Ménière's Disease

Ménière's Basics - Inner Ear Tsunami

• Inner ear disorder: recurrent vertigo, hearing loss, tinnitus, aural fullness.
• Pathophysiology: Endolymphatic hydrops (↑ endolymph volume/pressure) causing membranous labyrinth distension.
• Classic Tetrad:
  • Vertigo: Spontaneous, rotational, 20 min - 12 hrs; often with nausea.
  • Hearing Loss: Fluctuating, low-frequency SNHL, progressive.
  • Tinnitus: Low-pitched, roaring; worsens pre/during attacks.
  • Aural Fullness: Ear pressure sensation.
• Onset: 40-60 yrs. Prevalence: ~200/100,000. Bilateral in up to 50% eventually.

⭐ Characteristic hearing loss: initially unilateral, fluctuating, low-frequency sensorineural.

Symptom Spotlight - The Dizzying Quartet

• Episodic Vertigo:
  • Rotational, sudden onset.
  • Duration: 20 minutes to 12 hours (rarely up to 24 hours).
  • Often severe, with nausea, vomiting, nystagmus.
  • Patients are symptom-free between attacks.
• Sensorineural Hearing Loss (SNHL):
  • Fluctuating, progressive.
  • Initially affects low frequencies (classic).
  • Cochlear recruitment may be present.
• Tinnitus:
  • Low-pitched, roaring, hissing, or buzzing.
  • Often unilateral, on the affected side.
  • Intensity may fluctuate, often worse during attacks.
• Aural Fullness / Pressure:
  • Sensation of blockage or pressure in the affected ear.
  • Often precedes or accompanies other symptoms.

⭐ Fluctuating, low-frequency sensorineural hearing loss is a hallmark of early Ménière's disease, often recovering initially but becoming permanent over time as the disease progresses and affects higher frequencies too.

Diagnosis Decoded - Confirming the Culprit

• Clinical Dx (AAO-HNS 2015 Criteria):
  • Definite MD: ≥2 spontaneous vertigo episodes (20 min - 12 hrs); audiometric low-mid frequency SNHL (one ear); fluctuating aural symptoms (tinnitus, fullness) in that ear.
  • Probable MD: ≥2 vertigo episodes (20 min - 24 hrs); fluctuating aural symptoms (one ear).
• Investigations:
  • Audiometry: Confirms SNHL, typically low-frequency initially; may become flat.
  • MRI Brain (Gadolinium): Excludes retrocochlear pathology (e.g., vestibular schwannoma).
• Key Differentials: Vestibular migraine, BPPV, Labyrinthitis, Acoustic neuroma.

⭐ Electrocochleography (ECoG) can show an increased SP/AP ratio (>0.4), suggestive of hydrops, but is not routine for diagnosis.

Treatment Tactics - Taming the Turmoil

Treatment follows a stepwise escalation, prioritizing vertigo control while aiming to preserve hearing function.

⭐ For refractory Ménière's, intratympanic gentamicin offers high vertigo control (~90%) but carries a 10-30% risk of worsening hearing; IT steroids are a less ablative alternative.

High‑Yield Points - ⚡ Biggest Takeaways

• Classic Triad: Episodic vertigo (20 min - 12 hrs), fluctuating SNHL (low-frequency), tinnitus; often aural fullness.
• Pathophysiology: Endolymphatic hydrops (↑ endolymph).
• Hearing Loss Pattern: Initially unilateral, low-frequency sensorineural hearing loss; can become permanent.
• Key Diagnostic Test: Audiometry confirms SNHL; ECoG (↑ SP/AP ratio) is supportive.
• First-line Management: Low-salt diet, diuretics, betahistine; vestibular suppressants for acute attacks.
• Refractory Treatment: Intratympanic gentamicin, endolymphatic sac decompression, labyrinthectomy.