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Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

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Concept and Management of Meniere’s Disease in Unani Medicine-A Review

Abdul Nasir¹*, Minhaj Ahmad², Zehra Zaidi¹, SM Arif Zaidi³

¹ Assistant Professor, Department of Ain, Uzn Anaf wa Halaq (Eye & ENT), School of Unani Medical Education & Research, Jamia Hamdard  (Deemed to be University), New Delhi, India.

² Associate Professor, Department of Jarahiyat (Surgery), School of Unani Medical Education & Research, Jamia Hamdard  (Deemed to be University), New Delhi, India.

³ Professor, Department of Jarahiyat (Surgery), School of Unani Medical Education & Research, Jamia Hamdard  (Deemed to be University), New Delhi, India.

INTRODUCTION

Meniere’s disease is a disorder of the inner ear where endolymphatic system is distended with endolymph. It is also called endolymphatic hydrops and characterized by Spontaneous episodic attacks of vertigo, tinnitus, sensorineural hearing loss which usually fluctuates and often a sensation of aural fullness.^1,2 Despite this well-known symptom complex, it remains a controversial and often difficult condition to diagnose and treat.

Prosper Meniere was the first who identified Meniere’s disease in the early 1800s. It affects between 0.3 and 1.9 per 1,000 people that is 2 persons per 1,000 people approximately.³ The worldwide incidence of Meniere's disease is approximately 12 out of every 1,000 people.⁴ Perhaps 100,000 patients develop Meniere's disease every year.⁵ Meniere's disease has a prevalence of approximately 200 cases/100,000 persons in the United States, or in other words, less than 0.2 % of the population has Meniere's disease.⁶ It is commonly seen in the age group of 35-60 years and male are more affected than females.¹ Inner ear consists of 2 parts: bony labyrinth & membranous labyrinth. Membranous labyrinth is filled with endolymph while space between membranous & bony labyrinths is filled with perilymph. It consists of the cochlear duct, the utricle & saccule, the 3 semi-circular ducts and the endolymphatic duct & sac. Cochlear duct is subdivided by two longitudinally running membranes that separate three chambers, the scala tympani, scala media and scala vestibuli. The scala media is triangular in section, the other boundaries represented by Reissner's membrane which runs obliquely with respect to the basilar membrane from a ridge of tissue, the spiral limbus near the modiolus to the lateral wall that runs along the inside of the bony wall. The organ of Corti runs in a spiral along the floor of the scala media, situated on its lower boundary, an acellular layer called the basilar membrane.^1,7,8 The purpose of this study is an overview of Meniere’s disease and its understanding through Unani medicine and management of Meniere’s disease.

CONCEPT OF MENIERE’S DISEASE IN UNANI MEDICINE

Amraz-e- Uzn Anaf wa Halaq is a branch of Unani Medicine where diseases related with Eyes, Ears, Nose and Oral cavity has been explained. As per the unani text, Uzn is an important sense organ when the patient complained of post nasal discharge and its exacerbation in winter, called Nazlah and abnormal accumulation of (Balgham) phlegm and causative pathologic substances in the brain. These phlegm (Balgham) or pathogenic substances of brain poured down to ear causing Dawar (vertigo), Taneen (tinnitus), Sumam (deafness) and other features.

The etiological factors are: exposure to cold breeze, diving or swimming, probing the external auditory canal, sound pollution, untreated chronic systemic disease. According to Unani physicians the treatment is based on lifestyle modification, warming up the body, strengthening the brain and the nervous system, enhancing the digestive system, modifying the condition of defecation, as well as the removal of waste materials and accumulated abnormal humors from the body, especially from the head.^9-12

AETIOLOGY^1,7,8,13

The exact cause of Meniere’s disease is not known but various theories have been postulated as:

1. Defective absorption by endolymphatic sac
2. Vasomotor disturbance
3. Allergy
4. Sodium and water retention
5. Hypothyroidism
6. Autoimmune and viral aetiologies

PATHOLOGY

The main pathology of distended endolymphatic system affects the cochlear duct (scala media), the saccule and lesser extant to utricle and semicircular canals. The dilated cochlear duct may fill completely the Scala Vestibule which interferes with hearing leading to diminished hearing and tinnitus. The distended Utricle, Saccule and Semicircular canals may show disturbance in maintaining the body balance leading to Vertigo. Thus the triad symptoms are experienced by the patients is very prominent ^1,5,7,8,14.

