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

Published:October 29, 2020DOI:https://doi.org/10.1016/j.anl.2020.10.009

      Abstract

      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.

      Keywords

      1. Introduction

      Meniere's disease is an inner ear disease that is characterized by recurrent attacks of vertigo, fluctuating hearing loss and tinnitus. The pathophysiology of this disease is assumed to be endolymphatic hydrops, which was first revealed in human temporal bone studies by Yamakawa in Japan [
      • Yamakawa K
      Uber die pathologische Veranderung bei einem Meniere-Kranken.
      ] and Hallpike and Cairns in England [
      • Hallpike C.S.
      • Cairns H
      Observations on the pathology of meniere's syndrome: (section of otology).
      ] almost simultaneously in 1938. The cause of endolymphatic hydrops is unknown.
      Since there is no gold standard diagnostic test, Meniere's disease remains a clinical diagnosis based on a detailed history taking and physical examination, and several diagnostic criteria have been proposed in different areas. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) has produced diagnostic guidelines of Meniere's disease in 1995 [
      • Monsell E.M.
      • Balkany T.A.
      • Gates G.A.
      • et al.
      Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Meniere’s disease. American Academy of Otolaryngology-Head and Neck Foundation.
      ]. The International Barany Society modified them in 2015 by an extended consensus between international scientific societies [
      • Lopez-Escamez J.A.
      • Carey J.
      • Chung W.H.
      • Goebel J.A.
      • Magnusson M.
      • Mandala M.
      • et al.
      Diagnostic criteria for Meniere's disease.
      ]. The Japan Society of Equilibrium Research proposed diagnostic criteria of Meniere's disease in 1974 and revised them in 1987 and 2017 [
      • Ikezono T.
      • Itoh A.
      • Takeda N.
      • Nakamura T.
      • Asai M.
      • Ikeda T.
      • et al.
      Documents for standards in diagnostic criteria for dizziness.
      ]. In the latest criteria, Meniere's disease is classified into Meniere's disease with typical cochlear and vestibular symptoms, and atypical Meniere's disease with either cochlear symptoms or vestibular symptoms. Furthermore, identification of endolymphatic hydrops in the affected ear by contrast-enhanced MRI is added in the criteria for certain Meniere's disease. Moreover, a number of different treatment modalities have been adopted for Meniere's disease, ranging from lifestyle changes (e.g. reducing stress) and medication (e.g. anti-vertigo drugs, diuretics), to extensive surgery (e.g. endolymphatic sac surgery, selective destruction of the vestibule).
      The Japan Society for Equilibrium Research developed the 1st edition of Japanese Clinical Practice Guidelines of Meniere's disease in 2011. The aim of the guideline was to assist clinical decision making in the diagnosis and treatment of patients with Meniere's disease. This review introduced important extracts regarding Meniere's disease from Japanese Clinical Practice Guideline of Meniere's disease and delayed endolymphatic hydrops 2nd ed. Tokyo: Kanehara Shuppan; 2020 updated by the Japan Society for Equilibrium Research.

      2. Methods

      2.1 Collecting evidence

      We used PubMED, Ichushi Web (the web site of the Japan Medical Abstract Society), and the Cochrane Library, and carried out information retrieval. We conducted retrieval on the clinical questions (CQs) about remedy. The retrieval expression used were key words of the disease and those of CQs. Languages were limited to English and Japanese. We did not narrow down our research results by research design, form of thesis, or a period of time. In the Cochrane Library, we searched systematic reviews and randomized controlled trials using keywords of the diseases. Additionally, each member of the Committee for Clinical Practice Guidelines carried out a manual search through the documents.

      2.2 Evaluation of evidence

      2.2.1 Level of evidence

      To represent the level of evidence, we adopted the method of representation described below.
      • Ia: Meta-analysis of randomized controlled trials.
      • Ib: At least one randomized controlled trial.
      • IIa: Concurrently-controlled cohort study without randomization (e.g. prospective study, concurrent cohort study).
      • IIb: Non-concurrently-controlled cohort study without randomization (e.g. historical cohort study, retrospective cohort study).
      • III: Case control study (retrospective study).
      • IV: Before-after study without control
      • V: Case report, case series study.
      • VI: Expert opinions (including committee reports).

      2.2.2 Decision criteria of recommendations and of the grade of recommendation

      In deciding recommendations for treatments, we looked up suggestions by Fukui and Tango [
      • Fukui T.
      • Tango T
      Shinryougaidorain sakusei no tejyun version 4.3.
      ] and by GRADE [
      Center MINDSG.
      Minds handbook for clinical practice guideline development.
      ]; accordingly, our committee took the following factors into consideration: level of evidence, quality of evidence, consistency of study, directness (magnitude of clinical effectiveness, external validity, indirect evidence, and assessment of surrogate outcomes), clinical applicability, and evidence about harms and costs.
      We adopted a five-grade recommendation described below.
      • A: Strongly recommended because the scientific basis is strong.
      • B: Recommended because there is some scientific basis.
      • C1: Recommended despite having only a weak scientific basis.
      • C2: Not recommended because there is only a weak scientific basis.
      • D: Not recommended because scientific evidence shows treatment to be ineffective or harmful.

      3. Diagnosis

      The Japan Society for Equilibrium Research proposed diagnostic criteria of Meniere's disease in 1974 and revised them in 1987 and 2017 [
      • Ikezono T.
      • Itoh A.
      • Takeda N.
      • Nakamura T.
      • Asai M.
      • Ikeda T.
      • et al.
      Documents for standards in diagnostic criteria for dizziness.
      ]. In the latest criteria used in this review, diagnostic criteria for Meniere's disease as well as for two atypical Meniere's disease: Cochlear type and Vestibular type are postulated. Each criterion is composed of two parts: symptoms and examination findings.

