Clinical Practice Guideline
for
MENIERE’S DISEASE
Developed for the
Aerospace
Medical Association
by their
constituent organization
American
Society of Aerospace Medicine Specialists
Overview: Meniere's Disease (Morbus Meniere) is also known as Idiopathic Endolymphatic
Hydrops. It is
a disorder of the inner ear and is sometimes described as "glaucoma of the
ear". One of the most common causes
of dizziness originating from the inner ear, Meniere's is classically
characterized by a symptom tetrad of: (a) fluctuating or episodic rotational
vertigo, lasting more than five minutes per episode and not relieved by absence
of movement; (b) fluctuating hearing loss; (c) fluctuating tinnitus; (d) and
fluctuating sensation of fullness in the affected ear. However, these symptoms will rarely be all
encountered simultaneously; instead, most patients will complain of one symptom
such as hearing loss or dizziness. At
this time there is no single effective cure for Meniere's Disease.
Aeromedical Concerns: A search of the Defense Technical Information Center (DTIC)
reference base revealed three documents concerning Meniere's disease and
aeromedical ramifications. In one study
undertaken by the Air Force at Brooks AFB, six rhesus monkeys underwent an endolymphatic shunt procedure with pre- and post- testing
of audiological and vestibular function. The results showed no impairment of audiological function; however, two of the animals showed a
temporary (2-3 months) impairment of vestibular function. A report by Mitchell, et al. in 1967 examined
the medical records of 84 patients referred to USAF Aeromedical Consultation
Service because of vertigo or diseases capable of producing vertigo. The second most frequent category, making up
less than one-third of the evaluees, had Meniere's
disease. Finally, a NAMI report from
1965 looked at four patients who received streptomycin sulfate in the treatment
of Meniere's in terms of a lack of return of their symptoms and the effect of
the drug on hearing, the semicircular canals, otolith organs, ataxia, and the Coriolis illusion.
The authors suggest that the disease may "represent a disturbance
to the secretory cells of the christa."
In one study of 574
patients with Meniere’s disease, over 300 had vertiginous attacks lasting 30
minutes to 12 hours. Over half of the
cases had between one and four attacks per week and 1-10 per day, and
approximately 94% had some degree of hearing loss. Medical therapy includes use of benzodiazepines,
anticholinergics, and antihistamines. Some experts advocate restriction of sodium
intake and the use of diuretics. Surgery
is used in some patients with varied results.
Because of the unpredictable and
sudden nature of the attacks and their potentially incapacitating effects, a
military flying waiver is granted only in exceptional and documented stable
circumstances. Additionally up to 30% of
patients may present with bilateral disease.
Patients may also develop Tumarkin's crises
(a.k.a. "drop attacks") as the disease progresses.
In the Federal Aviation
Administration’s Aviation Medicine office the medical certification of Meniere’s Disease depends on the stability of the
condition. If the airman is in remission
for six months or more, they may be granted a medical certificate. Certification has been granted with the use
of diuretic therapy. The airman is cautioned
that if the condition returns, they must cease flying and notify the medical
certification division.
Medical Work-up: Physical examination should include evaluation for nystagmus and balance.
An audiometric examination (hearing test) is required, including air and
bone conduction thresholds as well as speech
discrimination testing. An electronystagmograph (ENG), Auditory Brain Stem response
(ABR), and CT or MRI of the head (to rule out tumors such as acoustic neuroma) should be performed. Further expert evaluation is strongly suggested which should include eletrocochleography
(ECOG), eye tracking and rotary chair tests.
Aeromedical Disposition (military and civilian): It is essential to obtain a thorough history of frequency,
duration, severity and the character of vertiginous attacks, as well as hearing
loss and change over time, if any, and whether symptoms of tinnitus or fullness
in either or both ears have been present.
Past history of syphilis, mumps or other serious infections,
inflammation of the eye, autoimmune disorder or allergy, and ear surgery are of
significance.
Waiver Experience (military): According to a military database, 58 individuals have been
thoroughly evaluated for Meniere's Disease through
December 1997. Of those, 13 (22%) have
been granted flying waivers.
Waiver Experience (civilian): During calendar year 2000 there were 34 First, 25 Second and
88 Third class airmen granted medical certification with this condition
by the FAA.
References:
Allen, John M, Ph.D.,
personal conversation, Aeromedical Consultation Service,
Casano PJ. Meniere's Disease, Public Service Brochure of the
American Academy of Otolaryngology - Head and Neck Surgery, Alexandria, VA,
1993.
Graybiel A, et al. Practical and Theoretical Implications Based on
Long-Term Follow-Up of Meniere's Patients Treated With Streptomycin Sulfate,
Unclassified NAVMED Report, DTIC Accession No.
AD-625-865, Naval Aerospace Medical Institute,
Mitchell WL,
et al. Dizziness and Vertigo in Aviators, Unclassified Report, DTIC Accession
No. AD-660559,
Rayman, RB, Clinical Aviation Medicine, 3rd edition, Castle
Connolly Graduate Medical Publishing, LLC, 2000, pp. 130, 133-34.
Wolfe JW. Endolymphatic
Shunt Effects, In-house Work Unit Report, DTIC Accession No. DF-325930,
November 27, 2001