I was diagnosed with Meniere's disease a year ago and am still in the dark about what causes it and what I can expect for my future. The vertigo can be almost unbearable sometimes, but no one seems to be able to recommend anything to relieve it. Can you help?

K.D.

Your comment, "no one seems to be able to recommend anything to relieve it," suggests you have not seen an appropriate specialist. If so, you may not have been correctly diagnosed. Even when correctly diagnosed, Meniere's is often incorrectly treated by nonspecialists. Thus, your first task is to find an ear, nose and throat (ENT) surgeon or an otologist (ear specialist) who can help you with your problem.

Meniere's disease typically consists of discrete episodes during which four symptoms are present: severe vertigo, hearing loss, tinnitus and aural pressure (ringing and pressure in the ears). At least in the early stages of the illness, these symptoms occur primarily during an episode. As the illness progresses, some symptoms (especially the tinnitus and hearing loss) may persist between attacks. Attacks last less than one day -- usually for two or three hours. It is typical for the patient to have several attacks in a short interval, followed by a long remission (perhaps months to years), followed by another series of attacks. In most patients, vertigo attacks cease after several years, but hearing loss is permanent. Approximately half the patients with Meniere's have disease in both ears. In such patients, hearing loss is usually bad enough to require hearing aids.

What causes Meniere's disease? The inner ear, which is responsible for both hearing and balance, is a collection of fluid-filled chambers encased in the bony skull base. There are two fluid compartments within the inner ear, divided by a thin membrane. In Meniere's disease, there is a relative overabundance of fluid in one compartment. This distorts and damages the membrane dividing the two compartments. We do not know whether this distortion causes the symptoms of Meniere's disease or is merely an incidental byproduct of the (as yet poorly understood) disease process.

How is Meniere's disease treated? The most widely accepted medical treatment involves a salt-restricted diet and diuretics, which increase urination. In addition, vertigo attacks are treated with medications such as diazepam (Valium) and meclizine (Antivert). Antidepressants and drugs that treat nausea are also occasionally useful. Many doctors advocate avoiding stress, alcohol and caffeine.

Surgery is reserved for those who do not respond to medical treatment -- roughly 10 percent of patients. If the patient still has useful hearing in the affected ear, the goal of surgery is to relieve symptoms and conserve hearing. Endolymphatic sac surgery "decompresses" the fluid-glutted compartment, but some authorities consider it a "sham" surgery. Needless to say, this is a controversial operation, and careful patients will discuss the evidence for and against this operation with their surgeon.

If the patient has no useful hearing in the affected ear, other options are available, including chemically destroying the balance system, cutting the balance nerve, and removing the inner ear (labyrinthectomy). These procedures have a sounder scientific basis than the endolymphatic sac operation. The chemical procedure is the least risky of the three, and is, arguably, the first-line surgical therapy for Meniere's patients who lack useful hearing.

I want to emphasize the importance of correct diagnosis in this disease. A number of illnesses mimic Meniere's disease, and the other illnesses are treated differently. Also, some poor clinicians label ANY case of recurrent vertigo as Meniere's. To avoid suffering unnecessarily due to such errors, I urge you to consult an appropriate specialist.

For more information, Alec Salt at the Washington University School of Medicine in St. Louis maintains a very fine website called The Meniere's Page.