Meniere’s Disease and Fluid build up in the ears – Chronic cerebrospinal venous insufficiency

Ross Hauser, MD

We will often be contacted by people with a diagnosis of Meniere’s Disease. If you have this same diagnosis it is likely that you share the symptoms and conditions that these people tell us about. They have hearing loss, dizziness, vertigo, sensitivity to high-pitched sounds, lightheadedness, loss of balance, fatigue, swallowing difficulties, vision problems, and some people suggesting that they have an altered sense of reality or dissociation with reality. Some of these people have been suffering from Meniere’s Disease for years and even decades. Many also have tinnitus, inner ear pressure, and a lot of neck and shoulder pain.

Some will tell us that their Meniere’s Disease gets better when they have upper cervical spine chiropractic adjustments. They will also tell us that their chiropractors have noted a reverse curve in their cervical spine and vertebrae misalignment, especially C1-C2 Atlantoaxial instability. Others will tell us about their Idiopathic (no one knows where it is coming from) Intracranial Hypertension.

This article will concentrate on the aspects of Meniere’s Disease caused by upper cervical instability and the connection to Intracranial Hypertension and Chronic Cerebrospinal Venous Insufficiency.

A brief introduction to Meniere’s Disease

Meniere’s disease is a disorder of the inner ear that causes spontaneous episodes of vertigo – a sensation of a spinning motion – along with fluctuating hearing loss, ringing in the ear (tinnitus), and sometimes a feeling of fullness or pressure in the ear. In many patients, low-frequency hearing loss is seen. Meniere’s disease comprises symptoms related to the Eustachian tube, the upper cervical spine, the temporomandibular joints, and the autonomic nervous system. Please see my companion article Ear pain, ear fullness, sound sensitivity, tinnitus, Meniere’s Disease, and hearing problems caused by neck instability.

A February 2022 review in the Journal of the American Medical Association otolaryngology, head & neck surgery (6) found that “The most common reported causes of Meniere’s disease were autoimmune or immune-mediated, genetic, or structural dysfunction of the inner ear.”

An April 2022 paper (7) noted: Menière’s disease diagnosis is straightforward in typical presentations, but a proportion of patients present with atypical symptoms. Atypical symptoms included disequilibrium, imbalance, drop-attacks, rocking vertigo, unexplained vomiting and varying forms of nystagmus (involuntary eye movement).

The cervical spine, temporomandibular joint, and Eustachian tube all are connected through the autonomic nervous system as well as peripheral nerves such as the trigeminal nerve. A more comprehensive explanation of this is in the temporomandibular dysfunction can be found in my article: The evidence and comparisons of TMJ injection treatments and conservative care treatments.

All of these symptoms can easily appear if some condition were causing fluid to accumulate in the inner ear because of Eustachian tube dysfunction. The Eustachian tube in adults is about 3-4 cm (an inch to an inch and a half)  long and is normally filled with air. It connects the inner ear with the pharynx to equalize pressure on both sides of the eardrum between the atmosphere and the inner ear. It is normally closed but opens when we swallow, yawn, or chew. When descending in an airplane or scuba diving, ear pain and potentially even eardrum rupture may develop if the Eustachian tube does not open quickly enough to release the increasing pressure. With improper functioning of one or both Eustachian tubes, the body cannot appropriately regulate inner ear pressures which can result in poor balance, tinnitus, dizziness, vertigo, and a host of other symptoms. One study reported that 75% of patients with Meniere’s disease show a strong association with head and neck movements in the atlanto-occipital and atlantoaxial joints triggering attacks of vertigo.

Cervical spine disorders and symptoms were significantly more in the Meniere’s patients than in a control group.

This study published in 1998 in the medical journal Cranio, (1) is heavily cited by research more than two decades later. Here researchers wrote:

“This study compares the frequency of signs and symptoms from the cervical spine in 24 patients diagnosed with Meniere’s disease and 24 control subjects . .. Symptoms of cervical spine disorders, such as head and neck/shoulder pain, were all significantly more frequent in the patient group than in the control group (24 patients without Meniere’s disease).

