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Inner Ear, Meniere Disease, Medical Treatment: Differential Diagnoses & Workup

Author: John C Li, MD, Private Practice in Otology and Neurotology; Medical Director, Balance Center
Contributor Information and Disclosures

Updated: Mar 25, 2009

Differential Diagnoses

Benign Paroxysmal Positional Vertigo
Inner Ear, Perilymphatic Fistula
CNS Causes of Vertigo
Inner Ear, Tinnitus
Inner Ear, Autoimmune Disease
Migraine-Associated Vertigo
Inner Ear, Evaluation of Dizziness
Thyroid, Thyrotoxic Storm Following Thyroidectomy
Inner Ear, Labyrinthitis
Inner Ear, Meniere Disease, Surgical Treatment

Other Problems to Be Considered

Acoustic neuroma and other brain tumors
Autoimmune processes (especially lupus, rheumatoid arthritis, sarcoidosis, periarteritis, giant cell arteritis, Susac and Cogan syndromes)
Congenital anomalies
Diabetes
High cholesterol or triglyceride levels
Inner ear inflammation
Labyrinthitis
Lyme disease
Microvascular compression syndromes
Multiple sclerosis
Neurosyphilis
Otosclerosis
Perilymphatic fistula
Salt or water imbalance
Thyroid disease
Thyroid hormone disease
Transient ischemic attacks and stroke
Trauma
Vestibular migraine
Viral infections

Workup

Laboratory Studies

  • A panel of blood tests is used to rule out obvious metabolic imbalances, infections, and hormonal problems. Tests of the following should be performed:
    • Thyroid stimulating hormone (TSH), T4, and T3 to rule out hyperthyroidism and hypothyroidism
    • Glucose to rule out diabetes
    • Sedimentation rate and antinuclear antibody to rule out autoimmune disorders
    • Urine to rule out proteinuria and hematuria and indicators of otorenal syndrome
    • CBC count to rule out anemia and leukemia
    • Electrolyte levels to rule out salt/water imbalance
    • Fluorescent treponemal antibody (FTA-ABS) to rule out neurosyphilis and Lyme disease
  • Allergy testing is needed for allergy-mediated Ménière disease.

Imaging Studies

  • MRI of the brain is used to detect the following:
    • Abnormal masses or anatomy, specifically, acoustic neuromas or other cerebellopontine angle lesions
    • Other lesions (eg, multiple sclerosis, Arnold-Chiari malformations)
    • Tumors (rarely found but should be ruled out)
  • CT scans are used to detect the following:
    • Dehiscent superior semicircular canals
    • Widened cochlear and vestibular aqueducts

Other Tests

  • Audiometry is particularly helpful to document present hearing acuity and subsequent fluctuations. Occasionally, patients fail to notice loss at specific frequencies.
    • A low-frequency or mixed low- and high-frequency loss may develop. Typically, lower frequencies are affected more often than higher frequencies because of preferential sensitivity of the apex to hydrops.
    • Administering multiple hearing tests to document fluctuating hearing loss is helpful in diagnosing Ménière disease.
  • Transtympanic electrocochleography (ECoG) is used to detect distortion of nerve-containing membranes of the inner ear (presumably due to pressure fluctuations of the perilymph pressure) and may show evidence of cochlear involvement.
    • ECoG is used to measure the ratio of summating potential (probably arising from movement of the basilar membrane) and action potential on the nerve in response to auditory stimuli. Hydrops is suggested when the ratio is greater than 35%.
    • ECoG is most accurate when Ménière disease is active.
  • Electronystagmography (ENG) and videonystagmography (VNG) is performed to test vestibular function of the inner ear, particularly that of the semicircular canals.
    • Typically, endolymphatic hydrops causes reduced vestibular response in the affected ear, but increased vestibular response may develop secondary to an irritative lesion.
    • ENG is used to determine responsiveness of the inner ear to movement and caloric stimulation. It tests central and peripheral function and can help localize lesion sites.
    • Perform ENG when the patient has an empty stomach and when therapy with meclizine, antihistamines, and sedatives has been discontinued for 2 weeks, as these drugs may alter the test results.
    • ENG may cause dizziness and nausea.
  • Direction of spontaneous nystagmus during or after an episode of Ménière syndrome is not a reliable indicator of the lesion site. An irritative phase may occur during the attack (fast phases directed toward involved ear), followed by a paretic phase (fast phases directed toward the opposite ear).

More on Inner Ear, Meniere Disease, Medical Treatment

Overview: Inner Ear, Meniere Disease, Medical Treatment
Differential Diagnoses & Workup: Inner Ear, Meniere Disease, Medical Treatment
Treatment & Medication: Inner Ear, Meniere Disease, Medical Treatment
Follow-up: Inner Ear, Meniere Disease, Medical Treatment
Multimedia: Inner Ear, Meniere Disease, Medical Treatment
References
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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. 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].

  3. 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].

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  7. 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].

  8. 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].

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  10. 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].

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  14. 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].

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Further Reading

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Keywords

meniere's disease, menieres disease, meniere disease, meniere, inner ear, meniere disease medical treatment, endolymphatic hydrops, cochleovestibular hydrops, cochlear hydrops, vestibular hydrops, Meniere syndrome, Ménière syndrome, Meniere disease, Ménière disease, Meniere's syndrome, Ménière's 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.

Medical Editor

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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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: Nothing to disclose.

CME Editor

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 unstricted gift unknown

 
 
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