Ménière’s Disease: A Detailed Guide to the Inner-Ear Disorder

Last Updated on May 13, 2026 by Nurseslab.in Editorial Team

Overview

Ménière’s disease is a chronic disorder of the inner ear characterised by recurrent spontaneous attacks of vertigo together with fluctuating sensorineural hearing loss, tinnitus, and a feeling of pressure or fullness in the affected ear. It generally begins in one ear, although both ears can become involved over time. Attacks are unpredictable: one person may have an isolated episode followed by years of stability, while another may experience clusters of attacks that substantially disrupt work, travel, sleep, and independence.

The disorder has no single definitive test and no universal cure. Diagnosis depends on a characteristic clinical pattern, confirmation of hearing loss, and exclusion of mimicking conditions. Treatment aims to reduce the frequency and severity of vertigo, relieve nausea, maintain hearing and communication, manage tinnitus, restore balance, prevent falls, and protect quality of life. A stepwise plan is usually safest because more aggressive treatments may control vertigo at the cost of hearing or balance function.

Inner-Ear Anatomy and Function

The inner ear contains the cochlea, which converts sound vibrations into nerve signals, and the vestibular organs, which detect head movement, gravity, and linear acceleration. These delicate structures form the membranous labyrinth and are filled with endolymph. Hair cells bend as fluid moves, producing electrical signals that travel through the eighth cranial nerve to the brain. A separate surrounding fluid, perilymph, has a different electrolyte composition. Precise pressure and chemical balance are essential for normal hearing and equilibrium.

Ménière’s disease is associated with endolymphatic hydrops, an abnormal expansion of the endolymph-containing spaces. Hydrops may disturb the mechanical and electrical environment of both hearing and balance receptors. It is an important pathological feature, but it is not identical to the clinical disease: hydrops can occur in other conditions and may be detected without the classic symptom pattern. Why hydrops develops and why symptoms fluctuate remain incompletely understood.

Causes and Proposed Mechanisms

Most cases are idiopathic, meaning that no single cause is proven. The disease probably represents a final common pathway produced by several biological influences rather than one uniform disorder.

• Impaired endolymph regulation: Abnormal production, circulation, or absorption of inner-ear fluid may contribute to hydrops.
• Genetic susceptibility: Familial clustering occurs in a minority of cases, and several genetic pathways are under investigation.
• Immune mechanisms: Autoimmune or inflammatory responses may alter inner-ear homeostasis in some patients.
• Migraine biology: Vascular and sensory-processing pathways overlap with vestibular migraine, and the two conditions may coexist.
• Previous viral or inflammatory injury: Earlier inner-ear damage has been proposed, but a specific infectious cause is rarely demonstrated.
• Allergic or metabolic influences: These may matter in selected individuals, although routine broad testing is not supported without clinical clues.
• Secondary hydrops: Trauma, infection, surgery, congenital abnormalities, or other ear disorders can create a similar fluid imbalance and symptom pattern.

Who Is Affected?

Ménière’s disease can develop at any age but most often begins in adulthood, particularly between 40 and 60 years. It is uncommon in children. Estimates vary because there is no single diagnostic test and other vestibular disorders are frequently confused with it. The disease usually starts unilaterally. National Institute on Deafness and Other Communication Disorders information indicates that both ears are affected in roughly 15% to 25% of patients. Bilateral disease has greater implications for hearing rehabilitation and the choice of destructive treatments.

Core Symptoms

• Episodic vertigo: A false sensation that the person or surroundings are spinning or moving. Attacks begin spontaneously and typically last 20 minutes to 12 hours in definite disease. Severe nausea, vomiting, sweating, pallor, and inability to walk may accompany them.
• Fluctuating sensorineural hearing loss: Lower frequencies are often affected early. Hearing may improve between attacks initially, but repeated injury can lead to permanent loss, broader frequency involvement, reduced speech understanding, and sound distortion.
• Tinnitus: Ringing, roaring, buzzing, humming, or another internally perceived sound in the affected ear. It may intensify before or during an attack and can later become constant.
• Aural fullness: Pressure, congestion, discomfort, or a blocked sensation in the affected ear despite a normal ear canal and eardrum.
• Imbalance: Unsteadiness may persist for hours or days after an attack. Chronic imbalance can develop later as vestibular function declines.
• Sound sensitivity and distortion: Loudness recruitment can make moderately loud sounds uncomfortable, and music or speech may sound altered.
• Drop attacks: Sudden falls without loss of consciousness can occur when abrupt vestibular signals disturb postural reflexes. These are uncommon but carry major injury risk.

