Tinnitus Treatment

• Multifaceted Approaches - Non-Drug:
  A broad range of non-pharmacological treatment options are available for the treatment and remediation of tinnitus. These include
  (A) physical:
  (1) hearing aids,
  (2) cochlear implants, and
  (3) masking devices,
  
  (B) re-orientative:
  (1) biofeedback,
  (2) cognitive therapy, and
  (3) TRT (Tinnitus Retraining Therapy) being the most prominent.
  
  Masking devices (click to read; requires free subscription) are comprehensively reviewed by Vernon and Meikle in a special issue of Otolaryngol Clin North Am on Tinnitus. In the same source, see Miyamoto and Bichey on cochlear implants, Steenerson and Cronin on TES (transcutaneous electrical stimulation), and Jastreboff and Jastreboff on TRT.
  
  TRT, first developed by Pawel Jastreboff (at Emory), appears to provide significant improvement in a high percentage of tinnitus patients (possibly as high as 80%) and is well-documented on his Tinnitus and Hyperacusis Center site.
  
  In the biofeedback tradition, the well-known ENT expert Dr. Murray Grossan has developed an integrated approach detailed on the HealthyHearing (click to read) website, and on his dedicated site TInnitusReliefNet.
  
  

• Drug Therapy:
  A number of agents have been studied, ranging from
  (1) anesthetics (lidocaine, or lidocaine oral analogs),
  (2) anxiolytics, especially in the benzodiazepine class (in particular, the highly successful alprazolam (Xanax), as well as clonazepam (Klonopin, Rivotril)),
  (3) antidepressants (especially promising here, the tricyclic nortriptyline (Aventyl, Pamelor)),
  (4) antihistamines, and
  (5) anticonvulsants (carbamazepine (Tegretol), among others).
  Vernon and Meikle, in Otolaryngol Clin North Am (click to read), have comprehensively reviewed alprazalom, while Gananca et al. review clonazepam (click to read) in the Tinnitus Journal.

Tinnitus Treatment: CAM

• B12:
  An early study suggests that supplemental cobalamin, a special form of B12, may provide some relief in patients with severe tinnitus. Due to its relatively poor gastric absorption, B12 is often taken sublingually (or by injection, if needed), in amounts from 50 µg to 2 mg (toxicity is not a concern).
  

• Zinc:
  Ochi, in his recent study Zinc Deficiency and Tinnitus provides a foundation for the use of zinc in tinnitus treatment. A regimen of zinc gluconate, which may be supplemented with niacin, with doses as low as 34 - 68mg daily for a two week duration, significantly benefited tinnitus; supplementation of higher amounts (90 - 150mg daily) may also benefit some patients.
  
  

• Gingko biloba:
  Despite one negative study which used a clinically suboptimal and hence probably sub-therapeutic dose, several studies in the literature are favorable on the use of Gingko biloba in tinnitus (see the Ernest and Stevinson review Ginkgo biloba for Tinnitus, supported by a later evidence-based journal review in Bandolier). Ginkgo dosages may range from a total of 120 to 480 mg/daily, equally divided across mealtimes, using a standardized 50:1 concentrate of 24% gingko flavonoids, yielding significant benefit with negligible side effects.
  
  

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  Further Readings:
  
  

• Medlineplus provides valuable links and references on Tinnitus, including an excellent interactive Tinnitus Tutorial.
  
  

• ATA (American Tinnitus Association) is a comprehensive clearinghouse of information and news. See especially their Tinnitus Treatment Options.
  
  

• Finally, the best assessment of CAM (complementary and alternative medicine) approaches to tinnitus is Seidman and Babu's Alternative Medications and Other Treatments for Tinnitus: Facts from Fiction (April 2003) in the journal Otolaryngologic Clinics of North America. (Open access, requires free subscription).

Meniere's Disease and Vertigo

• new: Sertaline (Zoloft and SSRIs)
  Recent studies of the activity of selective serotonin reuptake inhibitors (SSRIs) antidepressants provides compelling evidence for a role of serotonergic transmission in vestibular function (Staab & Ruckenstein, Arch Otolaryngol Head Neck Surg (2005): Chronic Dizziness and Anxiety: Effect of Course of Illness on Treatment Outcome); and Furman et al., J. Neurol. Neurosurg. Psychiatry (2005): Migraine–anxiety related dizziness (MARD): a new disorder?). See also the recent appreciation of Schwartz & Longwell (Am Fam Physician (2005): Treatment of vertigo); the authors, in association with American Family Physician (AFP) journal (published by AAFP (American Association of Family Physicians)), also provided a patient-oriented guide to vertigo: Vertigo - A Type of Dizziness with useful balance exercises.
  
