GP - Meniere's disease

Question 1

What is Meniere’s disease?

Answer 1

An inner ear disorder affecting balance and hearing

It’s a syndrome characterised by:

Fluctuating sensorineural hearing loss (usually unilateral and affects low frequencies)

Tinnitus

Aural fullness

Vertigo

Question 2

What causes Meniere’s disease?

Answer 2

Unknown

However, it’s associated with endolymphatic hydrops

Question 3

What is endolymphatic hydrops?

Answer 3

Increased endolymph volume in the membranous labyrinth and decreased perilymph volume in the bony labyrinth –> swelling of the membranous labyrinth –> sensorineural hearing loss, tinnitus, aural fullness, vertigo

Question 4

Give 3 risk factors for Meniere’s disease

Answer 4

Autoimmunity e.g. SLE, RA, antiphospholipid syndrome

Viral infection

Na+ and K+ imbalance in inner ear fluid

Genetics

Question 5

Is Meniere’s disease more common in women or men?

Answer 5

Women

Question 6

Give 3 complications of Meniere’s disease

Answer 6

• Falls
• Anxiety and depression
• Affects ability to drive

Question 7

What clinical features do you expect to see in Meniere’s disease?

Answer 7

• Fluctuating sensorineural hearing loss (usually unilateral and affects low-frequency hearing) –> initially fluctuating but eventually permanent hearing loss
• Tinnitus
• Aural fullness (usually precedes a vertigo attack)
• Vertigo, N&V, unsteadiness, gait problems
• Otholitic crises of Tumarkin - drop attacks without LOC that occur without warning

Question 8

What examinations would you carry out as a GP?

Answer 8

• Head and neck examination
• + Rhomberg test
• Patient unable to walk heel-to-toe in a straight line
• + Unterberger’s test - if asked to march on the spot with their eyes closed, the person will turn to the affected side

Question 9

What must you do to confirm the diagnosis of Meniere’s disease?

Answer 9

Other than clinical features and audiometry that suggests fluctuating sensorineural loss that affects low frequency hearing, you MUST refer patient to ENT to confirm the diagnosis

Question 10

What investigations would you do for Meniere’s disease?

Answer 10

Audiometry confirming sensorineural hearing loss, low frequency

Question 11

Give 3 differential diagnoses

Answer 11

BPPV

Labyrinthitis

Vestibular neuronitis

Migraine

TIA

Question 12

What advice would you give as a GP?

Answer 12

Advice:

• Advise that an acute attack of vertigo will normally settle within 24 hrs in most people
• Advise people experiencing vertigo to keep medication readily accessible, and consider the risks before undertaking activities like operating dangerous machinery, using ladders, going swimming
• Advise not to drive if they feel dizzy

Question 13

What pharmacological management can you give as a GP to someone with Meniere’s disease?

Answer 13

• Buccal/ IM prochlorperazine for rapid relief of N&V (for acute attacks)
• If symptoms don’t improve after 5 days, reassess to exclude an alternative diagnosis
• Betahistine and vestibular rehabilitation exercise for preventing recurrent attacks of Meniere’s disease
• Tell the patient to inform the DVLA - they should cease driving until there is satisfactory control of symptoms
• Referral to ENT for assessment to confirm the diagnosis

Question 14

When should you refer patients with Meniere’s disease?

Answer 14

Hospital admission if severe symptoms

Referral to ENT to confirm the diagnosis of Meniere’s disease

Hearing loss