Meniett device in meniere disease: Randomized, double-blind, placebo-controlled multicenter trial

Treatment of Menière's disease: a scoping review of the current evidence

PURPOSE

The management of unilateral Menière's disease (MD) in adult patients remains contentious, with various therapeutic options proposed but no established gold standard. This scoping review aims to evaluate the current treatment options for unilateral MD, identifying challenges in management and providing guidance for ENT physicians in selecting effective therapies.

METHODS

A comprehensive literature search of the MEDLINE and Embase databases was conducted without date restrictions, assessing various treatment modalities for MD. Randomized controlled trials (RCTs) were selected to ensure the highest quality of evidence was reviewed.

RESULTS

Thirty-four RCTs met the inclusion criteria. The current evidence base encompasses dietary interventions, systemic drug therapy, intratympanic treatments, positive pressure therapy, low-level laser therapy, and non-destructive surgical techniques. However, the evidence supporting these treatments is limited and inconsistent. Notably, none of the RCTs considered the heterogeneity of MD patient populations, which may explain the variability in study results.

CONCLUSION

This review highlights the limited evidence supporting current treatments for unilateral MD, emphasizing the need for high-quality, placebo-controlled trials. Future research should incorporate biomarker-based stratification, large patient cohorts, standardized outcome measures, and long follow-up periods to enhance the consistency and comparability of findings.

Developing a core outcome set for Menière's disease trials, the COSMED study: a scoping review on outcomes used in existing trials

Introduction

Menière's disease (MD) is an inner ear disorder characterized by episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. As of yet, the etiology of MD remains unknown, which contributes to the lack of an evidence-based treatment. Outcomes and outcome measurement instruments (OMIs) used in trials assessing the effectiveness of potential MD treatment are randomly selected due to the absence of established guidelines on this matter. The objective of this review is to give an overview of the outcome domains, outcomes and OMIs used in randomized controlled trials (RCTs) evaluating treatment effects in MD to 2024. This will be the first step of developing a Core Outcome Set (COS) for MD trials.

Methods

A literature search of the PubMed, Embase and Cochrane library databases was conducted from inception to November 2024. All RCTs on the treatment effect of various therapies for patients suffering from MD were included. Among other details, we extracted and analyzed all outcome domains, outcomes, and OMIs used in these RCTs.

Results

A total of 76 RCTs were included, revealing a diverse range of outcomes and OMIs used across the included studies. Outcome domains encompassed dizziness, hearing, tinnitus, aural fullness, quality of life (QoL) and other. Outcomes used most frequently included: the severity of vertigo attacks, the number of vertigo attacks, vestibular function, hearing loss, severity of hearing loss, QoL related to dizziness, and Qol related to tinnitus. The latter two were most commonly measured with the Dizziness Handicap Inventory (DHI), the Functional Level Scale (FLS) and the Tinnitus Handicap Inventory (THI) respectively. For the other outcomes, there was little uniformity in the use of OMIs. Moreover, there was a notable lack of validated OMIs used in the included RCTs.

Conclusion

This scoping review highlights the need for standardizing outcome selection for RCTs focusing on the treatment of MD. In this first step of developing a Core Outcome Set for MD, we identified a potential list of outcomes to be used in the next steps of 'the Core Outcome Set for Menière's Disease (COSMED)' study.

Placebo effect in randomized controlled trials for Meniere's disease: A meta-analysis

PURPOSE

Meniere's Disease is a condition known for its recurrent vertigo, fluctuating sensorineural hearing loss, aural fullness, and tinnitus. Previous studies have demonstrated significant influence of placebo treatments. Our objective was to quantify the magnitude of the placebo effect in randomized controlled trials for Meniere's Disease.

MATERIALS AND METHODS

A systematic review was performed by searching PubMed, SCOPUS, CINAHL, and Cochrane databases from inception through September 27, 2022. Data extraction, quality rating, and risk of bias assessment were performed by two independent reviewers. A meta-analysis of mean differences with 95 % confidence interval, weighted summary proportions, and proportion differences were calculated using random and fixed effects models.

