Vertigo is more than a Hitchcock movie. It’s the common symptom in an unpredictable condition — Ménière’s disease — that is diagnosed in 45,000 Americans yearly. Vertigo also can be key to recognizing this chronic, incurable problem.¹ Although Ménière’s disease usually affects only one ear at the outset, it may progress to the second. Treatment can be difficult, stymied with trial and error. Despite these challenges, an astute nurse’s prompt recognition, appropriate treatment, and education can make a difference in a patient’s hearing, balance, and quality of life.

The inner ear participates in both hearing and balance, and both can be affected by Ménière’s disease. (Ménière was the first physician to theorize that vertigo, hearing loss, and tinnitus can all come from the inner ear.) The inner ear consists of a hearing area, the cochlea, and two movement-sensing areas, the semicircular canals and the vestibule. The inner ear’s movement-sensing function is called the vestibular function.

The inner ear is filled with fluid. The hearing and balance areas share the same fluids, one of them being endolymph. An increase in endolymph (endolymphatic hydrops) is the abnormal change found in Ménière’s. This increase can cause bulging and rupture of the membrane surrounding the endolymph. The increased pressure can cause compression of the inner ear’s smallest function unit, the hair cell.

Symptoms

For years, Ménière’s disease was described as having a triad of symptoms: vertigo, hearing loss, and tinnitus all occurring in the same ear. Now, aural fullness is included, too. Ménière’s can cause symptoms beyond hearing and balance, because in addition to being used for upright balance, vestibular information is used reflexively for clear vision during head movement and some autonomic nervous system function.² Possible symptoms include blurred vision and “bouncing” or jerking vision.

Unfortunately, the symptoms of Ménière’s disease don’t stop with the attack symptoms; a large number of other symptoms — as diverse as cold sweats, lightheadedness, diarrhea, anxiety, stiff neck, and vomiting — are possible before, during, after, and between attacks. The symptoms of late disease also differ from early disease.

Ménière’s is unpredictable, and its symptoms may or may not have a pattern. They may be calm or violent. They can occur at any time interval; years can go by between attacks. They may or may not be preceded by a warning. The tinnitus may or may not go away. The hearing may or may not return fully. The disease may or may not worsen over time.

Early disease is characterized by spontaneous attacks lasting 20 minutes to 24 hours consisting of —³

• Vertigo that can be violent and incapacitating
• Onset of a hearing loss or an increase in a previous loss, the start of tinnitus, or an increase or a change in character from the previous level
• Aural fullness or an increase in the previous intensity, all in the same ear
• Irregular intervals of days, weeks, or years between attacks

A warning may precede an attack, consisting of a change in aural fullness, tinnitus, or balance. The warning could also be an ill-defined feeling of foreboding. It may give only enough warning for a patient to seek a safe place to lie down.

Vertigo, the most disruptive of the four attack symptoms, is the perception of movement that isn’t occurring. This can be a mild sensation of movement or spinning so violent a patient can do little more than lie rigidly in bed. Nausea and vomiting and autonomic nervous system fight-or-flight symptoms such as fear, anxiety, dry mouth, pounding heart, and diarrhea can occur with the vertigo. Any movement of the person’s head or the bed he or she is lying on causes a massive but temporary increase in symptoms.

Aural fullness is a pressure or “plugged up” feeling in the ear that can be an annoyance or very disturbing. The tinnitus may be barely audible or so loud a patient can’t tolerate it. Hearing loss ranges from almost unnoticeable to a loss of the ability to understand speech. During this early period of the disease, hearing loss, tinnitus, and aural fullness can fluctuate and return to normal after attacks or be present all the time.

In the hours after an attack, patients may be too exhausted to do little beyond sleep. If they do get up, they may find walking or any other upright movement a difficult and odd experience. Balance can be “off” for days to weeks after an attack because of the disruption of signals to the brain. Disturbances, such as jerking, bouncing, or blurred vision; motion intolerance; imbalance; clumsiness; odd posture; lightheadedness; and a general woozy feeling along with malaise also can occur, particularly in the day or two after an attack. Some patients may even have these symptoms right up until their next attack. Symptoms of Ménière's disease can be intensified by not sleeping or resting enough, holding the head rigidly still, or consuming central nervous system depressing drugs, including anesthetic agents and alcohol. In addition to all this, Ménière’s disease and any other vestibular disorder causing permanent damage can impair cognition.⁴

Diagnosis

There is no gold standard test for Ménière’s disease, so the diagnosis is usually based on the patient’s history when other possibilities such as acute viral infection, brain tumor, and multiple sclerosis have been ruled out and a sensorineural hearing loss and abnormal electrocochleogram are documented. (An ECOG is an electrophysiological test tracking the electrical activity that sound creates within the inner ear.)

