Professional Documents
Culture Documents
Meniere Disease
Lukas Koenen; Claudio Andaloro.
Objectives:
Identify the use of the Rinne and Weber test in the history and physical of patients with
Meniere disease.
Review the importance of improving care coordination among the interprofessional team
to enhance the delivery of care for patients affected by Meniere disease.
Introduction
Meniere disease (MD) is a disorder of the inner ear characterized by hearing loss, tinnitus, and
vertigo. In most cases, it is slowly progressive and significantly impacts the social functioning of
the individual affected.[1]
Hearing loss, tinnitus, and vertigo are all common symptomatic complaints with many potential
causes, yet true Meniere disease is quite rare and is fundamentally a diagnosis of exclusion. The
current diagnostic criteria defined by the Barany society by Lopez-Escamez, et al. can help
differentiate between probable and definite Meniere's disease.
Patients with a definite Meniere disease, according to the Barany Society, have:
1. Two or more spontaneous episodes of vertigo with each lasting 20 minutes to 12 hours
Etiology
Studies of the temporal bone revealed endolymphatic accumulation (hydrops) in the cochlea and
the vestibular organ in patients with Meniere disease. Current research links endolymphatic
hydrops to a hearing loss of >40dB. Vertigo may or may not be associated.[3] Therefore
endolymphatic hydrops is not entirely specific to Meniere disease and can be found in cases of
idiopathic sensorineural hearing loss.
The exact etiology of Meniere disease remains unclear. Different theories exist, but genetic and
environmental factors play a role.[4] The relation to common comorbidities remains elusive.
Epidemiology
The prevalence of Meniere disease varies between 3.5 per 100.000 and 513 per
100.000 and occurs more often in older, white, female patients.[5][6][7]
Several comorbidities have been identified which occur in an increased fashion in patients with
Meniere disease:
Migraine: Migraine occurs more often in patients diagnosed with Meniere disease, although
there is likely significant overlap/misclassification of patients with basilar migraine wrongly
diagnosed as having Meniere disease. There are theories regarding a vascular etiology for
Meniere disease, but they remain unproven.[8]
Autoimmune diseases: Several autoimmune diseases are associated with Meniere disease,
namely rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis. IgE has
been proposed as a contributory factor in some studies of middle ear samples in Meniere disease.
[9][10]
Genetic component: Meniere disease is a polygenic disorder. Ten percent of cases in patients of
European descent have familial Meniere disease. The condition may show autosomal dominant
or recessive inheritance but is most commonly sporadic. Precise genetics in Meniere disease is an
area of active research.[11]
Pathophysiology
The precise pathophysiology of Meniere disease is unknown. The most consistent histologic
abnormality is endolymphatic hydrops, though not everyone with documented hydrops develops
MD. Endolymphatic hydrops describes the expansion of the volume of the endolymphatic spaces
and dilatation of Reissner's membrane. The exact pathophysiology of endolymphatic hydrops is
likewise unknown, though the most common theories postulate an imbalance between the
secretion and resorption of endolymph in the cochlea.[12]
History and Physical
In the emergency room or general practice, the physician must differentiate between vertigo of
central, peripheral, and cardiovascular origin. According to Harcourt et al., signs and symptoms
suggestive of a central origin of vertigo are additional neurological symptoms or signs, acute
deafness, a new type or onset of headache, or vertical/torsional/rotatory nystagmus.[13]
A full otologic history is crucial to the clinical investigation for any hearing- or balance-related
complaint. The patient should be questioned about the character of vertigo (with meticulous
attention paid to differentiating true whirling vertigo complaints from more generalized
imbalance or presyncopal sensations), hearing loss, and earlier episodes of these symptoms.
Duration of episodes of vertigo and hearing loss should also be noted, likewise any positional
triggers (vertigo when turning the head would suggest BPPV, for example, while lightheadedness
upon standing suggests orthostatic hypotension). Family history of hearing and balance problems
should also be elicited.
Rinne and Weber: Will show sensorineural hearing loss in acute Meniere disease or advanced
disease, but this will depend on the degree of hearing loss. For this reason, a formal audiology
evaluation is required.