RESULTS

A total of 15 studies (N = 892) were included in the review. Significant improvement was seen in the functional level scores of the pooled placebo groups, with a mean difference of -0.6 points, (95%CI: -1.2 to -0.1). There was no difference in pure tone audiometry, speech discrimination score, or vertigo frequency at 1 and 3 months for the placebo group. Patient-reported vertigo episodes were improved in 52.5 % (95%CI: 39.2 to 65.5) of the placebo group and was significantly less than the pooled experimental group (90.1 %, 95%CI: 39.2 to 65.5, p < 0.001).

CONCLUSIONS

The placebo effect in Meniere's Disease trials is associated with some symptomatic improvement in subjective outcomes, such as patient reported vertigo episodes. However, the clinical significance is questionable across other outcomes measures, especially when analyzing objective data. The extent and strength of the placebo effect continues to be a hurdle in the search for better treatment options.

Meniere's disease: Pathogenesis, treatments, and emerging approaches for an idiopathic bioenvironmental disorder

Meniere's disease (MD) is a severe inner ear condition known by debilitating symptoms, including spontaneous vertigo, fluctuating and progressive hearing loss, tinnitus, and aural fullness or pressure within the affected ear. Prosper Meniere first described the origins of MD in the 1860s, but its underlying mechanisms remain largely elusive today. Nevertheless, researchers have identified a key histopathological feature called Endolymphatic Hydrops (ELH), which refers to the excessive buildup of endolymph fluid in the membranous labyrinth of the inner ear. The exact root of ELH is not fully understood. Still, it is believed to involve several biological and bioenvironmental etiological factors such as genetics, autoimmunity, infection, trauma, allergy, and new theories, such as saccular otoconia blocking the endolymphatic duct and sac. Regarding treatment, there are no reliable and definitive cures for MD. Most therapies focus on managing symptoms and improving the overall quality of patients' life. To make significant advancements in addressing MD, it is crucial to gain a fundamental understanding of the disease process, laying the groundwork for more effective therapeutic approaches. This paper provides a comprehensive review of the pathophysiology of MD with a focus on old and recent theories. Current treatment strategies and future translational approaches (with low-level evidence but promising results) related to MD are also discussed, including patents, drug delivery, and nanotechnology, that may provide future benefits to patients suffering from MD.

Positive pressure therapy for Ménière's disease

BACKGROUND

Ménière's disease is a condition that causes recurrent episodes of vertigo, associated with hearing loss and tinnitus. It is often treated with medication, but different interventions are sometimes used. Positive pressure therapy is a treatment that creates small pressure pulses, generated by a pump that is attached to tubing placed in the ear canal. It is typically used for a few minutes, several times per day. The underlying cause of Ménière's disease is unknown, as is the way in which this treatment may work. The efficacy of this intervention at preventing vertigo attacks, and their associated symptoms, is currently unclear.

OBJECTIVES

To evaluate the benefits and harms of positive pressure therapy versus placebo or no treatment in people with Ménière's disease.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; CENTRAL; Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with a diagnosis of Ménière's disease comparing positive pressure therapy with either placebo or no treatment. We excluded studies with follow-up of less than three months.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) change in hearing, 6) change in tinnitus and 7) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We used GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: We included three studies with a total of 238 participants, all of which compared positive pressure using the Meniett device to sham treatment. The duration of follow-up was a maximum of four months.  Improvement in vertigo A single study assessed whether participants had an improvement in the frequency of their vertigo whilst using positive pressure therapy, therefore we are unable to draw meaningful conclusions from the results.  Change in vertigo Only one study reported on the change in vertigo symptoms using a global score (at 3 to < 6 months), so we are again unable to draw meaningful conclusions from the numerical results. All three studies reported on the change in the frequency of vertigo. The summary effect showed that people receiving positive pressure therapy had, on average, 0.84 fewer days per month affected by vertigo (95% confidence interval from 2.12 days fewer to 0.45 days more; 3 studies; 202 participants). However, the evidence on the change in vertigo frequency was of very low certainty, therefore there is great uncertainty in this estimate.   Serious adverse events None of the included studies provided information on the number of people who experienced serious adverse events. It is unclear whether this is because no adverse events occurred, or whether they were not assessed and reported.  AUTHORS' CONCLUSIONS: The evidence for positive pressure therapy for Ménière's disease is very uncertain. There are few RCTs that compare this intervention to placebo or no treatment, and the evidence that is currently available from these studies is of low or very low certainty. This means that we have very low confidence that the effects reported are accurate estimates of the true effect of these interventions. Consensus on the appropriate outcomes to measure in studies of Ménière's disease is needed (i.e. a core outcome set) in order to guide future studies in this area and enable meta-analyses of the results. This must include appropriate consideration of the potential harms of treatment, as well as the benefits.

