Introduction
Intratympanic gentamicin injections (1) or revision surgery (2) have been used for the treatment of
patients with Ménière’s disease who have relapsed following
endolymphatic sac surgery (EDS) or intratympanic gentamicin
injection. Ménière’s disease is a condition with vertigo, tinnitus
(ringing or buzzing noises in the ears) and progressive deafness.
Ménière’s disease is caused by a dysfunction of the endolymphatic
sac in the inner ear. It is an unpredictable disease that requires
various types of treatment. It is estimated at approximately 1 in
every 1,000 individuals suffers from Ménière’s disease. The disease
may develop at any age, but more commonly does so when the patient
is aged between 40 and 60 years old. With respect to the treatment,
the conservative therapy is the first choice. Gentamicin injection
and surgery are only performed to the patients with intractable
cases. The success rate of either treatment is relatively high and
up to 90% of the patients may control their symptoms. The
gentamicin injection may be performed without hospital admission,
but the surgery requires hospitalization. There is a risk of
hearing impairment following gentamicin injection and success of
either treatment have been previously reported (2,3).
Thus far there has only been one study concerning the treatment of
Ménière’s disease by SSRIs (3). A
potential link between Ménière’s disease and anxiety or depression,
and the use of serotonin selective reuptake inhibitors (SSRIs) in
patients with Ménière’s disease was first reported by Overton
(3). Over two years, we treated
three patients for symptoms associated with Ménière’s disease with
an SSRI (sertraline), with either the complete resolution of the
disease or a significant improvement in the symptoms. Ménière’s
disease, which has uncertain etiology and multiple ineffective
treatments, warrants a clinical trial assessing the efficacy of
SSRIs, as evidence from 1861 to the present day links Ménière’s
disease with stress, sympathetic stimuli and labyrinthine
microcirculation (3–5). The objective of this report is to
describe the benefits of administering SSRIs to patients with
relapsed Ménière’s disease. The written informed consent was
obtained from the patients.
Case reports
Case 1
A 59-year-old female first presented at the Hino
Municipal Hospital (Tokyo, Japan) following a relapse in spells of
vertigo 15 years following EDS (Table
I). The patient’s vertigo attacks usually lasted several hours,
with nausea and a worsening of tinnitus, and occurred a few times a
week. Careful analysis of the patient’s history revealed marked
anxiety regarding the vertigo attacks, although the patient’s
Hospital Anxiety and Depression Scale (HADS) score revealed no
significant anxiety. The patient had no history of migraine or a
present migraine. Sertraline (50 mg/day) therapy was commenced. The
patient’s vertigo spells as well as anxiety improved for two weeks
and stabilized. The symptoms of Ménière’s disease did not recur.
Sertraline treatment ceased after six months. The patient’s
functional level scale (FL) score (6) improved from 4 to 1, and the patient
remained symptom-free a year later.
 | Table ISummary of cases. |
Table I
Summary of cases.
| Case | Side | Gender | Age (years) | PTA (dB) | Migraine | Prior to SSRI
treatment | Following SSRI
treatment |
|---|
|
|
|
|---|
| Right | Left | FL | DHI (P,E,F) | HADS (A,D) | FL | DHI (P,E,F) | HADS (A,D) |
|---|
| 1 | Left | Female | 59 | 18.8 | 50.0 | No | 4 | 60 (12,26,22) | 9 (6,3) | 1 | 0 (0,0,0) | 8 (5,3) |
| 2 | Right | Male | 45 | 41.3 | 12.5 | No | 4 | 60 (10,28,22) | 8 (5,3) | 1 | 0 (0,0,0) | 7 (4,3) |
| 3 | Right | Female | 72 | 41.3 | 18.8 | Yes | 4 | 54 (12,22,20) | 8 (5,3) | 1 | 22 (4,8,10) | 7 (4,3) |
Case 2
A 45-year-old male experienced a relapse in vertigo
spells seven years after intratympanic gentamicin treatment. The
patient had no history of anxiety disorders or migraines, past or
present. The patient feared a relapse of Ménière’s disease and
wanted to be a candidate for EDS. Although the patient’s HADS score
was within the normal range, the patient’s anxiety regarding the
attacks was marked. The vertigo attacks occurred several times a
week for ~1 h. The patient was persuaded to undergo treatment with
sertraline (50 mg/day) for two weeks prior to surgery. The vertigo
spells were completely controlled. Sertraline treatment was
continued for six months and, a year later, the symptoms remained
well controlled.
