HSC Section 8_April 2017

Reprinted by permission of Otolaryngol Head Neck Surg. 2016; 154(5);824-834.

Systematic Review

Otolaryngology– Head and Neck Surgery 2016, Vol. 154(5) 824–834 American Academy of Otolaryngology—Head and Neck

A Systematic Review of Diuretics in the Medical Management of Me´nie` re’s Disease

Surgery Foundation 2016 Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599816630733 http://otojournal.org

Matthew G. Crowson, MD 1 , Aniruddha Patki, MD 1 , and Debara L. Tucci, MD, MS, MBA 1

Received September 22, 2015; revised January 7, 2016; accepted January 14, 2016. M e´nie`re’s disease (MD) or syndrome is a relatively common condition of the inner ear that may affect up to 190 per 100,000 people in the United States. 1 Prevailing theories on its pathogenesis point to endolymphatic hydrops as one derangement responsible for producing dysfunction within the cochlea and peripheral vestibular apparatus. While the exact pathophysiology remains unknown, it is held by many that hydrops of the endolymph within the labyrinth is contributory. 2 It is believed that during an acute attack, pressure within the scala media increases to a critical point where either a ‘‘stretch’’ or rupture of Reissner’s membrane ensues. 3,4 This event results in admixture of endolymph and perilymph leading to disruption of the ionic gradient, ultimately pro- ducing the classic symptoms of fluctuating hearing loss, tin- nitus, and aural fullness. As firm evidence of a unifying pathogenic mechanism is lacking, MD has proven difficult to successfully manage. Options for therapy range from low-salt diet restriction and diuretics to benzodiazepine and steroid regimens for acute attacks. Invasive surgical procedures are considered in refractory cases. Despite the widespread use of diuretics for this condition, limited evidence for its efficacy has been demonstrated in published literature. An excellent systema- tic review of the effect of diuretic treatment in MD patients was published in 2006 and subsequently updated in 2010. 5 The authors found that there were no trials of high enough quality to meet the standards for their systematic review. Clinical recommendations and guidelines are best sup- ported by data and evidence generated through high-quality 1 Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA This article was presented at the 2015 AAO-HNSF Annual Meeting & OTO EXPO; September 27-30, 2015; Dallas, Texas. Corresponding Author: Matthew G. Crowson, MD, Duke University Medical Center, Division of Head and Neck Surgery and Communication Sciences, 2301 Erwin Road, Durham, NC 27710, USA. Email: matthew.crowson@dm.duke.edu

Sponsorships or competing interests that may be relevant to content are dis- closed at the end of this article.

Abstract Objective. (1) Review evidence for the use of oral diuretic medications in the management of Me´nie`re’s disease. (2) Analyze therapy-related hearing and vertigo outcomes. Data Sources. Literature was obtained through directed searches of MEDLINE, EMBASE, Web of Science, EBSCO Host, Cochrane Reviews, and linked citations through semi- nal papers. We searched independent electronic databases for articles that reported the use of diuretics in patients with Me´nie`re’s disease. Review Methods. All articles of level 4 evidence or higher, per the Oxford Centre for Evidence-Based Medicine, were included with no limit for number of patients, duration of therapy, or follow-up period. Two independent investigators reviewed the articles for inclusion eligibility. Outcomes were tabulated, includ- ing subjective or quantitative measures of hearing, tinnitus, ver- tigo episode frequency, and medication adverse effects. Results. Nineteen articles were included from 1962 to 2012 from 11 countries. Twelve retrospective case series, 4 rando- mized controlled trials, 2 case-control trials, and 1 prospective case series were identified. Six studies investigated isosorbide; 5, hydrochlorothiazide; 2, acetazolamide; 2, chlorthalidone; and 1 each of betahistine, hydrochlorothiazide, chlorthalidone, acetazo- lamide, hydrochlorothiazide-triamterene, and nimodipine. Eight (42.1%) studies reported hearing outcomes improvement. Fifteen (79.0%) studies reported vertigo outcomes improve- ment. Ten (52.6%) studies reported no side effects, and 4 stud- ies (21.1%) reported abdominal discomfort. No significant morbidity or mortality was reported in any study. Conclusion. Multiple low evidence–level studies report that oral diuretic therapy may be beneficial in the medical man- agement of Me´nie`re’s disease. Improvement in vertigo epi- sode frequency was consistently reported, with less convincing evidence for improvement in hearing outcomes.

Keywords Me´nie`re’s disease, diuretics, conservative therapy, medical management

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