  A recent RCT study (Zoger et al., J Clin Psychopharmacol (2006): The Effects of Sertraline on Severe Tinnitus Suffering-A Randomized, Double-blind, Placebo-Controlled Study) has shown that a fixed dose of the SSRI antidepressant sertaline (Zolft), 25 mg/daily on the first week and 50 mg/daily on the following 15 weeks, decreased reported tinnitus severity at 16 weeks' follow-up, and also yielded more improvement in perceived tinnitus loudness, for subjects suffering severe refractory tinnitus; treatment was well tolerated after a somewhat high (17%) dropout rate during the first 2 weeks. The study also found significant correlations between reduction of tinnitus and improvements in depressive and anxiety symptoms., suggesting a possible relationship between tinnitus and anxiety and depressive disorders. This is confirmatory of the earlier findings of JP Staab (Laryngoscope (2004): A Prospective Trial of Sertraline for Chronic Subjective Dizziness)
  who found that sertraline (administered at a daily dose of 25 mg, increased to a maximum daily dose of 200 mg.) significantly reduced chronic subjective dizziness in patients without active physical neurotologic illness, including those with and without psychiatric comorbidity.
  
  This is in contrast to an earlier study (Robinson et al, Psychosom Med (2005): Randomized Placebo-Controlled Trial of a Selective Serotonin Reuptake Inhibitor in the Treatment of Nondepressed Tinnitus Subjects) which tested a different SSRI antidepressant, paroxetine (Paxil), and found that the majority of individuals in this study did not benefit from paroxetine in a consistent fashion. However we note that in this study, patients were treated for a total of 31 days at the maximal dose (50mg/daily), and this represents an uncommonly short duration of antidepressant therapy (compare this to the 16 week duration in the Robinson study), which would typically require 6 - 12 weeks to fully determine antidepressant efficacy, and if as Zoger et al. speculate, at least part of the anti-tinnitus benefit may be related to antidepressant activity, this may account for the failure of Robinson et al. to detect a true clinical benefit and suggests that the trial was insufficiently powered.
  
  Meniere's Watch notes in this connection that although anti-anxiety agents, especially the benzodiazepines, have on weak or ancedotal evidence been used for the treatment of vertigo / dizziness, treatment with SSRI antidepressants not only may effectively relieve dizziness in patients with major or minor psychiatric symptoms, including those with peripheral vestibular conditions and migraine headaches, but patients typically obtain better symptom relief with SSRIs than with either vestibular suppressants or benzodiazepines (Staab et al., Arch Otolaryngol Head Neck Surg (2002): Serotonin reuptake inhibitors for dizziness with psychiatric symptoms). See also Staab & Ruckenstein (Arch Otolaryngol Head Neck Surg (2005): Chronic Dizziness and Anxiety: Effect of Course of Illness on Treatment Outcome) who found SSRIs to be effective for patients with chronic subjective dizziness (CSD) and anxiety; Simon et al. (Psychosomatics (2005): Fluoxetine for Vestibular Dysfunction and Anxiety: A Prospective Pilot Study) found that fluoxetine (Pprozac) at 20–60 mg/day led to significant or near significant reductions in anxiety measures and in impairment due to dizziness.
  
  

• new: Vertigoheel
  Schneider et al. (Arzneimittelforschung (2005): Treatment of vertigo with a homeopathic complex remedy compared with usual treatments: a meta-analysis of clinical trials) conducted a meta-analysis of four recent clinical trials, two observational studies and two randomized double-blind controlled trials, evaluating the homeopathic preparation Vertigoheel compared with usual therapies (betahistine, Ginkgo biloba extract, dimenhydrinate) for vertigo, in a total of 1388 patients. The meta-analysis showed equivalent reductions with Vertigoheel and with control treatment in mean reduction of the number of daily episodes, mean reduction of the duration, and mean reduction of the intensity. Vertigoheel was non-inferior in all variables, indicating good efficacy and tolerability of Vertigoheel in patients with vertigo.
  