Most of the patients (75%) reported a strong association between head-neck movements in the atlanto-occipital and atlanto-axial joints and triggered attacks of vertigo. Also, 29% of the patients could influence their tinnitus by mandibular movements. Signs of cervical spine disorders, such as limitations in side-bending and rotation movements, were significantly more frequent in the patient group than in the control group. Tenderness to palpation of the transverse processes of the atlas and the axis, the upper and middle trapezius, and the levator scapulae muscle were also significantly more frequent in the patient group. The study shows a much higher prevalence of signs and symptoms of cervical spine disorders in patients diagnosed with Meniere’s disease compared with control subjects from the general population.”

Vestibular vertigo of Meniere’s disease and Benign Paroxysmal positional vertigo

A 2021 study (2) found a similar connection to problems in the neck.

“Vertigo and dizziness are one of the most common and least understood symptoms. Vestibular vertigo of Meniere’s disease and Benign Paroxysmal positional vertigo (BPPV – dizziness caused by moving your head) and cervicogenic dizziness (dizziness traced to neck pain) are classified as separate entities. Cervicogenic dizziness is not considered the domain of Otolaryngologists, as it is mainly related to neck proprioceptors (neck movements). Headache and neck pain, have been found to be associated with both Meniere’s disease and Benign Paroxysmal positional vertigo, so is cervicogenic dizziness.”

The doctors of this study then sought to make a connection and an association between cervical signs and symptoms in patients with Vestibular Vertigo of Meniere’s disease, Benign Paroxysmal Positional Vertigo, and cervicogenic dizziness.

• “Most of the Meniere’s Disease patients  (80% for unilateral and 88.23% for bilateral), Benign Paroxysmal Positional Vertigo (75%for right-sided BPPV, 66.67% for left-sided BPPV) and cervicogenic dizziness (90%) had associated symptoms of neck pain or headache and were found to be positive for neck tightness and/or asymmetry of the shoulder.

Chronic cerebrospinal venous insufficiency and Meniere’s Disease

If you have made it to this article, you are likely someone who has been through a long medical history with Meniere’s Disease and are researching a bit deeper than simple facts about how many people are affected with Meniere’s Disease or that you have fluid in your ears possibly caused by various problems including autoimmune disease such as multiple sclerosis, allergy-causing Endolymphatic hydropsor or excessive build-up of the endolymph fluid in the inner ear, and/or a family history of Meniere’s disease. It is equally unlikely that at the onset of your Meniere’s Disease that anyone spoke to you about the connection to neck instability unless you brought up neck pain as part of your conditions to your doctors. Even then you were probably suggested to a change in diet and various hearing and balance tests and told that there is no cure for Meniere’s Disease but it could be managed by medication and change of lifestyle. Then you were told that in some people, Meniere’s disease will just go away or achieve spontaneous remission.

Again, in this article, we will discuss and focus on those aspects of upper cervical spine instability which may be the underlying cause of Meniere’s disease. Let’s being with a discussion of Chronic cerebrospinal venous insufficiency.

Chronic Cerebrospinal Venous Insufficiency is exactly what it sounds like. You have a chronic problem moving cerebrospinal fluid out of your brain via the venous or vein network. Since Meniere’s disease may be a condition caused by Multiple Sclerosis your doctor may have suggested you get a brain MRI to rule out MS. Once MS was ruled out and you had many of the coexisting conditions that were mentioned above along with your Meniere’s Disease, you and your doctor and perhaps your neurologist may be at a loss as to what may be causing the Meniere’s Disease and these other symptoms and conditions. Craniocervical Instability, upper cervical spine instability, cervical spine instability, and Multiple Sclerosis share the following challenges.

What are we seeing in this image? Chronic cerebrospinal venous insufficiency and how it may cause Meniere’s disease.

