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, Brooks AFB, TX, Dec, 1997

 

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, Pensacola, FL, Oct 1965.

 

Mitchell WL, et al. Dizziness and Vertigo in Aviators, Unclassified Report, DTIC Accession No. AD-660559, USAF School of Aerospace Medicine, Brooks AFB, TX, Jul 1967.

 

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, USAF School of Aerospace Medicine, Brooks AFB, TX, Aug 1985.

 

 

November 27, 2001