Meniere’s Disease

Summary

Ménière's disease is a disorder of the inner ear that is characterised by episodes of vertigo, fluctuating hearing loss, tinnitus, and a feeling of fullness in the affected ear.

Signs and symptoms

Ménière's disease is characterised by spontaneous vertigo attacks, often described as spinning or rocking, accompanied by nausea and vomiting. 

After the acute vertigo attack, the individual may experience unsteadiness for several days. Tinnitus, typically described as 'roaring,' initially occurs during attacks but can become permanent over time, significantly affecting quality of life. 

Fluctuating sensorineural hearing loss, primarily in low frequencies and usually unilateral at first, eventually becomes permanent and does not fluctuate as the disease progresses. 

Aural fullness, a sensation of pressure or discomfort in the ear, often precedes a vertigo attack and may occur during the episode, though it may not be present in advanced stages of the disease.

Usually, Ménière's disease manifests unilaterally, although bilateral cases have been reported, with symptoms not typically occurring simultaneously in both ears.

The attacks can involve predominantly aural symptoms (hearing loss, tinnitus, or ear fullness in the affected ear) and/or vertigo. These attacks typically last for a few hours, ranging from a minimum of 20 minutes to a maximum of 24 hours. They can occur in clusters over a few weeks, but periods of remission lasting months or years are also possible.

Assessment

• Head and neck examination findings are usually normal.
• Horizontal and/or rotatory nystagmus that can be suppressed by visual fixation may be present.
• The person may be unable to stand with their feet together and eyes closed (Romberg's test) or walk heel-to-toe (tandem) in a straight line.  
• If asked to march on the spot with their eyes closed (Unterberger's test), the person may be unable to maintain their position and will turn to the affected side.

Red flags

• Rule out a cerebrovascular event in people with acute vertigo.
  
• Red flags for central pathology that require immediate hospital admission include:
  
• New unilateral hearing loss.
• Focal neurological signs (facial weakness, diplopia, or limb weakness).

When to refer to ENT

If Ménière's disease is suspected, refer to ENT services to confirm the diagnosis.

A definite diagnosis requires all of the following criteria:

• Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours.
• Audiometrically documented low-to-medium frequency sensorineural hearing loss in one ear
• Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear.
• Not better accounted for by an alternative vestibular diagnosis. 

While awaiting referral, attacks of Ménière's disease–like symptoms may have to be managed in primary care.

Management

Reassure the person that although Ménière's disease is a long-term condition, vertigo usually significantly improves with treatment. 

Advise that an acute attack of vertigo will normally settle within 24 hours in most people. If there is no improvement after 5–7 days, or there is any deterioration in symptoms, alternative diagnoses should be excluded. 

• To help alleviate nausea, vomiting, and vertigo acute attacks consider prescribing a short course (up to 7 days) of prochlorperazine or an antihistamine (such as cinnarizine, cyclizine, or promethazine teoclate).
• For recurrent attacks consider prescribing a trial of betahistine to reduce the frequency and severity of attacks of hearing loss, tinnitus, and vertigo, for a length of time in accordance to patient’s response.