Inner Ear, Meniere Disease, Medical Treatment Clinical Presentation

  • Author: John C Li, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: May 18, 2011
 

History

The typical history involves episodic attacks of true whirling vertigo. These episodes are usually preceded by a variable sense of ear pressure and fullness, decreased hearing, and a low-tone roaring tinnitus.

  • Episodes of vertigo usually last minutes to hours and are often associated with severe nausea and vomiting. In general, patients feel "run down," imbalanced, and nauseated for several hours to days after an acute attack.
  • The timing and frequency of the attacks vary. Some patients can regularly predict when they will have an attack. Others note a completely random pattern. Attacks have been linked to triggers such as foods, menstrual cycles, and psychosocial stress.
  • Some patients are completely asymptomatic between episodes. However, many notice progressive deterioration of hearing and balance function with each successive attack.
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Physical

Results of the physical examination vary depending on the disease phase. Physical examination results may be completely normal during remission, particularly if the patient is asymptomatic.

  • During an acute attack, patients generally have severe vertigo and are often in significant distress.
    • Many present to the physician's office with signs of recent vomiting.
    • Patients are occasionally diaphoretic and pale.
    • Vital signs may show elevated blood pressure, pulse, and respiration.
  • Neurotologic examination may reveal significant nystagmus. Pneumo-otoscopy of the affected ear may elicit symptoms or cause nystagmus.
    • In general, the Romberg test (ie, observation of sway or loss of balance while the patient is standing with his or her eyes closed) reveals significant increase in instability and worsening with the eyes closed.
    • If the patient is able to stand with his or her eyes closed, the Fukuda marching step test (ie, observation of directional drift while the patient is marching with his or her eyes closed) may show significant deviation.
    • The Dix-Hallpike test (ie, observation of nystagmus while moving a patient from sitting to supine with the head angled 45° to 1 side and then the other) may be positive, indicating coexisting benign positional vertigo.[1]
  • Hearing is frequently affected.
    • The Weber tuning fork test usually shows results lateralized away from side of the affected ear.
    • In general, the Rinne test indicates that air conduction remains better than bone conduction.
  • Perform a complete neurologic evaluation during the physical examination is important. New-onset vertigo may be an early sign of stroke, migraine, or brainstem compression, which require emergency care vastly different from those of Ménière disease.
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Causes

A wide range of disorders (eg, metabolic imbalance, hormonal problems, infections) may cause increased endolymph pressure. Autoimmune diseases (eg, lupus, rheumatoid arthritis) may cause an inflammatory response in the labyrinth. Allergy has also been implicated in many cases of difficult-to-treat Ménière disease.

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Contributor Information and Disclosures
Author

John C Li, MD  Private Practice in Otology and Neurotology; Medical Director, Balance Center

John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Tinnitus Association, Florida Medical Association, and North American Skull Base Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael E Hoffer, MD  Director, Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center of San Diego

Michael E Hoffer, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: American biloogical group Royalty Other

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

Gerard J Gianoli, MD  Clinical Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine; Vice President, The Ear and Balance Institute; Chief Executive Officer, Ponchartrain Surgery Center

Gerard J Gianoli, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society

Disclosure: Vesticon, Inc. None Board membership

Christopher L Slack, MD  Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

References

  1. Paparella MM. Benign paroxysmal positional vertigo and other vestibular symptoms in Ménière disease. Ear Nose Throat J. Oct 2008;87(10):562. [Medline].

  2. Pullens B, van Benthem PP. Intratympanic gentamicin for Ménière's disease or syndrome. Cochrane Database Syst Rev. Mar 16 2011;3:CD008234. [Medline].

  3. Monsell EM. New and revised reporting guidelines from the Committee on Hearing and Equilibrium. American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. Otolaryngol Head Neck Surg. Sep 1995;113(3):176-8. [Medline].

  4. Bretlau P, Thomsen J, Tos M, et al. Placebo effect in surgery for Menière's disease: nine-year follow-up. Am J Otol. Jul 1989;10(4):259-61. [Medline].

  5. Densert B, Sass K. Control of symptoms in patients with Meniere's disease using middle ear pressure applications: two years follow-up. Acta Otolaryngol. Jul 2001;121(5):616-21. [Medline].

  6. Glasscock ME 3rd, Jackson CG, Poe DS, et al. What I think of sac surgery in 1989. Am J Otol. May 1989;10(3):230-3. [Medline].

  7. Gottshall KR, Hoffer ME, Moore RJ, et al. The role of vestibular rehabilitation in the treatment of Meniere's disease. Otolaryngol Head Neck Surg. Sep 2005;133(3):326-8. [Medline].

  8. Kato BM, LaRouere MJ, Bojrab DI, et al. Evaluating quality of life after endolymphatic sac surgery: The Ménière's Disease Outcomes Questionnaire. Otol Neurotol. May 2004;25(3):339-44. [Medline].

  9. Kitahara T, Kondoh K, Morihana T, et al. Surgical management of special cases of intractable Meniere's disease: unilateral cases with intact canals and bilateral cases. Ann Otol Rhinol Laryngol. May 2004;113(5):399-403. [Medline].

  10. Monsell EM, Wiet RJ. Endolymphatic sac surgery: methods of study and results. Am J Otol. Sep 1988;9(5):396-402. [Medline].

  11. Odkvist LM, Arlinger S, Billermark E, et al. Effects of middle ear pressure changes on clinical symptoms in patients with Ménière's disease--a clinical multicentre placebo-controlled study. Acta Otolaryngol Suppl. 2000;543:99-101. [Medline].

  12. Pyykkö I, Ishizaki H, Kaasinen S, et al. Intratympanic gentamicin in bilateral Menière's disease. Otolaryngol Head Neck Surg. Feb 1994;110(2):162-7. [Medline].

  13. Shea JJ Jr. Classification of Menière's disease. Am J Otol. May 1993;14(3):224-9. [Medline].

  14. Shea JJ Jr, Ge X. Streptomycin perfusion of the labyrinth through the round window plus intravenous streptomycin. Otolaryngol Clin North Am. Apr 1994;27(2):317-24. [Medline].

  15. Silverstein H, Lewis WB, Jackson LE, et al. Changing trends in the surgical treatment of Ménière's disease: results of a 10-year survey. Ear Nose Throat J. Mar 2003;82(3):185-7, 191-4. [Medline].

  16. Silverstein H, Smouha E, Jones R. Natural history vs. surgery for Menière's disease. Otolaryngol Head Neck Surg. Jan 1989;100(1):6-16. [Medline].

 
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Tinnitus model. Two phenomena in the auditory cortex are associated with peripheral deafferentation: 1) hyperactivity in the lesion projection zone and 2) increased cortical representation of the lesion-edge frequencies (here, C6) in the lesion projection zone. These two phenomena are presumed to be the neurophysiological correlates of tinnitus. The red letters correspond to octave intervals of a fundamental frequency.
 
 
 
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