      3.1 Diagnostic criteria for Meniere's disease

      • A.
        Symptoms
        • 1.
          Recurrent attacks of vertigo. Each vertigo develops spontaneously, lasting 10 min to several hours.
        • 2.
          Attacks are accompanied by fluctuating cochlear symptoms (hearing loss, tinnitus or aural fullness).
        • 3.
          No neurological symptoms except for the eighth cranial nerve.
      • B.
        Examination findings
        • 1.
          Audiometrically demonstrated sensorineural hearing loss. Fluctuation of hearing level occurs in association with vertigo attacks, especially at the early stages.
        • 2.
          Signs of peripheral vestibular dysfunction such as horizontal or horizontal/torsional nystagmus and/or postural imbalance.
        • 3.
          No neurological dysfunction except for the eighth nerve
        • 4.
          Other known diseases causing vertigo associated with hearing loss can be excluded.
        • 5.
          Identification of endolymphatic hydrops in the affected ear by contrast-enhanced MRI
      Diagnostic categories
      Certain Meniere's disease
      To meet all the points in criteria A and B.
      Definite Meniere''s disease
      To meet all the points in criteria A and points 1–4 in criteria B.
      Probable Meniere''s disease
      To meet all the points in criteria A.

      3.2 Diagnostic criteria for atypical Meniere's disease

      3.2.1 Cochlear type of atypical Meniere's disease

      • A.
        Symptoms
        • 1.
          Recurrence of cochlear symptoms such as hearing loss, tinnitus or aural fullness without vertigo attacks.
        • 2.
          No neurological symptoms except for the eighth cranial nerve.
      • B.
        Examination findings
        • 1.
          Audiometrically demonstrated sensorineural hearing loss. Low- or pan-frequency sensorineural hearing loss are usual.
        • 2.
          No neurological dysfunction except for the eighth nerve
        • 3.
          Other known diseases causing recurrence of cochlear symptoms can be excluded.
      Diagnostic category
      Definite cochlear type of atypical Meniere''s disease
      To meet all the points in criteria A and B.

      3.2.2 Vestibular type of atypical Meniere's disease

      • A.
        Symptoms
        • 1.
          Recurrent attacks of vertigo like typical Meniere's disease. The attacks are not accompanied by fluctuating cochlear symptoms.
        • 2.
          No neurological symptoms except for the eighth cranial nerve.
      • B.
        Examination findings
        • 1.
          Signs of peripheral vestibular dysfunction such as horizontal or horizontal/torsional nystagmus and/or postural imbalance
        • 2.
          No neurological dysfunction except for the eighth nerve
        • 3.
          Other known diseases causing recurrent attacks of vertigo can be excluded.
      Diagnostic category
      Definite vestibular type of atypical Meniere''s disease
      To meet all the points in criteria A and B.
      Note: Vestibular type of atypical Meniere''s disease should be diagnosed after exclusion of recurrent vertigo caused by mechanism other than endolymphatic hydrops.

      4. Examination for the diagnosis of Meniere's disease

      Meniere's disease is characterized by recurrent vertigo attacks associated with cochlear symptoms such as hearing loss, tinnitus and aural fullness, and its underlying pathophysiology is assumed to be endolymphatic hydrops. Examinations for Meniere's disease are composed of three categories: 1) audiological tests, 2) vestibular function tests, 3) tests for estimating endolymphatic hydrops, and 4) MRI imaging of endolymphatic hydrops.

      4.1 Audiological tests

      Pure tone audiometry shows low-tone sensorineural hearing loss at the early stage of the disease. It is usually fluctuating and reversible. As the vertigo attacks recur, hearing loss tends to progress and begins to involve middle and high frequency regions. After developing to flat-type hearing loss > 40 dBHL, it commonly becomes irreversible. In a portion of cases, unaffected ears are further involved during the course of the disease, resulting in bilateral Meniere's disease.

      4.2 Vestibular function tests

      During the attacks of vertigo, nystagmus toward affected side (irritative nystagmus) is observed, whereas nystagmus toward unaffected side (paralytic nystagmus) is observed after the attacks.
      Vestibular function tests such as the caloric test and the vestibular evoked myogenic potentials show normal responses during the early stage of the disease. However, they tend to show abnormal responses as vertigo attacks recur.

      4.3 Tests for estimating endolymphatic hydrops

      There are a couple of tests for estimating endolymphatic hydrops. The electrocochleography [
      • Gibson W.P.
      • Moffat D.A.
      • Ramsden R.T
      Clinical electrocochleography in the diagnosis and management of Meneere's disorder.
      ], glycerol test [
      • Klockhoff I.
      • Lindblom U
      Glycerol test in Meniere's disease.
      ], furosemide test [
      • Futaki T.
      • Kitahara M.
      • Morimoto M
      The furosemid test for Meniere's disease.
      ], and glycerol/ furosemide cervical vestibular evoked myogenic potential (cVEMP) test [
      • Murofushi T.
      • Matsuzaki M.
      • Takegoshi H
      Glycerol affects vestibular evoked myogenic potentials in Meniere's disease.
      ,
      • Seo T.
      • Shiraishi K.
      • Kobayashi T.
      • Mutsukazu K.
      • Fujita T.
      • Saito K.
      • et al.
      Revision of a furosemide-loading vestibular-evoked myogenic potential protocol for detecting endolymphatic hydrops.
      • Shojaku H.
      • Takemori S.
      • Kobayashi K.
      • Watanabe Y
      Clinical usefulness of glycerol vestibular-evoked myogenic potentials: preliminary report.
      infer the presence of endolymphatic hydrops. Positive ratios of endolymphatic hydrops in patients with definite Meniere's disease estimated by the electrocochleography and glycerol test range from 46% to 71% and from 43% to 63%, respectively.

      4.4 MRI imaging of endolymphatic hydrops

      MRI imaging has been available for visualization of endolymphatic hydrops in patients with Meniere's disease, in addition to exclusion of brain lesions. Three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) imaging is obtained after intravenous administration of contrast medium using 3T MRI unit with 32-channel head coil to differentiate endolymph from perilymph [
      • Nakashima T.
      • Naganawa S.
      • Sugiura M.
      • Teranishi M.
      • Sone M.
      • Hayashi H.
      • et al.
      Visualization of endolymphatic hydrops in patients with Meniere's disease.
      ]. Positive ratio of endolymphatic hydrops in patients with definite Meniere's disease estimated by the contrast-enhanced MRI of the inner ear ranges from 73.2% to 94.2%, which is higher than that of the tests for estimating endolymphatic hydrops [
      • Pyykko I.
      • Nakashima T.
      • Yoshida T.
      • Zou J.
      • Naganawa S
      Meniere’s disease: a reappraisal supported by a variable latency of symptoms and the MRI visualisation of endolymphatic hydrops.
      ,
      • Yoshida T.
      • Sugimoto S.
      • Teranishi M.
      • Otake H.
      • Yamazaki M.
      • Naganawa S.
      • et al.
      Imaging of the endolymphatic space in patients with Meniere's disease.
      .