The following diagnostic terminology has been suggested for Ménière’s disease:³

Possible Ménière’s disease: When vertigo occurs without a documented hearing loss or if there’s a hearing loss without vertigo but with imbalance; bumping into things and vague feelings such as floating.

Probable Ménière’s disease: If one episode of spontaneous vertigo is experienced along with a documented hearing loss and either tinnitus or aural pressure also have occurred.

Definite Ménière’s disease: After at least two episodes of spontaneous vertigo lasting 20 minutes or longer, documented hearing loss at least once, and either tinnitus or aural fullness is occurring.

Certain Ménière’s disease: Diagnosed only after endolymphatic hydrops has been confirmed postmortem during temporal bone dissection.

Treatment

The etiology of Ménière’s disease is unknown, making treatment difficult, mostly symptomatic, and aimed at vertigo since no treatment has demonstrated any positive long-term effect on hearing loss or tinnitus.⁵ Treatment is also difficult to evaluate because an improvement may be a normal remission, not the result of the intervention.

This doesn’t mean that Ménière’s disease is untreatable, but rather that treatment is by trial and error on a patient-by-patient basis. Treatments are generally aimed at fluid management, symptom suppression, and/or improvement or replacement of balance function.

Fluid management: Endolymph fluid management is the goal of several treatments. A low-sodium diet is overwhelmingly the treatment of choice. If the diet change is ineffective, a diuretic, typically hydrochlorothiazide (Hydrodiuril), alone or in combination with triamterene (Dyazide, Maxzide), is used. If a patient continues to have attacks and can’t function, some physicians offer endolymphatic sac surgery to mechanically drain the excess endolymph from the inner ear. This option is controversial because the sole controlled study of the surgery found it no more beneficial than not doing it.⁶ Another treatment that may have an effect on endolymph is the application of small bursts of air pressure into the ear through middle ear pressure equilization tubes using the FDA approved Meniett machine. The exact mechanism isn’t understood, but it’s thought that applying small pressure waves for five minutes a few times each day forces endolymph through the inner ear into its most distant part, the endolymphatic sac.⁷

Symptom suppression: Symptom blockers such as diazepam (Valium) and promethazine (Phenergan) are given during attacks of violent vertigo to suppress the vertigo and stop the nausea and vomiting, but they are of limited use between attacks and may delay vestibular compensation, the body’s natural postattack recovery.

Listening to a constant level of noise, such as a fan, can be helpful when tinnitus is distracting. If the tinnitus is intolerable, tinnitus masking (covering up the tinnitus with additional noise) or tinnitus retraining therapy (which trains the brain to interpret the tinnitus differently) may be needed. A certified audiologist can provide expert services in this area.

As a last resort, patients with frequent, intolerable, disabling attacks of vertigo that are uncontrolled by medical treatment may be offered treatment or surgery to destroy part of the vestibular system or cut the nerve carrying balance information. These are not first-line treatments because both hearing and balance can be severely damaged, and permanent visual difficulties can occur. Such treatments include —⁸

• Transtympanic gentamicin (Garamycin) injection into the middle ear, which diffuses into the inner ear, damaging and destroying vestibular hair cells. The goal is to administer the least amount of the drug possible to stop the vertigo attacks.
• Vestibular nerve section surgery to cut the nerve carrying vestibular information to the brain.
• Labyrinthectomy, surgery to remove all the vestibular hair cells. A byproduct of the surgery is total loss of hearing in the ear.

Functional replacement: If there’s significant hearing loss, amplification may help, and in the case of a severe, bilateral loss, cochlear implantation can be effective as well. An audiologist can counsel these patients about treatment options and assistive devices to help in their lives.

Functional improvement: Vestibular rehabilitation therapy is a system of assessment and treatment for people with vestibular disorders and balance impairments. It helps use remaining vestibular function more thoroughly and teaches patients to rely more on vision and proprioception when necessary. It can help improve general balance between attacks in early Ménière’s and improve the imbalance of late disease, but it can’t stop the violent attacks of vertigo.

Nursing implications

In the words of one nurse with Ménière’s disease, “Regardless of the diagnosis, a patient with severe vertigo has very special needs. Until I experienced these symptoms, I had no idea how much suffering dizziness could cause.”⁹ An acute attack of Ménière’s disease produces problems for patients, and their needs don’t stop at the end of it.

What are these needs? Maslow’s hierarchy of needs, developed by the mid-20th century psychologist Abraham Maslow, is a good framework to help identify, understand, prioritize, and deal with them.¹⁰ This hierarchy begins with the most basic needs and builds up to the most sophisticated.

