What is the recommended workup and treatment for a patient presenting with symptoms of Meniere's disease?

Workup for Menière's Disease

Diagnose Menière's disease clinically when a patient presents with 2 or more spontaneous vertigo episodes lasting 20 minutes to 12 hours, accompanied by documented low-to-mid frequency sensorineural hearing loss, fluctuating aural symptoms (tinnitus, ear fullness), after excluding other disorders. 1

Essential Diagnostic Workup

Required Testing

• Obtain an audiogram in all patients being evaluated for Menière's disease to document the characteristic low-to-mid frequency sensorineural hearing loss 1, 2
• The hearing loss pattern initially fluctuates in the low-to-mid frequency range but may eventually involve all frequencies as disease progresses 2, 3

Imaging Considerations

• Consider MRI of the internal auditory canal and posterior fossa only in patients with nonfluctuating sensorineural hearing loss to exclude cerebellopontine angle tumors (particularly vestibular schwannomas) 1
• MRI is not routinely needed when the clinical presentation is classic for Menière's disease with fluctuating symptoms 1

Testing NOT Routinely Recommended

• Do not routinely order vestibular function testing or electrocochleography to establish the diagnosis 1
• These tests are time-consuming (approximately 1 hour), may cause discomfort with position changes, and can provoke vertigo and nausea during testing 1

Critical Differential Diagnosis Assessment

Vestibular Migraine

• Determine if patients meet diagnostic criteria for vestibular migraine when assessing for Menière's disease 1
• Vestibular migraine presents with vertigo episodes lasting minutes to days (often >24 hours), frequently with headache history, visual auras, light sensitivity, and motion intolerance 1, 2
• In migraine, "hearing loss" may represent difficulty processing sound rather than true hearing loss, and auditory complaints are often bilateral 1

Other Key Differentials to Exclude

• Benign paroxysmal positional vertigo (BPPV): Brief vertigo episodes (<1 minute) provoked by specific head position changes 2
• Labyrinthitis: Sudden severe vertigo with prolonged symptoms (>24 hours) and hearing loss 2
• Vestibular neuritis: Acute prolonged vertigo without hearing loss 2
• Ask specifically about loss of consciousness (never occurs in Menière's disease), head position triggers (suggests BPPV), and neurologic symptoms 1

Detailed Clinical History Requirements

Vertigo Characterization

• Confirm true vertigo (spinning/rotational sensation) versus vague dizziness or lightheadedness 1
• Document spontaneous versus provoked onset, duration of active vertigo (must be 20 minutes to 12 hours for definite diagnosis), and concurrent otologic symptoms 1
• Ask about drop attacks (Tumarkin's otolithic crisis), which may occur in later disease stages 2, 3

Associated Symptoms

• Document fluctuating hearing loss, tinnitus, and aural fullness specifically before, during, or after vertigo attacks 1
• Inquire about migraine history (current or past), as there is high co-occurrence with Menière's disease 4

Medical and Social History

• Obtain thorough otologic history: prior ear surgery, chronic infections, otalgia, previous hearing loss 1
• Review medications (blood pressure medications, diuretics, chronic vestibular suppressants) 1
• Document family history and social habits: tobacco, caffeine, alcohol, recreational drugs 1
• Exclude diseases mimicking Menière's: otosyphilis, autoimmune inner ear disease, perilymphatic fistula, superior semicircular canal syndrome, Lyme disease, multiple sclerosis 4

Documentation and Monitoring

• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss, plus any change in quality of life at each visit 1
• Regular audiometric testing is essential to monitor hearing progression over time 2, 3
• Encourage patients to keep a symptom journal documenting attack frequency, duration, triggers, and associated symptoms 1

Common Pitfalls to Avoid

• Do not rely on patient's vague description of "dizziness"—specifically ask about spinning/rotational sensation to confirm true vertigo 1
• Do not order extensive vestibular testing routinely; the diagnosis is clinical 1
• Do not miss vestibular migraine, which can closely mimic Menière's disease but has different treatment implications 1
• Recognize that elderly patients with long-standing Menière's may not manifest frank vertigo but rather "vague dizziness" or vestibular disturbance 1
• Remember that 10-25% of cases may eventually affect both ears, impacting surgical decision-making 2

Treatment Approach

Begin with conservative management including low-sodium diet (1500-2300 mg daily), avoidance of caffeine and alcohol, and consider diuretics as first-line therapy, progressing to more invasive interventions only after conservative measures fail. 1, 2, 3

Stepwise Treatment Algorithm

First-Line Conservative Management

• Low-sodium diet (1500-2300 mg daily) to reduce fluid retention and stabilize inner ear fluid dynamics 1, 2, 3
• Limit alcohol and caffeine consumption to prevent symptom exacerbation 1, 3
• Address stress management and sleep hygiene 4

Second-Line Medical Therapy

• Diuretics may be offered for maintenance therapy to reduce symptoms or prevent attacks 1, 3
• Betahistine (histamine analogue) may be offered to increase vasodilation to the inner ear 1, 3
• Antihistamines if allergies are suspected as contributing factors 1, 3

Acute Attack Management

• Offer a limited course of vestibular suppressants (such as meclizine) to patients during Menière's disease attacks 1
• Benzodiazepines and anti-emetics for symptomatic control during vertigo episodes 4
• Avoid chronic use of vestibular suppressants as they can impair central compensation 4

Third-Line Interventions for Refractory Disease

• Intratympanic steroid injections may be offered to patients with active Menière's disease not responsive to conservative measures 1, 2, 3
• Intratympanic gentamicin should be offered to patients with active Menière's disease not responsive to non-ablative therapy 1, 2
• Vestibular rehabilitation/physical therapy should be offered for patients who have failed less definitive therapy and have non-usable hearing 1

Surgical Options (Rarely Needed)

• Endolymphatic sac decompression (hearing-sparing procedure) for patients with usable hearing who fail medical management 2, 3, 4
• Vestibular nerve section (hearing-sparing) for severe vertigo with preserved hearing 3, 4
• Labyrinthectomy (ablative, sacrifices hearing) for severe symptoms with non-usable hearing 3, 4

Hearing Rehabilitation

• Conventional hearing aids for patients with usable hearing 2, 3
• CROS (Contralateral Routing of Signal) hearing aids when speech discrimination is severely compromised 2, 3
• Cochlear implants for severe hearing loss where amplification provides limited benefit 2, 3

Therapies NOT Recommended

• Do not prescribe positive pressure therapy for patients with Menière's disease 1, 2

Patient Education and Counseling

• Counsel patients about the natural history, measures for symptom control, treatment options, and outcomes 1
• Explain that Menière's disease is an adult-onset disorder (most commonly between ages 40-70 years) with sporadic, unpredicted attacks 1
• Inform patients that hearing may worsen, persist, or stabilize over time, but complete restoration is not currently possible 2, 3
• Discuss that up to 60% of patients show improvement with placebo in clinical trials, making treatment efficacy assessment difficult 2
• Provide resources and encourage joining support groups (Vestibular Disorders Association, Menière's Society) 1

Quality of Life Monitoring

• Assess quality of life impact as part of ongoing management 2, 3
• Address the emotional impact of the condition, which should not be underestimated 1
• Recognize that symptoms may cause patients to feel sick, tired, or have difficulty hearing or paying attention 1