Abstract
Ménière's disease: the treatment evidence we still do not haveAn attack of Ménière's disease involves fullness in one ear, roaring tinnitus, and vertigo lasting between 20 min and 12 h.Patients might vomit, cannot stand or drive, and cannot predict the next attack.Attacks cluster unpredictably and can remit spontaneously for months or years.Over time, the disease can cause permanent hearing loss and chronic imbalance, profoundly affecting quality of life and employment.Treatment can reduce vertigo attacks, but cannot reverse established hearing or balance loss.Ménière's disease affects an estimated 0.05-0.20% of adults worldwide (including 250,000-750,000 people in the EU), is more common in women, and occurs more frequently in Europe and North America than in east Asia.More than 160 years after the disease was first described, its cause remains uncertain.Endolymphatic hydrops (build-up of inner-ear fluid that distends the membranous labyrinth) has been associated with Ménière's disease, along with genetic, inflammatory, immune, migraine-related, and anatomical mechanisms.Increasingly, the disease is understood not as a single disorder with one cause, but as a heterogeneous clinical syndrome.Uncertainty extends across the treatment pathway.Patients are commonly advised to reduce salt and caffeine and might receive betahistine, intratympanic corticosteroids to reduce vertigo, or intratympanic gentamicin that controls vertigo by destroying vestibular function but can also damage hearing.A 2023 Cochrane review found no placebo-controlled randomised trials of salt or caffeine restriction.Betahistine did not outperform placebo whereas intratympanic treatments have mainly been compared with other active treatments, showing which performs better but not their individual efficacy.The evidence does not become stronger as treatment becomes more invasive.Surgical practice varies between countries, but surgery might be considered when less invasive treatments are unsuccessful.Endolymphatic sac decompression (ESD) removes bone over the sac to relieve pressure whereas a newer procedure called endolymphatic duct blockage (EDB) clips the duct shut to alter endolymphatic fluid dynamics.A 2023 Cochrane review of surgical interventions identified only two randomised trials and judged the evidence for their efficacy to be of low or very low certainty.