What are the symptoms and management options for Meniere's disease?

Meniere's Disease: Symptoms and Management

Meniere's disease is characterized by the classic triad of episodic vertigo, fluctuating sensorineural hearing loss, and tinnitus, with aural fullness often considered the fourth cardinal symptom. 1, 2

Diagnostic Criteria and Clinical Presentation

Core Symptoms

• Vertigo: Spontaneous attacks lasting 20 minutes to 12 hours
• Hearing Loss: Audiometrically documented fluctuating low- to mid-frequency sensorineural hearing loss
• Tinnitus: Often fluctuating in intensity, typically worsening during or before attacks
• Aural Fullness: Sensation of pressure in the affected ear

For definitive diagnosis, a patient must experience at least two spontaneous vertigo attacks with documented fluctuating hearing loss in the affected ear before, during, or after one of the episodes 1.

Additional Clinical Features

• Nausea and vomiting during attacks
• Difficulty standing or walking during episodes
• Drop attacks (Tumarkin's Otolithic Crisis) may occur in later stages 2
• Progressive hearing loss that initially affects low to mid-frequencies but may eventually involve all frequencies 1

Differential Diagnosis

Condition	Distinguishing Features
Vestibular migraine	May have shorter (<15 min) or longer (>24 hr) attacks; less likely to have hearing loss; often has history of migraine; photophobia common [1]
BPPV	Brief vertigo (seconds) triggered by position changes; no hearing loss [2]
Vestibular neuritis	Prolonged vertigo (days); no hearing loss [2]
Labyrinthitis	Prolonged vertigo with sudden non-fluctuating hearing loss [2]
Vestibular schwannoma	Chronic imbalance rather than episodic vertigo; progressive non-fluctuating hearing loss [2]

Management Options

First-Line Treatments

• Dietary Modifications:

  • Low-sodium diet (1500-2300 mg daily) 1
  • Limit alcohol consumption
  • Limit caffeine intake

• Medications:

  • Diuretics to reduce fluid volume 1, 3
  • Betahistine (histamine analogue) to increase vasodilation to inner ear 1, 4
  • Antivertigo medications for acute symptoms
  • Antihistamines if allergies are suspected

Second-Line Treatments

• Noninvasive Therapies:

  • Vestibular rehabilitation (physical therapy) 1
  • Hearing aids for hearing loss 1, 3

• Middle Ear Injections:

  • Intratympanic steroids 3
  • Intratympanic gentamicin (for refractory vertigo) - note that this reduces vestibular function but complete ablation is not typically required 5

Third-Line/Surgical Options

• Hearing-Sparing Procedures:

  • Endolymphatic sac decompression 1, 3
  • Vestibular nerve section (middle fossa approach) - can provide complete relief of vertigo in up to 94% of cases while preserving hearing in 76% of patients 6

• Ablative Procedures (for severe, refractory cases):

  • Labyrinthectomy (sacrifices remaining hearing) 1, 6

Monitoring and Follow-up

Clinicians should document resolution, improvement, or worsening of:

• Vertigo frequency and severity
• Tinnitus intensity
• Hearing loss progression
• Quality of life impact 1

Quality of Life Considerations

Meniere's disease can significantly impact quality of life, causing:

• Anxiety and depression
• Social isolation
• Reduced work productivity
• Fear of unpredictable attacks 2

Patient Education

Patients should be encouraged to:

• Keep a symptom journal to identify potential triggers
• Join support groups for knowledge and emotional support
• Understand the unpredictable and fluctuating nature of the disease 1

Common Pitfalls in Diagnosis and Management

• Misdiagnosing vague "dizziness" as Meniere's disease without confirming true rotational vertigo
• Failing to obtain audiometric documentation of fluctuating hearing loss
• Overlooking vestibular migraine, which can closely mimic Meniere's disease
• Underestimating the emotional and psychological impact of the condition
• Delaying referral for more aggressive interventions when conservative measures fail

Careful documentation of symptoms, regular audiometric testing, and systematic progression through treatment options are essential for optimal management of this challenging condition.