What is the diagnostic approach for Ménière’s disease?

Diagnostic Approach for Ménière's Disease

Clinicians should diagnose definite or probable Ménière's disease in patients presenting with 2 or more episodes of vertigo lasting 20 minutes to 12 hours (definite) or up to 24 hours (probable) and fluctuating or nonfluctuating sensorineural hearing loss, tinnitus, or pressure in the affected ear, when these symptoms are not better accounted for by another disorder. 1

Diagnostic Criteria

Definite Ménière's Disease

• Two or more spontaneous attacks of vertigo, each lasting 20 minutes to 12 hours
• Audiometrically documented low- to mid-frequency sensorineural hearing loss (SNHL) in the affected ear on at least one occasion before, during, or after one of the episodes of vertigo
• Fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear
• Other causes excluded by appropriate testing

Probable Ménière's Disease

• At least 2 episodes of vertigo or dizziness lasting 20 minutes to 24 hours
• Fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear
• Other causes excluded by appropriate testing

Essential Diagnostic Steps

1. Obtain a detailed history focusing on:

   • Vertigo characteristics (spontaneous onset, duration 20 minutes to 12 hours)
   • Presence of fluctuating hearing loss, tinnitus, or aural fullness
   • Temporal relationship between vertigo and auditory symptoms
   • Rule out positional triggers (which suggest BPPV instead)
   • Absence of loss of consciousness (never a symptom of MD)

2. Perform audiometric testing

   • An audiogram is mandatory when assessing a patient for Ménière's disease 1
   • Look for low- to mid-frequency sensorineural hearing loss
   • Document fluctuations in hearing over time when possible

3. Consider imaging selectively

   • MRI of the internal auditory canal and posterior fossa may be offered in patients with non-fluctuating sensorineural hearing loss, tinnitus, or aural pressure 1
   • Particularly important when symptoms are not clearly consistent with Ménière's disease
   • Helps exclude other causes like vestibular schwannoma or other cerebellopontine angle tumors

4. Avoid routine vestibular function testing

   • Vestibular function tests and electrocochleography (ECochG) should not be routinely ordered to establish the diagnosis 1
   • These tests may show abnormalities but lack sufficient sensitivity and specificity for diagnosis 2
   • Consider these tests only when results will alter patient management or when patients present with atypical symptoms

Differential Diagnosis

Careful exclusion of other conditions that mimic Ménière's disease is essential:

• Vestibular migraine

  • Often presents with vertigo but typically has migraine features
  • May have light sensitivity and motion intolerance
  • Auditory symptoms are often bilateral rather than unilateral

• Other conditions to exclude:

  • Otosyphilis
  • Autoimmune inner ear disease
  • Perilymphatic fistula
  • Superior semicircular canal syndrome
  • Lyme disease
  • Multiple sclerosis
  • Vestibular paroxysmia
  • Temporal bone tumors 3
  • Benign paroxysmal positional vertigo (BPPV)
  • Cerebrovascular events

Diagnostic Pitfalls to Avoid

• Misinterpreting "dizziness": Ensure patients are describing true vertigo (spinning sensation) rather than lightheadedness or presyncope
• Overlooking audiometric documentation: Hearing loss must be documented audiometrically at least once
• Premature diagnosis: Don't diagnose Ménière's disease after a single episode of vertigo
• Unnecessary testing: Avoid routine vestibular function testing or electrocochleography that may delay diagnosis and increase costs
• Missing comorbid conditions: Screen for migraine history due to high rate of co-occurrence with Ménière's disease 3

Documentation Requirements

Document the following to establish and track the diagnosis:

• Frequency and duration of vertigo episodes
• Audiometric findings showing low- to mid-frequency SNHL
• Presence of fluctuating tinnitus and aural fullness
• Resolution, improvement, or worsening of symptoms over time
• Impact on quality of life 1

By following this structured diagnostic approach, clinicians can accurately diagnose Ménière's disease and distinguish it from other vestibular and neurological conditions that may present with similar symptoms.