  Another double-blinded, randomized, controlled clinical trial (J Altern Complement Med (2005): The Homeopathic Preparation Vertigoheel® Versus Ginkgo biloba in the Treatment of Vertigo in an Elderly Population: A Double-Blinded, Randomized, Controlled Clinical Trial) compared the effects of Ginkgo biloba treatment with the homeopathic remedy Vertigoheel for atherosclerosis-related vertigo, finding that both treatments improved vertigo status, and that Vertigoheel was not inferior to Gingko biloba.
  
  And the recent systematic review of Karkos and colleagues (Karkos et al., J Laryngol Otol (2006: ‘Complementary ENT’: a systematic review of commonly used supplements) concluded that regarding the use of Vertigoheel in vertigo, identified two double-blind RCTs and a meta-analysis, with the first RCT suggesting that Vertigoheel was equally effective in reducing the severity, duration and frequency of vertigo compared with betahistine, the second RCT suggesting that Vertigoheel was a suitable alternative to Ginkgo biloba in the treatment of atherosclerosis-related vertigo, and the meta-analysis of four clinical trials confirming that Vertigoheel was equally effective compared with betahistine, Ginkgo biloba and dimenhydrinate (Dramamine).
  
  

• new: High Fluid Intake:
  Naganuma and colleagures (Laryngoscope (2006): Water May Cure Patients With Meniere Disease) conducted a smal time-series study with historical control to test whether sufficient water intake (35 mL/kg per day [1.183 oz / per 2.205 lbs] of water for 2 years) is effective in the long-term control of vertigo and hearing activity in patients with Meniere's disease for whom conventional therapy has proven unsuccessful, finding that patients in the intervention group dramatically relieved vertigo during the last 6 months of the study period, suggesting that modulation of the intake of water may a simple and cost-effective medical treatment for patients with Meniere's disease.
  
  

• Betahistine v. Cinnarizine:
  Menière's disease (MD) is characterized by attacks of hearing loss, tinnitus and disabling vertigo (for diagnosis, etiology & therapy. Betahistine (Serq), a non-sedating antivertiginous (vertigolytic) drug (which is also a calcium antagonist), is used by many people to reduce the frequency and severity of these attacks, functioning as both a vestibular suppressant and a mild vasodilator. The industry-standard Cochrane review (James & Burton, Cochrane (2000): Betahistine for Menière's disease or syndrome) examined this therapy, finding that there is conflicting evidence relating to its effects, and concluding that there is insufficient evidence to say whether betahistine has any effect on Menière's disease.
  
  Given that the Cochrane report was published in 2004 but not updated past 2000, Evidencewatch has undertaken a systematic review of the literature on betahistine therapy in MD, and we find that the Cochrane conclusion is now against the weight of the current evidence to date and hence in error.
  
  Thus, Amelin et al., (Zh Nevrol Psikhiatr Im S S Korsakova (2003): Comparative efficacy of betaserc and cinnarizine of vertigo in patients with migraine) compared betaserc (16 mg, 3 times daily before meal) and cinnarizine (25 mg, 3 times daily), finding both highly effective but betaserq more effective as a vertigolytic agent. Novotny & Kostica (Int Tinnitus J (2002): Fixed combination of cinnarizine and dimenhydrinate versus betahistine dimesylate in the treatment of Meniere's disease: a randomized, double-blind, parallel group clinical study) evaluated the efficacy and tolerability of the fixed combination Arlevert of cinnarizine, 20 mg, and dimenhydrinate (Benadryl), 40 mg () in comparison to betahistine dimesylate (12 mg), concluding that Arlevert proved to be a highly efficient and safe treatment option for Meniere's disease for both the management of acute episodes and as long-term treatment, with efficacy and safety comparable to the widely used standard therapy of betahistine.
  
  In addition, the investigation by Petrova et al. (Int Tinnitus J (2004): Investigation of Betaserc in Auditory and Vestibular Disturbances) led to the recommendation of 16 mg Betaserc three times daily in the acute phase of vestibular vertigo, finding that the medication was very well tolerated, with no sedative effect, and hence suitable for long-term treatment.
  
