Meniere's disease is recognized as the idiopathic form of recurrent inner ear disease with the triad of fluctuating hearing loss, tinnitus and vertigo (1). There is no generally accepted tratment strategy for the disease. Betahistine dihydrochloride is recommended as first choice medical treatment and in case of failure in medical treatment and if hearing is worth saving, endolymphatic shunt surgery can be employed (2). I am a 36 year-old-pediatric oncologist and I have been followed with the diagnosis of Meniere's disease for 13 years. At the time of diagnosis I had serious vertigo attacks lasting 4-24 hours, tinnitus and bilateral hearing loss at low frequencies. After 6 months treatment of betahistine dihydrochloride and low-salt diet, the hearing loss was relieved. For 9 years I have experienced 1-2 vertigo attacks per year which were controlled with diphenhydramine and diuretics in acute attack and betahistine dihydrochloride three 16 mg at least 3 months.

For the last four years I have started myself a schedule consisting of betahistine dihydrochloride 8 mg/day resembling metronomic therapy which is a well-known practice in cancer treatment. I have experienced no vertigo attacks, nor have tinnitus or hearing difficulty for 4 years. All audiometric test results made once a year were normal during this period. No side effects developed related with the medication. Betahistine dihydrochloride is an orally administered, centrally acting histamine H1 receptor agonist with partial H3 antagonistic activity. It was clinically studied and is still used mainly as a vasodilator for the treatment of Meniere's disease (3). Its proposed mode of action is to cause vasodilation in ischemic areas of the stria vascularis and dark cells in the areas implicated in the pathogenesis of Meniere's disease (4). Strupp et al. (5) have found that the number of attacks after 12 months was significantly lower in the high dosage group (48 mg tid, n=62) than in the low dosage group (16 mg tid, n=21, 24 mg, n=29) with betahistine dihydrochloride therapy. Taking the medication in a metronomic fashion may regulate the circulation in affected areas continuously. No serious adverse effects was reported with long-term or high dose administration of betahistine dihydrochloride. Prospective clinical studies with adequate numbers of patients will reveal the efficiency of this metronomic therapy with continuous low-dose betahistine dihydrochloride in treatment of Menière's disease.


1. Minor LB, Schessel DA, Carey JP. Ménière's disease. Curr Opin Neurol. 2004 Feb;17(1):9-16.   View Abstract

2. Westhofen M. [Article in German] [Menière's disease : evidence and controversies] HNO. 2009 May;57(5):446-54.   View Abstract

3. Barak N. Betahistine: what's new on the agenda? Expert Opin Investig Drugs. 2008 May;17(5):795-804.   View Abstract

4. Phillips JS, Prinsley PR. Prescribing practices for Betahistine. Br J Clin Pharmacol. 2008 Apr;65(4):470-1. Epub 2008 Feb 12.   View Abstract

5. Strupp M, Hupert D, Frenzel C, Wagner J, Hahn A, Jahn K, Zingler VC, Mansmann U, Brandt T. Long-term prophylactic treatment of attacks of vertigo in Menière's disease--comparison of a high with a low dosage of betahistine in an open trial. Acta Otolaryngol. 2008 May;128(5):520-4.  View Abstract

Serhan Kupeli
Chief of Pediatric Oncology Unit
Diyarbakir Children's Diseases Hospital
Diyarbakir, Turkey

Case 1: Capillary Hemangioma

A 75 year old female was seen with a history of left-sided nasal obstruction with on and off intermittent episodes of epistaxis. CT scan of the paranasal sinuses showed progressively enhancing soft-tissue density or mass occupying entire left nasal cavity causing deviated nasal septum to right side. Diagnostic nasal endoscopy showed a grayish white mass in the left nasal cavity. The external surface was covered by a hemorrhagic crust. The mass was removed by endoscopic approach and was sent for histopathology examination. Histopathology described thickened epithelial covering of squamous type with multiple irregular papillary folds lined by multilayered epithelium that was regular and with uniform nuclei with fibrovascular core infiltrating deeply into the fibro myxoid connective tissue stroma.

Figure 1: View of Capillary Hemangioma Filling the Left Nasal Cavity Click on Pictures to Enlarge

Click on Pictures to Enlarge

Figure 2:  CT Scan of Capillary Hemangioma

The pathologist at our institute reported it as an angiofibroma.
Click on Pictures to Enlarge

View Surgery YouTube Video

But considering the rarity of the extra nasopharyngeal angiofibroma in females, we decided to seek a second opinion and to differentiate between capillary hemangioma and nasopharyngeal angiofibroma. A special stain with CD 31 and CD 34 was set up that revealed its true nature as a capillary hemangioma. Click on Pictures to Enlarge

Abstract:  The Virtual Nystagmotheque is a collection of animations about different nystagmus and other ocular movements, intended for teaching purposes and professional speaking.  It also describes the main differential diagnosis for these ocular movements and how to do some diagnostic tests in a very simple manner.  It was made using digital video, edited and integrated into a commercial animation computer program.

Author:  Manuel Oliva Dominguez, Otolaryngologist,  ENT Department, Hospital Universitario de Puerto Real, Spain

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