What is the recommended investigation for a patient with Meniere's disease and tinnitus to confirm the diagnosis and guide management?

Investigation for Tinnitus in Menière's Disease

An audiogram is mandatory and should be obtained immediately when assessing any patient with suspected Menière's disease and tinnitus—this is essential for confirming the diagnosis and cannot be bypassed. 1

Essential Diagnostic Investigation

Audiometric Testing (Required)

Audiometry is the cornerstone investigation and must include:

• Pure tone audiometry measuring thresholds at 250-8000 Hz, with particular attention to low-to-mid frequencies (≤2000 Hz) where Menière's disease characteristically causes sensorineural hearing loss 1, 2
• Speech recognition testing (word recognition scores/WRS) in each ear to assess functional hearing and rule out retrocochlear pathology 1
• Bone conduction testing to confirm the sensorineural nature of hearing loss and exclude conductive components 1

Why audiometry is non-negotiable: The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that audiometric data is necessary to differentiate probable versus definite Menière's disease, as hearing loss is a required diagnostic criterion. 1 Without documented sensorineural hearing loss on audiometry, the patient does not meet criteria for definite Menière's disease and an alternative diagnosis must be considered. 1

Key diagnostic findings to identify:

• Asymmetric hearing loss defined as >15 dB difference in pure tone average (500,1000,2000 Hz) between ears OR >15% difference in word recognition scores 1, 2
• Low-to-mid frequency sensorineural hearing loss (≤2000 Hz), which is the characteristic pattern in Menière's disease 1, 2
• Fluctuating hearing thresholds when compared to previous audiograms, though this may not be captured on a single test 1

Additional Baseline Assessment

Tinnitus characterization should document:

• Laterality (unilateral vs bilateral), pitch, loudness, quality, and temporal pattern 3
• Impact on quality of life using validated measures 1
• Associated symptoms including aural fullness and vertigo characteristics 1, 3

Selective Imaging (Not Routine)

MRI of the internal auditory canal and posterior fossa may be offered only in specific circumstances: 1

• Non-fluctuating sensorineural hearing loss (atypical for Menière's disease)
• Asymmetric hearing loss requiring exclusion of vestibular schwannoma or other retrocochlear pathology 1
• Word recognition scores worse than expected for the pure tone average, suggesting possible retrocochlear involvement 1
• Focal neurological abnormalities on examination 3

Important caveat: MRI is not routinely indicated for typical Menière's disease presentation with fluctuating symptoms. 1 The guideline panel was divided on MRI use, with many comfortable using non-ablative therapies without imaging. 1

Tests That Should NOT Be Routinely Ordered

Vestibular function testing and electrocochleography should not be routinely ordered to establish the diagnosis of Menière's disease. 1 These tests do not improve diagnostic accuracy for typical presentations and add unnecessary cost and patient burden. 1

Clinical Algorithm for Investigation

1. Obtain audiogram immediately in all patients with suspected Menière's disease and tinnitus 1
2. Review audiometric findings:
   • If low-to-mid frequency sensorineural hearing loss present → supports Menière's diagnosis 1
   • If asymmetric hearing loss or poor word recognition → consider MRI to exclude retrocochlear pathology 1, 3
   • If no hearing loss documented → does not meet criteria for definite Menière's disease; reconsider diagnosis 1
3. Document baseline symptoms for future comparison to track disease progression 1
4. Reserve MRI for atypical features or red flags only 1, 3

Common pitfall to avoid: Do not rely on tuning fork examination alone—a recent systematic review demonstrates insufficient accuracy for clinical screening, and formal audiometry remains essential. 1, 2