Meniere's disease is an inner ear disease named after the physician who actually discovered it. The patients usually present with fluctuation of hearing loss, ringing in the ears, and episodes of dizziness characterized by a spinning sensation or an illusion of movement sensation that we call vertigo.

Dr. Habib Rizk is an Associate Professor in the Department of Otolaryngology, Head and Neck Surgery. Dr. Rizk completed his medical degree and residency training at St. Joseph University in Beirut, Lebanon, and went on to complete a fellowship at MUSC. Dr. Rizk is on the Board of Directors of the American Balance Society, a member of the Equilibrium Committee of the American Academy of Otolaryngology, as well as a representative of the Academy in a joint task force of the American Academy of Neurology to investigate quality improvement measures in neurotology. His research focuses on hearing-related and dizziness-related research.

Hello, everyone,

and welcome to our June

Science Never Sleeps podcast.

Today, our guest

is Dr. Habib Rizk,

Associate Professor

in the Department

of Otolaryngology,

Head and Neck Surgery.

Dr. Rizk completed

his medical degree

and residency training

at St. Joseph University

in Beirut, Lebanon,

and went on to complete

a fellowship at MUSC.

Dr. Rizk is on

the board of directors

of the American Balance Society,

a member

of the Equilibrium Committee

of the American Academy

of Otolaryngology,

as well as a representative

of the Academy

in a joint task force

of the American Academy

of Neurology

to investigate

quality improvement measures

in neurotology.

His research focuses

on hearing-related

and dizziness-related research.

Welcome, Dr. Rizk.

Thank you, Loretta.

Dr. Rizk, today we are

discussing Meniere's disease.

Would you explain

to our audience what it is

and what are the symptoms

of Meniere's disease?

So, Meniere's disease

is a benign inner ear disease

named after the physician

who actually discovered it.

The patients

usually present with

fluctuation of hearing loss,

ringing in the ears,

and episodes of dizziness

characterized by

a spinning sensation

or an illusion

of movement sensation

that we call vertigo.

Vertigo, just like the movie.

Exactly.

Is there a genetic component

to this disease?

Meniere's patients,

we now know they fall

into multiple phenotypes,

one of them is the genetic

familial phenotype.

Another one

is the migraine phenotype.

There's a higher propensity

of migraine

in Meniere's patients.

And it seems like there's

a subgroup of Meniere's

that comes with a migraine,

and it seems like the migraine

affects the pathology.

A third group would be the head

trauma or any type of trauma,

including surgical trauma

after a middle ear

or an inner ear surgery.

The fourth group

is a group of patients

who tend to have more

autoimmune disorders.

And more recent literature

about Meniere's

is postulating

that Meniere's

is a type

of autoinflammatory disorder

in the same range

as periodic fever

and those other

rheumatological diseases.

And finally, the biggest group

is the idiopathic group

where we believe

there's a dysregulation

in one of the water transport

mechanisms within the cell.

Is it because

of a genetic malformation

or a mutation due to

a viral illness, we don't know,

but there's something

that happens at that level

that deregulates the fluid

and electrolyte balance.

I'm going to ask a question

related to all of this

because you indicated

that women may have

a higher incidence

of Meniere's.

And if I'm correct,

I understand migraines

are more prevalent in women,

and some autoimmune,

like lupus.

Do you think

there's a hormonal component

to any of this?

That's an excellent question.

The hormonal component

is more seen

in the migraine or vestibular

migraine pathologies,

which are the migraine

dizziness pathologies.

There's not a clear-cut cause

where hormones are the cause

of the Meniere's disease onset,

but some patients

may have episodes

triggered by

hormonal fluctuation.

So, even if hormones

may not be the necessary problem

to start with,

it might end up

affecting the frequency

and the nature

of the episode,

especially if there's a migraine

associated with it.

And I'm going to just say,

this is very layperson science

I'm speaking of now,

but when you think

about young women,

when they're having

their menstrual cycle,

they take a water pill.

I wonder if there's been

any research

or any kind of

taking a look at, okay,

if you're on

your menstrual cycle

and you're having Meniere's

and you take a water pill

for your menstrual cycle,

if that decreases

the Meniere's

or anything like that.

It would be interesting

to consider.

It's an interesting question.

I don't think

we ever looked at it

specifically

in that population,

because Meniere's

is a rare disease.

