Meniere's Disease
Meniere's Disease
Meniere's Disease
MENIERE’S DISEASE
Presented by:
Francisco, Michaela
Golena, Aiden
3Y2 – 1B (Group 1)
Submitted to:
This disease can develop at any age, but it is more likely to happen to adults between 40
and 60 years of age. It is prevalent in several million people across the world, the
worldwide incidence is approximately 12 out of every 1,000 people.
Meniere’s disease develops in two stages: early and late stage. In its early stages, there is
sudden and unpredictable episodes of vertigo. There will be some loss of hearing, which
typically returns to normal once vertigo subsides and the ear may feel uncomfortable and
blocked. Tinnitus is also common in early stage. In the late stage, vertigo episodes become less
frequent and, in some cases, never come back. However, balance, hearing, and vision problems
can continue. A person might also experience drop attacks which involve spontaneously losing
posture or suddenly falling down while remaining conscious.
For the diagnosis, a doctor will carry out an interview and physical examination, ask
about the person’s medical and family history, and consider the signs and symptoms. A diagnosis
of Meniere's disease requires: two episodes of vertigo, each lasting 20 minutes or longer but not
longer than 12 hours, and a hearing loss verified by a hearing test. Blood tests and imaging scans
such as an MRI are used to rule out disorders that can cause problems similar to those of
Meniere's disease, such as a tumor in the brain or multiple sclerosis. If there are no other causes
of tinnitus, vertigo, and sensorineural hearing loss, then it is diagnosed as Meniere’s disease.
No cure exists for this disease, but a number of treatments can help reduce the severity
and frequency of vertigo episodes. The first-line treatment commonly includes dietary
modification such as restriction of salt, caffeine, alcohol intake and several drugs. A doctor may
prescribe medications to take during a vertigo episode to lessen the severity of an attack. This
may include motion sickness medications, such as meclizine or Diazepam (Valium), to reduce
the spinning sensation, and anti-nausea medications, such as Promethazine, to control nausea and
vomiting during an episode of vertigo. When first-line treatment does not offer a satisfactory
symptom control, especially for vertigo, more invasive treatments classified into: conservative
and ablative, are recommended. Intratympanic (IT) administration of corticosteroids or
gentamicin is commonly used. Corticosteroids have been shown to have a lower risk of hearing
damage but less efficacy in vertigo attack control compared to gentamicin. While Gentamicin
has been proven as an effective treatment for vertigo in MD with a potential risk of hearing loss
If treatment and management have not been effective, or if symptoms are severe surgical
procedure might be an option. Procedures include: (1) Endolymphatic sac decompression, a
treatment that is performed to maintain the hydrostatic pressure and endolymph homeostasis in
the inner ear, (2) Labyrinthectomy, a removal of portion of the inner ear to treat vertigo if one
has little hearing in the affected ear, and (3) Vestibular nerve section, the process of cutting
the vestibular part of the cochleovestibular cranial nerve to eliminate recurrent attacks of vertigo.
General Objectives:
This case study aims to broaden the students’ knowledge regarding Meniere’s Disease, and
it is designed to develop and enhance the skills and attitude in the application of different
nursing processes and management of the patient with Meniere’s Disease.
Specific Objectives:
A. Patient’s Profile
In the previous 2 years, the patient reported recurrent episodes of rotational vertigo (about
1/month) lasting from a few minutes to 1-2 hours, often with a right ear fluctuating hearing loss.
Migraine and vertigo never occurred together.
This patient, a 54-year-old female, was suffering from vertigo –whirling sensation, tinnitus,
and nausea and vomiting according to her husband. Few hours after, above symptoms are now
associated with unilateral hearing loss (right side), diaphoresis and sometimes rolling of the
eyeballs after being examined by the doctor and diagnosed with Meniere’s Disease.
D. Family History
The patient’s family history has hypertension and DM in her mother side but there are no
other medical illnesses indicated. No known history of HPN, DM, Cancer from the father side.
Her family history was positive for migraine (mother and one of three sisters).