  Schneider et al. (Int J Clin Pharmacol Ther (2003): Influence of 3 antivertiginous medications on the vigilance of healthy volunteers) examined the comparative efficacy of three antivertiginous medication:s cinnarizine 20 mg and dimenhydrinate 40 mg (Arlevert), dimenhydrinate 50 mg, or betahistine dimesylate 12 mg, finding the fixed combination Arlevert exerts only a minor effect on vigilance, not significantly different from betahistine. It would however appear that all these agents, despite been classified as non-sedating may nonetheless exhibit dose-dependent impairment on performance: so, cinnarizine at 15mg showed no effects on performance, but impaired performance at 30mg and above (Nicholson et al., Aviat Space Environ Med (2002): Central effects of cinnarizine: restricted use in aircrew), and although an earlier study (Gordon et al., J Psychopharmacol (2001): The effects of dimenhydrinate, cinnarizine and transdermal scopolamine on performance) found that cinnarizine and transdermal scopolamine did not affect performance abilities (although dimenhydrinate did significantly impaired performance), the tested dose of cinnarizine was 15mg, which is consonant with the other findings, as it appears that impairment sets in only at doses of 30mg and above.
  
  More recently, Scholtz et al. (Clin Ther (2004): Treatment of vertigo due to acute unilateral vestibular loss with a fixed combination of cinnarizine and dimenhydrinate: a double-blind, randomized, parallel-group clinical study) found a distinct benefit in using a fixed combination of cinnarizine (Sturgeon) 20 mg and dimenhydrinate (Dramamine) 40 mg versus the respective monotherapies in this population of patients with acute vestibular vertigo. And Kantor & Jurkiewicz (Pol Merkuriusz Lek (2006): Assessment of betahistine dihydrochloride effectiveness in the treatment of vertigo of a different aetiology based on videonystagmography test results) used the VNG (videonystagmography) test to analyze the efficacy of betahistine treatment, compared to a control group treated with different drugs.
  
  Conclusion:
  Thus it would appear that the fixed combination Arlevert (cinnarizine 20 mg and dimenhydrinate 40 mg) is at least as effective as the treatment standard of betahistine dimesylate 12mg, with comparable safety and tolerability profile. Furthermore, from the earlier findings of Novotny et al. (Int Tinnitus J (1999): The efficacy of Arlevert therapy for vertigo and tinnitus) we know that Arlevert is more effective than either of its component drugs alone in treating vertigo and tinnitus.
  
  

• Nimodipine:
  Given the demonstrable efficacy of cinnarizine, a calcium antagonist, it is natural to inquire as to whether other such agents might be beneficial in MD therapy. Pianese et al. (Otol Neurotol (202): New approaches to the management of peripheral vertigo: efficacy and safety of two calcium antagonists in a 12-week, multinational, double-blind study) evaluated the efficacy and safety profile of one 30-mg nimodipine oral tablet 3x daily with meals versus one 150-mg cinnarizine verum oral capsule daily at dinner for 12 weeks for the treatment of vestibular vertigo, finding both regimens effective, with comparable safety and tolerability profiles. This finding awaits cross-verification by additional studies.
  

• Intratympanic Gentamicin:
  Chemical perfusion of the inner ear is an increasingly popular treatment for Ménière's disease, primarily for patients refractory to medical (pharmacological) treatment. Atlas & Parnes (J Otolaryngol (2003): Intratympanic gentamicin for intractable Meniere's disease: 5-year follow-up) found that intratympanic gentamicin titration therapy provides excellent vertigo control, with a similarly significant improvement in both personal and occupational functioning; this is in substantial agreement with the findings of systematic review of Diamond et al (J Otolaryngol (2003): Systematic review of intratympanic gentamicin in Meniere's disease). And Suryanarayanan & Cook (J Laryngol Otol (2004): Long-term results of gentamicin inner ear perfusion in Meniere's disease) reported on the long-term results of treatment with gentamicin delivered via round window micro-catheter. Patients with Ménière's disease underwent continuous, low dose (10 mg/ml) gentamicin infusion at 5 microlitre per hour for 10 days, through a micro-catheter placed into the round window niche. They found that long-term vertigo control can be achieved using low dose gentamicin, which appears to stabilize the vestibular function, enhancing the chance of effective vestibular rehabilitation, while preserving hearing and vestibular function in the majority of patients.
  
