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
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
