Diagnosis

Meniere disease

Etiology

Cause [z7p]

• The exact cause is unknown

• Possible theories: [oib]

  • Genetic factors

  • Inflammatory

  • Immunologic dysfunction

  • Infection

  • Trauma

  • Vasculopathy

Pathophysiology [z7p][dvv][oib]

• Accumulation of endolymphatic fluid in the cochlea and the vestibular organ due to:

  • Excessive endolymph production from the stria vascularis

  • Reduced endolymph resorption in the endolymphatic sac

  • Other factors: Disturbances of barometric pressure, osmotic pressure, hydrostatic pressure, and perfusion pressure

Complications [dvv]

• Sudden loss of muscle tone (crises of Tumarkin)

Epidemiology

Incidence per 100.000 [6nz][t5p][vhs][ckq][uvc][swf]

Approach

• Diagnostic criteria according to the Barany Society: [dvv]

  1. >2 episodes of spontaneous vertigo lasting 20 minutes to 12 hours

  2. Low- to medium-frequency sensorineural hearing loss in one ear

  3. Fluctuating aural symptoms (fullness, hearing, tinnitus) in the affected ear

  4. Not better accounted for by any other vestibular diagnosis

• Blood tests: FBC, ESR, thyroid function, syphilis, glucose, renal function, lipids

• Orthostatism: anaemia, blood pressure (lying and standing), arrhythmias, carotid bruits

• Otology: Otoscopy, hearing tests (Weber's test and Rinne's test)

• Neurology: Cranial nerve exam (nystagmus), gait, balance and co-ordination (Romberg's test and finger-nose test)

• Audiometry: sensorineural hearing loss

• Caloric tests

• Electronystagmography

• Video nystagmography

• Glycerol dehydration test

• Cervical spondylosis with associated vertigo

• BPPV: Dix-Hallpike maneuver

• Electrocochleography

• Brainstem auditory evoked potentials

• MRI brain scan

• Standard lateral mastoid radiographs

Treatment

1. Symptomatic treatment of attacks:

   • Prochlorperazine, Cinnarizine, Cyclizine, or Promethazine

2. Life style changes: [dvv][yzh]

   • A low-sodium diet (<2000 mg per day)

   • Avoiding caffeine, chocolate, alcohol, tobacco and excessive fatigue

   • Hearing aid or a cochlear implant

3. Prophylaxis:

   • Diuretic (combination hydrochlorothiazide and triamterene): reduce the vertigo

   • Betahistine, a capillary vasodilator: reduce vertigo and improve the cochlear symptoms (hearing loss, tinnitus)

4. Middle ear injection: Steroids, Gentamicin [dvv]

5. Surgery: patients who fail medical therapy [qb1][dvv]

   • Endolymphatic sac surgery: drainage or decompression

   • Intratympanic gentamicin

   • Labyrinthectomy

   • Vestibular neurectomy

Differential diagnoses

Acoustic neuroma, Anemia, Benign paroxysmal positional vertigo, Brain tumor, Cerumen, Cholesteatoma, Diabetes mellitus, Drug side effects, Encephalitis, HIV, Hypothyroidism, Intracerebral hemorrhage, Labyrinthitis, Lyme disease, Meningitis, Migraine, Multiple sclerosis, Orthostatic hypotension, Otitis media, Polyarteritis nodosa, Presbyacusis, Rheumatoid arthritis, Salicylate intoxication, Stroke, Syncope, Syphilis, Transient ischemic attack, Vestibular neuronitis, Wernicke encephalopathy