Frenzel goggles: May show horizontal nystagmus with a fast-beating component away from the
affected vestibular organ in the acute setting.
Dix-Hallpike maneuver: A test for BPPV wherein the patient's head is rotated to one side, and the
neck hyperextended. The patient is then taken rapidly from a seated to supine position with the
eyes open, and the eyes are examined for rotational nystagmus +/- the development of
vertiginous symptoms. This is then repeated with the head turned to the contralateral side. If
positive, this is diagnostic of BPPV.
Head impulse testing (HIT): In contrast to other peripheral vestibular disorders, this test has a
low sensitivity in Meniere disease.[14]
Evaluation
Audiometric evaluation is mandatory in all patients with Meniere disease. Fluctuating low
frequency unilateral sensorineural hearing loss is characteristic of the disease. The hearing loss
can progress to all frequencies. Tinnitus is common and ipsilateral.[15]
All patients with one-sided hearing loss should undergo magnetic resonance imaging (MRI) to
rule out retrocochlear pathology. In some countries, a BERA (brainstem evoked response
audiometry) is sufficient. There is no need to perform imaging in the acute setting, but it may be
done within a few weeks after the onset of symptoms. High-resolution MRI imaging may
directly show endolymphatic hydrops in the affected organs. More research is underway to show
if this is of clinical use.[16][17]
Vestibular (caloric) function testing may show a significantly under-functioning affected organ in
42% to 74% and a complete loss of function in 6% to 11%.[18]
Treatment / Management
Different treatment options for Meniere disease exist with substantial variability between
countries. None of the treatment options cure the disease. As many treatments significantly
impact the functioning of surrounding structures, one should start with non-invasive approaches
with the fewest possible side effects and proceed to more invasive steps.
1. Sodium restriction diet: Low-level evidence suggests that restricting sodium intake may
help to prevent Meniere attacks.[13]
2. Thiazide diuretics: Form the mainstay of medical treatment in many centers. Evidence
suggests they reduce the frequency and severity of symptomatic episodes but do not appear
to prevent hearing loss.[19]
3. Betahistine: Substantial disagreement exists in the medical community about the use of
betahistine. A Cochrane review found low-level evidence to support the use of betahistine
with substantial variability between studies.[20]
4. Intratympanic steroid injections: May reduce the number of vertigo attacks in patients
with Meniere disease while preserving auditory function.[21]
Differential Diagnosis
Basilar migraine: Associated with vertigo but without aural symptoms
Vestibular neuronitis: Associated with vertigo lasting for several days, no aural symptoms
Benign paroxysmal positional vertigo: Associated with vertigo related to head movements,
lasting seconds to minutes, no aural symptoms
Central vertigo: causes include stroke, multiple sclerosis, seizure disorder, others
Peripheral vertigo of non-otogenic origin: Commonly seen in elderly patients with peripheral
neuropathy and deconditioning
Orthostatic hypotension: Not true vertigo, but patients may describe themselves as "dizzy"
As with vertigo, loss of hearing is highest in the early years of the disease and stabilizes in later
years. Usually, there is no recovery from hearing loss. Patients with Meniere disease in one ear
are at higher risk of developing it in the contralateral ear; one systematic review reports bilateral
involvement of the vestibular organ in up to 47% of patients over 20 years.[24][25][26]
Complications
In later stages of the pathology, patients may experience sudden unexpected loss of muscle tone
(drops) without loss of consciousness, termed crises of Tumarkin.[27]
Patients with Meniere disease report significantly impaired quality of life compared to healthy
individuals, and the prevalence of anxiety and depression is significantly higher in MD patients
compared to the general population.[28][29]
Consultations
Refer patients with signs suggestive of Meniere disease for otolaryngologic consultation and
formal audiometric evaluation.
Vertigo, tinnitus, and hearing loss are extremely common and can be caused by serious or life-
threatening pathology.
Review Questions
Disclosure: Claudio Andaloro declares no relevant financial relationships with ineligible companies.