In this image, we are seeing the veins that make up the cervical venous system. The cervical venous system is part of the brain drainage system or glymphatic system. Fluids and waste products from the brain make their way out of the brain through this system. When these veins are compressed or impinged upon by the bones of the neck, the vertebrae, you can develop Chronic cerebrospinal venous insufficiency, your brain is not draining correctly. This can lead to conditions such as brain fog, memory problems, intracranial hypertension, pseudotumor cerebri (vision and headache problems) dizziness, head pressure, eye pain, and decreased or blurry vision, and as we will see in the research of this article Meniere’s Disease.

What are we seeing in this image? Arterial and venous obstruction of fluid into and out of the brain

I like to explain to patients this vital component of their brain health, the ability to flush out waste fluids from the brain and replace these fluids with fresh fluid, as the analogy of a Brain Toilet Obstruction. The feedback from our patients made it clear this analogy seemed to resonate with them as the best way to understand the fluid in and fluid out of “brain-draining.”

In this split image, the image to the left shows a stable neck with a normal cervical spine curvature. Everything is in the cervical spine in is its proper place. Cerebrospinal fluid drains and refills within the brain.

In the image to the right, we see cervical spine instability. The displacement of the C1 is exerting pressure on the arteries and veins leading into and out of the brain. The Cerebrospinal fluid is now backing up into the brain. In this situation, the fluid build up of Meniere’s Disease may occur.

The brain needs to drain out or flush out toxins and refill itself with fresh fluids. In the image to the right, it is pointed out that obstruction of the veins and arteries will cause a “clogged toilet.” What happens when the toilet clogs?

• The arteries that bring fresh oxygen, nutrients, and clean fluids to the brain will be impeded.
• The veins that help flush out toxic buildup will clog.

Research connecting Chronic cerebrospinal venous insufficiency and Meniere’s Disease

The researchers of a May 2017 study in the medical journal Acta Otolaryng (3) suggest and confirm a correlation between chronic cerebrospinal venous insufficiency (CCSVI) diagnosis and Meniere’s Disease. The researchers further suggest that chronic cerebrospinal venous insufficiency could be considered a new ultrasound vascular pattern of the cerebrospinal venous system in patients affected by definite Meniere’s Disease.

An August 2020 study in the medical journal Laryngoscope (4) evaluated the incidence of chronic cerebrospinal venous insufficiency in Meniere’s Disease patients and the effect of bilateral percutaneous transluminal (balloon) angioplasty of the jugular/azygos veins compared to medical therapy. Note: We do not offer angioplasty in our office, however, some patients may require this type of treatment. This study is presented here to show the connection between Meniere’s Disease and cerebrospinal venous insufficiency. Here are the learning points of this research:

• Five hundred fourteen subjects were included in the study, 412 affected by definite Meniere’s Disease, and 102 healthy controls.
• All patients underwent audiovestibular and vascular examination.
• Patients with Meniere’s Disease and concomitant cerebrospinal venous insufficiency were divided into two subgroups: patients who underwent vascular intervention with bilateral percutaneous transluminal angioplasty (PTA) of the jugular/azygos veins and patients treated with medical therapy (Medication).

Results: Over 80% of Meniere’s Disease patients had cerebrospinal venous insufficiency

• Chronic cerebrospinal venous insufficiency was diagnosed in 330/412 (80.1%) of Meniere’s Disease patients.
• Conclusions: The results of the present study confirm the close relationship between vascular disorders and Meniere’s Disease. The encouraging responses to vascular interventional therapy on Meniere’s Disease symptoms suggest that this may be a promising path for interpretation and treatment of this complex disease.

Note: As explained previously, some people have blockage of the veins caused by vascular disease, some people have cerebrospinal venous insufficiency caused by cervical spine instability. We treat cervical spine instability.

In this video Ross Hauser, MD discusses general problems of ear pain, ear fullness, sound sensitivity, and hearing problems.

Atlantoaxial instability: C1 and C2 hypermobility causes cervical spine instability and artery, vein, and nerve compression

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.