  Chia et al. (Otol Neurotol (2004): Intratympanic Gentamicin Therapy for Meniere's Disease: A Meta-analysis) systematically reviewed the literature between 1978 - 2002 on intratympanic gentamicin therapy for MD, found that safety and efficacy of this therapy depended considerably on the gentamicin delivery technique deployed: the titration method of demonstrated significantly better complete and effective vertigo control compared with other methods; while the low-dose method demonstrated significantly worse complete vertigo control compared with other methods; in addition, the weekly method of delivery trended toward less overall hearing loss, while the multiple daily method demonstrated significantly more overall hearing loss.
  
  The problem with this therapy however is that it may induce some toxic effects on hearing (Huang et al., Lin Chuang Er Bi Yan Hou Ke Za Zhi (2004): Intratympanic gentamicin in Meniere's disease), although intratympanic gentamicin is still overall a safe and efficient treatment for the vertiginous spells of MD (see the high methodological quality study of Stokroos & Kingma, Acta Otolaryngol (2004): Selective vestibular ablation by intratympanic gentamicin in patients with unilateral active Meniere's disease: a prospective, double-blind, placebo-controlled, randomized clinical trial), and when use in the early course of the disease, may prevent some of the sensorineural hearing deterioration associated with it.
  
  The mode of administration can be manipulated to avoid potential cochlear damage and other cochleotoxic effects with gentamicin therapy: Lange et al. (Laryngoscope (2004): Long-term results after interval therapy with intratympanic gentamicin for Meniere's disease) explored new single-shot and interval MD treatment with intratympanic gentamicin, finding the interval therapy treatment modality effective with very low side effects, with cochleotoxic side effects prevented by treatment intervals of 7 days. These researchers have further clarified the optimal regimen (Lange et al., HNO (2003): Intratympanic interval therapy of Meniere disease with gentamicin with preserving cochlear function): gentamicin should be administered at most three times: on days 1, 8 and 15, yielding that over half of patients only needed a single dose of gentamicin to obtain a sufficient reaction (this is the single shot-therapy modality); they found the intratympanic injection-technique (single dose=0.3 ml=12 mg) performed under local anaesthesia to be simple and superior to any other procedure, observing that peak concentration of gentamicin is reached after 2–6 days (average 4.6 days), and advising that as soon as signs of inner ear reaction are observed, treatment can be assumed effective and must be stopped immediately to avoid over-intoxication and damage to the cochlea.
  
  Hillman et al. (Laryngoscope (2004): Vestibular nerve section versus intratympanic gentamicin for Meniere's disease) compared for the first time vestibular nerve section and transtympanic gentamicin therapy, both known procedures with proven efficacy in the treatment of Meniere's-associated vertigo in MD refractory to medical management, and both with known hearing loss as a potential complication. They found that gentamicin causes a higher level of treatment-related hearing loss, with vestibular nerve section demonstrating a higher vertigo control rate, although overall gentamicin still exhibited low risk for hearing deterioration (see Gilony et al., Harefuah (2004): Intratympanic gentamicin treatment for intractable Meniere's disease).
  
  

• Intratympanic Steroid Perfusion:
  A common MD therapy is intratympanic steroid perfusion (ISP), of methylprednisolone and/or dexamethasone. However, long-term efficacy of this therapy is doubtful: Dodson et al. (Ear Nose Throat J (2004): Intratympanic steroid perfusion for the treatment of Meniere's disease: a retrospective study) failed to find any long-term alleviation of vertigo or hearing loss with this therapy (short-term alleviation of vertigo was seen in approximately half of the trial patients, so ISP treatment may still be useful for temporary MD symptom relief). And a more recent randomized, prospective, single-blind study, Araujo et al. (Arch Otolaryngol Head Neck Surg (2005): Intratympanic dexamethasone injections as a treatment for severe, disabling tinnitus: does it work?) found no advantage in intratympanic injections of dexamethasone over saline solution in the treatment of severe, disabling tinnitus.
  
  

• Vertigo Therapy:
  Two forms of acute vertigo can be distinguished: (1) spontaneous vertigo and (2) provoked vertigo, usually by postural changes, generally called paroxysmal positional vertigo (PPV, also known as benign (paroxysmal) positional vertigo (B(P)PV).
  
  At present, treatment of MD-associated vertigo is optimally via either betahistine (Serq / Betaserq), or cinnarizine + dimenhydrinate (Arlevert), with one or more of the agents shown immediately below for therapy of acute spontaneous vertigo serving as adjunct therapy if required, with the first line agents themselves (betahistine, Arlevert) achieving even as monotherapy high success rates for efficacy with favorable safety profiles. Patients who fail to achieve highly significant relief from one agent should try a course of the other, as response may be highly individual.
  