Interventions for Menière's disease: an umbrella systematic review

OBJECTIVES

To systematically review the efficacy of interventions for Menière's disease (MD) to report clinical implications of the results and to identify areas for future valuable research.

METHODS

In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Abstracts (PRISMA-A) guideline, a systematic online database search was conducted in which MEDLINE (PubMed), Embase (Ovid) and CENTRAL (Cochrane Library) were searched until May 2021 in order to search for the efficacy of treatment was analysed in a systematic review. Systematic reviews (SRs) on treatments for MD were screened for eligible interventions. From these SRs, we included placebo randomised controlled trials (RCTs). A separate search was conducted to identify RCTs on treatment modalities that were systematically reviewed yet published after the conduction of these SRs. The primary outcome was control of vertigo as defined by the American guideline as published in 1995. The PRISMA-A and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to appraise and evaluate the certainty of evidence.

RESULTS

We found five SRs from which 19 RCTs were extracted. Five RCTs were added by the separate search resulting in a total of 25 RCTs (n=1248) which evaluated the efficacy of betahistine dihydrochloride, intratympanic injections with gentamicin or steroids, endolymphatic sac surgery and pressure pulse therapy. Evidence on the efficacy of interventions for patients with MD is generally of low certainty. Betahistine (48 mg per day and 144 mg per day) and positive pressure therapy probably do not reduce MD symptoms when compared with placebo. Intratympanic injection with gentamicin or steroids, or treatment with endolymphatic surgery may reduce symptoms in MD when compared with placebo.

CONCLUSIONS

A definite effective and well-tolerated therapy for MD has yet to be discovered and information on the natural course of disease is one of the biggest flaws in current research.

PROSPERO REGISTRATION NUMBER

CRD4201502424.

Efficiency of a novel middle ear pressure device for intractable definite Meniere's disease and delayed endolymphatic hydrops after certification by the public health insurance system in Japan

BACKGROUND

Middle ear pressure therapy (MEPT) is effective in treating intractable vertigo in patients with definite Meniere's disease (MD) and delayed endolymphatic hydrops (DEH) refractory to conservative treatment. A novel middle ear pressure device, the EFET01^®, which requires no transtympanic ventilation tubes, was developed in Japan, approved by the Japanese Ministry of Health, Labour and Welfare, and has been used under Japanese national health insurance since September 2018.

OBJECTIVES

To examine short-term therapeutic effect of MEPT using the ETET01^® compared with previous clinical trial results.

METHODS

Patients selected according to Japan Society for Equilibrium Research (JSER) guidelines underwent MEPT using the EFET01 from September 2018 to July 2021, and 44 patients were enrolled in this retrospective study. Clinical data analysed at 4 months after the start of MEPT were compared with those of the previous clinical trial for the EFET01.

RESULTS

MEPT using the EFET01 showed the same therapeutic efficacy as that of the previous clinical trial, i.e. improvement in the intensity and frequency of vertigo with no effect on hearing, even under JSER guidelines for proper use of MEPT.

CONCLUSION

MEPT using the EFET01 provided an effective treatment option for intractable vertigo in patients with definite MD and DEH.

