Ménière's disease, named after the French physician, Prosper Ménière, is a rare disorder that affects the inner ear. It can cause vertigo, tinnitus, hearing loss, and aural fullness (feeling of pressure in your ear).

Ménière's disease attacks

The symptoms of Ménière's disease usually appear without warning and are called ‘attacks’. The attacks usually last for around 2-3 hours, although following an attack it may take 1-2 days for the symptoms to disappear completely.

Ménière's disease progresses through different stages. The early stage may consist of between 6-11 attacks a year. In the later stages, there are usually fewer attacks and they eventually stop. However, hearing loss, tinnitus, and balance problems may become constant.

Ménière's disease is thought to be caused by a problem with the pressure in the inner ear. However, this has not yet been proven.

How common is Ménière's disease?

It is difficult to establish how common Ménière's disease is because the diagnosis criteria tend to vary. However, in the UK it is estimated that around one in 1,000 people develop Ménière's disease.

Ménière's disease can occur at any age, but it most commonly affects people who are between 40-60 years of age. Ménière's disease is slightly more common in women than in men, with 30% more women affected. In 5-7% of cases, there may be a family history of Ménière's disease.

Outlook

In 60-80% of people with Ménière's disease, the symptoms will improve and disappear after 2-8 years. However, some people will be left with permanent hearing loss, tinnitus, or both. In around 40% of people, the hearing loss affects both ears.

A variety of medications are available to treat Ménière's disease. It is estimated that these treatments allow 60-87% of people with Ménière's disease to continue with their normal daily activities. There are also a range of techniques and therapies that can help with the tinnitus and balance problems.

People with Ménière's disease may find that the condition has a significant impact on their emotional health. The unpredictable attacks can cause anxiety, and the hearing loss may lead to depression. There are a number of support groups that can provide assistance.

Vertigo
Vertigo is the sensation that you or the environment around you is moving or spinning.

Tinnitus
Tinnitus is the medical name for the perception of noise in one ear, both ears or in the head. The noise comes from inside the body rather than an outside source.

The symptoms of Ménière's disease vary from person to person. They can occur without warning and at irregular intervals.

Primary symptoms

The main symptoms of Ménière's disease are:

• vertigo - the sensation that you, or the environment around you, is moving or spinning
• tinnitus - the perception of noise in one ear, both ears, or in your head, where the noise comes from inside the body rather than from an outside source
• hearing loss
• aural fullness - a sense of pressure, or fullness, in the inner ear

Each of the primary symptoms of Ménière's disease are described below in more detail.

Vertigo

Vertigo is usually the most prominent symptom of Ménière's disease. The symptoms of vertigo include:

• feeling as though you are spinning, even when standing completely still
• dizziness
• nausea (feeling sick)
• vomiting
• loss of balance
• difficulty standing
• difficulty walking
• drop attacks (sudden, unexpected falling to the ground) can occur rarely

Symptoms that may occur during a severe attack of vertigo include:

• palpitations (an irregular heartbeat)
• sweating
• diarrhoea

A vertigo attack can last for just a few minutes, but it will often last for 2-3 hours. It is difficult to predict exactly when an attack will take place, so you should keep any vertigo medication that you have with you at all times.

As vertigo can leave you disorientated and unbalanced, you should avoid activities such as driving, using ladders, or going swimming.

Tinnitus

Tinnitus is the medical name for the perception of noise in one ear, both ears, or in your head. The noise comes from inside your body, rather than from an outside source. Tinnitus is usually more noticeable when you are tired, or when it is quiet, as there is less background noise to distract you from the sounds that are caused by tinnitus.

The sound that you hear could be:

• a ringing sound
• a buzzing sound
• humming
• whistling, or
• music

Hearing loss

Ménière's disease particularly affects the way that you hear low sounds, making them increasingly difficult to pick up. It can also make you more sensitive to loud sounds.

For most people, the condition only affects one ear, which is called unilateral Ménière’s Disease. However, over the course of many years, the other ear can become affected as well.

Aural fullness

Many people describe aural fullness as an additional symptom of Ménière's disease. It is a feeling of pressure, or discomfort, in the inner ear.

