Initial Diagnostic Tests for Meniere's Disease
An audiogram is mandatory and should be obtained in all patients suspected of having Meniere's disease, while vestibular function testing and electrocochleography should NOT be routinely ordered. 1, 2
Essential Testing
Audiometry (Required)
Audiometric testing is the only required diagnostic test for establishing the diagnosis of Meniere's disease. 1, 2 The audiogram must include:
- Pure tone thresholds at frequencies from 250-8000 Hz, including 3000 and 6000 Hz 3
- Speech recognition testing (word recognition/discrimination scores) in each ear 1, 3
- Assessment for conductive component to rule out middle ear pathology 1
- Documentation of low- to mid-frequency sensorineural hearing loss in the affected ear, which is required for definite diagnosis 1, 2
The audiogram serves multiple critical functions: it differentiates definite from probable Meniere's disease, establishes baseline hearing before treatment, identifies bilateral disease, and guides treatment decisions regarding ablative versus non-ablative therapies. 1
MRI Imaging (Selective Use)
MRI of the internal auditory canal and posterior fossa may be offered in patients with nonfluctuating sensorineural hearing loss, tinnitus, or ear pressure. 1, 2 This imaging is used to exclude other conditions such as vestibular schwannoma that can mimic Meniere's disease. 2, 4 However, MRI is not required for all patients—only when symptoms are not better accounted for by another disorder. 1
Tests That Should NOT Be Routinely Ordered
Vestibular Function Testing (Not Recommended)
Clinicians should NOT routinely order vestibular function testing to establish the diagnosis of Meniere's disease. 1, 2 This includes:
- Videonystagmography (VNG) with caloric testing 2
- Rotary chair testing 2
- Video head impulse testing (vHIT) 2
- Vestibular evoked myogenic potentials (cVEMP and oVEMP) 2
These tests do not establish the diagnosis and add unnecessary cost and time without improving diagnostic accuracy. 1
Electrocochleography (Not Recommended)
Electrocochleography (ECochG) should NOT be routinely ordered for diagnosis. 1, 2 Despite earlier advocacy for this test, the evidence shows:
- Results fluctuate throughout the disease course 2
- Sensitivity and specificity are inconsistent 2, 5
- The test does not correlate reliably with disease stage or symptom duration 5
- Limited diagnostic value compared to clinical criteria and audiometry 5
Clinical Diagnostic Criteria
The diagnosis is primarily clinical, based on:
- Two or more spontaneous vertigo episodes lasting 20 minutes to 12 hours (definite) or up to 24 hours (probable) 1, 2
- Audiometrically documented fluctuating low- to mid-frequency sensorineural hearing loss in the affected ear 1, 2
- Fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear 1
- Exclusion of other causes by appropriate testing 1
Important Differential Diagnosis Consideration
Assess for vestibular migraine when evaluating suspected Meniere's disease. 2 This is critical because:
- Vestibular migraine is highly prevalent (2.7% in population studies, 10% in outpatient clinics) 1
- Up to 35% of Meniere's disease patients also meet criteria for vestibular migraine 1, 3
- Both conditions can coexist, complicating treatment decisions 1
- When uncertainty exists, proceed through noninvasive therapeutic trials before any surgical or ablative interventions 1
Common Pitfalls to Avoid
- Do not rely on tuning fork tests alone for clinical screening—they lack sufficient accuracy for surgical candidacy assessment 1, 3
- Do not order routine laboratory tests unless specific risk factors are present 3
- Do not pursue ablative treatments until adequate trials of conservative management have been attempted, especially when vestibular migraine cannot be excluded 1
- Recognize that fluctuating hearing may only be documented with serial audiograms—a single audiogram may miss this key diagnostic feature, as only 28.6% of patients show fluctuation on multiple audiograms 6