Effects of transtympanic intermittent pressure therapy using a new tympanic membrane massage device for intractable Meniere's disease and delayed endolymphatic hydrops: a prospective study

BACKGROUND

The retrospective study showed that the effect of the middle ear pressure treatment by the tramstympanic membrane massage (TMM) device was similar to that of the Meniett device.

OBJECTIVES

The new TMM device named EFET device was prospectively evaluated in patients with Meniere's disease (MD) and delayed endolymphatic hydrops (DEH) and we compared the effects to the Meniett device.

MATERIALS AND METHODS

23 ears of 19 patients were treated with an EFET device, and 17 ears of 15 patients were treated with the Meniett device. All patients suffering from intractable MD and DEH were treated for 4 months. The insertion of a transtympanic ventilation tube was necessary for the Meniett device, but not the EFET device.

RESULTS

In patients treated by the EFET and Meniett devices, the frequency of vertigo significantly improved after treatment. The distribution of vertigo outcomes at 4 months after treatment did not differ between patients treated with the both devices.

CONCLUSIONS AND SIGNIFICANCE

Middle ear pressure treatment by the EFET device is effective and provides minimally invasive options for intractable MD and DEH like the Meniett device.

Diagnostic and therapeutic strategies for Meniere's disease of the Japan Society for Equilibrium Research

OBJECTIVE

We provided diagnostic and therapeutic strategies for Meniere's disease in accordance with Japanese Clinical Practice Guideline of Meniere's disease and delayed endolymphatic hydrops 2nd ed. Tokyo: Kanehara Shuppan; 2020 edited by the Japan Society for Equilibrium Research.

METHODS

The Committee for Clinical Practice Guidelines was entrusted with a review of the scientific literature on the above topic. Clinical Questions (CQs) concerning the treatment for Meniere's disease were produced, and the literature according to each of them including CQ was searched. The recommendations are based on the literature review and the expert opinion of a subcommittee.

RESULTS

Diagnosis criteria of Meniere's disease are classified into Meniere's disease with typical cochlear and vestibular symptoms, and atypical Meniere's disease with either cochlear symptoms or vestibular symptoms. Treatment of Meniere's disease was composed of lifestyle changes, medications such as anti-vertigo drugs and diuretics, middle ear positive pressure treatment, and selective destruction of the vestibule.

CONCLUSION

Meniere's disease is diagnosed based on clinical histories and examination findings after processes of differential diagnosis. Treatment option of the disease should be selected in order of invasiveness, according to the severity of the disease and the response to each treatment.

Vertiginous Episodes in Menière Disease following Transmyringeal Ventilation Tube Insertion: A Systematic Review on the Current State of Evidence

Introduction  Menière disease (MD) is a disorder characterized by episodes of vertigo, sensorineural hearing loss, tinnitus and aural fullness. Objectives  To assess the effect of ventilation tube insertion (VTI) on vertiginous episodes in patients (≥ 18 years old) with MD. Data Synthesis  A systematic literature search on randomized clinical trials (RCTs), nonrandomized trials and other systematic reviews was performed. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to assess the overall certainty of evidence. Two RCTs and four nonrandomized studies were identified. Data extraction was only possible for one RCT. Results showed that the number of patients with no vertigo attacks significantly increased following active treatment (relative risk 1.52; [95% confidence interval: 1.19-1.94]). The quality of evidence was rated as low. None of the nonrandomized trials included a proper control group, which hindered data extraction and quality assessment. Conclusion  There are currently no RCTs that specifically assess the efficacy of VTI in patients with MD. Current limited data suggest a considerable positive effect on the number of vertiginous episodes in patients with MD. However, due to poor evidence, a fluctuating course and a substantial placebo-effect associated with MD-treatment, no solid conclusion(s) regarding the efficacy of VTI can be made. There is a need for high-quality RCTs.