      5. Treatments for Meniere's disease

      Treatments for Meniere`s disease are classified into those in the acute period and intermittent period. The aim of the former is alleviation of dizziness and nausea during the attacks, and improvement of hearing loss. The aim of the latter is prevention of vertigo attacks.

      5.1 Treatments in the acute period

      Patients with severe vertigo and nausea typically require intravenous administration of fluids during the emergency department stay. To reduce symptoms, anti-vertigo drugs and antiemetics are used. The anti-vertigo drugs include antihistamines, benzodiazepines, and anticholinergics. Intravenous infusion of 7% sodium bicarbonate is also effective to reduce vestibular symptoms. The antiemetic drugs include metoclopramide and domperidone. Symptomatic care with anti-vertigo drugs should be used mainly during the period when patients suffer from severe vertigo and nausea. Acute sensorineural hearing loss associated with vertigo attacks are treated with steroids, which are administered orally or intravenously, according to the treatments for sudden sensorineural hearing loss [
      • Okada M.
      • Hato N.
      • Nishio S.Y.
      • Kitoh R.
      • Ogawa K.
      • Kanzaki S.
      • et al.
      The effect of initial treatment on hearing prognosis in idiopathic sudden sensorineural hearing loss: a nationwide survey in Japan.
      ,
      • Wei B.P.
      • Mubiru S.
      • O’Leary S
      Steroids for idiopathic sudden sensorineural hearing loss.
      .

      5.2 Treatments in the intermittent period

      Several medical and surgical treatments have been postulated to reduce and/or prevent attacks in Meniere's disease. Fig. 1 shows the treatment algorithm for Meniere's disease proposed by the Japan Society for Equilibrium Research, which is modified from the algorithm reported by Sajjadi and Paparella (2008) [
      • Sajjadi H.
      • Paparella M.M
      Meniere's disease.
      ]. The treatment options are listed in order of the invasiveness of the treatments. An appropriate treatment option should be selected, according to the severity of the disease and failure of the response to treatments.
      Fig 1
      Fig. 1Treatment algorithm for Meniere's disease.

      5.2.1 Lifestyle changes

      Meniere's disease has an aspect of lifestyle-related disease. Stress, fatigue, and shortage of sleep have some association with pathogenesis of Meniere's disease [
      • Takahashi M.
      • Odagiri K.
      • Sato R.
      • Wada R.
      • Onuki J
      Personal factors involved in onset or progression of Meniere's disease and low-tone sensorineural hearing loss.
      ]. Characters of patients with Meniere's disease tend to be nervous, meticulous, compulsory, or perfectionistic. It is recommended to advise patients to reduce their stress by avoiding overwork and decreasing unpleasant or obligatory activities. Moderate exercises such as aerobics are also recommended to reduce the number of attacks and to improve hearing loss [
      • Onuki J.
      • Takahashi M.
      • Odagiri K.
      • Wada R.
      • Sato R
      Comparative study of the daily lifestyle of patients with Meniere's disease and controls.
      ].

      5.2.2 Medications

      Diuretics are used to reduce the degree of endolymphatic hydrops. Isosorbide, an osmotic diuretic is most commonly used in Japan (See CQ2). Anti-vertigo drugs, vitamin B12, and Chinese herbs are also used (See CQ1). When patients have heavy stress or insomnia, which are considered as underlying trigger of attacks, anxiolytics or hypnotics may be used.

      5.2.3 Middle ear positive pressure treatment

      Middle ear positive pressure treatment is a less-invasive method for treatment of intractable vertigo in patients with Meniere's disease as compared to surgery. In this treatment, after a tympanostomy tube is inserted in affected ear, positive pressure is provided to the ear canal using a pressure pulse generator device, Meniett (LiNA Medical USA, Inc., USA) [
      • Shojaku H.
      • Watanabe Y.
      • Mineta H.
      • Aoki M.
      • Tsubota M.
      • Watanabe K.
      • et al.
      Long-term effects of the Meniett device in Japanese patients with Meniere's disease and delayed endolymphatic hydrops reported by the Middle Ear Pressure Treatment Research Group of Japan.
      ]. This device is approved by Food and Drug Administration in the United States, but not by Pharmaceuticals and Medical devices Agency in Japan.
      Instead, the middle ear pressure device (Daiichi Medical Co., Ltd., Japan), which is an upgraded tympanic membrane massage device is approved and available in Japan recently. The middle ear pressure device can be used without a tympanostomy tube, and it has similar efficacy with Meniett deviece in reducing the frequency of vertigo attacks (See CQ4) [
      • Watanabe Y.
      • Shojaku H.
      • Junicho M.
      • Asai M.
      • Fujisaka M.
      • Takakura H.
      • et al.
      Intermittent pressure therapy of intractable Meniere's disease and delayed endolymphatic hydrops using the transtympanic membrane massage device: a preliminary report.
      ].

      5.2.4 Endolymphatic sac surgery

      Endolymphatic sac surgery is to make an incision in the lateral wall of the endolymphatic sac after simple mastoidectomy for releasing endolymphatic hydrops. To improve the efficacy of the surgery, several methods such as insertion of Silastic sheeting into the sac or intra-sac administration of high-dose of steroids have been reported [
      • Sajjadi H.
      • Paparella M.M
      Meniere's disease.
      ,
      • Kitahara T
      Evidence of surgical treatments for intractable Meniere's disease.
      . This treatment can suppress vertigo attacks without in approximately 75% of patients with intractable vertigo with Meniere's disease (see CQ5).