E. Social and Personal History
The patient never drinks alcohol but does smoke 1 stick in a day if she feels stress. The
patient reported the first attack of migraine at the age of 20 years, which more typically occurred
before menstruation, at a frequency of 1-2/month.
GENERAL SURVEY
As a final result, her audiometric threshold showed a right-sided low frequency sensorineural hearing
loss.
The outer ear includes the portion of the ear that we see—the pinna/auricle and the ear canal.
Pinna
The pinna or auricle is a concave cartilaginous structure, which collects and directs sound waves
traveling in air into the ear canal or external auditory meatus.
Ear Canal
The ear canal maintains the proper conditions of temperature and humidity necessary to preserve
the elasticity of the tympanic membrane. Glands, which produce cerumen (earwax) and tiny
hairs in the ear canal, provide added protection against insects and foreign particles from
damaging the tympanic membrane.
B. MIDDLE EAR
The middle ear is composed of the tympanic membrane and the cavity, which houses the
ossicular chain.
Tympanic Membrane
The eardrum is very sensitive to sound waves and vibrates back and forth as the sound waves
strike it. The eardrum transmits the airborne vibrations from the outer to the middle ear and also
assists in the protection of the delicate structures of the middle ear cavity and inner ear.
The middle ear cavity is located in the mastoid process of the temporal bone. The middle ear
cavity extends from the tympanic membrane to the inner ear. It is approximately two cubic
centimeters in volume and is lined with mucous membrane. The middle ear cavity is actually an
extension of the nasopharynx via the eustachian tube.
Eustachian Tube
The eustachian tube acts as an air pressure equalizer and ventilates the middle ear. Normally the
tube is closed but opens while chewing or swallowing.
Ossicular Chain
The middle ear is connected and transmits sound to the inner ear via the ossicular chain. The
ossicular chain amplifies a signal approximately 25 decibels as it transfers signals from the
tympanic membrane to the inner ear.
Cochlea
The hearing part of the inner ear is the cochlea. The cochlea is spiral-shaped, similar to the shape
of a snail. The cochlea is composed of three fluid-filled chambers that extend the length of the
structure. The two outer chambers are filled with a fluid called perilymph.
process of hearing begins with the occurrence of a sound. Sound is initiated when an event
moves and causes a motion or vibration in air. When this air movement stimulates the ear, a
sound is heard.
In the human ear, a sound wave is transmitted through four separate mediums along the auditory
system before a sound is perceived: in the outer ear—air, in the middle ear— mechanical, in the
inner ear liquid and to the brain—neural.
Sound Transmission through the Outer Ear
Air transmitted sound waves are directed toward the delicate hearing mechanisms with the help
of the outer ear, first by the pinna, which gently funnels sound waves into the ear canal, then by
the ear canal.
When air movement strikes the tympanic membrane, the tympanic membrane or eardrum moves.
At this point, the energy generated through a sound wave is transferred from a medium of air to
that which is solid in the middle ear. The ossicular chain of the middle ear connects to the
eardrum via the malleus, so that any motion of the eardrum sets the three little bones of the
ossicular chain into motion.
The ossicular chain transfers energy from a solid medium to the fluid medium of the inner ear
via the stapes. The stapes is attached to the oval window. Movement of the oval window creates
motion in the cochlear fluid and along the Basilar membrane. Motion along the basilar
membrane excites frequency specific areas of the Organ of Corti, which in turn stimulates a
series of nerve endings.
With the initiation of the nerve impulses, another change in medium occurs: from fluid to neural.
Nerve impulses are relayed through the VIII C.N., through various nuclei along the auditory
pathway to areas to the brain. It is the brain that interprets the neural impulses and creates a
thought, picture, or other recognized symbol.
IV. PATHOPHYSIOLOGY
V. GORDON’S FUNCTIONAL PATTERN
Health Management and Health Perception
According to her husband, she was During hospitalization, the patient was a
experiencing vertigo, which included a compliant to the medication based on
whirling sensation, tinnitus, nausea, and physician’s order.
vomiting. After being examined by a doctor
and diagnosed with Meniere’s Disease, the
above symptoms are now associated with
unilateral hearing loss (right side),
diaphoresis, and sometimes rolling of the
eyeballs.