Typical Course of an Attack

Some patients notice warning symptoms such as increasing tinnitus, muffled hearing, ear pressure, disequilibrium, or a vague sensory change. Others have no warning. During the attack, movement often makes vertigo and nausea worse, so the person may need to lie still in a dark, quiet place. Hearing may feel reduced and tinnitus louder. After rotational vertigo settles, fatigue, headache, motion sensitivity, and unsteadiness may persist into the next day or longer.

Attack frequency is highly variable. Episodes can cluster over days or weeks and then disappear for months or years. Over time, dramatic rotational attacks may become less frequent, while permanent hearing loss, tinnitus, and chronic balance difficulty become more prominent. This older “staging” description is useful for counselling but does not predict every patient’s course.

Diagnostic Criteria

The diagnosis is clinical and should be made after considering common mimics. Guideline criteria distinguish definite and probable disease.

• Definite Ménière’s disease: At least two spontaneous vertigo episodes lasting 20 minutes to 12 hours; audiometrically documented low- to mid-frequency sensorineural hearing loss in one ear on at least one occasion before, during, or after an episode; fluctuating hearing loss, tinnitus, or pressure in that ear; and no better alternative diagnosis.
• Probable Ménière’s disease: At least two episodes of vertigo or dizziness lasting 20 minutes to 24 hours; fluctuating aural symptoms in the affected ear; and no better alternative diagnosis. Audiometric confirmation may not yet meet definite criteria.

Diagnostic Evaluation

1. Detailed episode history: Describe whether the sensation is true spinning, light-headedness, imbalance, or visual motion; note duration, frequency, triggers, warning symptoms, recovery, falls, nausea, and neurological features.
2. Aural history: Identify which ear is affected, fluctuation in hearing, tinnitus character, fullness, sound distortion, ear pain, discharge, surgery, infection, noise exposure, and previous sudden hearing loss.
3. Migraine assessment: Ask about headache, light or sound sensitivity, visual aura, motion sensitivity, and personal or family migraine history because vestibular migraine is a major mimic and may coexist.
4. Medication and medical history: Review ototoxic medicines, blood-pressure drugs, sedatives, alcohol, cardiovascular risks, autoimmune disease, infection, trauma, and anxiety symptoms.
5. Physical examination: Examine the ear canal and eardrum; assess eye movements, spontaneous and gaze-evoked nystagmus, cranial nerves, coordination, gait, standing balance, cardiovascular status, and neurological warning signs.
6. Positional testing: The Dix–Hallpike or roll test is used when brief, position-triggered vertigo suggests benign paroxysmal positional vertigo.
7. Pure-tone audiometry: Measures air and bone conduction across frequencies. Fluctuating low- or mid-frequency sensorineural loss supports the diagnosis.
8. Speech testing: Measures speech recognition and can document distortion or a decline not fully explained by tone thresholds.
9. Tympanometry: Assesses middle-ear pressure and eardrum mobility, helping exclude conductive causes of fullness or hearing loss.
10. Serial hearing tests: Comparing results during and between attacks can demonstrate fluctuation and monitor progression.
11. Magnetic resonance imaging: MRI of the internal auditory canals and posterior fossa may be offered when hearing loss is asymmetric or another retrocochlear disorder is possible. Routine imaging is not required solely to “prove” Ménière’s disease.
12. Vestibular tests: Videonystagmography with caloric testing, video head impulse testing, vestibular-evoked myogenic potentials, rotary chair testing, or posturography may define vestibular function, assist rehabilitation, or support difficult treatment decisions. No individual result confirms the disease.
13. Electrocochleography: May provide evidence compatible with hydrops in selected cases, but sensitivity and specificity are insufficient for routine diagnosis.
14. Laboratory tests: Blood tests are selected when anaemia, thyroid disease, metabolic disturbance, autoimmune disease, syphilis, or another systemic condition is suspected; indiscriminate panels are usually low yield.
15. Symptom diary: Document attack timing, duration, hearing changes, tinnitus, diet, sleep, migraine symptoms, menstrual or hormonal context where relevant, treatment use, and functional impact.