Physiologic and survival

The physiologic and survival needs are the most basic human needs for oxygen, water, food, and functioning body systems, including the vestibular system.

Ménière’s disease not only can come between a person and food and water, it can also cause fluid and nutritional losses from vomiting, nausea, anorexia, and, at times, diarrhea. Treatment with a low-sodium diet and diuretic also can cause dehydration and electrolyte imbalance. During attacks of vertigo, a patient may not be able to carry out personal hygiene and skin care.

Central nervous system drugs and anesthetics can impair balance between attacks or even during a remission. These must be used with caution. Treatment with symptom blockers and IV fluids may be needed during attacks. The patient also may need assistance with elimination and personal hygiene.

When the physiologic needs are met, the higher needs of the hierarchy can emerge; life is no longer defined by what’s missing. If these needs aren’t met, the vestibular dysfunction will define patients’ lives.

Potential nursing diagnoses —

• Elimination: diarrhea
• Body fluid: fluid volume deficit
• Altered nutrition: less than body requirement
• Neurosensory: sensory perceptual alterations, vestibular
• Hygiene: self-care deficit
• Safety: high risk for fall

Safety and security

Safety and security needs are the next to emerge in the hierarchy. An attack of Ménière's is an unsafe time when injuries can occur, particularly if a patient receives no warning or can’t find a safe place to recline during the attack. The time after an attack and between attacks also can be dangerous for the patient suffering from imbalance, motion sensitivity, and visual disturbances. Because of the potential for danger, people with Ménière’s disease can feel profoundly insecure. They worry about when the next attack will occur, if it will be stronger, or if they’ll be able to find a safe place to lie down.

In addition to balance and attack issues, their safety can be affected by a hearing loss. A patient with a unilateral loss won’t be able to determine sound direction and will have trouble understanding conversations with background noise. Vision is also an issue for some patients. Nystagmus causes jerking vision during attacks, and vision may bounce during head movement in patients with bilateral disease.

Steps can be taken to help patients feel more secure even during an exacerbation. First, they should know as much as possible about their disease. They should carry a cell phone with the numbers of people able to help during an attack, have plans for finding a safe place to lie down, and educate friends, family, and coworkers about Ménière’s disease and how they can help. Using a cane or a walker during periods of severe imbalance can help. Patients should make their homes more balance-friendly by removing or securing throw rugs, removing clutter, and having adequate lighting. Vestibular rehabilitation therapy may be helpful.

When the safety needs are met, a person can feel relaxed, sleep restfully, learn, remember, and perceive. Fear, anxiety, dread, nervousness, and the feeling of losing control occur when the security needs are not met. These sensations aren’t just unpleasant; they may interfere with balance ability.¹¹

Potential nursing diagnoses —

• Neurosensory: sensory perceptual alterations, visual, hearing, vestibular
• Safety: potential for injury
• Impaired physical mobility: potential for trauma
• Activity/rest: activity intolerance
• Fatigue
• Ego integrity: anxiety
• Fear
• Powerlessness
• Teaching/learning: knowledge deficit

Loving/belonging

Ménière’s also affects the need for loving and belonging. Ménière’s can change people’s self-concept and how others view them. Fear of having an attack may cause a person to avoid social and other commitments. Others may leave the person with Ménière’s disease out of activities. Impaired hearing also may change or end relationships.

Talking to other people with Ménière’s may lessen social isolation. The Meniere’s Network (www.earfoundation.org) and the Vestibular Disorders Association (www.vestibular.org) help people network. When the loving and belonging needs go unmet, feelings of loneliness, rejection, friendlessness, and rootlessness surround a person.

Potential nursing diagnoses —

• Ego integrity: body image disturbance
• Impaired adjustment: altered role performance
• Social interaction: social isolation
• Impaired social interaction
• Impaired verbal communication
• Self-esteem

Ménière’s disease also may keep people from rising to the level of self-esteem. If this need is unmet, patients can suffer from feelings of inferiority, helplessness, and discouragement.
Potential nursing diagnoses —

• Ego integrity: hopelessness
• Self-esteem disturbance

Self-actualization

Self-actualization sits at the top of Maslow’s hierarchy and can be attained only when lower needs are met. Self-actualization allows people to feel like productive members of society, and when unmet, they are left feeling restless.

Ménière’s disease is hard to diagnose with certainty, and treatment is symptomatic and not always effective. It can produce a wide range of symptoms in addition to vertigo, hearing loss, tinnitus, aural fullness, and visual difficulties. How often attacks will come, their strength, and how much damage will occur are unknowns patients must live with. This disorder can be an occasional nuisance or cause patients to lose hearing, balance ability, self-respect, and jobs.