## Acute Management of Meniere Disease Attack ### Clinical Presentation of Acute Attack This patient is experiencing an **acute exacerbation of endolymphatic hydrops** with severe vertigo, vegetative symptoms (nausea, vomiting), and objective vestibular signs (nystagmus, past-pointing). Notably, hearing is preserved during this particular attack, which is typical — hearing loss is **not** present in every attack. ### Immediate Management Strategy **Key Point:** Acute Meniere attacks are self-limited and managed **symptomatically** with bed rest, antiemetics, and vestibular suppressants. The goal is to control acute symptoms until the attack resolves (usually within hours to days). ### Pharmacological Approach | Agent | Role | Route | Indication | |-------|------|-------|------------| | **Vestibular suppressants** (betahistine, cinnarizine) | Reduce vertigo intensity | Oral or IM | Acute attack | | **Antiemetics** (metoclopramide, ondansetron) | Control nausea/vomiting | IV/IM preferred in acute setting | Severe vegetative symptoms | | **Benzodiazepines** (diazepam) | Muscle relaxation, anxiety reduction | IV/IM | Severe vertigo with anxiety | | **IV fluids** | Hydration | IV | Refractory vomiting | | **Diuretics** (furosemide + amiloride) | Prophylaxis, not acute treatment | Oral | Long-term prevention | **High-Yield:** **Diuretics are prophylactic**, not acute treatments. They reduce endolymphatic fluid accumulation over weeks to months and are given between attacks, not during acute episodes. ### Why Other Options Are Incorrect ```mermaid flowchart TD A[Acute Meniere Attack]:::outcome --> B{What is the phase?}:::decision B -->|Acute attack: severe vertigo| C[Symptomatic management]:::action B -->|Between attacks: prophylaxis| D[Diuretics + salt restriction]:::action C --> E[Bed rest, antiemetics, vestibular suppressants]:::action C --> F[IV fluids if vomiting severe]:::action D --> G[Furosemide + amiloride, low-sodium diet]:::action H[Intratympanic gentamicin]:::action --> I{When used?}:::decision I -->|Refractory to medical therapy| J[Ablative procedure for hearing loss]:::outcome ``` ### Clinical Pearl **Clinical Pearl:** Intratympanic gentamicin is reserved for **refractory cases** (attacks despite 3–6 months of medical therapy) and causes permanent vestibular ablation and potential hearing loss. It is **not** first-line for acute attacks. **Warning:** Do not order MRI for every acute vertigo episode. MRI is indicated if the diagnosis is uncertain or if there are atypical features (bilateral symptoms, progressive neurologic signs, or headache). Normal MRI at initial workup does not need to be repeated for each attack. ### Prognosis **Key Point:** Most acute Meniere attacks resolve spontaneously within 2–4 hours. Supportive care and symptom control are the mainstays of acute management. [cite:Ballenger's Otolaryngology 19e Ch 8; Harrison 21e Ch 468] 
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