  Therapy of acute spontaneous vertigo:
  (1) levo-sulpiride i.v. , 50 mg in 250 physiologic solution, once or twice a day;
  (2) methoclopramide i.m., 10 mg once or twice a day, or tiethilperazine rectally, once or twice a day, to reduce neurovegetative symptoms;
  (3) diazepam i.m., 10 mg once or twice a day, to decrease internucelar inhibition;
  (4) sulfate magnesium i.v., two ampoules in 500 cc physiological solution, twice a day, or piracetam i.v., one ampoule in 500 cc physiological solution, twice a day, to decrease vestibular damage;
  (5) at onset of the acute symptoms, patients must lie on their healthy side with the head and trunk raised 20°, in a quiet but not darkened room;
  (6) if the patient is able to swallow without vomiting, it is important to reduce nystagmus and stabilize the visual field with gabapentine, per os, 300 mg twice or three times a day.
  (7) the first step of the physical therapy of acute vertigo is vestibular electrical stimulation, that is to say, a superficial paravertebral electrical stimulation of neck muscles, aimed to reduce antigravitary failure and to increase proprioceptive cervical sensory substitution. See Cesarani et al. (Neurol Sci (2004): The treatment of acute vertigo).
  
  

• Benign (Paroxysmal) Positional Vertigo
  Although much of the literature concerning positional maneuvers for the treatment of BPPV has until recently been largely based on isolated reported clinical experiences, several well-controlled have taken an evidence-based approach, especially to the issue of the efficacy of so-called Canalith Repositioning (Epley maneuver). Bruintjes et al. (Ear Nose Throat J (2005: Efficacy of the Epley maneuver for posterior canal BPPV: a long-term, controlled study of 81 patients) concluded that conclude that the Epley maneuver can provide effective and long-term control of symptoms in patients with BPPV. In their large study, Steenerson et al. (Laryngoscope (2005): Effectiveness of Treatment Techniques in 923 Cases of Benign Paroxysmal Positional Vertigo) tested intervention with canalith repositioning, liberatory maneuvers, log roll maneuvers, and redistribution exercises, finding that BPPV treatment efficacy for either repositioning, liberatory, or log roll maneuvers in combination with redistribution exercises.
  
  Furthermore, Woodworth et al. found in their recent meta-alalysis (Laryngoscope (2004): The Canalith Repositioning Procedure for Benign Positional Vertigo: A Meta-Analysis) concluded from their review of nine studies that met the inclusion criteria that: "The CRP is more effective than control in resolving vertigo and positive Dix-Hallpike associated with BPPV. This finding was consistent among a variety of studies using different study designs. Untreated patients may demonstrate symptom improvement with time; however, many will continue to have a positive Dix-Hallpike when examined. Resolution of vertigo in untreated patients is therefore most likely because of avoidance of provocative positions." This finding is in substantial agreement with that of Hinton & Pinder (Cochrane Review (2004): The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo) who found from three earlier RCTs that there is some evidence that the Epley manoeuvre is a safe effective treatment for posterior canal BPPV.
  
  The Canalith Repositioning technique was been extensively studied clinically by a panel of otolaryngologists, physiotherapists, and researchers from McGill University and its teaching hospitals, whose findings were reported by Dannenbaum et al. (J Otolaryngol (2004): 2-year review of a novel vestibular rehabilitation program in Montreal and Laval, Quebec) who concluded that a range of modest to major improvements was seen in patients who had completed vestibular rehabilitation, the VRP technique being found to be beneficial for patients with a variety of vestibular disorders.
  
  The procedure itself is well described by Li (eMedicine (2004): Benign Paroxysmal Positional Vertigo), detailed by Halmalyi & Cremer (J Neurol Neurosurg Psychiatry (2000): Assessment and treatment of dizziness) and illustrated by Hain (American Hearing Research Foundation (2001): Balance and Vestibular Rehabilitation Therapy). There is also a patient-oriented online ilustrated self-therapy guide (Radtke, Neurologische Klinik (1999): Self-treatment of benign positional vertigo).
  
  

• Ginger:
  In a small double-blind, crossover, placebo trial (Grontved & Hentzer, ORL J Otorhinolaryngol Relat Spec (1986): Vertigo-reducing effect of ginger root. A controlled clinical study), the effect of powdered ginger rhizome upon vertigo and nystagmus was studied in eight healthy volunteers, with ginger reducing vertigo significantly better than placebo.
  