According to the client, she usually ate During hospitalization, the client confirmed
healthy meals such as rice, vegetables, and that she has had less vertiginous attacks,
meat for breakfast, lunch, and dinner. But which has resulted in less nausea and
she's experiencing vomiting when vertigo vomiting.
attacks.
Elimination Pattern
Activity-Exercise Pattern
According to the client, her exercise routine During hospitalization, she maintains proper
started with doing household chores around hygiene, eat meals and taking medication on
the house before she spent the majority of her time and cooperative when she asked the
time relaxing due to vertigo. medical staff regarding information.
Sleep-Rest Pattern
Cognitive-Perceptional Pattern
The client is oriented to people, time and The patient reports immediately improvement
place. Also, she experiences whirling whirling sensation and tinnitus.
sensation and tinnitus.
Self-Perception/Self-Concept Pattern
She feels uncomfortable when vertigo attacks The patient only socialize with medical staff
during or after. and calmness.
Role-Relationship Pattern
The client’s permanent address is in The client is monitored and feels support from
Muntinlupa City. She stays together with her her husband as well her family.
husband.
Coping/Stress Tolerance
The client experience difficulty with coping The client’s family and her husband are there
stress due to her symptoms. to support and cope up with stress.
Value/Belief Pattern
The client is a Roman Catholic, but his family The patient hoping for fast recovery after she
and his wife rarely goes to church every knows the findings.
Sunday but have faith in God.
Day 1:
Patient M.N.O was adimitted at Jose Reyes Memorial Medical Center at 10:00 am with diagnosis
of Meniere sease. Patient was suffering from vertigo -whirlin nsation, tinnitus, and nausea and
vomiting vital signs an 20/70 mmHg, Respiratory rate 18 cpm, Oxyge turation 99%, Pulse rate
76 bpm, Temperature 36.7. TI mission order is Diet: Low salt diet, Vital signs every urs,
diagnostic CBC with platelet count, Na, K, Urinalysi Toric simulation test. And monitor risk for
injury an edication are given 40 mg of Prednisone 1 tablet/day for ys, Promethazine (Phenergan)
12.5mg 1 tab in th orning before meals and at bedtime PO BID meclizin ntivert) 50 mg 1 tab OD
PO one-hour before trav drochlorothiazide (Dyzide) 25mg 1 tab OD PO.
Day 2:
Patient is currently checked by the doctor at exactly 9:00AM in the morning and nurse check the
vital signs of the patient. Vital signs are 130/90 mmHg, respiratory rate at 19 cpm, Oxygen
Stauration at 98%, Pulse rate at 70bpm, Temperature is at 36.9. Patient is having her breakfast
after the vital signs was taken and her diet was low salt diet. Vital signs every 4 hours.
Day 3:
Patient's vertigo was attacking and she is very dizzy. Currently assisting the patient when her
vertigo attacks. Medicines that are taken by the patient are Prednisnone 40mg, Promethazine
12.5 ng in the morning before meals and at bedtime, and Meclizine 50mg. Patient's vital signs
were taken every 4 hours and she is taking anti-vertigo drugs.
VII. PHYSICAL ASSESSMENT
Temp - 36⁰C
Pulse - 76 bpm
02 sat – 99%
RR – 18 cpm
BP – 110/70 mmhg
depigmentation.
EARS Tympanic membranes are shiny and gray. Auricles are aligned with
the outer canthus of the eye. Auricles are firm and non-tender.
(+) Tinnitus
2. CT Scan
They are obtained to detect possible dehiscences of the semicircular canals, congenital
abnormalities, widened cochlear and vestibular aqueducts, and subarachnoid hemorrhage.
3. Electronystagmography
Electronystagmography (ENG or electrooculography) is used to evaluate people with vertigo
(a false sense of spinning or motion that can cause dizziness) and certain other disorders that
affect hearing and vision. Electrodes are placed at locations above and below the eye to
record electrical activity.