Secondary symptoms

As Ménière's disease is an unpredictable and sometimes difficult condition to manage, it can often cause a number of secondary symptoms. These include:

• stress - feeling under pressure
• anxiety - feeling anxious or worried
• depression - feelings of extreme sadness, despair, or inadequacy

Ménière's disease can often have a significant impact on a person’s day-to-day activities. The condition can sometimes have an adverse affect on work and family life. For example:

• you may need to change your job if it previously involved using ladders, scaffolding, or operating machinery
• you may need to stop driving, which could limit your social contact
• the hearing loss can make it difficult to interact with others, both in the workplace and at home
• you may find it difficult to sleep as a result of the tinnitus, which can leave you feeling tired and stressed

These changes may leave you feeling stressed, anxious, or depressed. You should speak to your GP if you are finding it difficult to come to terms with the affect that Ménière's disease is having on your life. They will be able to offer be able to offer advice and support.

Stages of Ménière's disease

Menière's disease is categorised into three stages:

• early stage
• middle stage
• late stage

The progression of Menière's disease varies between individuals, so you may not necessarily progress through each of these stages. In general, people experience more attacks during the first few years, and then as the attacks decrease in frequency, the hearing loss becomes progressively worse.

The stages of Menière's disease are described in more detail below.

Early stage

The early stage of Menière's disease consists of sudden and unpredictable attacks of vertigo. These are usually accompanied by nausea, vomiting, and dizziness. You may lose some hearing during the attack, and there is often tinnitus at the same time. Your ear may also feel blocked and uncomfortable with a sense of fullness.

Attacks of vertigo at this stage can last from 20 minutes to 24 hours, but they usually last around 2-3 hours. The length of time between attacks will also vary. It is estimated that most people experience 6-11 attacks a year. Your hearing and the full sensation in your ear will usually return to normal between attacks.

Middle stage

The middle stage of Menière's disease consists of continuing attacks of vertigo, with the attacks becoming less severe. Tinnitus and hearing loss often become worse. During the middle stage, you may experience some periods of remission (where your symptoms go away), which can last for up to several months.

Late stage

During the late stage of Menière's disease, the episodes of vertigo occur far less frequently and they may stop altogether. However, you may be left with balance problems, and you may be unsteady on your feet, particularly in the dark.

Your hearing problems and tinnitus may become progressively worse during the late stage of Menière's disease. The longer the condition lasts, the more likely it is to affects both ears. Around 40% of people may find that both ears are affected.

Vertigo
Vertigo is the sensation that you or the environment around you is moving or spinning.

Tinnitus
Tinnitus is the medical name for the perception of noise in one ear, both ears or in the head. The noise comes from inside the body rather than an outside source.

Palpitations
Palpitations refer to an irregular heartbeat, or the sensation of skipped or extra heartbeats.

The cause of Ménière's disease is not yet known, although it is thought to be caused by a problem with the pressure in the inner ear.

The inner ear

The inner ear is made up of:

• the cochlea - a coiled, spiral tube that contains two fluid-filled chambers and is responsible for hearing
• the vestibular apparatus - a complex set of tubes that help to control balance

The cochlea and the vestibular apparatus are enclosed by the membranous labyrinth (a system of sacs and tubes). The membranous labyrinth is filled with a fluid called endolymph.

Endolymphatic hydrops

If the pressure of the endolymph fluid (the fluid inside the inner ear) changes - for example, because there is too much fluid, this is called endolymphatic hydrops

Changes in the pressure of the fluids in the inner ear can cause the symptoms of Ménière's disease, such as vertigo and tinnitus. It is therefore thought that endolymphatic hydrops is responsible for Ménière's disease, although this has not yet been proven.

In most cases, the cause of the endolymphatic hydrops is unknown, but there are a number of possible risk factors.

Possible risk factors

In most cases it is not known what causes endolymphatic hydrops, although some possible risk factors are listed below.

• An allergy - an adverse reaction to a particular substance, such as a food.
• Autoimmuity - when your immune system starts producing antibodies that attack your own tissues and organs.
• Genetic (inherited) factors - for example, if there is a family history of the condition.
• A metabolic disturbance involving the balance of sodium and potassium in the fluid in your inner ear. Your metabolism is the process that turns food into energy. If it is disturbed, you may end up with too little or too much sodium or potassium in your body.
• Vascular factors (to do with blood vessels) - there is a link between Ménière's disease and migraines, which are thought to be caused by the narrowing and widening of blood vessels.
• Some viral infections - such as meningitis (an infection of the membranes that surround the brain and spinal cord).
   

Vertigo
Vertigo is the sensation that you or the environment around you is moving or spinning.

Tinnitus
Tinnitus is the medical name for the perception of noise in one ear, both ears or in the head. The noise comes from inside the body rather than an outside source.