And one of the main problems

of getting to a cure

or to a medication

that works is that, as I said,

Meniere's seems to be

a heterogeneous disease.

-Mm-hm.

-So, even though

the endpoint manifestation

is the same,

there might be

several mechanisms working.

And that's why certain

medications are working

on a group of patients

and not the others.

And that's why it's so important

to do the research as well.

-Correct.

-And speaking of research,

I understand a recent

clinical trial with Meniere's

failed in phase III but is now

being done on tinnitus.

Can you talk a little

more about that?

Yes, this is a trial

that was based on the fact

that steroids seem to help in

certain category of patients

to reduce the vertigo attacks

of Meniere's.

And that company, Otonomy,

did that trial,

phase I, II, and III,

using a gel that allows

a timed release of steroids,

which would allow us

to inject the middle ear,

and that steroid would be

delivered over a period

of several days to weeks

into the inner ear.

The idea was great.

Unfortunately,

the results did not show

a greater efficacy

of that steroid than placebo.

And now that same company

is trying to see

if that works

for tinnitus,

because along the way

some of the secondary outcomes

that were collected,

tinnitus seems

to have responded

in a greater-than-chance ratio.

So we're going to study it

systematically,

or at least that industry

is sponsoring the study

to study it systematically

in tinnitus patients.

And that study is slated

And MUSC is a site of that.

Wonderful.

What you said kind of

leads me to the question.

Is there any relationship

between Meniere's

or at least those symptoms?

They sound a little similar,

sometimes, to a stroke or a TIA.

Do you ever speak

with your colleagues

about stuff like that?

Well, as I said initially,

that Meniere's is

a benign inner ear disorder,

but anybody who presents

to the emergency room

with a severe vertigo attack,

one of the most important

aspects of evaluation

is to rule out the stroke,

because some strokes can

present as a vertigo attack.

However, once you have the

stereotypical manifestation

of hearing loss, ringing,

coming at the time

of the attack of vertigo,

that paints a picture.

We might not be able to diagnose

it at the first time,

but then as we follow

the patient

and as we observe

the hearing loss

presenting on the audiogram,

which is the hearing test,

we can definitively diagnose

Meniere's disease.

And then after you define it,

what do you do?

So there are many aspects

to treating Meniere's disease,

but there's no cure.

So, the approach for

Meniere's disease is gradual,

it's related to the frequency

of the episodes,

to the amount

of hearing loss

that we encounter

in those patients,

and to the level of disruption

of their quality of life.

And, as you know,

this also varies

from patient to patient.

Some patients are fine

with one episode a week,

where others,

one episode every two weeks

can wreck their quality of life,

they need to call out.

It can lead

to significant disability

and loss of productivity.

So the first step

of treating Meniere's

usually is reducing

the salt in the diet.

So that's kind of

a general recommendation.

It's not based on hard evidence

but based on empirical evidence,

meaning with habit

and with clinical experience

over the past 50 years

people have reported

improvement with that.

And we ask the patients

to aim for

1500 milligrams per day

sodium intake,

which is even less

than what your cardiologist

would recommend

for high blood pressure.

-Mm-hm.

-It is tough.

And I tell patients,

I'm a little bit

more permissive,

and I tell patients it's okay

or 1700 milligrams,

but avoid bad fluctuations.

Like don't go

one day at one gram

and one day

at four grams of sodium.

The next step would be

there are two options

and they are reported

as options

by the most recent guidelines

of the American Academy

of Otolaryngology,

is a diuretic called

triamterene hydrochlorothiazide.

It's a combination pill

of two diuretics.

And the other option

would be betahistine.

Betahistine is a product that

is not available in the U.S.

unless you get it

from a compounding pharmacy.

It was never cleared

by the FDA,

but it's a safe drug.

And it works by increasing

blood flow into the inner ear.

Those two medications

are listed as options

because the level of evidence

is not very, very high.

It does work on some people.

And on others it doesn't.

And so far we haven't

been able to narrow down

which patient

from the get-go will respond.

So we don't have a profile

of the patient

who will respond

to this drug or not.

We do try them

on a lot of patients,

and some of them it works

and some it doesn't.

Can I ask you

a quick question?

-Yes.

-And this may be

a little ignorant

but I'm going to ask it anyhow.