      5.2.5 Selective destruction of the vestibule

      Since vertigo attacks are caused by dysfunction of the peripheral vestibule, they can be suppressed by destruction of the vestibular end-organ in the inner ear and/or its afferents. There are two methods in selective destruction of the vestibule: the intratympanic administration of gentamicin and the vestibular neurectomy.
      Intratympanic gentamicin therapy: Intratympanic administration of gentamicin utilizes its characteristics of selectively affecting the vestibular system. Hearing loss triggered by this treatment is relatively mild. There are two ways in administration: the “shot-gun” protocol and the “titration” protocol. In the shot-gun protocol, gentamicin is administered in multiple times in consecutive days. In the titration protocol, gentamicin is administered once a week. In both methods, administration is continued until appearance of nystagmus or rise in hearing threshold > 10–15 dB. This treatment can completely control vertigo in approximately 90% of patients [
      • Hsieh L.C.
      • Lin H.C.
      • Tsai H.T.
      • Ko Y.C.
      • Shu M.T.
      • Lin L.H
      High-dose intratympanic gentamicin instillations for treatment of Meniere's disease: long-term results.
      ,
      • Stokroos R.
      • Kingma H
      Selective vestibular ablation by intratympanic gentamicin in patients with unilateral active Meniere's disease: a prospective, double-blind, placebo-controlled, randomized clinical trial.
      (see CQ6).
      Vestibular neurectomy: Vestibular neurectomy is an amputation of vestibular nerve in a craniotomy procedure, which can almost completely prevent the recurrence of vertigo attacks [
      • Sajjadi H.
      • Paparella M.M
      Meniere's disease.
      ]. Although hearing preservation is expected after vestibular neurectomy, which is carried out jointly with highly skilled neuro-otologists and neurosurgeons, this treatment should be selected after failure of all other treatments (see CQ7).

      6. Clinical questions

      6.1 CQ1: are anti-vertigo drugs effective for the treatment of Meniere's disease?

      6.1.1 Recommendations

      There is insufficient evidence to show whether betahistine has any effect on vertigo, hearing loss or tinnitus in patients with Meniere's disease. Short-term therapy (< 3 months) may have some suppressive effects on vertigo symptoms and frequency of vertigo attacks (Grade of recommendation: B). However, long-term therapy (> 3 months) is not recommended because it has no effect (Grade of recommendation: C2).
      The efficacy of diphenidol for the treatment of Meniere's disease has not been demonstrated. Short-term therapy may have some suppressive effects on vertigo symptoms (Grade of recommendation: C1).
      Reports used for the judgement of the recommendation grade: Level Ia [
      • James A.L.
      • Burton M.J
      Betahistine for Meniere’s disease or syndrome.
      ,
      • Nauta J.J
      Meta-analysis of clinical studies with betahistine in Meniere's disease and vestibular vertigo.
      , Level Ib [
      • Adrion C.
      • Fischer C.S.
      • Wagner J.
      • Gurkov R.
      • Mansmann U.
      • Strupp M
      Efficacy and safety of betahistine treatment in patients with Meniere's disease: primary results of a long term, multicentre, double blind, randomised, placebo controlled, dose defining trial (BEMED trial).
      ,
      • Albera R.
      • Ciuffolotti R.
      • Di Cicco M.
      • De Benedittis G.
      • Grazioli I.
      • Melzi G.
      • et al.
      Double-blind, randomized, multicenter study comparing the effect of betahistine and flunarizine on the dizziness handicap in patients with recurrent vestibular vertigo.
      ,
      • Mira E.
      • Guidetti G.
      • Ghilardi L.
      • Fattori B.
      • Malannino N.
      • Maiolino L.
      • et al.
      Betahistine dihydrochloride in the treatment of peripheral vestibular vertigo.
      ,
      • Strupp M.
      • Hupert D.
      • Frenzel C.
      • Wagner J.
      • Hahn A.
      • Jahn K.
      • et al.
      Long-term prophylactic treatment of attacks of vertigo in Meniere's disease–comparison of a high with a low dosage of betahistine in an open trial.
      ,
      • Futaki T.
      • Kitahara M.
      • Morimoto M
      Evaluation of the effect of diphenidol on peripheral dizziness by a double-blind study.
      ].

      6.2 CQ2: are diuretics effective for the treatment of Meniere's disease?

      6.2.1 Recommendations

      There is insufficient evidence to show the effects of diuretics on vertigo, hearing loss or tinnitus in patients with Meniere's disease. However, diuretics may have suppressive effects on vertigo symptoms, frequency of vertigo attack and progression of hearing loss. They can be considered as a treatment options to suppress vertigo and hearing loss (Grade of recommendation: C1). Isosorbide (90 ml/day), an osmotic diuretic may also be considered as a treatment option to prevent the recurrence of vertigo attacks within six months after the last vertigo attack (Grade of recommendation: C1).
      Reports used for the judgment of the recommendation grade: Level Ib [
      • Crowson M.G.
      • Patki A.
      • Tucci D.L
      A systematic review of diuretics in the medical management of Meniere's disease.
      ,
      • James A.L.
      • Thorp M.A
      Meniere’s disease.
      ,
      • Thirlwall A.S.
      • Kundu S
      Diuretics for Meniere’s disease or syndrome.
      ,
      • Kitahara M.
      • Watanabe I.
      • Hinoki M.
      • Mizukoshi K.
      • Matsunaga T.
      • Matsunaga T.
      • et al.
      Clinical study of isosorbide on Mniere's disease: inter-group comparative study with betahistine mesylate by multi-centered double-blind trial.
      • Kitahara M.
      • Watanabe I.
      • Hinoki M.
      • Mizukoshi K.
      • Matsunaga T.
      • Matstunaga T.
      • et al.
      Dose-response test for isosorbide on Mniere's disease.
      , Level III [
      • Suzuki M.
      • Kitahara M.
      • Kodama A.
      • Uchida K.
      • Izukura H.
      • Kitanishi T.
      • et al.
      Isosorbide treatment of Ménière’s disease; A clinical evaluation of the administration period.
      ].

      6.3 CQ3: are anti-viral drugs effective for the treatment of Meniere's disease?

      6.3.1 Recommendations

      The efficacy of anti-viral drugs for the treatment of Meniere's disease has not been demonstrated. They are not recommended as a treatment option for Meniere's disease (Grade of recommendation: D).
      Reports used for the judgement of the recommendation grade: Level Ib [
      • Derebery M.J.
      • Fisher L.M.
      • Iqbal Z
      Randomized double-blinded, placebo-controlled clinical trial of famciclovir for reduction of Meniere's disease symptoms.
      ,
      • Guyot J.P.
      • Maire R.
      • Delaspre O
      Intratympanic application of an antiviral agent for the treatment of Meniere's disease.
      , Level V [
      • Gacek R.R
      Recovery of Hearing in Meniere's disease after antiviral treatment.
      ].

