A 55-year-old presents with recurrent episodic vertigo lasting 20-30 minutes, low-pitched tinnitus, and hearing loss predominantly in the lower frequencies (250-1000 Hz). Glycerol dehydration test shows >15 dB improvement in hearing threshold. The MOST appropriate initial medical therapy targeting the underlying pathophysiology is:

• A Systemic corticosteroids alone as first-line treatment for all Meniere's patients
• B Betahistine (histamine H3 receptor antagonist/H1 agonist) to increase cochlear blood flow and improve endolymphatic sac resorption, combined with dietary sodium restriction (<2g/day) and a loop diuretic (furosemide) or thiazide-triamterene ✓
• C Intratympanic gentamicin as first-line therapy to ablate vestibular function
• D Endolymphatic sac decompression as the preferred initial treatment

Explanation

First-line medical treatment for Meniere's disease consists of: (1) betahistine (16-48 mg TID) — an H3 receptor antagonist that increases histamine release, dilates cochlear microvasculature, and improves endolymphatic sac drainage; (2) dietary sodium restriction (<2g NaCl/day) to reduce endolymph production; (3) diuretics (hydrochlorothiazide-triamterene or acetazolamide) to reduce endolymph volume. Intratympanic gentamicin is reserved for medically refractory Meniere's with disabling vertigo; it ablates vestibular function but risks SNHL. Endolymphatic sac surgery is performed when medical management fails over 6-12 months.

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.