So this is

an inner ear situation

and it has a lot to do

with electrolytes

and kind of a water imbalance,

if you will.

But when you talked about

lowering your sodium intake,

do any

high blood pressure medicines

affect or offer any benefit,

or is this really

totally unrelated

to high blood pressure,

it's more a water

and electrolyte imbalance?

That's actually

an excellent question.

There are some reports

of association

of cardiovascular morbidities

with Meniere's,

especially when it presents

at the later stage in life,

because Meniere's

can manifest in two peaks,

one in young adults

and one after the age of 65.

The majority of patients

we see

are in the fourth

or fifth decade of life.

So there have been reports

of higher incidence

of high blood pressure

with it,

but it's not a direct

correlation to the disease.

The water pill

I'm talking about,

the triamterene

hydrochlorothiazide,

can be used as a high blood

pressure medication,

but it's not a very effective

high blood pressure medicine,

it's a soft one.

So it's not like, usually,

the first line of treatment

for high blood pressure.

Okay.

Which also leads me

to believe or to ask,

is there a category

of people

that this affects

more than others?

You said it could affect

the young or the old.

Are there sex,

gender differences?

Are there race differences?

Who do you see most

coming into the clinic?

So, the general incidence

that is reported

for Meniere's disease,

in the U.S.,

in the Western countries,

is 190 patients

per 100,000 people.

So it's about

two in a thousand,

almost the same as MS.

It has higher prevalence

in female patients.

There's no

racial predisposition,

which speaks to the

heterogeneity of the disease,

the multiple factors

that could lead to that.

And as I said previously,

some of those factors

can be familiar or genetics,

but they're not, like,

the most important ones.

Okay.

So, let's speak

about the research

related to this disease.

And I wanted to let

our audience know,

I recently understood

that Otolaryngology

as a department has one

of the best research profiles

in the country for across the

ear, nose, and throat spectrum.

So, I know you guys

are very proud

of the research work

that's being done

in your department.

So, tell me what kind

of research is being done

in regard to this disease.

Yeah, thank you,

we are pretty fortunate

to have a supportive department

for research.

And for Meniere's disease,

we currently have

two foundation grants

from the American Hearing

Research Foundation

and Cures Within Reach

Foundation

to study the effect

of a migraine medication

called Venlafaxine

in the treatment

of Meniere's disease.

And this is based on

the primary hypothesis

that this is

a water-electrolyte problem.

And that specific migraine drug,

Venlafaxine,

one of its side effects

is that it can cause

retention of water

in the cells.

And the research

was supported

partly because

of a big incidence

of comorbid migraine

with Meniere's,

but also because

of that side effect profile

of the drug.

We've currently enrolled

20 patients.

None has dropped out.

We're currently ongoing,

aiming to reach 40 patients.

And we'll see

the results of that.

That's exciting.

First of all,

how can folks learn more

about this particular research?

How long will

the clinical trial go on?

And when do you expect

to get some analysis

-of the data?

-So, we're currently expecting

to continue enrollment

till the end of this year.

-Okay.

-And we might ask

for an extension.

In order to learn more,

I usually give out my email

for patients

who are interested

in knowing more

about that research.

My email is RizkH@MUSC.edu.

Wonderful.

I hope that everybody

takes advantage of this.

This is one of the reasons why

we do Science Never Sleeps

here at the Medical University,

to encourage our public

to be aware

of the research

that goes on,

to understand

how it actually benefits

the translation

of the research

into the clinical care

that you offer,

and to help them to engage

with our scientific community.

So, delighted to have you

so generously offer your email.

When you are able

to treat successfully

a patient with Meniere's,

and they have

significant hearing loss,

cochlear implants

or are there other options

for them to regain

some of their hearing?

Definitely.

I mean, again,

we were talking earlier

about how this

spectrum of treatment,

as the disease progresses,

and in some people

it doesn't.

In some people

it's a very benign form,

very infrequent attacks.

But if you have somebody

who has the unfortunate type

where it's kind of very frequent

attacks, one after the other,

and the hearing

does not recover,

we try, initially,

steroid injections

in the drum.

That's also an option

that is geared

toward reducing

the vertigo attacks

but also hopefully

lifting the hearing back

to as close as possible

to baseline.