Effects of endolymphatic hydrops on acoustic energy absorbance

Background: The presence of endolymphatic hydrops (EH) may cause hearing loss and affect the transmission of acoustic energy to the inner ear.Objectives: Acoustic energy absorbance on wideband acoustic immittance (WAI) was evaluated, focusing especially on EH in the vestibule.Material and methods: A total of 32 ears from 16 patients who underwent 3-T magnetic resonance imaging (MRI) to evaluate the presence of EH were examined, retrospectively. The degree of EH in the vestibule was classified into three grades (no, mild, and significant), and pure tone audiometry (PTA) and WAI were measured before and after a glycerol drip.Results: Ears with significant EH showed significantly higher hearing levels and air-bone gaps (ABG), and higher absorbance values on WAI at low frequencies (560-600 Hz) than ears with mild or no EH. Changes in absorbance values were observed in some ears without threshold change on PTA.Conclusions and Significance: This study showed significantly higher absorbance values of acoustic energy with significant vestibular EH at low frequencies. Considering ABGs observed in ears with significant EH, the presence of EH in the vestibule might cause an obstacle to the transmission of acoustic energy to the inner ear.

Clinical long-term effects of surgical treatment for intractable Meniere's disease: a more than 13-year follow-up after pressure treatment and further surgical treatment for intractable vertigo

Background: Meniere's disease appears to be a complex inner ear disorder and also remains a controversial and often difficult disease as regards determination of diagnosis, pathogenesis and especially optimal treatment.Aims/objectives: To investigate the long-term effects of progressive surgical treatment in the management of the vertigo attacks of intractable Meniere's disease.Material and methods: Eighteen patients with medically intractable and active Meniere's disease were opted to try Meniett pulse generator (Meniett), endolymphatic sac decompression (ESD) and triple semicircular canal occlusion (TSCO) in order to control the attacks of vertigo. Patients were indicated on the symptom report card the maximum level of vertigo, activity and stress.Results: Of 18 patients with medically intractable and active Meniere's disease during mean 165-month follow-up, the attacks of vertigo were effectively controlled in 14 patients by Meniett (77.78%), 2 patients by Meniett and ESD (11.11%), 2 patients by Meniett, ESD and TSCO (11.11%).Conclusions and significance: It is of great importance for intractable Meniere's disease to select surgically combined treatment process including Meniett, ESD and TSCO to effectively control the attacks of vertigo and a long-term follow-up.

Chronic cerebrospinal venous insufficiency and menière's disease: Interventional versus medical therapy

OBJECTIVES/HYPOTHESIS

To evaluate the incidence of chronic cerebrospinal venous insufficiency in Menière's disease patients and the effect of bilateral percutaneous transluminal angioplasty of the jugular/azygos veins compared to medical therapy.

STUDY DESIGN

Prospective case-control study.

METHODS

Five hundred fourteen subjects were included in the study, 412 affected by definite Menière's disease, and 102 healthy controls. All patients underwent audiovestibular and vascular examination. Patients with Menière's disease and concomitant cerebrospinal venous insufficiency were divided in two subgroups: patients who underwent vascular intervention with bilateral percutaneous transluminal angioplasty (PTA) of the jugular/azygos veins and patients treated with medical therapy.

RESULTS

Chronic cerebrospinal venous insufficiency was diagnosed in 330/412 (80.1%) Menière's disease patients and in 12/102 healthy individuals (11.8%) (P < .001). In the two chronic cerebrospinal venous insufficiency subgroups, a significant difference in Dizziness Handicap Inventory scores was found between patients in the PTA group compared to patients treated with medical therapy (31 ± 8.6 vs. 48.1 ± 14.4; P < .001); no significant differences were found for the Tinnitus Handicap Inventory scores (50.8 ± 16.58 vs. 49.6 ± 17.5; P = .23). Subjective evaluation of aural fullness was significantly better in patients in the PTA group (P = .003) as well as pure-tone average, which was significantly different between groups (49.8 ± 16.5 dB in the PTA group vs. 55.8 ± 13 in the medical therapy group; P = .035).

