What is Meniere's disease

Meniere's Disease: Diagnosis, Characteristics, and Management

Meniere's disease is a chronic inner ear disorder characterized by episodic vertigo attacks lasting 20 minutes to 12 hours, fluctuating low- to mid-frequency sensorineural hearing loss, tinnitus, and aural fullness in the affected ear. 1, 2

Diagnostic Criteria

According to the American Academy of Otolaryngology-Head and Neck Surgery, definite Meniere's disease requires:

• Two or more spontaneous attacks of vertigo, each lasting 20 minutes to 12 hours
• Audiometrically documented fluctuating low- to mid-frequency sensorineural hearing loss 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 fullness) in the affected ear 1

Pathophysiology

• The underlying pathology involves endolymphatic hydrops - excessive accumulation of endolymph fluid in the inner ear 1, 3
• Multiple factors may contribute to this condition:
  • Genetic susceptibility
  • Autoimmune mechanisms
  • Vascular events
  • Allergic reactions
  • Infectious agents
  • Autonomic nervous system dysfunction 4, 5

Clinical Presentation

• Classic tetrad of symptoms:

  • Episodic vertigo (rotational spinning sensation)
  • Fluctuating hearing loss (initially affecting low to mid-frequencies)
  • Tinnitus (often fluctuating in intensity)
  • Aural fullness/pressure 2, 3

• Additional features:

  • Hearing loss may eventually progress to involve all frequencies
  • Tinnitus often worsens during or before attacks
  • Some patients may experience drop attacks (Tumarkin's Otolithic Crisis) in later stages 2
  • Bilateral involvement occurs in 25-40% of cases 4
  • Headache may accompany attacks 4

Differential Diagnosis

Meniere's disease must be distinguished from other vestibular disorders:

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
BPPV	Brief vertigo (seconds) triggered by position changes; no hearing loss
Vestibular neuritis	Prolonged vertigo (days); no hearing loss
Labyrinthitis	Prolonged vertigo with sudden non-fluctuating hearing loss
Vestibular schwannoma	Chronic imbalance rather than episodic vertigo; progressive non-fluctuating hearing loss
Stroke/ischemia	May have other neurological symptoms; usually no associated hearing loss or tinnitus [2]

Management Approach

First-Line Treatment

• Dietary modifications:
  • Low-sodium diet (1500-2300 mg daily) 2
  • Avoid caffeine, alcohol, and tobacco
• Medications:
  • Diuretics to reduce endolymphatic fluid
  • Betahistine (commonly used in Europe) 2, 4
• Symptomatic treatment during acute attacks:
  • Vestibular suppressants
  • Anti-emetics
  • Benzodiazepines for anxiety if needed 6

Second-Line Treatment

• Intratympanic therapies:
  • Gentamicin (chemical labyrinthectomy) - effective for vertigo control but may affect hearing 3, 7
  • Steroids - particularly if autoimmune mechanisms are suspected 4, 6

Surgical Options (for refractory cases)

• Hearing-preserving procedures:
  • Endolymphatic sac decompression
  • Vestibular nerve section
• Ablative procedures:
  • Labyrinthectomy (sacrifices remaining hearing) 2

Patient Education and Monitoring

• Encourage patients 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 2

• Regular follow-up to monitor:

  • Vertigo frequency and severity
  • Tinnitus intensity
  • Hearing loss progression
  • Quality of life impact 2

Prognosis and Quality of Life

• Meniere's disease can significantly impact quality of life, causing anxiety, depression, and social isolation 2
• The condition often shows a natural tendency to improve over time, with many patients experiencing fewer vertigo attacks after several years
• However, hearing loss may continue to progress despite reduction in vertigo episodes

Common Pitfalls

• Misdiagnosis due to overlap with other vestibular disorders, particularly vestibular migraine
• Focusing only on vertigo management while neglecting hearing preservation
• Delaying appropriate interventions when conservative management fails
• Underestimating the psychological impact of the disease on patients' quality of life

1, 2