Ear, Nose & Throat
A 40 year old woman presents to the Emergency Department complaining of vertigo. She describes intermittent episodes that usually last around 2 hours and are associated with a "ringing" in her right ear. She has no significant past medical history. On examination you find she is afebrile with normal cardiovascular and respiratory observations and examinations. You find no focal neurological deficit in her limbs. On cranial nerve examination you find Weber's test lateralises to the left ear. What is the most likely diagnosis?
Answer:
Suspect Meniere's disease if the person has classic symptoms of:- Episodes of spontaneous vertigo, described as spinning or rocking, with or without nausea and vomiting. Unsteadiness can persist for several days after the acute attack of vertigo.
- Tinnitus, usually described as 'roaring'. Initially, this appears during attacks, but later becomes permanent and may significantly affect quality of life.
- Fluctuating sensorineural hearing loss, initially in low frequencies (usually unilateral). Eventually, as the disease progresses, hearing loss becomes permanent and does not fluctuate.
- Aural fullness (a sensation of pressure in the ear, or ear discomfort), which often occurs in advance of a vertigo attack — may also be present during the episode. However, it may not be experienced once the disease has progressed.
Meniere’s Disease
Ear, Nose & Throat
Last Updated: 12th February 2021
Meniere's disease is a disorder affecting the inner ear characterised by episodes of vertigo, fluctuating hearing loss, and tinnitus and is associated with a feeling of fullness in the affected ear.
Pathophysiology
In most people with Meniere's disease, the cause is unknown. There is a general view that abnormal endolymph production and/or absorption resulting in endolymphatic hydrops with swelling of the membranous labyrinth (vestibular system and cochlear duct) may lead to the classic symptoms of Meniere's disease.
The diagnosis of Meniere's disease is most commonly made in people aged 30–60 years. Women are affected slightly more often than men.
Clinical features
Suspect Meniere's disease if the person has classic symptoms of:
- Episodes of spontaneous vertigo, described as spinning or rocking, with or without nausea and vomiting. Unsteadiness can persist for several days after the acute attack of vertigo.
- Tinnitus, usually described as 'roaring'. Initially, this appears during attacks, but later becomes permanent and may significantly affect quality of life.
- Fluctuating sensorineural hearing loss, initially in low frequencies (usually unilateral). Eventually, as the disease progresses, hearing loss becomes permanent and does not fluctuate.
- Aural fullness (a sensation of pressure in the ear, or ear discomfort), which often occurs in advance of a vertigo attack — may also be present during the episode. However, it may not be experienced once the disease has progressed.
Acute attacks of Meniere's disease:
- May be preceded by a change in tinnitus, increased hearing loss, or a sensation of aural fullness shortly before the onset of vertigo.
- Are present for at least 20 minutes, but typically last a few hours (no more than 24 hours).
- Can occur in clusters over a few weeks, although months or years of remission can also occur.
- Can involve mainly aural symptoms, predominantly vertigo, or both.
Perform a complete physical examination. In a person with Meniere's disease:
- Head and neck examination findings are usually normal.
- The person may be unable to stand with their feet together and eyes closed (Romberg's test) or walk heel to toe in a straight line.
- If asked to march on the spot with their eyes closed, the person may be unable to maintain their position and will turn to the affected side (Unterberger's test).
- During an episode of vertigo, unidirectional, horizontal-torsional nystagmus may be seen.
There are no specific diagnostic tests for Meniere's disease, therefore the diagnosis is based on the presence of key clinical features. Refer to ENT for confirmation of diagnosis.
Management
- Patient advice
- Reassure the person that Meniere's disease is a long-term condition, but vertigo usually significantly improves with treatment.
- Advise that an acute attack of vertigo will normally settle within 24 hours in most people.
- Advise people experiencing sudden attacks of vertigo to:
- Keep medication readily accessible.
- Consider the risks before undertaking activities such as operating dangerous machinery, using ladders or scaffolding, or going swimming.
- Not to drive when they are dizzy, or if they might experience an episode of vertigo while driving.
- Acute attack:
- If symptoms are severe, hospital admission may be required for intravenous (IV) labyrinthine sedatives and fluids to maintain hydration, and nutrition.
- To rapidly relieve (severe) nausea or vomiting associated with Meniere's disease, consider administration of buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine or cyclizine.
- To help alleviate nausea, vomiting, and vertigo in other people with Meniere's disease, consider prescribing a short course (7 days, 14 days if required previously) of prochlorperazine, or an antihistamine (for example cinnarizine, cyclizine, or promethazine teoclate). If the person has had previous attacks of Meniere's disease and responded well to one of these drugs, consider trying that drug as first-line treatment.
- Prevent recurrent attacks:
- Consider prescribing a trial of betahistine to reduce the frequency and severity of attacks of hearing loss, tinnitus, and vertigo.
- If betahistine does not provide the clinical benefit required, and there are recurrent attacks of Meniere's disease despite its use, refer to ENT specialist for consideration of other possible interventions.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
