Morbidity in Menieres disease : Aspects on quality of life and triggering factors

Sammanfattning: Menieres disease is an inner ear disorder of unclear origin, characterized by severe attacks of simultaneously appearing fluctuant hearing loss, vertigo, tinnitus and a feeling of aural fullness. The disease has a wellknown natural course. In the early stage symptoms occur episodically, followed by complete remission, but during the course of the disease the hearing impairment progresses and becomes permanent, While the vertigo becomes less prominent with time. The sudden and unexpected attacks can cause a dramatic influence on the patient's quality of life, particularly as it is combined with increasing hearing loss and tinnitus. It is a well known clinical issue that stress might trigger the attacks, but so far the only correlation found has been a same day association between stress and attacks. AIMS OF THE PRESENT INVESTIGATION 1.To assess which of three different surgical treatments of vertigo (Endolymphatic Sac Surgery, ELS, intratympanical gentamicin injections or vestibular neurectomy) was most beneficial to patients with Menieres disease. 2. To evaluate health-related quality of life issues from a general and disease specific perspective. 3 To find if stress can trigger attacks of Menieres disease 4. To propose a policy for treatment of patients with Menieres disease MATERIAL AND METHODS 1. 40 surgically treated patients with Menieres disease were followed up with extended clinical tests, including vestibular and audiological tests, computerized postural tests, functional balance tests and a questionnaire. 2. 112 Meniere patients, both surgically treated and untreated, answered a battery of disease specific and generic quality of life questionnaires. The sense of coherence, which measures coping ability, was also evaluated. 3. In a case- crossover study, 46 Meniere patients answered questionnaires concerning the frequency of stress both in the period before an attack of Menieres disease and in a period without attacks. RESULTS AND CONCLUSIONS 1. The outcomes with regard to vertigo were similar regardless of treatment modality. About 80 % of the patients in each group reported a total or substantial improvement of vestibular symptoms, but the gentamicin treated patients had more adverse effects on hearing and vestibular neurectomy resulted in some surgical complications. 2. The patients rate their quality of life as being significantly poorer than reference groups of healthy subjects, in both the physical and the psychosocial dimensions. Vertigo impairs the physical dimension of quality of life, while tinnitus and hearing loss have influence on the psychosocial dimension. Strong sense of coherence seems to be an important predictor of the patient's evaluation of disease-specific as well as general quality of life, but the impact of the sense of coherence is stronger on psychosocial than physical aspects. 3. Being subjected to emotional stress increases the risk for an attack of Menieres disease to occur one to three hours later. Mental stress has less impact on the risk for having a Meniere-attack and physical stress has not been found to trigger attacks of Menieres disease. 4. When medical treatment has failed, ELS may be a useful first choice of treatment modality in patients with serviceable hearing. Recent treatment regime with low dose gentamicin can be used if ELS has failed or if for some reason surgery in general anesthesia not is advisable. Vestibular neurectomy should be saved for special cases and performed in a limited number of patients. Considering the role of stress as a trigger of attacks it might be fruitful to test whether different kinds of stress management techniques could be taught to patients with the effect of reducing the number of attacks.