What are the typical symptoms and clinical presentation of Meniere's disease?

Symptoms of Meniere's Disease

Meniere's disease presents with a classic tetrad of symptoms: recurrent episodes of rotational vertigo lasting 20 minutes to 12 hours, fluctuating low-to-mid frequency sensorineural hearing loss, tinnitus, and aural fullness in the affected ear. 1, 2

Core Diagnostic Symptoms

Vertigo Episodes

• True rotational (spinning or whirling) vertigo that occurs in spontaneous attacks, each lasting specifically 20 minutes to 12 hours per episode 2
• At least two discrete episodes are required for definite diagnosis 1, 2
• The vertigo is not positional (distinguishing it from BPPV) 2
• Episodes lasting seconds suggest BPPV instead, while episodes lasting days suggest labyrinthitis or vestibular neuritis 2

Hearing Loss

• Fluctuating low-to-mid frequency sensorineural hearing loss documented on audiometry 1, 2
• The fluctuating nature is pathognomonic (characteristic) of the disease 2
• Must be documented before, during, or after at least one vertigo episode 2
• Initially fluctuates but may eventually involve all frequencies as disease progresses 1
• Hearing loss often worsens over time despite treatment 1

Tinnitus

• Occurs in the affected ear and varies in intensity with disease activity 2
• May worsen before or during attacks 2

Aural Fullness

• Sensation of pressure or fullness in the affected ear 2, 3
• Fluctuates with disease activity, often worsening before or during attacks 2

Additional Associated Symptoms

Between Acute Attacks

• Persistent imbalance or ongoing unsteadiness between episodes, distinct from the episodic vertigo 2
• Represents chronic vestibular dysfunction 2
• Contributes to total disability and reduced quality of life 4

Late-Stage Manifestations

• Drop attacks (Tumarkin's otolithic crisis) may occur in later stages 1, 2
• Characterized by sudden falls without loss of consciousness and no warning before the fall 2

Critical Diagnostic Timing

Duration specificity is essential for accurate diagnosis:

• Definite Meniere's disease: vertigo episodes lasting 20 minutes to 12 hours 2
• Probable Meniere's disease: episodes lasting up to 24 hours 2

Common Pitfalls to Avoid

Do not confuse Meniere's disease with these mimics that have distinct timing patterns:

• Vestibular migraine: vertigo episodes lasting minutes to days, often with headache history 1
• BPPV: brief vertigo episodes (seconds) provoked by head position changes 1, 2
• Labyrinthitis: sudden severe vertigo with prolonged symptoms (>24 hours) and hearing loss 1, 2
• Vestibular neuritis: acute prolonged vertigo without hearing loss 1, 2
• Cerebellopontine angle tumors: progressive unilateral hearing loss with imbalance 1

Important Clinical Considerations

• 10-25% of cases may eventually affect both ears over time 1
• Symptoms may not develop or occur simultaneously, requiring careful longitudinal follow-up 3
• If untreated for 10 or more years, hearing may deteriorate as vertiginous episodes gradually subside 3
• The Weber tuning fork test will lateralize to the unaffected ear in unilateral cases 5