CONCLUSIONS

The results of the present study confirm the close relationship between vascular disorders and Menière's disease. The encouraging responses to vascular interventional therapy on Meniére's disease symptoms suggest that this may be a promising path for interpretation and treatment of this complex disease.

LEVEL OF EVIDENCE

2b Laryngoscope, 130: 2040-2046, 2020.

Fluctuating Sensorineural Hearing Loss

BACKGROUND

Several otologic conditions can present with fluctuating sensorineural hearing loss, including Ménière's disease, autoimmune inner ear disease, and enlarged vestibular aqueduct. Although these 3 etiologies vary greatly, distinguishing between these conditions at initial presentation can be challenging. Furthermore, initial treatment of these conditions is often similar. In this review, we discuss historical and current perspectives on diagnosis and treatment of these conditions.

SUMMARY

A literature search was performed regarding fluctuating hearing loss, and current treatment of these etiologies of fluctuating hearing loss was summarized. Immediate measures at the onset of acute hearing loss include corticosteroid therapy, while preventative and chronic therapies, which can limit disease severity and frequency, vary based on the specific condition treated. Key Messages: Fluctuating hearing loss can represent a range of pathologies, but the precise etiology may not be clear at initial presentation. Timely treatment and long-term follow-up, along with appropriate diagnostics, are necessary to optimize long-term hearing.

The Clinical Benefit of Device Therapy for Meniere's Disease in Adults: Systematic Review and Meta-Analysis

OBJECTIVES

This study aimed to assess the clinical benefit of device therapy on controlling the symptoms of Meniere's disease (MD).

MATERIALS AND METHODS

We searched PubMed, Embase, the Cochrane Library, China National Knowledge Internet, and Wanfang Data before January 13, 2018. We selected randomized controlled clinical trials, case-controlled studies, and cohort studies that dealt with outcomes of device therapy for the treatment of MD.

RESULTS

Sixteen trials met our inclusion criteria. The use of device therapy resulted in improved vertigo control, which was described as a reduction in the number of vertigo days by month (weighted mean difference [WMD]: 3.15, 95% confidence interval [CI]: 2.00-4.31), in the number of vertigo episodes by month (WMD: 7.37, 95% CI: 2.40-12.35), and in the vertigo visual analog score (WMD: 41.51, 95% CI: 34.68-48.34). In addition, the overall complete vertigo control (class A) rate was 50% (95% CI: 37%-64%). The device therapy also reduced the number of sick days by month (WMD: 4.56, 95% CI: 2.15-6.97), and the functional level improved (WMD: 2.66, 95% CI: 2.15-3.17). The electrocochleographic parameters decreased. The device therapy proved beneficial for hearing changes (WMD: 3.19, 95% CI: 0.66-5.71). No publication bias was found in the funnel plot and the results of Egger's test.

CONCLUSION

This study showed that the device therapy might reduce vertigo attacks and sick days in patients with MD. Additionally, the function level and hearing level may improve after the device therapy. In addition, the decrease in electrocochleographic parameters showed that inner ear electrophysiology improved after device therapy.

Advances in pharmacotherapy of vestibular and ocular motor disorders

INTRODUCTION

Vertigo and dizziness are common chief complaints of vestibular and ocular motor disorders (lifetime prevalence 30%). Treatment relies on physical, pharmacological, psychological and rarely surgical approaches. Eight groups of drugs are currently used in vestibular and ocular motor disorders, namely anti-vertiginous, anti-inflammatory, anti-menière's, anti-migrainous medications, anti-depressants, anti-convulsants, aminopyridines and agents that enhance vestibular plasticity.

AREAS COVERED

The purpose of this review is to summarize the pharmacological characteristics and clinical applications of medications that are used for peripheral, central and functional vestibular and ocular motor disorders. The level of evidence for the respective drugs is described alongside the pathophysiological premises supporting their use. The authors place particular focus on translation and back-translation in vestibular pharmacological research and the repurposing of known drugs for new indications and rare disorders.