      6.4 CQ4: are middle ear positive pressure treatments effective for the treatment of Meniere's disease?

      6.4.1 Recommendations

      There is insufficient evidence to prove the effectiveness of middle ear positive pressure treatments over placebo (insertion of a tympanostomy tube) on the symptoms of Meniere's disease. However, middle ear positive pressure treatment using Meniett device for longer than 4 months may have suppressive effects on the frequency of vertigo attacks. It may be recommended as a treatment option to prevent the recurrence of vertigo attacks (Grade of recommendation: B).
      The effectiveness of middle ear positive pressure treatments using the middle ear pressure device, which is approved and available in Japan recently for vestibular symptoms in Meniere's disease, is not different from that of Meniette device, and it may also be recommended as treatment option to prevent the recurrence of vertigo attacks (Grade of recommendation: B).
      The efficacy of middle ear positive pressure treatments for the treatment of cochlear symptoms such as hearing loss or tinnitus in patients with Meniere's disease has not been demonstrated. They are not recommended as a treatment option for cochlear symptom (Grade of recommendation: C2).
      Reports used for the judgement of the recommendation grade: Level Ia [
      • Ahsan S.F.
      • Standring R.
      • Wang Y
      Systematic review and meta-analysis of Meniett therapy for Meniere's disease.
      ,
      • van Sonsbeek S.
      • Pullens
      • van Benthem PP B.
      Positive pressure therapy for Meniere’s disease or syndrome.
      , Level Ib [
      • Densert B.
      • Densert O.
      • Arlinger S.
      • Sass K.
      • Odkvist L
      Immediate effects of middle ear pressure changes on the electrocochleographic recordings in patients with Meniere's disease: a clinical placebo-controlled study.
      ,
      • Gates G.A.
      • Green Jr., J.D.
      • Tucci D.L.
      • Telian S.A
      The effects of transtympanic micropressure treatment in people with unilateral Meniere's disease.
      ,
      • Gurkov R.
      • Filipe Mingas L.B.
      • Rader T.
      • Louza J.
      • Olzowy B.
      • Krause E
      Effect of transtympanic low-pressure therapy in patients with unilateral Meniere's disease unresponsive to betahistine: a randomised, placebo-controlled, double-blinded, clinical trial.
      ,
      • Odkvist L.M.
      • Arlinger S.
      • Billermark E.
      • Densert B.
      • Lindholm S.
      • Wallqvist J
      Effects of middle ear pressure changes on clinical symptoms in patients with Meniere's disease – a clinical multicentre placebo-controlled study.
      ,
      • Russo F.Y.
      • Nguyen Y.
      • De Seta D.
      • Bouccara D.
      • Sterkers O.
      • Ferrary E.
      • et al.
      Meniett device in meniere disease: randomized, double-blind, placebo-controlled multicenter trial.
      • Thomsen J.
      • Sass K.
      • Odkvist L.
      • Arlinger S
      Local overpressure treatment reduces vestibular symptoms in patients with Meniere's disease: a clinical, randomized, multicenter, double-blind, placebo-controlled study.
      , Level IIb [
      • Watanabe Y.
      • Shojaku H.
      • Junicho M.
      • Asai M.
      • Fujisaka M.
      • Takakura H.
      • et al.
      Intermittent pressure therapy of intractable Meniere's disease and delayed endolymphatic hydrops using the transtympanic membrane massage device: a preliminary report.
      ].

      6.5 CQ5: is the endolymphatic sac surgery effective for the treatment of Meniere's disease?

      6.5.1 Recommendations

      There is insufficient evidence to show the beneficial effect of endolymphatic sac surgery over placebo surgery in patients with Meniere's disease. However, the surgery may have suppressive effects on the frequency of vertigo attacks and the progression of hearing in patients with intractable Meniere's disease. Because the endolymphatic sac surgery is the only surgical treatment of Meniere's disease with preservation of the inner ear function, it can be considered as a treatment options to prevent the recurrence of vertigo attacks and progression of hearing loss before destructive surgery (Grade of recommendation: C1).
      Reports used for the judgement of the recommendation degree/grade: Level Ia [
      • Pullens B.
      • Giard J.L.
      • Verschuur H.P.
      • van Benthem P.P
      Surgery for Meniere’s disease.
      ,
      • Pullens B.
      • Verschuur H.P.
      • van Benthem P.P
      Surgery for Meniere’s disease.
      • Sood A.J.
      • Lambert P.R.
      • Nguyen S.A.
      • Meyer T.A
      Endolymphatic sac surgery for Meniere's disease: a systematic review and meta-analysis.
      Level Ib [
      • Bretlau P.
      • Thomsen J.
      • Tos M.
      • Johnsen N.J
      Placebo effect in surgery for Meniere's disease: nine-year follow-up.
      ,
      • Welling D.B.
      • Nagaraja H.N
      Endolymphatic mastoid shunt: a reevaluation of efficacy.
      .

