 24h), fluctuating hearing loss (HL), ear fullness and tinnitus. The natural history of the disease is characterized by variable periods of exacerbation and remission of symptoms, although cochlear symptoms can also be observed among episodes. The hallmark of an acute attack is prolonged vertigo. Each episode of vertigo is characterised by a sudden unheralded intense sensation of movement, most commonly rotation or spinning, lasting 20 minutes to 12 hours. Because of the brief duration of each attack the clinical examination of a patient with MD is often performed during the inter-critic period and finds no abnormalities. In the few cases where patients have been observed during a crisis appear quite unwell because of the unpleasant sensation of vertigo. They may be sweaty and pale, unable to stand up safely, nauseated and vomiting. They may have an horizontal nystagmus that changes direction as the attack progresses (beating toward the side of the disease at the beginning and after toward the safe hear). Following an attack, patients are left with a sense of “hangover” for a day or two before recovering to a normal function. Each crisis can be control by the use of vestibular suppressant and antiemetic medication, in association with electrolyte adjustment and rehydration. Because of the nausea and vomit complained by the patient, the more adapt drug and form available should be choice in every single case. Medications can be divided into different classes, including benzodiazepines, antihistamines, anticholinergics and antidopaminergics; also calcium channel blockers may be used as vestibular suppressant, although their role in this context hasn’t been yet cleared. Moreover, because of the possible autoimmune origin of MD, the use of oral or intratympanic corticosteroids has been also proposed both to reduce the acuity of the crisis and to promote the audio-vestibular recovery. Last but not least is described the use of osmotic diuretics (mannitol, glycerol etc.) administered intravenously. The rationale for their use is based on the supposition that these drugs can alter the fluid balance of inner ear, leading to a depletion of endolymph and a correction of hydrops. All these molecules, administered alone or in combination, constitute a possible treatment during a crisis of MD, although to date there is not consensus and are not available strong evidence about the recommendation of any of these drugs. The method of administration depends on the development of vegetative symptoms and the availability in the formulation of each molecule, so it could be orally, intramuscularly, intravenously or rectally. We underline that, because of the action inhibiting the vestibular compensation of the most of these drugs, their use should be limited to the acute phase and stopped as soon as possible. In this phase a molecule as betaistine, that is described to favour vestibular compensation because of his action against H3 receptors, may play an important role and help the patient to recovery as soon as possible after each episode and come back to his usual activity.