From the Guidelines
The workup for Meniere's disease should include a comprehensive medical history, physical examination, and specialized testing, starting with audiometric testing, as recommended by the 2020 clinical practice guideline 1. The diagnosis of Meniere's disease is primarily based on clinical symptoms, including episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness, as outlined in the 2020 guideline 1. Key components of the workup include:
- Audiometric testing, such as pure tone audiometry, speech discrimination, and tympanometry, to document characteristic low-frequency sensorineural hearing loss, as recommended by the 2020 guideline 1.
- Vestibular function tests, like electronystagmography (ENG) or videonystagmography (VNG), to assess balance function and identify vestibular abnormalities.
- Electrocochleography (ECoG) to show increased summating potential to action potential ratio, suggesting endolymphatic hydrops.
- Imaging studies, particularly MRI with contrast of the internal auditory canals, to exclude other pathologies like vestibular schwannoma or multiple sclerosis.
- Laboratory tests, including complete blood count, thyroid function tests, syphilis serology, and autoimmune markers, to rule out other causes.
- A glycopyrrolate test to help distinguish Meniere's from vestibular migraine. Additionally, vestibular rehabilitation/physical therapy should be offered to patients with chronic imbalance, as recommended by the 2020 guideline 1. This comprehensive approach is necessary because Meniere's remains a clinical diagnosis of exclusion, with no definitive single diagnostic test available, as noted in the 2020 guideline 1.
From the Research
Diagnostic Approach for Meniere's Disease
- The diagnosis of Meniere's disease often relies on a combination of clinical history, physical exam, audiometry, and adjunctive tests such as electrocochleography (ECOG) and electronystagmography (ENG) 2.
- A study found that 1 in 3 practitioners relied solely on history, physical exam, and audiometry for diagnosis, while 2 in 3 relied in part on adjunctive tests 2.
- Bedside examination, including video head impulse test, skull vibration-induced nystagmus, positional test, and post head shaking test, can also be useful in diagnosis, with a characteristic phenotypic pattern observed in patients with Meniere's disease 3.
Role of Imaging in Diagnosis
- Intravenous gadolinium-enhanced inner ear magnetic resonance imaging (IV Gd-enhanced inner ear MRI) is a new technique for diagnosing Meniere's disease, with a sensitivity of 93.8% and specificity of 81.3% 4.
- MRI can identify endolymphatic hydrops (EH) and perilymphatic enhancement (PE) in the inner ear, with EH observed in 93.7% of symptomatic ears and 68.7% of asymptomatic ears 4.
- A systematic review found that MRI can be useful in diagnosing Meniere's disease, particularly in identifying saccular hydrops, but further research is needed to establish its role in clinical practice 5.
Vestibular Tests
- Vestibular tests, including video Head Impulse Test (vHIT), cervical Vestibular Evoked Myogenic Potential (cVEMP), and air caloric test, can be used to evaluate patients with Meniere's disease, with a sensitivity of 100% and specificity of 50% 4.
- However, the reliability of individual tests, such as vHIT, is limited, and a combination of tests is recommended for accurate diagnosis 4.
Clinical History and Hearing Tests
- Clinical history and hearing tests are essential components of the diagnostic workup for Meniere's disease, with a thorough anamnesis and bedside examination crucial in diagnosis 3.
- Hearing tests, including conventional audiometry, can help identify hearing loss associated with Meniere's disease, with a positive correlation between hearing thresholds and the degree of cochlear EH observed 4.