      6.6 CQ6: is the selective destruction of the vestibule effective for the treatment of Meniere's disease?

      6.6.1 Recommendations

      Intratympanic gentamicin therapy is an effective treatment to prevent the recurrence of vertigo attacks in patients with intractable Meniere's disease, but it carries a risk of worsening hearing loss (Grade of recommendation: B).
      Prior to intratympanic gentamicin therapy, intratympanic steroid therapy can be considered as a treatment option for Meniere's disease (Grade of recommendation: B).
      While there is not sufficient evidence to prove effectiveness of vestibular nerve section, it is a treatment option that can be considered to prevent the recurrence of vertigo attacks in cases refractory to the other treatments including intratympanic gentamicin therapy (Grade of recommendation: C1).
      Reports used for the judgement of the recommendation grade: Level Ia [
      • Pullens B.
      • van Benthem P.P
      Intratympanic gentamicin for Meniere’s disease or syndrome.
      ,
      • Syed M.I.
      • Ilan O.
      • Nassar J.
      • Rutka J.A
      Intratympanic therapy in Meniere's syndrome or disease: up to date evidence for clinical practice.
      , Level 1b [
      • Stokroos R.
      • Kingma H
      Selective vestibular ablation by intratympanic gentamicin in patients with unilateral active Meniere's disease: a prospective, double-blind, placebo-controlled, randomized clinical trial.
      ,
      • Patel M.
      • Agarwal K.
      • Arshad Q.
      • Hariri M.
      • Rea P.
      • Seemungal B.M.
      • et al.
      Intratympanic methylprednisolone versus gentamicin in patients with unilateral Meniere's disease: a randomised, double-blind, comparative effectiveness trial.
      ,
      • Postema R.J.
      • Kingma C.M.
      • Wit H.P.
      • Albers F.W.
      • Van Der Laan B.F
      Intratympanic gentamicin therapy for control of vertigo in unilateral Menire's disease: a prospective, double-blind, randomized, placebo-controlled trial.
      . Level IV [
      • Hillman T.A.
      • Chen D.A.
      • Arriaga M.A
      Vestibular nerve section versus intratympanic gentamicin for Meniere's disease.
      ], Level V [
      • Goksu N.
      • Yilmaz M.
      • Bayramoglu I.
      • Bayazit Y.A
      Combined retrosigmoid retrolabyrinthine vestibular nerve section: results of our experience over 10 years.
      ,
      • Schmerber S.
      • Dumas G.
      • Morel N.
      • Chahine K.
      • Karkas A
      Vestibular neurectomy vs. chemical labyrinthectomy in the treatment of disabling Meniere's disease: a long-term comparative study.
      .

      7. Conclusions

      To conclude, we have provided diagnostic and therapeutic strategies for Meniere's disease in accordance with the 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 in this review.

      Financial disclosures

      None.

      Declaration of Competing Interest

      None.

      Acknowledgments

      The members of Committee for Clinical Practice Guidelines of Japan Society for Equilibrium Research who edited part of the 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, with exception of the authors, are Prof. Katsumi Doi, Prof. Koichi Omori, Prof. Yatsuji Ito, Dr. Mitsuhiro Aoki, Dr. Susumu Shindo, Dr. Takenori Miyashita, Prof. Tetsuo Ikezono, Prof. Shinichi Usami, Prof. Izumi Koizuka, Prof. Mitsuya Suzuki, Prof. Takeshi Tsutsumi, Prof. Arata Horii, Prof. Tatsuya Yamasoba, and Prof. Hiroshi Yamashita.

