What are the diagnostic and management approaches for a patient presenting with symptoms of Menderes disease?

Symptoms of Ménière's Disease

Ménière's disease presents with four cardinal symptoms: episodic vertigo lasting 20 minutes to 12 hours, fluctuating low- to mid-frequency sensorineural hearing loss, tinnitus (ringing or buzzing in the ear), and aural fullness (sensation of ear pressure or plugging). 1

Core Symptom Complex

Vertigo Characteristics:

• Episodes last between 20 minutes to 12 hours (definite MD) or up to 24 hours (probable MD) 1
• Described as a spinning or rotational sensation, not simple lightheadedness 1
• Attacks are spontaneous and unpredictable 1
• May be accompanied by nausea and vomiting during acute episodes 1

Hearing Loss Pattern:

• Fluctuating sensorineural hearing loss, typically affecting low- to mid-frequencies (≤2000 Hz) initially 1
• Hearing may abruptly worsen then improve, especially early in disease onset 1
• Over time, hearing loss may become permanent and progressive 1
• Asymmetric between ears (≥15 dB difference in pure tone average or ≥15% difference in word recognition scores) 1

Tinnitus:

• Ringing, buzzing, roaring, or other phantom noises in the affected ear 1
• Sound quality varies between patients 1
• May fluctuate in intensity, often worsening during or before vertigo attacks 1

Aural Fullness:

• Sensation that the ear is full, plugged, or under pressure 1
• Typically occurs in the affected ear during or before attacks 1

Additional Clinical Features

Drop Attacks (Tumarkin's Otolithic Crisis):

• Sudden falls without warning or loss of consciousness 1
• Occur in later stages of disease, not present in all patients 1
• Result from sudden vestibular stimulation 1

Associated Symptoms:

• Headache during attacks (common finding) 1, 2
• Photophobia or light sensitivity during episodes 1
• Symptoms worsen with head movement during attacks 1
• Anxiety and fear between attacks due to unpredictability 1

Temporal Pattern and Natural History

Disease Onset:

• Most commonly begins between ages 40-70 years, with average onset in the fourth decade 1, 3
• Attacks are sporadic and unpredictable 1
• Initially unilateral in most cases, but 25-40% develop bilateral involvement over time 2

Disease Progression:

• Early stages: fluctuating symptoms with periods of remission 1
• Later stages: hearing loss may stabilize or worsen permanently 1
• Vertigo attacks may decrease in frequency over 10+ years while hearing deteriorates 1, 4
• Residual imbalance may persist between attacks 1

Diagnostic Symptom Criteria

Definite Ménière's Disease requires: 1

• Two or more spontaneous vertigo attacks lasting 20 minutes to 12 hours
• Audiometrically documented low- to mid-frequency sensorineural hearing loss in the affected ear on at least one occasion
• Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear
• Symptoms not better explained by another disorder

Probable Ménière's Disease requires: 1

• At least two episodes of vertigo or dizziness lasting 20 minutes to 24 hours
• Fluctuating aural symptoms in the affected ear
• Other causes excluded

Important Clinical Pitfalls

Red Flags Suggesting Alternative Diagnosis:

• Bilateral sudden hearing loss (consider autoimmune disease, meningitis, ototoxicity) 1
• Focal neurological symptoms (weakness, dysarthria, diplopia) suggest central pathology 1
• Continuous rather than episodic vertigo 1
• Vertigo episodes lasting seconds (consider BPPV) or days (consider vestibular neuritis) 1
• High-frequency hearing loss pattern (atypical for MD) 1

Documentation Requirements:

• Keep a symptom diary tracking frequency, duration, and severity of attacks 1
• Note triggers including sodium intake, stress, caffeine, alcohol, weather changes, and allergies 1
• Record impact on daily activities and quality of life 1