URINALYSIS
(bacteria)
Caloric Stimulation Rapid, side-to-side Slow side to side eye Abnormal results
Test eye movements in movements in both means there was a
both eye. eyes. damage to the nerve of
the inner ear due to
fluid imbalances.
Generic Name: Structurally For meniere’s Contraindicated in No side effects Monitor BP during
Triamterene related to folic disease patients seen on periods of dosage
acid. Like hypertensive to the patients. adjustment.
Brand Name: spironolactone Rationale: drug or to Hypotensive
Dyrenium has weak To reduce fluid sulfonamides: in GI: reactions, although
diuretic action build -up in the those with Diarrhea, rare, have been
Classification: and a ear. It cause existing nausea, reported. Take care
Fluid and potassium- you to make hyperkalemia, vomiting, with ambulation,
water balance sparing effect. more urine, anuria, acute and and other GI particularly for older
agent; Potassiu Promotes which helps chronic renal disturbances. adults.
m-sparing excretion of your body get insuffiency or
diuretics sodium, rid of extra salt significant renal CNS: Weigh patient under
chloride (to and water. impairment or Dizziness, standard conditions,
Dose: 25 mg lesser extent), severe hepatic headache, dry prior to drug
and carbonate. disease, and in mouth, anaphyl initiation and daily
Route: P.O Unlike those at risk for axis, weakness, during therapy.
spironolactone, metabolic or muscle
Frequency: blocks respiratory cramps. Diuretic response
OD potassium acidosis. usually occurs on
excretion by Skin: first day of therapy;
direct action on Pruritus, rash, maximum effect may
distal renal photosensitivit not occur for several
tubule rather y. days.
than by
inhibiting CV: Monitor and report
aldosterone. Hypotension oliguria and unusual
(large doses). changes in I&O ratio.
Consult physician
Metabolic: regarding allowable
Hyperkalemia a fluid intake.
nd other
electrolyte
imbalances
Generic Name: Not clearly Good non- Contraindicated in No side effects Determine if patient
Prednisone defined. invasive patients seen on is sensitive to other
Decreases antivertigo hypertensive to the patients. corticosteroids.
Classification: inflammation management drug or its
Corticosteroid mainly by regimen to components; in CNS: Establish baseline
stabilizing control those with Headache and and continuing data
Dose: leukocyte refractory systemic fungal insomnia regarding BP, I&O
40mg lysosomal vertigo in infections ration and pattern,
membrane; Meniere’s (Immediate GI: weight, fasting blood
Route: P.O suppresses disease release only) Nausea and glucose level and
immune cerebral malaria, Vomiting sleep pattern as
Frequency: response; Rationale: or active ocular reference for
OD for 7 days stimulates Helps to herpes simplex; GU: planning
bone marrow; control vertigo. and in those Menstrual individualized
and influences To lessen the receiving Irregularities pharmacotherapeuti
protein, fat, and hearing loss. immunosuppressi c patient care.
carbohydrate ve doses together CV:
metabolism. with live virus Hypertension Check and record BP
vaccines. during dose
stabilization period
at least 2 times daily
report an ascending
pattern.
- To prevent losing
- Position the patient balance and
in a comfortable promote comfort
position. from episodes of
vertigo.
Dependent: Dependent:
- Administered - To control
12.5mg of nausea and
Promethazine vomiting.
(Phenergan) 1 tab
PO BID, in the
morning before
meals and at
bedtime
- Nearby
- Transferred location
patient to a provides more
room near the constant
nurses’ station. observation
and quick
response to
call needs
- Patients,
especially
- Guaranteed older adults,
appropriate roo has reduced
m lighting, visual
especially capacity.
during the Lighting an
night. unfamiliar
environment
helps increase
visibility and
prevent
patient from
vertigo attack
because of the
dark
- These can
trigger the
- Educated attack and
patient about may worsen
foods to avoid patient’s
like salty and condition that
those with lots can predispose
of MSG, her to risk for
caffeinated injury
drinks,
alcoholic
beverages, use
of tobacco, and
stress
management - Nonskid
footwear
- Encouraged the provides sure
patient to use footing for the
shoes or patient with
slippers with diminished
nonskid soles foot and toe
when walking. lift when
walking
- Exercises
eases vertigo
- Educated and will help
patient about with gait
exercises to disturbances
improve
balance:
*Stand with
your feet
together, arms
at your sides,
and hold this
position for 30
seconds.
