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Meniere disease (Lecture)

Patient will present as → a 32-year-old male with complaints of recurrent, episodic vertigo lasting up to 8 hours per episode for the past 3 months. The attacks generally last less than half an hour and are associated with decreased low-frequency hearing in the left ear along with nonpulsatile tinnitus in the ipsilateral ear. You obtain an audiogram that shows a low-frequency hearing loss in the left ear only. 

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Ménière syndrome is a disorder of the endolymphatic compartment with the classic triad of episodic vertigo, unilateral low-frequency sensorineural hearing loss, and tinnitus.

Labyrinthitis involves the inflammation of both branches of the vestibulocochlear nerve (the vestibular portion and the cochlear portion) that affects balance and hearing. It is related to viral URIs and presents with acute onset, continuous vertigo, hearing loss, and tinnitus of several days to a week. The symptoms of labyrinthitis are the same as vestibular neuritis plus the additional symptoms of tinnitus and/or hearing loss.

Vestibular neuritis is an inflammation of the vestibular nerve. Vestibular neuritis presents with continuous vertigo, nausea, and vomiting, but not hearing loss or tinnitus. It is related to viral URIs, and develops over several hours, with symptoms worse in the first day, with gradual recovery over several days. The symptoms of vestibular neuritis are the same as labyrinthitis minus tinnitus and/or hearing loss.

Ménière syndrome is a disorder of the endolymphatic compartment with the classic triad of episodic vertigo, unilateral low-frequency sensorineural hearing loss, and tinnitus. Labyrinthitis is similar to Meniere’s disease except that labyrinthitis causes continuous symptoms (vs. the episodic symptoms of Meniere’s disease).

Benign paroxysmal positional vertigo (BPPV) is generally thought to be due to debris that has collected within a part of the inner ear. BPPV occurs with changes in position, especially rapid movements of the head. Nausea may occur, but vomiting is not significant. It causes episodic vertigo without hearing loss.

Acoustic neuroma is a benign tumor of the Schwann cells (the cells which produce myelin sheath). Patient will present with an insidious unilateral hearing loss, tinnitus, headache, facial numbness, continuous disequilibrium (unsteadiness), +/- vertigo.

"To differentiate labyrinthitis from Meniere's disease on your exam look for tinnitus and episodic symptoms.  Labyrinthitis is similar to Meniere's disease except that labyrinthitis causes continuous symptoms and has the combination of vertigo + hearing loss and (although it can) is less likely to present with tinnitus on exam questions."

Pt will often present with episodic peripheral vertigo lasting 1-8 hours with nystagmus, nausea, and vomiting.

The diagnosis of Meniere disease, made clinically, is primarily one of exclusion. Similar symptoms can result from vestibular migraine, viral labyrinthitis or neuritis, a cerebellopontine angle tumor (eg, acoustic neuroma), or a brain stem stroke

  • Although bilateral Meniere disease can occur, bilateral symptoms increase the likelihood of an alternate diagnosis (eg, vestibular migraine)

Patients with suggestive symptoms should have an audiogram and an MRI (with gadolinium enhancement) of the CNS with attention to the internal auditory canals to exclude other causes

  • An audiogram typically shows a low-frequency sensorineural hearing loss in the affected ear that fluctuates between tests
  • The Rinne test and the Weber test also may indicate sensorineural hearing loss

Treatment with a low salt diet, diuretics (HCTZ + triamterene) to reduce aural pressure

  • Should avoid caffeine/chocolate and ETOH because they can increase endolymphatic pressure

Meniere’s Disease and vertigo

IM_NUR_MenieresDisease_v1.2_Meniere’s Disease is a condition of the inner ear of unknown origin but characterized by excess endolymph in the vestibular and semicircular canals, causing increased fluid pressure in the inner ear; also known as endolymphatic hydrops. Symptoms usually begin between 30 to 60 years of age. Attacks are sudden and severe and may last hours or days.

Meniere’s Disease
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Thiazide diuretics
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Question 1
A 52 year-old female presents with complaints of intermittent episodes of dizziness, tinnitus, and hearing loss in the right ear for 6 months. She describes the dizziness as the "room spinning around her," with the episodes typically lasting for 2 to 4 hours. Physical examination reveals horizontal nystagmus and right ear hearing loss, but the remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?
Acute labyrinthitis
Acute labyrinthitis typically presents with an acute onset of continuous vertigo that lasts several days to a week and is associated with nausea and vomiting. It does not have any associated auditory or neurologic symptoms.
Positional vertigo
Positional vertigo occurs following changes in head positioning with very brief, less than 1 minute, episodes. Nystagmus occurs following the position change.
Acoustic neuroma
Acoustic neuroma typically presents with hearing loss and tinnitus. The neuroma grows slowly and central compensatory mechanisms can prevent or minimize the vertigo. Vertigo, when present, is continuous and not episodic.
Ménière's syndrome
Question 1 Explanation: 
Ménière's syndrome usually presents with episodes of vertigo that last from 1 to 8 hours, sensorineural hearing loss and tinnitus.
Question 2
A 34 year-old female presents with recurrent bouts of dizziness, tinnitus, and hearing loss. She states that the episodes are incapacitating and cause her to become nauseous and vomit. The attacks last about one hour and the symptoms disappear after a few days. The last two episodes were treated with meclizine (Antivert) and prochlorperazine (Compazine) at the emergency room. Audiologic testing reveals low-tone frequency hearing loss. Which of the following is the most appropriate long-term management for this patient?
Epley maneuver
Epley maneuver is used to treat benign paroxysmal positional vertigo.
Diuretics and low-sodium diet
Broad-spectrum antibiotics and Ibuprofen
Broad-spectrum antibiotics and ibuprofen are used to treat otitis media, not Meniere's disease.
Scopolamine transdermal patch
A scopolamine patch is useful for treatment of a single episode, but not long-term management.
Question 2 Explanation: 
Diuretics and a low sodium diet will decreases the endolymphatic pressure in the semicircular canals, which is believed to be elevated in Meniere's disease, and help relieve symptoms.
Question 3
A 58 year-old patient presents with spells of dizziness which is described as a spinning sensation. This has occurred several times a day for the last month. The patient also complains of some mild hearing loss, fullness, and a blowing sound in the right ear. Which of the following is the most likely diagnosis?
Meniere's syndrome
Labyrinthitis is an acute onset of continuous, usually severe vertigo lasting several days to a week, accompanied by hearing loss and tinnitus.
Benign paroxysmal positioning vertigo
Benign paroxysmal positioning vertigo is a type of vertigo associated with changes in head position, often rolling over in bed.
Vestibular neuronitis
Vestibular neuronitis is a paroxysmal, usually single attack of vertigo that occurs without accompanying impairment of auditory function and will persist for several days to weeks before clearing.
Question 3 Explanation: 
The classic findings of Meniere's syndrome consists of episodic vertigo, with discrete vertigo spells lasting 20 minutes to several hours in association with fluctuating low-frequency sensorineural hearing loss, tinnitus, and a sensation of aural pressure.
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