Differential Diagnosis

• Vestibular migraine: Episodic vertigo with migraine features; hearing loss is not usually a progressively fluctuating unilateral low-frequency pattern.
• Benign paroxysmal positional vertigo: Brief attacks triggered by rolling in bed, looking up, or changing head position, with characteristic positional nystagmus.
• Vestibular neuritis or labyrinthitis: A prolonged acute vestibular syndrome lasting days; labyrinthitis includes hearing loss.
• Sudden sensorineural hearing loss: Abrupt hearing reduction, sometimes with vertigo, requiring urgent treatment assessment.
• Vestibular schwannoma or another cerebellopontine-angle lesion: Usually progressive asymmetric hearing loss or tinnitus, sometimes with imbalance.
• Stroke or transient ischaemia: Consider especially with sudden persistent vertigo, severe gait inability, focal neurological signs, headache, or vascular risk.
• Autoimmune inner-ear disease: Often rapidly progressive or bilateral hearing loss, sometimes with vestibular symptoms.
• Superior canal dehiscence or perilymph fistula: Sound- or pressure-triggered vertigo, autophony, or symptoms after trauma or straining.
• Otosyphilis, ototoxicity, genetic hearing disease, or inflammatory ear disease: Distinguished by history, testing, and specialist assessment.
• Persistent postural-perceptual dizziness: Chronic non-spinning dizziness worsened by standing, motion, or complex visual environments, sometimes developing after vestibular attacks.
• Cardiovascular or metabolic causes: Arrhythmia, orthostatic hypotension, anaemia, hypoglycaemia, and medication effects can cause light-headedness rather than true vertigo.

Treatment Goals and General Principles

• Control acute vertigo and vomiting safely.
• Reduce future attack frequency and severity.
• Preserve hearing when possible and improve communication.
• Manage tinnitus, aural pressure, and sound sensitivity.
• Restore balance and reduce falls.
• Minimise sedation and avoid unnecessary long-term vestibular suppressants.
• Choose invasive therapy according to residual hearing, status of the opposite ear, bilateral risk, occupation, comorbidity, and patient preference.
• Measure outcomes using attack frequency, hearing, falls, daily function, and quality of life.

Management During an Acute Attack

• Stop driving, climbing, swimming, cooking over heat, or operating machinery as soon as warning symptoms begin.
• Sit or lie in a safe place, keep the head still, and reduce bright light, noise, and visual motion.
• Use a clinician-prescribed vestibular suppressant only for a limited period during severe attacks. Options vary by country and may include an antihistamine, anticholinergic, benzodiazepine, or related agent.
• Use prescribed anti-nausea medication when needed.
• Take small sips of fluid after vomiting unless a clinician has restricted intake.
• Avoid prolonged routine use of vestibular suppressants because sedation increases falls and can delay central compensation.
• Seek urgent assessment if the episode is new, atypical, prolonged, associated with neurological symptoms, or accompanied by sudden hearing loss.

Long-Term Lifestyle and Self-Management

• Regular meals and hydration: Avoid major fluctuations in fluid and solute intake. Dehydration and missed meals can worsen general dizziness.
• Sodium moderation: A consistent lower-sodium pattern may be tried, particularly when recommended by the treating team. Extreme restriction is unnecessary and may be unsafe with some conditions or medicines.
• Caffeine and alcohol: Reduce or avoid them if a clear personal relationship with attacks, tinnitus, sleep, or migraine exists.
• Nicotine avoidance: Supports vascular health and may reduce aggravation of tinnitus or dizziness.
• Sleep and stress management: Regular sleep, relaxation, counselling, or cognitive behavioural strategies can reduce distress and migraine-related triggers even when they do not remove the inner-ear disease.
• Exercise: Safe aerobic and balance activity supports conditioning and vestibular compensation between attacks.
• Trigger diary: Test one change at a time rather than imposing a highly restrictive diet based on assumptions.
• Emergency plan: Keep rescue medication accessible, identify a safe place to lie down, and arrange transport if an attack occurs away from home.