      References

        • Yamakawa K
        Uber die pathologische Veranderung bei einem Meniere-Kranken.
        J Otolaryngol Jpn. 1938; 44: 2310-2312
        • Hallpike C.S.
        • Cairns H
        Observations on the pathology of meniere's syndrome: (section of otology).
        Proc R Soc Med. 1938; 31: 1317-1336
        • Monsell E.M.
        • Balkany T.A.
        • Gates G.A.
        • et al.
        Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Meniere’s disease. American Academy of Otolaryngology-Head and Neck Foundation.
        Inc Otolaryngol Head Neck Surg. 1995; 113: 181-185
        • Lopez-Escamez J.A.
        • Carey J.
        • Chung W.H.
        • Goebel J.A.
        • Magnusson M.
        • Mandala M.
        • et al.
        Diagnostic criteria for Meniere's disease.
        J Vestib Res. 2015; 25: 1-7
        • Ikezono T.
        • Itoh A.
        • Takeda N.
        • Nakamura T.
        • Asai M.
        • Ikeda T.
        • et al.
        Documents for standards in diagnostic criteria for dizziness.
        Equilibrium Res. 2017; 76: 233-241
        • Fukui T.
        • Tango T
        Shinryougaidorain sakusei no tejyun version 4.3.
        EBM J. 2003; 4: 284-292
        • Center MINDSG.
        Minds handbook for clinical practice guideline development.
        Igakushoin, Tokyo2014
        • Gibson W.P.
        • Moffat D.A.
        • Ramsden R.T
        Clinical electrocochleography in the diagnosis and management of Meneere's disorder.
        Audiology. 1977; 16: 389-401
        • Klockhoff I.
        • Lindblom U
        Glycerol test in Meniere's disease.
        Acta Otolaryngol. 1966; 224: 449
        • Futaki T.
        • Kitahara M.
        • Morimoto M
        The furosemid test for Meniere's disease.
        Acta Otolaryngol. 1975; 79: 419-424
        • Murofushi T.
        • Matsuzaki M.
        • Takegoshi H
        Glycerol affects vestibular evoked myogenic potentials in Meniere's disease.
        Auris Nasus Larynx. 2001; 28: 205-208
        • Seo T.
        • Shiraishi K.
        • Kobayashi T.
        • Mutsukazu K.
        • Fujita T.
        • Saito K.
        • et al.
        Revision of a furosemide-loading vestibular-evoked myogenic potential protocol for detecting endolymphatic hydrops.
        Acta Otolaryngol. 2017; 137: 1244-1248
        • Shojaku H.
        • Takemori S.
        • Kobayashi K.
        • Watanabe Y
        Clinical usefulness of glycerol vestibular-evoked myogenic potentials: preliminary report.
        Acta Otolaryngol Suppl. 2001; 545: 65-68
        • Nakashima T.
        • Naganawa S.
        • Sugiura M.
        • Teranishi M.
        • Sone M.
        • Hayashi H.
        • et al.
        Visualization of endolymphatic hydrops in patients with Meniere's disease.
        Laryngoscope. 2007; 117: 415-420
        • Pyykko I.
        • Nakashima T.
        • Yoshida T.
        • Zou J.
        • Naganawa S
        Meniere’s disease: a reappraisal supported by a variable latency of symptoms and the MRI visualisation of endolymphatic hydrops.
        BMJ Open. 2013; 3: e001555https://doi.org/10.1136/bmjopen-2012-001555
        • Yoshida T.
        • Sugimoto S.
        • Teranishi M.
        • Otake H.
        • Yamazaki M.
        • Naganawa S.
        • et al.
        Imaging of the endolymphatic space in patients with Meniere's disease.
        Auris Nasus Larynx. 2018; 45: 33-38
        • Okada M.
        • Hato N.
        • Nishio S.Y.
        • Kitoh R.
        • Ogawa K.
        • Kanzaki S.
        • et al.
        The effect of initial treatment on hearing prognosis in idiopathic sudden sensorineural hearing loss: a nationwide survey in Japan.
        Acta Otolaryngol. 2017; 137: S30-Ss3
        • Wei B.P.
        • Mubiru S.
        • O’Leary S
        Steroids for idiopathic sudden sensorineural hearing loss.
        Cochrane Database Syst Rev. 2006; Cd003998https://doi.org/10.1002/14651858.CD003998.pub2
        • Sajjadi H.
        • Paparella M.M
        Meniere's disease.
        Lancet. 2008; 372: 406-414
        • Takahashi M.
        • Odagiri K.
        • Sato R.
        • Wada R.
        • Onuki J
        Personal factors involved in onset or progression of Meniere's disease and low-tone sensorineural hearing loss.
        ORL J Otorhinolaryngol Relat Spec. 2005; 67: 300-304
        • Onuki J.
        • Takahashi M.
        • Odagiri K.
        • Wada R.
        • Sato R
        Comparative study of the daily lifestyle of patients with Meniere's disease and controls.
        Ann Otol Rhinol Laryngol. 2005; 114: 927-933
        • Shojaku H.
        • Watanabe Y.
        • Mineta H.
        • Aoki M.
        • Tsubota M.
        • Watanabe K.
        • et al.
        Long-term effects of the Meniett device in Japanese patients with Meniere's disease and delayed endolymphatic hydrops reported by the Middle Ear Pressure Treatment Research Group of Japan.
        Acta Otolaryngol. 2011; 131: 277-283
        • Watanabe Y.
        • Shojaku H.
        • Junicho M.
        • Asai M.
        • Fujisaka M.
        • Takakura H.
        • et al.
        Intermittent pressure therapy of intractable Meniere's disease and delayed endolymphatic hydrops using the transtympanic membrane massage device: a preliminary report.
        Acta Otolaryngol. 2011; 131: 1178-1186
        • Kitahara T
        Evidence of surgical treatments for intractable Meniere's disease.
        Auris Nasus Larynx. 2018; 45: 393-398
        • Hsieh L.C.
        • Lin H.C.
        • Tsai H.T.
        • Ko Y.C.
        • Shu M.T.
        • Lin L.H
        High-dose intratympanic gentamicin instillations for treatment of Meniere's disease: long-term results.
        Acta Otolaryngol. 2009; 129: 1420-1424
        • Stokroos R.
        • Kingma H
        Selective vestibular ablation by intratympanic gentamicin in patients with unilateral active Meniere's disease: a prospective, double-blind, placebo-controlled, randomized clinical trial.
        Acta Otolaryngol. 2004; 124: 172-175
        • James A.L.
        • Burton M.J
        Betahistine for Meniere’s disease or syndrome.
        Cochrane Database Syst Rev. 2001; CD001873https://doi.org/10.1002/14651858.CD001873
        • Nauta J.J
        Meta-analysis of clinical studies with betahistine in Meniere's disease and vestibular vertigo.
        Eur Arch Otorhinolaryngol. 2014; 271: 887-897
        • Adrion C.
        • Fischer C.S.
        • Wagner J.
        • Gurkov R.
        • Mansmann U.
        • Strupp M
        Efficacy and safety of betahistine treatment in patients with Meniere's disease: primary results of a long term, multicentre, double blind, randomised, placebo controlled, dose defining trial (BEMED trial).
        BMJ. 2016; 352: h6816
        • Albera R.
        • Ciuffolotti R.
        • Di Cicco M.
        • De Benedittis G.
        • Grazioli I.
        • Melzi G.
        • et al.
        Double-blind, randomized, multicenter study comparing the effect of betahistine and flunarizine on the dizziness handicap in patients with recurrent vestibular vertigo.
        Acta Otolaryngol. 2003; 123: 588-593
        • Mira E.
        • Guidetti G.
        • Ghilardi L.
        • Fattori B.
        • Malannino N.
        • Maiolino L.
        • et al.
        Betahistine dihydrochloride in the treatment of peripheral vestibular vertigo.
        Eur Arch Otorhinolaryngol. 2003; 260: 73-77
        • Strupp M.
        • Hupert D.
        • Frenzel C.
        • Wagner J.
        • Hahn A.