Allergy
Allergy is the term used to describe an adverse (bad) reaction that the body has to a particular substance.

Immune system
The immune system is the body's defence system, which helps protect it from disease, bacteria and viruses.

Genetic
Genetic is a term that refers to genes. Genes are the characteristics inherited from a family member.

Blood vessels
Blood vessels are the tubes in which blood travels to and from parts of the body. The three main types of blood vessels are veins, arteries and capillaries.

You should visit your GP if you experience any of the symptoms of Ménière's disease. There is no single test for Ménière's disease, but your GP will ask about your symptoms and carry out a physical examination.

Pattern of symptoms

Ménière's disease can be difficult to distinguish from other diseases because there are several conditions that can also cause vertigo and hearing problems.

For example, migraines and ear infections, such as otitis media, can also affect your balance and hearing. A viral infection of the balance nerve (vestibular neuronitis), or the inner ear (labyrinthitis), can also produce similar vertigo attacks. However, in these conditions the hearing is not affected.

Ménière's disease may only become evident after a period of time, as a pattern of reoccurring attacks develops. Your GP will therefore ask you to describe your symptoms to find out if there is pattern emerging.

For Ménière's disease to be diagnosed, you will need to have the following primary symptoms:

• vertigo (a feeling that the environment around you is spinning) - at least two episodes of vertigo lasting 20 minutes or more within a single Ménière's disease attack
• hearing loss - tests must confirm that hearing loss is caused by damage to the sensitive hair cells inside the cochlea (the coiled tube in the inner ear), or as a result of damage to the auditory nerve (the nerve that transmits sounds to the brain), and
• tinnitus (perception of noise in your head), and/or
• aural fullness (feeling of pressure in your ear)

Note: in order to be diagnosed with Ménière's disease, you must have vertigo and hearing loss, and either tinnitus or aural fullness.

Physical examination

Your GP will carry out a general physical examination in order to rule out other possible causes of your symptoms. This may involve:

• listening to your heart beat
• checking your blood pressure
• examining the inside of your ears

If your GP suspects that something else may be causing your symptoms, you may be referred for further tests. If it is thought that you may have Ménière's disease, you may be referred to an ear nose and throat (ENT) specialist to test your hearing. This will usually be carried out at the ENT department of your local hospital.

Audiometry test

The ENT specialist will be able to assess the extent of your hearing loss and confirm a diagnosis of Ménière's disease. Hearing loss that is caused by Ménière's disease can be investigated using an audiometry test.

An audiometry test is carried out using a machine called an audiometer that produces sounds of different volume and pitch. You will listen to the sounds through headphones, and will be asked to signal when you hear a sound, either by raising your hand or pressing a button.

For an audiometry test to work, you must have normal hearing in one ear. The specialist can then detect the abnormalities in your ear that is affected by Ménière's disease by comparing it to you normal ear.

If your Ménière's disease is in the early stage, an audiometry test will not always be effective because hearing loss in this stage is often temporary.

Vertigo
Vertigo is the sensation that you or the environment around you is moving or spinning.

Tinnitus
Tinnitus is the medical name for the perception of noise in one ear, both ears or in the head. The noise comes from inside the body rather than an outside source.

There is no single treatment for Ménière's disease, mainly because the exact cause is still unknown.

However, your GP and ear, nose and throat (ENT) specialist will be able to help you to manage your symptoms using a variety of techniques. Possible treatments include:

• dietary advice, particualrly a low salt diet
• medication to treat attacks of Ménière's disease
• medication to prevent attacks of Ménière's disease
• treatment for tinnitus
• treatment for hearing loss
• physiotherapy to cope with balance problems
• surgery
• treatment for the secondary symptoms of Ménière's disease (stress, anxiety, and depression)

Your GP and ENT specialist will provide you with advice and information that is tailored to your individual needs, and develop a management plan that will help you to cope more effectively with your symptoms. In some cases, the treatment available may depend on what your local Health Board can provide.

Treatment during an attack

During an attack of Ménière's disease, you may be prescribed medication to treat the symptoms of:

• vertigo (a feeling that the environment around you is spinning)
• nausea (feeling sick)
• vomiting

The medications are usually prescribed for 7-14 days. The medications that are usually prescribed are:

• prochlorperazine, or
• an antihistamine

If these medicines are successful in treating your symptoms, you may be given a supply to keep at home so that you can take them the next time you have an attack.