Evidence supporting individual dietary restrictions is not equally strong for every patient. Lifestyle measures are generally low risk when balanced and practical, but failure to improve is not a personal failure. A clinician should review persistent attacks rather than repeatedly adding unsupported restrictions.

Preventive Medicines

• Diuretics: A thiazide-type or other diuretic may be offered to reduce attacks. Blood pressure, kidney function, sodium, potassium, gout risk, and dehydration require consideration.
• Betahistine: Commonly used in many countries as maintenance therapy. Evidence is mixed, availability varies, and suitability must be assessed, particularly with asthma, peptic ulcer disease, or interacting medicines.
• Migraine-directed prevention: Appropriate when vestibular migraine coexists or is the better diagnosis.
• Allergy, autoimmune, or infection treatment: Used only when a specific associated disorder is identified.
• Medication review: Sedatives, ototoxic agents, and blood-pressure medicines that worsen dizziness should be reassessed rather than stopped without advice.

Intra-Tympanic Treatments

When vertigo remains active despite non-invasive management, medicine can be injected through the eardrum into the middle ear, from where it diffuses toward the inner ear.

• Intra-tympanic corticosteroid: May reduce vertigo while posing less risk to hearing than gentamicin. Benefit varies, and repeat injections may be needed. Temporary discomfort, infection, dizziness, or a persistent eardrum perforation can occur.
• Intra-tympanic gentamicin: Deliberately reduces vestibular function in the treated ear and can control refractory vertigo. Hearing may worsen, imbalance can temporarily increase, and rehabilitation may be required. Dose and interval aim to balance vertigo control against toxicity.

Surgical Options

Surgery is reserved for disabling, well-established disease that has not responded to safer measures. Choice depends heavily on useful hearing in the affected and opposite ears.

• Endolymphatic sac surgery: Decompression or shunting aims to modify fluid pressure while preserving hearing. Reported benefit varies, and effectiveness remains debated.
• Vestibular nerve section: The vestibular portion of the eighth nerve is divided to control vertigo while attempting to preserve hearing. It requires intracranial surgery and carries neurological, cerebrospinal-fluid leak, infection, and hearing risks.
• Labyrinthectomy: Removes or disables the balance organ and usually sacrifices remaining hearing in that ear. It is considered when hearing is already non-serviceable and vertigo is severe.
• Cochlear implantation: May improve communication in severe hearing loss. In selected patients it can be combined with or follow destructive vestibular treatment.

Hearing Rehabilitation

• Hearing aids: Adjustable devices help with fluctuating thresholds, although repeated programming may be needed.
• Assistive listening technology: Remote microphones, television streamers, amplified telephones, and captioning improve signal-to-noise ratio.
• Communication strategies: Face the speaker, reduce background noise, request clear rather than louder speech, and confirm key information.
• Tinnitus support: Education, hearing aids, sound enrichment, sleep management, and cognitive behavioural therapy can reduce distress even when the sound persists.
• Cochlear implant assessment: Appropriate when severe sensorineural loss provides limited benefit from conventional hearing aids.

Vestibular Rehabilitation

Vestibular rehabilitation uses gaze-stabilisation, balance, walking, habituation, and conditioning exercises to promote central compensation. It is most useful for chronic imbalance between attacks or after gentamicin or surgery. It is not intended to stop an active fluctuating vertigo attack and can feel temporarily provocative. A vestibular physiotherapist should tailor exercises to fall risk, vision, sensation, musculoskeletal health, and bilateral involvement.

Complications

• Permanent sensorineural hearing loss and reduced speech understanding.
• Chronic tinnitus, sound distortion, and sound sensitivity.
• Persistent disequilibrium or oscillopsia, especially with bilateral vestibular loss.
• Falls, fractures, road-traffic risk, or workplace injury during unexpected attacks.
• Dehydration or electrolyte disturbance after prolonged vomiting.
• Anxiety, anticipatory fear, panic, low mood, social withdrawal, and reduced confidence.
• Loss of employment capacity where driving, heights, machinery, or safety-critical tasks are involved.
• Treatment complications including sedation, low blood pressure, hearing damage, persistent eardrum perforation, or surgical risks.