CLINICAL FEATURES OF MENIERE’S DISEASE

A typical vertigo attack has 3 phases:

1. Initial irritative phase due to increased potassium concentration–nystagmus usually horizontal or horizontal-torsional & beats towards the affected ear and lasts less than an hour.
2. Second paretic phase nystagmus beats away from affected ear because of peripheral hypofunction and reduced spontaneous neural activity and lasts usually several hours or sometimes 1 or 2 days.
3. Third recovery phase in which nystagmus again beats towards affected site; brainstem compensation lasts for several hours or sometimes 1 or 2 days

b) Deafness/Hearing loss^1,7,8

1. Diplacusis or double hearing is altered sound perception, which differs from that of a presented sound. Diplacusis could be manifested as binaural or monaural. In binaural diplacusis, the same tone is perceived differently in each ear. It is most frequently reported in Meniere's disease. Patient typically complains of 'distorted' sounds.
2. Intolerance to loud sounds.

c) Tinnitus with episodes of headache 

d) Feeling of fullness in the ears (Aural fullness)⁷

e) Emotional stress 

STAGES OF MENIERE’S DISEASE

It can be seen in table no.1

Table 1: Stages of Meniere’s Disease ^1,3

EXAMINATION ¹

1. Otoscopy – no abnormality in tympanic membrane. 
2. Nystagmus – seen only during acute attack, quick component of nystagmus is towards unaffected ear 
3. Tuning fork tests – indicate SNHL. Rinne +, ABC reduced, weber lateralized to better ear.

INVESTIGATIONS

Pure Tone Audiometry – SNHL ^1,7,8

1. Early stages – lower frequencies affected & curve is rising type 
2. When higher frequencies involved, curve becomes a flat or a falling type.^1,7,8

Speech Audiometry ^1,7,8

1. Discrimination score is usually 55-85% between attacks but impaired during & immediately following an attack. 
2. To differentiate from retrocochlear 
3. Recruitment positive 
4. Short increment sensitivity index (SISI) >70% 
5. Tone decay test-decay < 20dB ^1,7,8

Special Audiometry Tests ^1,7,8

1. Recruitment test
2. Short increment sensitivity index (SISI) test
3. Tone decay test

Electrocochleography ^1,7,8

1. Most sensitive & specific for Meniere’s when tone-burst and click stimuli are used, and when the responses are recorded transtympanically at the promontory.
2. Giving 4g oral NaCl for 3 days prior to electrocochleography may increase the sensitivity of the test. 

Serology 

Caloric test             

Glycerol test

VARIANTS OF MENIERE’S DISEASE⁷

Cochlear hydrops

Only cochlear symptoms are present but vertigo is absent and appears after several years. Itconfining increased pressure to cochlea only. 

Vestibular hydrops

There is episodic vertigo, while cochlear functions are normal.

Drop attacks (tumarkin’s or otolithic crises)

There is acute otolithic dysfunction of utricle or saccule due to changes in endolymphatic pressure, occur in the later stages of the disease. Patient simply drops to the ground without warning and can sustain a fracture or a serious injury.

Lermoyez Syndrome

Here symptoms of Meniere’s disease are seen in reverse order. 

CONCEPT OF MODERN TREATMENT

General measures: 

1. Reassurance, bed rest, low salt diet.
2. Avoiding smoking, excessive intake of alcohol, water, coffee and tea low salt diet.^8,14

Acute treatment

General measures plus intravenous fluids and electrolyte administration to combat their loss due to vomiting. Vestibular sedatives such as prochlorperazine, dimenhydrinate etc. and vasodilators such as carbogen which improves circulation in labyrinth.^1,7,8

Chronic treatment

In the chronic condition treatment consists of vestibular sedatives, vasodilators, diuretics, propantheline bromide, elimination of allergen, hormones (if hypothyroidism).^1,7,8

SURGICAL TREATMENT

Intratympanic Injection Gentamicin

Gentamicin is predominantly vestibulotoxic and acts by destroying the dark cells of the secretory epithelium, thus decreasing endolymph production.^1,7

Endolymphatic sac surgery

It reduce the frequency, duration & intensity of vertigo attacks.¹

Surgical Labyrinthectomy 

It stop the vertigo attacks at the expense of losing any remaining hearing on that side.^7,8

USOOL-E-ILAJ (PRINCIPLE OF TREATMENT) 

In the Unani system of medicine, the main emphasis of Usool-e-Ilaj (principle of treatment) are:¹⁵

1. Use of Musakkin (Sedative) 
2. Use of Mufatteh Urooq (Vasodilators)
3. Use of Mudire Baul (Diuretics)
4. Removal of Khilt Gair Tabai (Abnormal humour)

ILAJ (TREATMENT)

In the Unani system of medicine, the principle of treatment is based on Usool-bil-Zid (principle of contradiction). There are four treatment methods, or modalities: Ilaj-bil-Dawa (pharmacotherapy) Ilaj-Bil-Ghiza (diet therapy), Ilaj-bil-Tadabeer (regimental therapy) and Ilaj-bil-Yad (manual therapy/surgery).¹⁵

Ilaj Bil Dawa (pharmacotherapy): 

