What should be included in the initial workup for Meniere's (Meniere's disease)?

Initial Workup for Meniere's Disease

The initial workup for Meniere's disease should include a detailed history of vertigo episodes, audiometric testing, and assessment for vestibular migraine, while avoiding unnecessary imaging unless needed to rule out other conditions. 1

Detailed History Taking

When evaluating a patient with suspected Meniere's disease, focus on:

• Vertigo characteristics:

  • Duration (20 minutes to 12 hours for definite Meniere's)
  • Spontaneous vs. provoked onset
  • Frequency of attacks
  • Associated symptoms during attacks 1

• Otologic symptoms:

  • Fluctuating hearing loss
  • Tinnitus
  • Aural fullness/pressure sensation
  • Timing of these symptoms in relation to vertigo episodes 1

• Differential diagnosis indicators:

  • Headache history (for vestibular migraine)
  • Light sensitivity during attacks
  • Motion intolerance
  • Visual auras
  • Prior ear surgeries or infections
  • Neurologic symptoms 1

Essential Diagnostic Testing

1. Audiometric testing (STRONG RECOMMENDATION):

   • Pure tone thresholds
   • Speech recognition testing
   • Assessment for conductive components
   • Look specifically for low- to mid-frequency sensorineural hearing loss 1

2. Vestibular migraine assessment:

   • Screen for history of migraine headaches
   • Assess for migraine-associated symptoms during vertigo attacks
   • Note that 35% of Meniere's patients may also meet criteria for vestibular migraine 1

When to Consider Additional Testing

• Vestibular function testing (electronystagmography or videonystagmography):

  • Helps evaluate vestibular function
  • May show reduced caloric response in affected ear
  • Consider when diagnosis is uncertain 1

• Electrocochleography:

  • Measures electrical responses of the cochlea
  • May show increased summating potential/action potential ratio
  • Not required for initial diagnosis 1

• MRI of brain/internal auditory canals:

  • NOT routinely recommended for all patients
  • Consider only when:
    • Asymmetric hearing loss without vertigo
    • Neurologic symptoms present
    • Atypical presentation
    • To rule out retrocochlear pathology 1, 2

Diagnostic Criteria to Establish

For definite Meniere's disease, document:

1. Two or more spontaneous vertigo attacks lasting 20 minutes to 12 hours
2. Audiometrically documented low- to mid-frequency sensorineural hearing loss in the affected ear
3. Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear 1

Common Pitfalls to Avoid

• Misdiagnosis of vestibular migraine as Meniere's disease (or vice versa)

  • VM may have longer or shorter vertigo duration
  • VM often has light sensitivity and visual auras
  • VM typically has stable or minimal hearing loss 1

• Ordering unnecessary imaging

  • MRI is not needed for typical presentations
  • Reserve for atypical cases or when neurologic symptoms are present 2

• Failing to document hearing loss

  • Audiometric confirmation is essential for definite diagnosis
  • Serial audiograms may be needed to capture fluctuating loss 1

• Overlooking other conditions that can mimic Meniere's:

  • Otosyphilis
  • Autoimmune inner ear disease
  • Perilymphatic fistula
  • Superior semicircular canal syndrome
  • Lyme disease
  • Multiple sclerosis 2

By following this systematic approach to the initial workup of Meniere's disease, you can establish an accurate diagnosis and develop an appropriate treatment plan for your patient.