EXPERT OPINION

The use of drugs in vestibular and ocular motor disorders is often based on open-label, non-controlled studies and expert opinion. In the future, strong evidence derived from RCTs is needed to support the effectiveness and tolerability of these therapies in well-defined vestibular and ocular motor disorders. Vestibular pharmacological research must be guided by a better understanding of the molecular targets relevant in the pathophysiology of vestibular and ocular motor disorders.

Positive pressure device treatment for Menière's disease: an overview of the current evidence and a meta-analysis

OBJECTIVE

The objective was to critically assess the current evidence investigating the efficacy of using a positive pressure device in patients with definite or probable Menière's disease.

METHODS

We performed a systematic literature search in MEDLINE, EMBASE and PsycINFO up to February 2018. We included both systematic reviews and primary literature [randomized controlled trials (RCTs)] investigating positive pressure treatment, in patients (≥ 18 years of age), with Menière's disease. We assessed the internal validity of systematic reviews using the AMSTAR tool and risk of bias of primary studies using the Cochrane Risk of bias tool. We performed a meta-analysis for each outcome based on the identified studies. The overall certainty of evidence for the outcomes was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

RESULTS

The search for systematic reviews identified four relevant reviews. These all included the same four RCTs. An updated search identified one additional RCT. In total, five RCTs were included in the data synthesis. Our data synthesis showed no effect of positive pressure treatment on primary nor secondary outcomes. No serious adverse events were reported. The overall certainty of evidence ranged from very low to low, due to the serious risk of bias and imprecision.

CONCLUSION

The current available evidence does not support positive pressure device treatment in patients with Menière's disease. However, the limitations of the current literature hinder the possibility of any solid conclusion. There remains a need for randomized controlled trials of high quality to fully access the utility of this treatment.

Menière's disease: combined pharmacotherapy with betahistine and the MAO-B inhibitor selegiline-an observational study

OBJECTIVES

Since oral betahistine has a very high first-pass effect (ca. 99%), metabolized by monoamine oxidases (MAO), the benefits of a high-dosage betahistine monotherapy were compared with those of a lower dosage of betahistine in combination with the MAO-B inhibitor (MAO-B) selegiline on the frequency of acute attacks of vertigo in patients with Menière's disease (MD).

METHODS

Thirteen adults aged 40-75 years (mean 58.9 years; six females) had initially been treated with a high dosage of betahistine dihydrochloride for at least 1 year. Under this therapy, all of them had ≤ 1 attack for ≥ 3 months prior to the combination pharmacotherapy. Subsequently, they received 5 mg/day selegiline and the dosage of betahistine was reduced to about one tenth and then individually adjusted to the dosage needed to achieve the same treatment response (≤ 1 per 3 months, observational period of at least 6 months).

RESULTS

The initial dosage for the long-term "titration" of the attacks of vertigo was 9-80 24-mg tablets/day (mean 37.3), i.e. 216-1920 mg/day (mean 895.4 mg/day). After the combination with selegiline, the dosage needed to achieve the same benefit for ≥ 3 months was 3-36 24-mg tablets (mean 8.5), i.e., 72-864 mg/day [mean 204.9 mg/day, p < 0.001 (paired t test)]. One patient transiently stopped the treatment with selegiline, another one reduced the dosage to 2.5 mg/day and the attacks re-occurred after 2-4 weeks. Six out of 13 patients reported transient fullness of the head during the combined treatment; in 2 of them this went away when they switched to 2.5 mg bid. In the longer term (> 9 months), one patient had to increase the selegiline dosage to 5 mg bd, one patient stopped the treatment with selegiline.

CONCLUSIONS

The achievement of the same clinical effect with a significantly lower (about 1/5) dosage of betahistine can be explained by the inhibition of the MAO-B by selegiline leading to higher serum concentrations of betahistine. This approach is in line with recent developments to bypass the first-pass effect of betahistine by transbuccal or intranasal application. Despite the substantial methodological limitations of such an observational study, this combined pharmacotherapy could be an alternative to a high-dosage monotherapy with betahistine of MD.