• As Musakkin (Sedative) drugs, Khamira Khaskhash 3-5gm, Dayaqooza 10ml, Barshasha 1gm can be given for this purpose.¹⁵
• As Mufatteh Urooq (Vasodilators) and Mudire Baul (Diuretics), Banadiqul Bazoor 2 tab with sharbat bazoori 20 ml and sharbat Ustookhudoos 20 ml in the morning and evening. Or

Decoction of Tukhme Khayarain 10 gm, Tukhme Kharpaza 5 gm, Tukhme Kasni 5 gm, Kharkhasak 7 gm, Mako khushk 5 gm, Ustookhudoos 5gm, Badranjboya 5 gm along with Sharbat Deenar 20 ml.¹⁵

• Jawarish Jalinoos 5 gm twice daily after meal.
• Hareera Maghz badam in the morning and Itrifal Kashneezi 7 gm at night in case of Dawar (Vertigo)

Ilaj Bil Ghiza (Dietotherapy)

• Diet such as Jaiyyad ul Kaimus (normal chyme), Lateef (tense diet) and Saree-ul-Hazm (fast appetizer) are recommended.
• Pateint should take salt free diet as far as possible.
• Avoid excessive intake of alcohol, water, tea and coffee.

Ilaj-bil-Tadabeer (Regimental Therapy) ¹⁵

• Nutool Raas: Medical irrigation on head by decoction of rose leaves (Barge Gulab).
• Hijama (Cupping) on pre auricular region, neck and C7.
• Pashwiya (Foot bath) by decoction of Barge Beri and Badiyan.

CONCLUSION

It is concluded that Meniere’s disease is a condition that needs to be assessed correctly and proper measures should be adopted in its management. Erratic life styles, unhealthy eating habits and lack of exercise could contribute towards developing Meniere’s disease. Because it is critically diagnosed and poorly treated with increasing incidences even in the Indian society. The early treatment for Meniere’s disease should be started to avoid further complications with the help of unani medicine. Therefore, the treatment protocol for Menier’s disease should include use of Musakkin (Sedative), Mufatteh Urooq (Vasodilators), Mudir-e-Baul (Diuretics) and Removal of Khilt-e-Gair Tabai (Abnormal humour along with Ilaj-Bil-Tadabeer (regimental therapy) which will give promising results.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the all teachers and library staff of School of Unani Medical education and Research for their work through their keen observations and experiences.

CONFLICT OF INTEREST

The authors declare that they have no competing interests.

REFERENCES

1. Dhigra PL, Dhigra Shruti. Diseases of Ear, Nose & Throat. 7th ed. Chap 15: Elsevier; 2004.P.111-116.

2. Beasley NJ, Jones NS, "Menière's disease: Evolution of a definition" J Laryngol Otol, 1996; 110(12):1107-13.

3. Sandhya Rani. D, Madhusudan BG, "Ayurvedic Approach to Meniere's Disease-A Review" International Ayurvedic Medical Journal, 2019; 7(1):95-99.

4. Assimakopoulos D, Patrikakos G, "Treatment of Ménière's disease by intratympanic gentamicin application" J Laryngol Otol, 2003; 117(1):10-6. https://doi.org/10.1258/002221503321046586

5. Merchant SN, Adams JC, Nadol JB, "Pathophysiology of Meniere's syndrome are symptoms caused by endolymphatic hydrops" Otol Neurotol, 2005; 26(1):74-81. https://doi.org/10.1097/00129492-200501000-00013

6. Alexander, T. H. and J. P. Harris, "Current epidemiology of Meniere's syndrome" Otolaryngol Clin North Am, 2010; 43(5):965-970. https://doi.org/10.1016/j.otc.2010.05.001

7. Mohammad Maqbool. Textbook of ENT. 12th ed. New Delhi: Jaypee brothers medical publishers pvt ltd; 2013.P.

8. Tuli BS, Tuli IP, Singh A, Tuli AK. Textbook of ENT. 12th ed. New Delhi: Jaypee brothers medical publishers pvt ltd; 2005.P.106-108.

9. Ibn Sina. Al Qanoon Fit Tib. New Delhi: Idara Kitabus Shifa; 2010.

10. Razi AB. Kitab-ul-Havi fil Tibb. New Delhi: CCRUM; 1999.

11. Jurjani I. Zakhira Khawarazm Shahi. New Delhi: Idara Kitabus Shifa; 2010.

12. Arzani MA. Tibb-e-Akbar. New Delhi: Idara Kitabus Shifa; 2010.

13. Haybach PJ. Meniere's disease. What you need to know. Portland, OR: Vestibular Disorders Association; 1998.

14. Gavimath, Shivanand1, MangalaKS, "Management of Meniere's Disease-An Analytical Ayurveda Perspective" J. Adv. Res. Ayur Yoga Unani Sidd. Homeo, 2016; 3:19-21.

15. Dr. M Arif. Textbook of ENT with Regimental Therapy. 1st Ed. UP Computers, Atwara, Bhopal. 2018. P.169-179.