Prochlorperazine

Prochlorperazine can cause side effects including:

• tremors (shaking)
• abnormal, or involuntary, body and facial movements

They can also make some people feel sleepy. Check the patient information leaflet that comes with your medicine for the full list of possible side effects.

If you are vomiting, there is a type of prochlorperazine, called Buccastem, that you can take. This comes as a tablet that you place between your gums and your cheek on the inside of your mouth. The tablet dissolves and is absorbed into you body without you having to keep down tablets that you swallow.

Antihistamines

Possible antihistamines include:

• cinnarizine
• cyclizine
• promethazine teoclate

Antihistamines can also make you feel sleepy. Headaches and an upset stomach are also possible side effects. Check the patient information leaflet that comes with your medicine for the full list of possible side effects.

Serious attacks

If your GP, or another healthcare professional who is treating you, is concerned about severe nausea and vomiting during an attack of Ménière's disease, they may inject you with prochlorperazine. They can also give you a tablet of prochlorperazine that dissolves very quickly in your mouth (Buccastem - see above).

In very severe cases, you may need to be admitted to hospital to receive intravenous fluids (through a vein) to keep you hydrated.

Preventing attacks

Your GP can prescribe a medication called betahistine to help reduce the frequency and severity of attacks of Ménière's disease, or you may be advised to change your diet.

Special diets

Although it has not been proven, following a diet without added salt does seem to help control Ménière’s disease. It is possible that this type of diet might alter the fluids in your inner ear. Avoiding excessive caffeine, such as tea and coffee, is also usually recommended.

If you have migraines (severe headaches), avoiding possible migraine triggers may prove beneficial. Known migraine triggers include chocolate, nuts, and some red wines.

Betahistine

It is thought that betahistine reduces the pressure of the fluid in your inner ear, relieving the symptoms of Ménière's disease. Research that has been carried out into betahistines has not found enough evidence to confirm whether they are effective. However, your GP may recommend trying them.

Betahistines are usually available as tablets to be taken three times a day. Your GP will discuss how long you need to take them for, which could be a few weeks, or up to a year. Possible side effects include a headache, upset stomach, and a skin rash.

Treating tinnitus

There are a number of different treatment options that can be used to treat tinnitus that is caused by Ménière's disease. Some possibilities are described below.

• Sound therapy - the effects of tinnitus are often more pronounced in quiet environments. Sound therapy works by reducing the difference between the tinnitus sounds and the background sounds. This makes the tinnitus sounds less intrusive.
• Relaxation techniques - tinnitus can be a distressing and intrusive condition. Relaxing, by practising yoga, or special breathing techniques, may help you to avoid stress and anxiety.
• Cognitive behavioural therapy (CBT) - is a talking therapy that is based on the idea that your thoughts affect the way that you behave. Treatment aims to retrain the way that you think in order to change your behaviour so that you can cope more effectively with your tinnitus.

Your GP can refer you to a hearing therapist to discuss these techniques in more detail.

Treating hearing loss

If your Ménière's disease is in the middle or end stages, you may experience some permanent hearing loss. Ménière's disease tends to make you more sensitive to loud sounds, and also makes it more difficult for you to distinguish low-pitched sounds.

There are a variety of hearing aids available that may be suitable for you. Hearing therapists and organisations, such as Action on Hearing Loss can provide you with helpful advice for dealing with hearing loss.

Physiotherapy

A physiotherapist can help you to improve your balance by teaching you vestibular rehabilitation techniques. These are exercises that teach you how to cope with the abnormal and disorientating signals coming from your inner ear. You are taught to use alternative signals from your eyes, ankles, legs, and neck, to keep you balanced.

Physiotherapy is usually used in the middle or late stages of Ménière's disease, after the severe attacks of vertigo have stopped, but when balance problems may remain. Your GP will be able to refer you to a physiotherapist if they feel that it would benefit you.

Surgery

In severe cases, surgery can be performed to control the attacks of vertigo. However, surgical procedures are usually only used if other treatments have failed. About 10% of people with Ménière’s disease will require surgery.

The type of surgery you have will depend on your symptoms, and whether both ears are affected. You can either have:

• destructive surgery, or
• non-destructive surgery

Destructive surgery

Destructive surgery may be considered if only one ear is affected by Ménière's disease. The hearing in the affected ear must be considered to be ‘socially inadequate’ (you cannot hear enough to function in social situations). As an approximate guide, if you cannot hear sounds that are below 50 decibels (dB), this may count as socially inadequate.

