Otology & Neurotology

36:198Y199 ! 2014, Otology & Neurotology, Inc.

Letter to the Editor

no further attacks of vertigo, and we found a stabilization and, in some cases, even a slight improvement of
their low-tone hearing loss. We would like to recommend
this policyVthat partially coincides with the findings of
Luxford et al.Vbecause it could be a simple and straightforward first stepVwith a minimal risk of damageVin the
treatment of Menie`res disease.

DIETARY MODIFICATION AS ADJUNCT

TREATMENT IN MENIE`RES DISEASE

To the Editor: It was with great interest that we read the

article by Luxford et al. (1) that describes the possible role
of nutrition in Menie`res disease. We also suspect that
nutrition could play a major role. However, we suggest
that it is not sodium that should be avoided but potassium.
In our view, it is a relatively raised concentration of
potassium in the endolymph that causes a shift in the
osmotic situation. Water from the scala vestibuli could
diffuse via Reissners membrane, which is semipermeable,
into the scala media. This will lead to Menie`res patients
well-known endolymphatic hydrops. Incidentally, the relative dehydration/hyponatremia that we see in our military
population could also be caused by increased perspiration.
Hence, we have advised our patients to beware of a
relatively high potassium concentration. In essence, we
advise to drink a few extra glasses of water each day and we
recommend a reduced intake of food that is rich in potassium. Furthermore, we recommend that patients reduce
their intake of alcohol because this tends to have a diuretic
effect. Because stress is also known for causing more attacks, we also promote a reduction in caffeine.
Luxford et al. found a significant effect in the rating
of the functioning level by patients who maintained a
caffeine-free diet. The difference in the number of vertigo
spells approached significance. This was not the case for
the low-sodium diet.
Strikingly, patients found it easier to give up coffee than
salt. One might wonder whether this could be because they
actuallyVintuitivelyVnoticed a positive effect?
As we believe that a pressure differentialYbased steering
mechanism is at work within the middle ear that serves
as a protective measure by pulling the ossicular chain and
the eardrum tight when we are exposed to too much
noiseVsimilar to the contraction of the irisVwe are not
surprised to find a, in our view interesting, positive effect
of tenectomy of the musculus stapedius, which seems to
concur to some extent with our theory (2,3).
For years, it has been my common practice to place
grommets in the assumption that we could somehow influence pressure regulation.
As anecdotal evidence, we would like to mention that,
of the estimated 15 Menie`res disease patients that the first
author has treated through the years, only one patient with
an extraordinarily long patient history did not respond
positively to the placement of grommets in combination
with our recommendation to increase water intake and
reduce potassium intake. All other patients have had

J. Alexander de Ru, M.D., Ph.D.

Willem Chr. Heerens, M.Sc., Ph.D.

Department of Otorhinolaryngology
Central Military Hospital
Utrecht, The Netherlands
The authors disclose no conflicts of interest.

REFERENCES
1. Luxford E, Berliner K, Lee J, Luxford WM. Dietary modification
as adjunct treatment in Menie`res disease: patient willingness and
ability to comply. Otol Neurotol 2013;34:1438Y43.
2. Heerens WChr, De Ru JA. Applying physics makes auditory sense.
Available at: dspace.library.uu.nl/handle/1874/196752. Accessed
December, 2010.
3. Loader B, Beicht D, Hamzavi JS, Franz P. Tenotomy of the
stapedius and tensor tympani muscles reduces subjective dizziness
handicap in definite Menie`res disease. Acta Otolaryngol 2013;133:
368Y72.

RESPONSE TO LETTER TO THE EDITOR

CONCERNING: DIETARY MODIFICATION AS
NIE`RES
ADJUNCT TREATMENT IN ME
DISEASE: PATIENT WILLINGNESS AND
ABILITY TO COMPLY

In Reply: Thank you for your recent letter commenting

on our article entitled Dietary modification as adjunct
treatment in Menie`res disease: Patient willingness and
ability to comply, recently published in this journal.
Clinically, patients with Menie`res disease who adjust
their diet appear to benefit from those dietary modifications. Our study investigated patients willingness and
ability to modify their diets, including ease of use of the
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