Case 3
A 72-year-old female first presented at the Hino
Municipal Hospital following a relapse in vertigo spells 18 years
after EDS (Table I). The patient
had no history of anxiety disorders but did have a migraine
headache. The vertigo attacks had occurred three times a week for a
month and were usually accompanied by headache. The patient was
afraid of a relapse of Ménière’s disease. However, from the
patient’s clinical history, migraine-related vertigo was suspected
and sertraline (50 mg/day) therapy was initiated. Following two
weeks of treatment, the vertigo and headaches were controlled.
Sertraline treatment was continued for six months, and the patient
remained vertigo-free a year later.
In all three patients, vertigo attacks were
completely controlled by the administration of sertraline; however,
the hearing thresholds of the patients did not alter.
Discussion
It is difficult to determine whether the patients in
the present study were exhibiting Ménière’s disease itself; the
etiology was similar to that of Ménière’s disease, but was well
treated by SSRIs. The key for differential diagnosis is to consider
the clinical history of the patient very carefully. The
characteristic symptom of Ménière’s disease is rotating vertigo
attacks usually lasting up to several hours (3). Ménière’s disease may co-exist with
other conditions that cause vestibular symptoms and are responsive
to SSRIs. These include migraine-associated vertigo (MAV), panic
disorders and chronic subjective dizziness (CSD) (7). The diagnosis of MAV (8) is likely in Case 3, but the other two
patients had no history of migraines. However, MAV may cause
episodes of rotary vertigo, indistinguishable from the vertiginous
symptoms of Ménière’s attacks. MAV may also cause unilateral aural
symptoms (fullness and tinnitus) during attacks (8).
Panic disorders (9)
are unlikely in the patients in the present study, given that the
diagnostic criteria of a panic disorder include a discrete period
of intense fear or discomfort developing abruptly and reaching a
peak within 10 min. However, in Cases 1 and 2, a situation similar
to a panic disorder is suggested by the response to the SSRI. CSD
is unlikely, as CSD is defined not as vertigo attacks but as
‘persistent (≥3 months) sensations of nonvertiginous dizziness, or
subjective imbalance present on most days’ (7). However, it is difficult to determine
whether the information derived from the subjective complaints of
the patients is accurate. A study by Boleas-Aguirre et
al(10) revealed that anxious
patients with Ménière’s disease had a high likelihood of developing
CSD-like symptoms following gentamicin treatment even if they had
excellent vertigo control. The benefit of SSRIs in patients with
CSD has been reported (11), but
there are few reports concerning the use of antidepressants in
patients with Ménière’s disease. A previous study reported that
antidepressants are useful in the treatment of headaches in
patients with Ménière’s disease (12).
Levels of depression or anxiety in patients with
relapsed Ménière’s disease are not easily evaluated, and a
subjective scale such as HADS may not accurately indicate patient
mood changes. SSRIs may be a therapeutic option for the relapse of
Ménière’s disease following intensive therapy. Further study is
required to establish the efficacy of the therapy.
In conclusion, the three cases of relapsed Ménière’s
disease were successfully treated with an SSRI. However the SSRI
may have treated the associated morbidity and not Ménière’s disease
itself. Ménière’s disease that appears to be resistant to typical
otological treatment may not be Ménière’s disease alone.
Acknowledgements
This study was supported by a Grant-in-Aid for
Scientific Research (B) (No.23592494) from The Ministry of
Education, Culture, Sports, Science and Technology (MEXT) in
2011.
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