Meniere’s Disease
Meniere’s disease is an inner ear disorder characterised by episodes of vertigo, fluctuating hearing loss, tinnitus, and a feeling of fullness in the affected ear.
This updated UKMLA guide to Meniere’s disease is based on NICE CKS, which covers causes, symptoms, diagnosis and management.
Peripheral Vertigo: Key Differentials
| Feature | BPPV | Meniere’s disease | Vestibular neuronitis | Labyrinthitis |
|---|---|---|---|---|
| Core mechanism | Displaced otoconia in semi-circular canals | Inflammation of the vestibular portion of CN VIII | Inflammation of the labyrinth (affecting both vestibular and cochlear structures) | Endolymphatic hydrops |
| Course | Recurrent attacks, may resolve spontaneously | Recurrent attacks + progressively worsen over time | Singe acute episode | Singe acute episode |
| Trigger | Change in head position | Spontaneous | Spontaneous | Spontaneous |
| Vertigo duration | <1 min | 20 min to 24 hours | Days to weeks | Days to weeks |
| Cochlear symptoms (hearing loss, tinnitus) | Absent | Present | Absent | Present |
| Diagnosis | Dix-Hallpike test | Clinical diagnosis + audiometry | Clinical diagnosis | Clinical diagnosis |
| Management | Epley manoeuvre and other repositioning manoeuvres +/- vestibular rehabilitation | Short-term vestibular suppressants +/- betahistine | Short-term vestibular suppressants +/- vestibular rehabilitation | Short-term vestibular suppressants +/- vestibular rehabilitation |
Causes
The exact underlying cause and pathophysiology of Meniere’s disease are unknown.
The most common theory suggests an imbalance between the production and absorption of endolymph
Clinical Features
Course of disease
- Progressive nature: symptoms tend to get worse over time
- Early: symptoms fluctuate, only present in an attack and resolve completely between episodes
- Late: hearing loss progresses and tinnitus becomes persistent; frequency of vertigo episodes often decreases
Typical presentation:
- Episodes of spontaneous vertigo attacks (lasting at least 20 min, typically a few hours, but <24 hours)
- Cochlear symptoms (typically unilateral)
- Hearing loss
- Tinnitus (‘roaring’)
- Ear fullness (sensation of pressure in the ear or discomfort)
BPPV vs Meniere’s disease:
- BPPV = positional vertigo lasting <1 min with NO hearing symptoms (e.g. hearing loss, tinnitus)
- Meniere’s disease = spontaneous vertigo lasting minutes to hours WITH hearing symptoms (e.g. hearing loss, tinnisuts)
Investigation and Diagnosis
If Meniere’s disease is suspected, refer to ENT to confirm the diagnosis
Pure tone audiometry is used to support the diagnosis, key findings:
- Unilateral sensorineural hearing loss (bilateral possible)
- Early disease: affects low-to-medium frequencies (up-sloping pattern)
- Late disease: progresses to also affect high-frequency hearing (the curve flattens over time)
Unlike in BPPV, NO clinical manoeuvres (e.g. Dix-Hallpike) can be used to diagnose Meniere’s disease.
If central causes of acute vertigo (e.g. cerebrovascular event) are suspected, immediate hospital admission is necessary.
Red flag features of central vertigo:
- New focal neurological deficit (e.g. facial weakness, limb weakness or sensory loss, diplopia, dysphagia)
- New unilateral hearing loss
- Cerebellar features (e.g. dysdiadochokinesis, ataxia, intentional tremor, slurred speech, hypotonia)
- New-onset headache
- HINTS examination suggesting a central cause:
- Normal head impulse test
- Vertical or direction-changing nystagmus
- Vertical skew deviation
Diagnostic Criteria
A definite diagnosis requires ALL the following to be met:
- Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours
- Audiometrically documented low-to-medium frequency sensorineural hearing loss in one ear, defining and locating to the affected ear on at least one occasion before, during, or after an episode of vertigo
- Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear
- Not better accounted for by an alternative vestibular diagnosis
Management
General / Conservative Management
Counsel the patient that:
- Although Meniere’s disease is a long-term condition, vertigo usually improves significantly with treatment
- Acute attacks of vertigo usually settle within 24 hours
Advise the patient to:
- Keep their medication readily accessible
- Consider risks before undertaking activities such as driving, swimming, operating dangerous machinery, using ladders or scaffolding
The DVLA states that people with ‘liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness’ should stop driving and inform the DVLA.
Acute Attack Management
Depends on the type and severity of symptoms:
| Presenting symptom | Management |
|---|---|
| Severe nausea or vomiting | Consider labyrinthine sedatives:
For very severe symptoms, consider hospital admission for IV treatment |
| Nausea, vomiting and vertigo | 1st line: consider a short course (up to 7 days) of oral
If the patient has previously responded well to one of these treatments, consider using the same option as 1st line. |
Long-term Management (Prevention of Recurrent Attacks)
1st line: consider betahistine
- A histamine analogue (H3 antagonist + partial H1 agonist)
- MoA: increases inner ear microcirculation and reduces endolymphatic pressure
If not responding well to betahistine: refer to ENT for alternative secondary care interventions
Note that vestibular rehabilitation has NO role in Meniere’s disease, it is not helpful to prevent attacks.
However, vestibular rehabilitation is useful in the other 3 most common peripheral vestibular disorders (BPPV, vestibular neuronitis, labyrinthitis).
On the other hand, betahistine only has a role in Meniere’s disease, but not the other 3 disorders (BPPV, vestibular neuronitis, labyrinthitis).
References
Related Articles
Benign Paroxysmal Positional Vertigo (BPPV)