        • Jahn K.
        • et al.
        Long-term prophylactic treatment of attacks of vertigo in Meniere's disease–comparison of a high with a low dosage of betahistine in an open trial.
        Acta Otolaryngol. 2008; 128: 520-524
        • Futaki T.
        • Kitahara M.
        • Morimoto M
        Evaluation of the effect of diphenidol on peripheral dizziness by a double-blind study.
        Pract Otol. 1972; 65: 85-105
        • Crowson M.G.
        • Patki A.
        • Tucci D.L
        A systematic review of diuretics in the medical management of Meniere's disease.
        Otolaryngol Head Neck Surg. 2016; 154: 824-834
        • James A.L.
        • Thorp M.A
        Meniere’s disease.
        BMJ Clin Evid. 2007; (2007, pii: 0505)
        • Thirlwall A.S.
        • Kundu S
        Diuretics for Meniere’s disease or syndrome.
        Cochrane Database Syst Rev. 2006; CD003599https://doi.org/10.1177/0194599816630733
        • Kitahara M.
        • Watanabe I.
        • Hinoki M.
        • Mizukoshi K.
        • Matsunaga T.
        • Matsunaga T.
        • et al.
        Clinical study of isosorbide on Mniere's disease: inter-group comparative study with betahistine mesylate by multi-centered double-blind trial.
        Otol Fukuoka. 1986; 32: 44-92
        • Kitahara M.
        • Watanabe I.
        • Hinoki M.
        • Mizukoshi K.
        • Matsunaga T.
        • Matstunaga T.
        • et al.
        Dose-response test for isosorbide on Mniere's disease.
        Jpn J Pharmacol Therapeutics. 1987; 15: 2975-2990
        • Suzuki M.
        • Kitahara M.
        • Kodama A.
        • Uchida K.
        • Izukura H.
        • Kitanishi T.
        • et al.
        Isosorbide treatment of Ménière’s disease; A clinical evaluation of the administration period.
        Equilibrium Res. 1993; : 116-120
        • Derebery M.J.
        • Fisher L.M.
        • Iqbal Z
        Randomized double-blinded, placebo-controlled clinical trial of famciclovir for reduction of Meniere's disease symptoms.
        Otolaryngol Head Neck Surg. 2004; 131: 877-884
        • Guyot J.P.
        • Maire R.
        • Delaspre O
        Intratympanic application of an antiviral agent for the treatment of Meniere's disease.
        ORL J Otorhinolaryngol Relat Spec. 2008; 70 (discussion 6-7): 21-26
        • Gacek R.R
        Recovery of Hearing in Meniere's disease after antiviral treatment.
        Am J Otolaryngol. 2015; 36: 315-323
        • Ahsan S.F.
        • Standring R.
        • Wang Y
        Systematic review and meta-analysis of Meniett therapy for Meniere's disease.
        Laryngoscope. 2015; 125: 203-208
        • van Sonsbeek S.
        • Pullens
        • van Benthem PP B.
        Positive pressure therapy for Meniere’s disease or syndrome.
        Cochrane Database Syst Rev. 2015; CD008419.pub2https://doi.org/10.1002/14651858
        • Densert B.
        • Densert O.
        • Arlinger S.
        • Sass K.
        • Odkvist L
        Immediate effects of middle ear pressure changes on the electrocochleographic recordings in patients with Meniere's disease: a clinical placebo-controlled study.
        Am J Otol. 1997; 18: 726-733
        • Gates G.A.
        • Green Jr., J.D.
        • Tucci D.L.
        • Telian S.A
        The effects of transtympanic micropressure treatment in people with unilateral Meniere's disease.
        Arch Otolaryngol Head Neck Surg. 2004; 130: 718-725
        • Gurkov R.
        • Filipe Mingas L.B.
        • Rader T.
        • Louza J.
        • Olzowy B.
        • Krause E
        Effect of transtympanic low-pressure therapy in patients with unilateral Meniere's disease unresponsive to betahistine: a randomised, placebo-controlled, double-blinded, clinical trial.
        J Laryngol Otol. 2012; 126: 356-362
        • Odkvist L.M.
        • Arlinger S.
        • Billermark E.
        • Densert B.
        • Lindholm S.
        • Wallqvist J
        Effects of middle ear pressure changes on clinical symptoms in patients with Meniere's disease – a clinical multicentre placebo-controlled study.
        Acta Otolaryngol Suppl. 2000; 543: 99-101
        • Russo F.Y.
        • Nguyen Y.
        • De Seta D.
        • Bouccara D.
        • Sterkers O.
        • Ferrary E.
        • et al.
        Meniett device in meniere disease: randomized, double-blind, placebo-controlled multicenter trial.
        Laryngoscope. 2017; 127: 470-475
        • Thomsen J.
        • Sass K.
        • Odkvist L.
        • Arlinger S
        Local overpressure treatment reduces vestibular symptoms in patients with Meniere's disease: a clinical, randomized, multicenter, double-blind, placebo-controlled study.
        Otol Neurotol. 2005; 26: 68-73
        • Pullens B.
        • Giard J.L.
        • Verschuur H.P.
        • van Benthem P.P
        Surgery for Meniere’s disease.
        Cochrane Database Syst Rev. 2010; CD005395.pub2https://doi.org/10.1002/14651858
        • Pullens B.
        • Verschuur H.P.
        • van Benthem P.P
        Surgery for Meniere’s disease.
        Cochrane Database Syst Rev. 2013; CD005395.pub3https://doi.org/10.1002/14651858
        • Sood A.J.
        • Lambert P.R.
        • Nguyen S.A.
        • Meyer T.A
        Endolymphatic sac surgery for Meniere's disease: a systematic review and meta-analysis.
        Otol Neurotol. 2014; 35: 1033-1045
        • Bretlau P.
        • Thomsen J.
        • Tos M.
        • Johnsen N.J
        Placebo effect in surgery for Meniere's disease: nine-year follow-up.
        Am J Otol. 1989; 10: 259-261
        • Welling D.B.
        • Nagaraja H.N
        Endolymphatic mastoid shunt: a reevaluation of efficacy.
        Otolaryngol Head Neck Surg. 2000; 122: 340-345
        • Pullens B.
        • van Benthem P.P
        Intratympanic gentamicin for Meniere’s disease or syndrome.
        Cochrane Database Syst Rev. 2011; CD008234.pub2https://doi.org/10.1002/14651858
        • Syed M.I.
        • Ilan O.
        • Nassar J.
        • Rutka J.A
        Intratympanic therapy in Meniere's syndrome or disease: up to date evidence for clinical practice.
        Clin Otolaryngol. 2015; 40: 682-690
        • Patel M.
        • Agarwal K.
        • Arshad Q.
        • Hariri M.
        • Rea P.
        • Seemungal B.M.
        • et al.
        Intratympanic methylprednisolone versus gentamicin in patients with unilateral Meniere's disease: a randomised, double-blind, comparative effectiveness trial.
        Lancet. 2016; 388: 2753-2762
        • Postema R.J.
        • Kingma C.M.
        • Wit H.P.
        • Albers F.W.
        • Van Der Laan B.F
        Intratympanic gentamicin therapy for control of vertigo in unilateral Menire's disease: a prospective, double-blind, randomized, placebo-controlled trial.
        Acta Otolaryngol. 2008; 128: 876-880
        • Hillman T.A.
        • Chen D.A.
        • Arriaga M.A
        Vestibular nerve section versus intratympanic gentamicin for Meniere's disease.
        Laryngoscope. 2004; 114: 216-222
        • Goksu N.
        • Yilmaz M.
        • Bayramoglu I.
        • Bayazit Y.A
        Combined retrosigmoid retrolabyrinthine vestibular nerve section: results of our experience over 10 years.
        Otol Neurotol. 2005; 26: 481-483
        • Schmerber S.
        • Dumas G.
        • Morel N.
        • Chahine K.
        • Karkas A
        Vestibular neurectomy vs. chemical labyrinthectomy in the treatment of disabling Meniere's disease: a long-term comparative study.
        Auris Nasus Larynx. 2009; 36: 400-405