Destructive surgery is used to destroy the part of your inner ear that is causing your vertigo attacks. Therefore, this type of surgery will only be considered if the hearing lost from the affected ear is permanent.

The destructive surgery could be done by:

• destroying the balance part of your audio-vestibular nerve - the nerve that transmits sounds and balance information to the brain, or
• destroying part of your vestibular labyrinth - the system of tiny, fluid filled channels in the ear (this procedure is called a labyrinthectomy)

After the surgery, your other ear will take over your hearing and balance functions.

Selectively destructive surgery

In selectively destructive surgery, the balance part of the inner ear is destroyed with a medicine called gentamicin. This is injected through the ear drum (the thin layer of tissue that separates the outer ear from the middle ear) and enters the labyrinth (the system of tubes in the inner ear).

Gentamicin should mainly cause damage to the balance part of your ear. However, it does carry a risk of damaging your hearing as well.

Some surgeons prefer to apply the gentamicin directly to the inner ear during a minor operation. This enables the exact dose of gentamicin that enters your ear to be controlled.

Non-destructive surgery

Non-destructive surgery may be used if your hearing in the ear that is affected by Ménière's disease is ‘socially adequate’ (you can hear sounds that are below 50 dB). This type of surgery aims to change the progression of Ménière's disease by reducing the severity and frequency of your symptoms.

Non-destructive surgery could be:

• endolymphatic sac decompression - this reduces the pressure in your inner ear by increasing the drainage of the endolymph fluid (the fluid inside the labyrinth in your inner ear)
• inserting ventilation tubes - these are inserted into you ear to reduce the changes in pressure that cause Ménière's disease, or
• injecting steroids through the eardrum (steroids are a type of medicine that contain powerful chemicals called hormones) - this is a new type of treatment that has not yet been proven to be beneficial

Results

There are very few trials (medical tests) looking into the effect of surgery on Ménière's disease, which is why surgery is rarely considered. If your ENT specialist thinks that you may benefit from having surgery, they will discuss the procedure and any risks in more detail with you.

Treatments for the secondary symptoms

As Ménière's disease is a difficult and unpredictable condition, it can often lead to the secondary symptoms of stress, anxiety and/or depression.

More information about these conditions and possible treatments can be found in the Health A-Z. Some possible treatments are described below.

• Counselling - is a talking therapy that allows you to talk about your feelings and the problems that you are experiencing, as well as discussing ways of improving your quality of life by learning to cope with the attacks of vertigo and hearing loss.
• Psychotherapy - is a talking therapy that helps you understand and accept your strengths and weaknesses and identify what makes you feel upset, or anxious, so that you can change your attitudes and behaviour.

Support groups and charities

There are several support groups and charities that can provide you with useful information and advice about living with Ménière's disease. They can also put you in touch with other people who have the condition so that you can share experiences and provide support to one another.

Action on Hearing Loss also has a dedicated section about Ménière's disease.

As the symptoms of Ménière's disease can affect your work and family life, you may need advice on financial and relationship issues.

Vertigo
Vertigo is the sensation that you or the environment around you is moving or spinning.

Tinnitus
Tinnitus is the medical name for the perception of noise in one ear, both ears or in the head. The noise comes from inside the body rather than an outside source.

During a Ménière's disease attack, your balance and hearing may be significantly impaired. This can make certain activities very dangerous.

The unpredictable nature of the condition means that you may need to change your daily activities so that you do not place yourself, or others, in danger. Situations that you may need to avoid include:

• going swimming
• climbing ladders or scaffolding
• being out on your own
• operating heavy machinery
• driving (see below)

Driving

If you drive and you are diagnosed with Ménière's disease, or you are experiencing the primary symptoms of vertigo and hearing loss, you must inform the Driver and Vehicle Licensing Agency (DVLA) about your condition.

The DVLA states that if you drive a car, or motorcycle, and you have recently been diagnosed with Ménière's disease, you must stop driving. Driving will not be permitted again until you have satisfactory control of your symptoms. Your GP or ear, nose and throat (ENT) specialist will have to confirm that your symptoms have improved and are under control.

If you drive a large goods vehicle, or a passenger-carrying vehicle, and you are diagnosed with Ménière's disease, your license will either be revoked or refused. You must be symptom-free for a year before reapplying for a licence.

The DVLA will send you a questionnaire to find out how your condition affects you. They will also ask for permission to contact your GP, or ENT specialist, so that they can make a more detailed assessment of your physical ability to drive.