*Walk 5 steps
and then stop
abruptly. Wait
for any dizzy
feeling to go
away and do it
again. Repeat
until you have
walked about
15 meters.
Walking
exercises for
vertigo may
improve your
balance and
your symptoms
of vertigo. You
may want to
have someone
next to you
while you do
these exercises
in case you lose
your balance. - To help
patient when
- Educated falling and
family or prevent
significant further
others to be possible
with the patient injuries like
all the times head injuries
Medication
Reminded the patient to take the prescribed medicine, have a written reminder of the correct
medication, time to take, and the drug’s right frequency to establish medication compliance
assurance.
- Prednisone 40mg 1 tablet/day for 7 days
- Promethazine (Phenergan) 12.5mg 1 tab in the morning before meals and at bedtime PO
BID
- Meclizine (Antivert) 50 mg 1 tab OD PO one hour before travel.
- Triamterene (Dyrenium) 25mg 1 cap OD PO.
Environment/Exercise
Instructed the patient not to over-extend herself if she can’t physically manage vigorous
exercise; do something more low impact, like walking with a nurse’s assistance.
Encouraged the patient to do deep breathing exercises.
Treatment
Instructed the patient that treatment for Meniere’s disease is a medication to reduce fluid
retention (diuretic) which prescribed by the doctor.
Some people with Meniere's disease may benefit from other non-invasive therapies and
procedures, such as:
- Rehabilitation: If you have balance problems between episodes of vertigo, vestibular
rehabilitation therapy might improve your balance.
- Hearing aid: A hearing aid in the ear affected by Meniere's disease might improve your
hearing. Your doctor can refer you to an audiologist to discuss what hearing aid options
would be best for you.
- Positive pressure therapy: For vertigo that's hard to treat, this therapy involves applying
pressure to the middle ear to lessen fluid buildup. A device called a Meniett pulse
generator applies pulses of pressure to the ear canal through a ventilation tube. You do
the treatment at home, usually three times a day for five minutes at a time. Positive
pressure therapy has shown improvement in symptoms of vertigo, tinnitus and aural
pressure in some studies, but not in others. Its long-term effectiveness hasn't been
determined yet.
Health Teaching
Certain self-care tactics can help reduce the impact of Meniere's disease. Advised the patient
to consider these tips for use during an episode:
- Sit or lie down when you feel dizzy. During an episode of vertigo, avoid things that can
make your signs and symptoms worse, such as sudden movement, bright lights, watching
television or reading. Try to focus on an object that isn't moving.
- Rest during and after attacks. Don't rush to return to your normal activities.
- Be aware you might lose your balance. Falling could lead to serious injury. Use good
lighting if you get up in the night.
Encouraged the patient to talk to people who share the condition, possibly in a support
group. Group members can provide information, resources, support and coping strategies.
Observation/Out-patient
Recommended the patient and family to get routine medical care. Don’t neglect checkups or
regular care from family doctor.
Diet
Encouraged the patient to limid salt intake. Consuming foods and beverages high in salt can
increase fluid retention. For overall health, aim for less than 2,300 milligrams of sodium
each day. Experts also recommend spreading your salt intake evenly throughout the day.
Advised the patient to limit caffeine, alcohol and tobacco. These substances can affect the
fluid balance in her ears.
Eat fresh fruits like bananas and apple. Eat vegetables such as spinach, carrots, broccoli, and
whole grains.
Limit the amount of canned, frozen, or processed foods with high sodium content.
Increase fluid intake.
Spiritual
Encouraged the patient to pray and talk with God.