Meniere's disease (ENT) Flashcards
Define Meniere’s disease.
An episodic auditory and vestibular disease characterised by sudden onset of vertigo, low-frequency hearing loss, tinnitus and sensation of fullness in the affected ear.
What is the difference between Meniere’s disease and Meniere’s syndrome?
Usually used interchangeably, but MD commonly used if it is idiopathic and Meniere’s syndrome if it is secondary to a number of known inner-ear disorders
Which groups does Meniere’s disease tend to occur in?
- F>M
- peak incidence 40-50 years old
What are the types of causes for Meniere’s disease? (4)
- idiopathic
- viral infections
- autoimmunity
- allergies
What is the pathophysiology of Meniere’s disease?
- overproduction/impaired endolymph resorption in the inner ear –> excess fluid in inner ear
- acute attack: excess endolymphatic fluid pressure causes distension and rupture of Reisner’s membrane
- –> release of potassium-rich endolymph into perilymphatic space –> injury to sensory and neural elements of the inner ear
- manifests clinically as sudden hearing loss, tinnitus and vertigo
What is the main triad of Meniere’s disease?
Vertigo + hearing loss (worsens around vertigo spells and unilateral) + tinnitus in affected ear
What are the clinical features of Meniere’s disease? (5)
- vertigo
- hearing loss (unilateral, worse with vertigo spells)
- tinnitus
- aural fullness
- drop attacks - sudden loss of balance in late disease
What is the vertigo like in Meniere’s disease?
- recurrent episodes of spinning sensations lasting minutes to hours
- usually associated with N&V
- attacks cluster in groups
What might you see on examination in Meniere’s disease? (4)
- positive Romberg’s test - falling when asked to stand with feet together and eyes closed
- Fukuda’s stepping test - turn towards affected side when asked to march in place with eyes closed
- nystagmus - uncontrolled repetitive eye movements
- tandem walk - inability to walk heel-toe in straight line
What 10 point scale can we use in Meniere’s disease? (Not important to memorise)
Closer to 10 = more likely MD
- rotational vertigo
- attacks of vertigo >10min
- rotational vertigo associated with 1+ hearing loss, tinnitus or aural pressure
- sensorineural hearing loss
- fluctuating hearing loss
- hearing loss or fluctuation associated with vertigo, tinnitus or aural pressure
- peripheral tinnitus lasting >5min
- tinnitus fluctuating or changing with 1+ vertigo, hearing loss or aural pressure
- aural pressure/fullness lasting >5min
- aural pressure fluctuating or changing with vertigo, hearing loss or tinnitus
What is the diagnosis if there is only foul-smelling non-resolving discharge and hearing loss (instead of Meniere’s disease)?
Cholesteatoma
What are some risk factors for Meniere’s disease? (4)
- recent viral infection
- genetic predisposition - Fx
- autoimmune disease (vasculitis, RA, lupus)
- increasing age
What are the first-line investigations for Meniere’s disease? (4)
- pure-tone audiometry and bone conduction with masking
- speech audiometry (normal)
- typanometry (normal)
- oto-acoustic emissions (OAE)
What is the main investigation done for Meniere’s disease?
Pure-tone audiometry for unilateral sensorineural hearing loss:
- Rinne’s test - air conduction>bone conduction bilaterally in MD (sensorineural vs conductive)
- Weber’s test - sound localises to contralateral ear in MD (sensorineural hearing loss)
What does speech audiometry show in Meniere’s disease?
Normal, absence of positive roll-over index
What do Rinne’s and Weber’s tests show in Meniere’s disease?
Sensorineural hearing loss:
- Rinne’s: air conduction>bone conduction bilaterally = sensorineural not conductive
- Weber’s: sound localises to contralateral ear
What are some differential diagnoses for Meniere’s disease? (6)
- acoustic neuroma - reduced word recognition
- vestibular migraine - very short (<15min) or prolonged (>24h) duration of vertigo + visual auras, hearing loss mild and stable over time
- vestibular neuronitis - NO hearing loss, tinnitus or aural fullness
- viral labyrinthitis - similar to vestibular neuronitis + hearing loss and tinnitus
- BPPV - episodic vertigo seconds-mins elicited by certain head movements, Hallpike’s test +ve
- vertebrobasilar insufficiency - vertigo several mins + N&V + severe imbalance
What do we give for acute attacks of Meniere’s disease?
Buccal or intramuscular prochlorperazine
What do we give for prevention and to reduce attack frequency in Meniere’s disease?
Betahistine
What maintenance therapy is there for Meniere’s disease?
Thiazide diuretics to reduce volume of endolymph
How do we generally manage Meniere’s disease? (4)
- dietary changes - reduce salt intake
- lifestyle modifications - limit caffeine/alcohol/smoking/stress
- diuretics - triamterene, hydrochlorothiazide
- acute attack: buccal/IM prochlorperazine
How do we manage symptomatic Meniere’s disease? (3)
- vestibular suppressant - meclizine, prochlorperazine
- anti-emetic or corticosteroid
- intratympanic injection - gentamicin
How do we manage tinnitus in Meniere’s disease? (4)
- tinnitus maskers
- tinnitus retraining therapy (TRT)
- hearing aids
- medication
How do we manage sudden hearing loss in Meniere’s disease?
Corticosteroid
How do we manage persistent hearing loss in Meniere’s disease?
Hearing aid + intensive high-quality audiological counselling
How do we manage Meniere’s disease if failure of medical and intratympanic therapies? (3)
- endolymphatic sac surgery
- vestibular nerve section
- labyrinthectomy if hearing impaired
What are some complications of Meniere’s disease? (2)
- falls
- profound hearing loss
Describe the prognosis of Meniere’s disease.
Symptoms tend to worsen over time regardless of medical intervention