Prognosis and Long-Term Course

The course cannot be predicted precisely. Many patients experience fewer major vertigo attacks over time, but this apparent “burnout” may reflect progressive loss of vestibular function rather than cure. Hearing commonly fluctuates early and may become permanently impaired. Some people retain useful hearing for decades, while others decline more rapidly. Bilateral involvement increases disability but is not inevitable.

Good outcomes depend on confirming the diagnosis, identifying coexisting migraine or positional vertigo, matching treatment intensity to disability, maintaining communication support, and addressing mental health and occupational consequences. Attack control should be documented over time because natural fluctuation can make an ineffective treatment appear successful.

Living Safely With Ménière’s Disease

• Follow local driving rules and ask the licensing authority or clinician what must be reported. Do not drive when attacks are uncontrolled or warning symptoms are present.
• Tell an employer or occupational-health service if work involves ladders, roofs, open water, fire, cutting equipment, heavy machinery, or responsibility for others’ safety.
• Use handrails, good lighting, non-slip surfaces, and a shower seat if balance is unreliable.
• Avoid swimming alone and take precautions near traffic, platforms, and heights.
• Keep a phone and rescue plan accessible; consider medical identification if drop attacks occur.
• Review alcohol, sedatives, and sleep medicines because combined effects can worsen imbalance.
• Make communication needs visible in healthcare settings; ask for written instructions when hearing fluctuates.
• Seek psychological support when unpredictability, tinnitus, or hearing loss causes distress or avoidance.

Nursing Care of a Patient with Ménière’s Disease

Nursing care focuses on safety during vertigo attacks, symptom relief, hearing support, nausea and hydration management, medication education, lifestyle guidance, anxiety reduction, and coordination with audiology and ear, nose, and throat specialists.

Assessment

• Assess vertigo episodes, including onset, duration, frequency, severity, triggers, associated nausea or vomiting, falls, ability to walk, and recovery time.
• Assess hearing symptoms, including fluctuating hearing loss, tinnitus, ear fullness, sound sensitivity, communication difficulty, and impact on work, school, driving, and relationships.
• Monitor balance, gait, nystagmus, Romberg test findings if performed, fall history, use of assistive devices, and safety risks at home or work.
• Assess nausea, vomiting, hydration status, oral intake, weight changes, mucous membranes, urine output, and risk for electrolyte imbalance during severe attacks.
• Review diagnostic tests and specialist findings such as audiometry, vestibular testing when ordered, MRI if used to rule out other causes, and ear, nose, and throat recommendations.
• Assess medication use, including vestibular suppressants, antiemetics, diuretics, betahistine where used, antihypertensives, sedatives, and medicines that may affect hearing or balance.
• Assess anxiety, fear of attacks, sleep quality, stress, depression, social isolation, coping strategies, dietary habits, caffeine, alcohol, nicotine use, and adherence to follow-up.

Priority Nursing Diagnoses

• Risk for injury related to vertigo, imbalance, falls, nausea, vomiting, or impaired gait.
• Disturbed sensory perception: auditory related to fluctuating sensorineural hearing loss, tinnitus, and ear fullness.
• Nausea related to vestibular dysfunction and vertigo episodes.
• Deficient fluid volume risk related to vomiting, reduced intake, diaphoresis, or medication effects.
• Anxiety related to unpredictable vertigo attacks, hearing changes, and fear of falling or losing independence.
• Ineffective coping related to chronic symptoms, lifestyle changes, work limitations, and social disruption.
• Deficient knowledge related to symptom management, medication use, dietary guidance, fall prevention, and follow-up needs.

Nursing Interventions

• During acute vertigo, help the patient lie still in a safe position, reduce sensory stimulation, dim lights, limit sudden head movement, and keep the environment quiet.
• Implement fall precautions, assist with ambulation, keep the bed low, ensure the call bell is within reach, remove hazards, and advise the patient not to walk alone during attacks.
• Administer prescribed vestibular suppressants, antiemetics, diuretics, betahistine where prescribed, or other medicines, and monitor symptom relief, sedation, dizziness, blood pressure, electrolytes, and adverse effects.
• Monitor hydration, intake and output, vomiting frequency, orthostatic symptoms, and electrolyte results when attacks are severe or diuretics are used.
• Teach slow position changes, avoiding sudden head movements, sitting or lying down when vertigo begins, and avoiding driving, climbing, swimming alone, or operating machinery during or soon after attacks.
• Encourage hearing support through audiology referral, hearing assessment, hearing aids if prescribed, communication strategies, and tinnitus coping measures.
• Support lifestyle strategies such as consistent meals, adequate sleep, stress reduction, limiting personal triggers, and following sodium, caffeine, alcohol, and nicotine guidance from the healthcare provider.
• Prepare and support the patient for specialist treatments when conservative measures fail, such as intratympanic steroid or gentamicin therapy, vestibular rehabilitation, hearing rehabilitation, or surgical options.
• Provide emotional support, validate the disruptive nature of unpredictable attacks, encourage symptom diaries, and refer for counselling or support groups when anxiety or depression affects function.