If that doesn't work,

sometimes we induce

the hearing loss

by injecting gentamicin

in the ear,

because those are

the patients

who are so miserable

from their vertigo attacks.

They're basically

needing to go to the ED

or having to need antiemetics,

one every other day.

They are at risk

of losing their job.

And this is affecting

their everyday life.

Then we make the decision

with the patient that, okay,

we need to control

the vertigo.

So we inject something

called gentamicin

which is toxic to the balance

portion of the ear.

-Okay.

-It has less incidence

of toxicity

to the hearing,

but it has a propensity

to cause hearing loss.

Traditionally,

we only inject it in patients

who already have had

hearing loss,

but the newer guidelines,

because of its effectiveness,

because of the severe

quality of life,

if all the conservative measures

have been exhausted,

we can consider a shot

of gentamicin

to see if it can control

the vertigo.

And in those cases,

in those cases

where the disease is severe

and patients end up

losing their hearing

whether because of Meniere's

or because of our intervention,

then we have to offer

rehabilitative strategies.

And those strategies

can range from a hearing aid,

if the hearing loss is mild,

to a cochlear implant

if there's profound deafness.

And in the most extreme cases

where we need to do

a labyrinthectomy,

which is a surgical

destruction of the ear

to stop the vertigo attacks,

then a cochlear implant

would be the only solution

to treat those patients,

those patients' hearing loss.

You know,

what your suggesting to me

really makes me understand

how very serious

this disease is

and how much it will

complicate one's life

if it's not well-controlled

and looked into.

I wonder,

for medical students

getting into the world

right now,

is this a disease

that they know anything about?

And I ask that question

because,

say your internal medicine

or general practitioner

has a patient

and the patient presents

with some of these symptoms.

Would they know

to think about this

or would they have

to go through a whole...

...roll of factors

to consider

whether this is

the case or not?

I think

it's often misdiagnosed.

-Mm.

-And sometimes, again,

understanding

the constellation of symptoms

and how they present

on and off

is a cardinal manifestation

of the disease.

So, sometimes

we get patients referred

because they have tinnitus,

but then when you explore

with the patient the symptom,

then the tinnitus is not

coming with the vertigo

and they're not time-locked.

But I'd rather

that a patient get sent

and not have

Meniere's disease

than a patient

is misdiagnosed

and not seen

for several months

-or until his disease evolved.

-Absolutely.

But that's

the wonderful thing

about the Medical University

of South Carolina

as an academic health center.

Our patients have access

to folks like you

and they have fabulous

general practitioners,

family medicine,

internal medicine,

that are probably very aware

of the Department

of Otolaryngology

and understand

the options

that are available

for their patients,

especially

if they can't figure out

what's going on with them.

So, that's the beauty

of who we are and what we do.

And I want

to thank you so much

for your passion

in the work that you do.

It's very clear

that this is an issue

that you strongly believe in

and want to resolve,

and I love that,

that's wonderful.

Are there any other research

opportunities going on

when it comes

to Meniere's disease?

Across the country,

not just at MUSC.

So, there are some

industry-sponsored trials.

There's one that is not slated

to begin before a few months

called the Sound Trial.

We were a site of phase II,

and they're going

to start phase III,

I believe,

And it's a trial

that is investigating

the efficacy of a drug

called Ebselen,

which is an antioxidant.

And preliminary results

from phase I and phase II

were encouraging, so phase III

has been approved by the FDA.

Wonderful.

That would be great.

I would love to see

some real action

going on with that.

For people that are

suffering like that,

it sounds miserable,

so I love the fact

that we will offer them

an opportunity, hopefully,

to check out

that clinical trial.

Dr. Rizk, thank you so much

for this wonderful discussion

on a disease

that is so challenging

and all the work you do

and your team in Otolaryngology

trying to make a difference

in Meniere's disease,

a disease I'd never heard of.

And I'm so proud

that we're able

to offer this information

to our audience.

And I hope that our listeners

will take advantage

of Dr. Rizk's email address.

If you have any issues

or know of anyone

who has an issue,

please look him up.

And thank you

to our devoted listeners

for your continued support

and interest in MUSC research.

To consider participating

in a clinical trial at MUSC

or to learn more

about our research,

visit our Facebook page,

MUSC Research,

or go to our website,

Research.MUSC.edu.

Until next time,

stay healthy.