  

• Radical Scavengers:
  Takumida et al. (Acta Otolaryngol (2003): Radical scavengers for Meniere's disease after failure of conventional therapy: a pilot study) explored the benefits of three radical scavengers in MD therapy: rebamipide (300 mg/day), vitamin C (600 mg/day) and/or glutathione (300 mg/day), finding that when these were administered orally for at least 8 weeks to patients with poorly controlled MD, most patients saw significant improvement of tinnitus and almost all saw marked improvement of vertigo; however, further confirmation of these findings is required, as this was a pilot study on a small 25 MD patient population.
  
  

• Diuretics:
  Although diuretics, often coupled with a low-salt dietary intake, are widely used in treating vertigo associated with MD, there is minimal evidence to back this practice. The major supporting study is the early one of Santos et al. (Otolaryngol Head Neck Surg (1993): Diuretic and diet effect on Meniere's disease evaluated by the 1985 Committee on Hearing and Equilibrium guidelines). However, although it was found that after 2 years of therapy, vertigo control was complete or substantial in 79% of the patients, Evidencewatch notes that hearing improved in 35% of the patients, but was worse in 22%, which we find to substantially mute the overall value of such therapy.
  
  In addition, Thirlwall & Kundu's systematic Cochrane review (Cochrane Database Syst Rev (2006): Diuretics for Ménière's disease or syndrome) recently concluded that there was insufficient quality evidence of the effect of diuretics on vertigo, hearing loss, tinnitus or aural fullness in clearly defined Ménière's disease.
  
  Finally, we noted that although field practice sometimes includes the sulfa diuretic acetazolamide (Diomax), there is no consistent and compelling support for this practice, and it's side effect profile as well as the potential for reanal and hepatotoxicity, including some fatalaties, suggest an unfavorable risk / potential benefit ratio, and it should be noted that one study [Brookes GB: Oral acetazolamide in Meniere's disease. J Laryngol Otol 1984, 98:1087-1095 ] has concluded that "oral acetazolamide has no place in the medical treatment of Meniere's disease".  
  

• Meniett Low-Pressure Pulse Generator
  The Meniett device (from Medtronic Xomed) is a local pulsated pressure treatment used for Meniere's disease, approved by the FDA in 2000. Essentially a portable pressure-pulse generator, the Meniett device is designed to restore the balance of the hydrodynamics of the inner ear. Therapy consists of the insertion of a standard ventilation tube into the tympanum, with pressure pulses generated by the Meniett technology transmitted into the middle ear across the tube. . The belief is that the pressure changes are conveyed to the inner ear, inducing a transport of fluids via the pressure outlets, thus reducing endolymphatic hydrops. The typical treatment cycle is consists of five-minute sessions three times daily. Patients can treat themselves with the device at home after appropriate training by a physician. To date, some preliminary evidence suggests that the Meniett device may be effective in treating Meniere's disease. Thomsen et al. (Otol Neurotol (2005): Local Overpressure Treatment Reduces Vestibular Symptoms in Patients with Meniere's Disease: A Clinical, Randomized, Multicenter, Double-Blind, Placebo-Controlled Study) found that local overpressure treatment by the Meniett device is noninvasive, nondestructive, safe, and efficacious, significantly reducing vestibular symptoms in patients with Meniere's disease; although the trend toward a reduction of the frequency of vertiginous attacks was not statistically significant, patient functionality level improved statistically significantly. (Consumer information is available from the manufacturer (Meniett.com)). However, the failure of the reduction in vertigo attacks to achieve statistical significance is a caution that indicates the need for further sufficiently powered studies to truly confirm clinical benefit, and indeed it appears that to date practitioners are not adopting the technology widely, as Kim et al. (Otolaryngol Head Neck Surg (2005): Trends in the diagnosis and the management of Meniere's disease: results of a survey) report that less than 10% routinely recommend the Meniett device. Similarly, the study of Boudewyns et al. (Acta Otolaryngol (2005): Meniett therapy: rescue treatment in severe drug-resistant Meniere's disease?) who found, despite a significant decrease in the median number of vertigo spells, no improvement in hearing status, tinnitus, functional level or self-perceived dizziness handicap.