xRead - Episodic Vertigo (January 2026)

10976817, 2020, S2, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599820909438 by Mayo Clinic Libraries, Wiley Online Library on [19/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Basura et al

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water. The optimal frequency for using the device is 3 appli cations of the pressure daily for at least 6 weeks. If there is no improvement in vertigo after 6 weeks, then it is unlikely that the device is efficacious for a particular patient. 261 The recommendation against use of positive pressure therapy is based on 2 recent SRs of RCTs of the use of the Meniett device for MD. Syed et al, 262 using multiple search registries, reviewed 4 RCTs that compared the Meniett device and a placebo device in patients with MD. Patients were followed for 2 weeks to 4 months. There was no sig nificant difference in the impact on vertigo control in either group (Meniett vs placebo). As such, the authors concluded that the Meniett device was not effective in the treatment of vertigo in MD. Van Sonsbeek et al, 263 utilizing multiple databases, reviewed 5 RCTs whose goals were to evaluate the effects of positive pressure therapy on vertigo control in MD patients. As in the other review, they determined that there was no compelling evidence that positive pressure treatment was effective for vertigo in MD. In contrast, proponents of Meniett device use point to potential efficacy based on an RCT in MD. Gu¨rkov et al 264 found that the Meniett device improved vertigo but did not improve hearing or vestibular function and thus recommend it as a second-line therapy after a 2-year trial. 265 They fur ther claimed that the Meniett device is a safe and effective option for vertigo control. Other findings and recommenda tions have been made by Ahsan et al 266 and by Zhang et al, 267 yet there are peer-reviewed publications that state that insertion of a tympanostomy tube alone may be effec tive in MD treatment. 268,269 Moreover, while the meta-analysis by Ahsan et al reported a slight short-term improvement in vertigo control in MD, much of the data from that anal ysis were from retrospective or level 4 studies. In addi tion, the average follow-up was only 5 months, and there were low numbers of patients in both treatment and con trol groups. There is some moderate quality evidence from 2 studies that hearing levels are worse in patients who use positive pressure therapy. While the positive pressure therapy device itself is minimally invasive, tympanostomy tubes are required that carry associated risks. These include the risks of anesthesia (minimal with topical or local anesthesia), and the specific risks of persistent tympanic membrane perfora tion (minimal; approximately 2%-4%) after treatment is completed that may be accompanied by chronic otorrhea (approximately 1%) and tympanosclerosis and possible resultant hearing loss or iatrogenic cholesteatoma. Thus, due to the recent RCTs and the Cochrane SR, the use of positive pressure therapy, such as that with a Meniett device, is not recommended. There may be rare exceptions in subpopula tions that are high risk for general anesthesia or contraindi cations to other destructive procedures where this therapeutic modality may be utilized as a last resort to treat MD. Providers need to clearly advise patients about the cur rent data that suggest that it may not be helpful in control ling MD symptoms.

STATEMENT 11. INTRATYMPANIC STEROID THERAPY: Clinicians may offer, or refer to a clinician who can offer, intratympanic (IT) steroids to patients with active Me´nie`re’s disease not responsive to noninva sive treatment. Option based on a systematic review and a randomized controlled trial with a preponderance of benefit over harm. Quality improvement opportunity: Improved vertigo control. National Quality Strategy domains: Effective Communication and Care Coordination, Prevention and Treatment of Leading Causes of Morbidity and Mortality, Person and Family Centered Care Aggregate evidence quality: Grade C, based on 1 Cochrane review that concluded limited efficacy for disability score and 1 small RCT looking at dexa methasone and gentamicin with 90% symptom reduction Level of confidence in evidence: High Benefits: Improved vertigo control, no risk of hear ing loss, less risk of systemic side effects, improved QOL (dizziness handicap), no loss of vestibular function (nonablative therapy) Risk, harm, cost: Cost, perforation, possible need for multiple injections, infection, discomfort of the procedure, time for treatment Benefit-harm assessment: Preponderance of benefit over harm Value judgments: While this is less definitive than gentamicin therapy, the favorable risk-benefit pro file makes this a good option for patients. Intentional vagueness: The term noninvasive refers to medical therapy and lifestyle modification. Role of patient preferences: Medium Exclusions: None Policy level: Option Differences of opinion: There was some contro versy regarding whether the aggregate evidence strength in favor of this intervention is a grade B or a grade C. Given this, a few panel members felt that this statement should be a recommendation rather than an option. Supporting Text The purpose of this statement is to elucidate the role of IT steroid therapy in the management of MD. First described in 1991, 270 evidence for the mechanism of action suggests that IT steroid therapy stabilizes the vascular endothelium and improves cochlear blood flow through anti-inflammatory effects, as well as effects on cochlear ion and fluid homeosta sis. 271-278 While there are fewer data for IT steroid therapy than for IT gentamicin therapy, there have been RCTs and a Cochrane review performed. Action Statement Profile: 11