Patient and Family Education

• Explain that Ménière’s disease is a chronic inner-ear condition that can cause vertigo, hearing loss, tinnitus, and ear fullness, and that treatment aims to reduce attacks and improve function.
• Teach the patient to keep a symptom diary recording vertigo episodes, foods, sodium intake, caffeine or alcohol, stress, sleep, medicines, hearing changes, tinnitus, and triggers.
• Review the medication plan, including when to use medicines for acute vertigo or nausea, how to take maintenance medicines, and when to report side effects such as severe drowsiness, dizziness, dehydration, or palpitations.
• Encourage a low-sodium eating plan if recommended, reading food labels, limiting high-salt processed foods, and discussing caffeine, alcohol, and nicotine reduction with the healthcare team.
• Teach fall-prevention measures at home, including clear walkways, good lighting, handrails, sitting during attacks, and asking for help when dizzy.
• Advise urgent medical assessment for new weakness, facial droop, severe headache, chest pain, fainting, new neurological symptoms, sudden hearing loss, persistent vomiting, dehydration, or vertigo that is different from usual attacks.
• Encourage regular follow-up with ear, nose, and throat specialists, audiology, vestibular rehabilitation, and primary care to monitor hearing, balance, medication effects, and quality of life.

Expected Outcomes

• The patient remains free from falls and injury during vertigo episodes.
• The patient reports reduced severity, duration, or frequency of vertigo episodes according to the treatment plan.
• Nausea and vomiting are controlled and hydration remains adequate.
• The patient uses safe movement, fall-prevention, hearing-support, and symptom-management strategies.
• The patient explains medication use, lifestyle recommendations, warning signs, and follow-up needs.
• The patient reports improved confidence, communication, activity participation, sleep, coping, and quality of life.

Evaluation

Evaluate nursing care by reviewing vertigo frequency and severity, fall events, nausea and vomiting, hydration, hearing changes, tinnitus distress, medication response, side effects, sodium and trigger management, anxiety, sleep, activity tolerance, audiology follow-up, and use of safety strategies. Revise the care plan if attacks increase, falls occur, hearing worsens, vomiting causes dehydration, medication side effects occur, anxiety limits daily life, or specialist treatment and vestibular rehabilitation are needed.

REFERENCES

1. Ménière’s disease. American Academy of Otolaryngology — Head and Neck Surgery. https://www.enthealth.org/conditions/menieres-disease. 
2. Koenen L, Andaloro C. Meniere Disease (https://www.ncbi.nlm.nih.gov/books/NBK536955/). 21 Aug 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
3. Lee A, Webster KE, George B, et al. Surgical interventions for Ménière’s disease (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9955726/). Cochrane Database Syst Rev. 2023 Feb;2(2):CD015249.
4. Ménière’s disease. Vestibular Disorders Association. https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/menieres-disease.
5. National Library of Medicine (U.S.). Meniere disease-self-care https://medlineplus.gov/ency/patientinstructions/000709.htm#:~:text=Avoid%20caffeine%20and%20alcohol%2C%20which,helps%20decrease%20Meniere%20disease%20symptoms. Last reviewed 2/26/2024.
6. Parra-Perez AM, Lopez-Escamez JA. Types of Inheritance and Genes Associated with Familial Meniere Disease (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10335989/). J Assoc Res Otolaryngol. 2023 Jun;24(3):269-279.
7. Webster KE, George B, Galbraith K, et al. Positive pressure therapy for Ménière’s disease (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9948539/). Cochrane Database Syst Rev. 2023 Feb;2(2):CD015248.

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