Overview

Meniere’s disease (MD) is characterised by episodes of sudden-onset vertigo, sensorineural hearing loss, tinnitus and aural fullness that is thought to be due to excess endolymphatic fluid.

Episodes last from 15 minutes to 12 hours.

Epidemiology

  • Incidence rate of 13.1 per 100,000
  • More common in women
  • Peak age of incidence in 40-50 years

Risk Factors

  • Allergy
  • Autoimmune disease
  • Migraines
  • Viral infection

Presentation

Patients classically have recurrent episodes of acute-onset vertigo, sensorineural hearing loss, and tinnitus. Episodes usually last from 20 minutes up to an hour. During episodes, features are:

  • Severe vertigo
  • Sensorineural hearing loss
  • Tinnitus – often described as “roaring”
  • Aural fullness – patients describe the ear as full
  • Symptoms are usually unilateral initially but can go on to become bilateral
  • Some patients have “drop attacks” – sudden loss of balance with no loss of consciousness or other neurological symptoms

Differential Diagnoses

Vestibular neuronitis

  • There is vertigo but no hearing loss as no part of the auditory pathway is involved
  • Usually follows a viral infection
  • Symptoms are not typically in episodes lasting 15 minutes to 2 hours

Labyrinthitis

  • There is vertigo but hearing loss is also present
  • Usually follows a recent viral infection
  • Symptoms are not typically in episodes lasting 15 minutes to 2 hours

Benign paroxysmal positional vertigo

  • Episodes of vertigo are triggered by changes in head position
  • There is usually no preceding viral infection
  • Vestibular schwannoma
  • Sensorineural hearing loss, vertigo, and tinnitus present with potential cranial nerve involvement e.g. absent corneal reflex is CN V is involved

Posterior stroke

  • Ataxia
  • Romberg’s test negative
  • Facial paralysis/dysphagia
  • Contralateral lower extremity weakness

Investigations

All patients

If Ménière’s disease is suspected, refer the patient to ENT to confirm the diagnosis. Further investigations in secondary care may involve:

  • Blood tests to exclude underlying systemic disease:
    • FBC
    • ESR
    • TFTs
    • LFTs
    • U&Es
    • Blood glucose
    • Syphilis testing
    • Serum lipids
    • Audiometry:
      • Confirms sensorineural hearing loss and helps diagnosis of MD
    • MRI brain:
      • If symptoms are unilateral to rule out vestibular schwannomas

Diagnosis

NICE

Diagnosis is made by an ENT specialist. To diagnose MD, the following must be present:

  • Vertigo – at least ≥2 episodes lasting ≥20 minutes within a single attack
  • Tinnitus and/or aural fullness
  • Sensorineural hearing loss confirmed by audiometry

Management

All patients

  • Acute attacks: antihistamines such as prochlorperazine/cyclizine/promethazine/cinnarizine
    • Use buccal/IM options if the patient is vomiting
  • If severe: admit to hospital
  • Consider vestibular rehabilitation programmes
  • Consider trialling betahistine to reduce the frequency and intensity of attacks
  • Notify DVLA: generally, patients can drive if their condition is under control

Monitoring

  • Patients are generally followed up with ENT doctors and audiologists. They should have regular hearing tests and have their symptoms monitored.

Patient Advice

  • Patients should be reassured that although MD is long-term, vertigo usually improves significantly with treatment
  • Patients should be safety-netted on seeking help if their symptoms do not settle after 5-7 days. They should last around 24 hours.
  • During an acute attack, the patient should:
    • Keep medication readily available
    • Be careful when carrying out risky activities e.g. driving, operating dangerous machinery, climbing etc.
  • Patients should avoid smoking and alcohol consumption, and try to maintain a healthy lifestyle through regular exercise and a balanced diet.
  • Patients need to notify the DVLA

Complications

  • Falls
  • Psychosocial problems e.g. depression/anxiety
  • Inability to drive

Prognosis

  • MD is chronic but symptoms fluctuate, with complete resolution between episodes
  • Later in the course of MD, the frequency of vertigo often decreases but hearing loss and tinnitus become persistent
  • In most patients, symptoms resolve around 5-15 years later but some symptoms may persist

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