Different medications for the treatment of Ménière's disease by intratympanic injection: A systematic review and network meta-analysis

Background: It is generally accepted that intratympanic injection provides an effective approach to manage severe vertigo in Ménière's disease. Although there are several medications available, that which is the most effective is still subject to debate. Objective: To assess the effectiveness and safety of the different medications used in the treatment of Ménière's disease by intratympanic injection using a network meta-analysis. Methods: PubMed, EMBASE, CINAHL and CENTRAL were searched. Only randomised controlled trials that compared the effectiveness of medications used for intratympanic injection to treat Ménière's disease with each other or a placebo were included. The primary outcome assessed was the effectiveness of medication in the management of vertigo symptoms. The effectiveness was expressed in terms of risk ratio (RR) with a 95% credible interval (CrI) for individual studies analysed. Network meta-analyses were performed by Stata version 15.0 using the network package. Results: Nine studies involving 314 patients treated with five different medications were included in the present analysis. A number of injections given varied from 1 to 10 and the follow-up time from 3 to 28 months. When compared to each other or to a placebo, Gentamicin was found to be the most efficacious medication, followed by Methylprednisolone, Latanoprost, Dexamethasone and Ganciclovir in order of effectiveness. However, no significant difference in efficacy was found between Gentamicin and Methylprednisolone when outcomes from studies with a follow-up time equal to or more than 24 months were analysed. It was not possible to conduct subgroup and sensitivity analysis because of the limited number of studies that were included. Conclusion: All medications are more effective than a placebo in the treatment of Ménière's disease by intratympanic injection. According to the SUCRA, Gentamicin ranked the most effective, with Gentamicin and Methylprednisolone equally effective in the long-term effect. When the potential risk of hearing loss induced by Gentamicin is taken into consideration, Methylprednisolone may be the best choice for the treatment of Ménière's disease by intratympanic injection.