Clinically, I often encounter a class of patients. The main complaint is often dizzy, accompanied by nausea and vomiting. Most of them are tinnitus on one side, hearing loss, and unstable walking. They can only lie flat in the static room during the attack. When the position changes slightly, they will turn around. a feeling of. These patients may have Meniere’s disease.
Meniere’s disease is an idiopathic inner ear disease with unexplained pathological features of membrane labyrinth. The clinical manifestations are paroxysmal vertigo, fluctuating hearing loss, tinnitus and ear swell.
Vestibular Meniere’s disease: The main symptoms are paroxysmal dizziness and ear swelling.
Cochlear Meniere’s disease: with fluctuations in hearing loss and tinnitus as the main symptoms.
The exact reason is unknown. There are mainly the following theories:
Endocytic fluid absorption disorder: endolymph fluid production, absorption imbalance;
Immune response: allergies, immune responses and autoimmune abnormalities;
Cochlear microcirculatory disorder;
Other: genetic, endocrine dysfunction, viral infection, etc.
Membrane labyrinth water swelling → cochlear tube, balloon enlargement → vestibular membrane push forward step → membrane labyrinth water increased, elliptical capsule and semicircular canal ampulla expansion → membrane labyrinth pressure increased, membrane labyrinth rupture;
Hair cells, supporting cells, nerve fiber cells, ganglion cell degeneration lesions, vascular atrophy → sensorineural hearing loss;
The epithelial sac folds become shallow or disappeared → epithelial cell degeneration, cystic wall fibrosis → endolymph fluid absorption disorder.
Dizziness: more persistent episodes20 minTo12 hours, often accompanied by nausea, vomiting and other autonomic dysfunction and unstable walking and other balance dysfunction, unconscious loss; intermittent vertigo episodes, but may be associated with balance dysfunction. Patients with bilateral Meniere’s disease may present with dizziness, instability, shaking or vibrating hallucinations;
Hearing loss: Generally, the volatility of the sensorineural hearing loss is low, and the early stage is mostly low-intermediate frequency, and the intermittent hearing can return to normal. As the disease progresses, hearing loss gradually worsens, and intermittent hearing cannot return to normal or pre-morbid levels. Most patients may experience rejuvenation;
Tinnitus: Most of them are accompanied by tinnitus, which can appear before or after the attack, and can be reduced or disappeared after repeated attacks. In the early stage of tinnitus, most of them are low-pitched sounds or running sounds, and late high-pitched humming or whistling;
Feeling of swelling of the ear: There is a feeling of fullness or pressure in the ear of the patient during the attack.
First, the basic inspection
Including otoscopy, pure tone audiometry and acoustic impedance test.
Second, according to the situation can choose the inspection project
1, audiological examination: including dehydration agent test, cochlear electrogram, otoacoustic emission,ABRand so on.
2Forecourt function examination: including spontaneous nystagmus, gaze nystagmus, visual motion, smooth tracking, saccade, position test, cold and heat test, rotation test, shaking head test, head pulse test, vestibular white rotation test, vestibular evoked myogenicity Potential(VEMP)Subjective vertical vision / subjective level vision.
3Balance function check: static or dynamic posture tracing, balance sensory integration ability test and gait evaluation.
4Tinnitus examination: tinnitus tone and intensity matching check.
5Imaging examination: the brain with a small cerebral angle of the inner auditory canalMRIIf there are conditions, it is feasible to occlude the inner eardrumMRIImaging.
6Etiological examination: including immunological examination, allergen examination, genetic examination, endocrine function examination, etc.
1,2次或2More than three episodes of vertigo20 minTo12 hours.
2At least one audiological examination during the course of the disease confirmed that the ear has a low to intermediate frequency of sensorineural hearing loss.
3, suffering from volatility, hearing loss, tinnitus and(Or)The ear is stuffy.
4Exclude vertigo caused by other diseases, such as vestibular migraine, sudden paralysis, benign paroxysmal positional vertigo, labyrinthitis, vestibular neuritis, vestibular paroxysmal disease, drug-induced vertigo, posterior circulation ischemia, cranial Internal occupying lesions, etc.; in addition, secondary membrane labyrinth hydrops need to be excluded.
According to the patient recently6Intermittent hearing during the month is the worst0.5,1.0And2.0 kHzThe average hearing threshold of pure tone is staged. The clinical stage of Meniere’s disease is related to the choice of treatment methods and prognosis. For bilateral Meniere’s disease, the clinical stages on both sides need to be determined separately.
Phase I: average hearing threshold ≤25 dBHL;
Phase II: The average hearing threshold is26~40 dBHL;
Phase III: The average hearing threshold is41~70 dBHL;
Four phases: average hearing threshold>70 dBHL.
First, the treatment of the attack
Treatment principles: control dizziness, symptomatic treatment.
Including antihistamines, benzodiazepines, anticholinergic drugs and anti-dopamine drugs, can effectively control the acute onset of vertigo, in principle, use no more than72 hours. Commonly used drugs in clinical practice include promethazine, diphenhydramine, diazepam, meclizine, prochlorperazine, droperidol and the like.
If the symptoms of acute vertigo are severe or the hearing loss is significant, glucocorticoids may be administered orally or intravenously as appropriate.
If the symptoms of nausea and vomiting are serious, you can use rehydration to support treatment.
Second, intermittent treatment
Therapeutic principles: Reduce, control or prevent the onset of vertigo while maximizing the protection of the patient’s existing inner ear function.
Explain to patients the knowledge of Meniere’s disease, to understand the natural course of the disease, possible predisposing factors, treatment methods and prognosis. Do a good job in psychological counseling and counseling to eliminate the fear of patients.
Regular work and rest, avoiding predisposing factors such as bad mood and stress. Patients are advised to reduce salt intake and avoid caffeine products, tobacco and alcohol products.
It can improve the blood supply to the inner ear, balance the bilateral vestibular nucleus discharge rate, and achieve the purpose of controlling the onset of vertigo by binding to the central histamine receptor.
It has the effect of relieving hydronephrosis and can control the onset of vertigo. Commonly used drugs in clinical practice include hydrochlorothiazide, triamterene, etc. The blood potassium concentration should be monitored regularly during the administration.
(五)Tympanic injection of glucocorticoid
It can control the onset of vertigo in patients, and the treatment mechanism may be related to improving the status of endolymphatic hydrops and regulating immune function. The method has no damage to the cochlea and vestibular function of the patient, and the initial injection effect is poor, and the tympanic administration can be repeated to improve the vertigo control rate.
(六)Tympanic low pressure pulse therapy
It can reduce the frequency of vertigo attacks and has no obvious effect on hearing. The treatment mechanism is unclear and may be related to stress-promoting endolymphatic absorption. The tympanic membrane is usually placed first, and the number of treatments depends on the frequency and severity of the symptoms.
(Seven)Tympanic injection of gentamicin
Effectively control the symptoms of vertigo in most patients(80％～90%)The incidence of hearing loss in the injected ear is approximately10％～30%, the mechanism is related to unilateral chemical labyrinthectomy.
Including endolymphatic sac surgery, three semicircular canal obstruction, vestibular neurotomy, labyrinthectomy and so on. The indication is that the vertigo is frequent and intense.6Patients who have not been treated for non-surgical treatment for a month.