Ménière's disease: Difference between revisions
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==Background== | ==Background== | ||
*Occurs due to increased endolymph within the cochlea and labyrinth | *Occurs due to increased endolymph within the cochlea and labyrinth (endolymphatic hydrops) | ||
*First attack usually occurs in patients >65yrs | *First attack usually occurs in patients >65yrs | ||
*Usually is unilateral but may become bilateral with time | *Usually is unilateral but may become bilateral with time | ||
==Clinical Features== | ==Clinical Features== | ||
*Episodes of sudden-onset vertigo with nausea/vomiting | *Episodes of sudden-onset [[vertigo]] with [[nausea/vomiting]] | ||
**Can include "drop attacks" where the patient feels knocked to the ground | |||
**Duration: usually 2-8hr | **Duration: usually 2-8hr | ||
**Frequency: Ranges from several episodes per week to several times per month | **Frequency: Ranges from several episodes per week to several times per month | ||
*Roaring tinnitus | *Roaring [[tinnitus]] | ||
*Diminished hearing | *[[hearing loss|Diminished hearing]] | ||
*Fullness in affected ear | *Fullness in affected ear | ||
*Between attacks patient is well (although decreased hearing may persist) | *Between attacks patient is well (although decreased hearing and constant tinnitus may persist) | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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*No workup required for classical Meniere disease in the ED | *No workup required for classical Meniere disease in the ED | ||
*Confirmed by ENT via glycerol testing or vestibular-evoked potentials | *Confirmed by ENT via glycerol testing or vestibular-evoked potentials | ||
*Imaging with MRI if suspicion or need to rule out lesions such as<ref>Lorenzi MC, Bento RF, Daniel MM, Leite CC. Magnetic resonance imaging of the temporal bone in patients with Ménière's disease. Acta Otolaryngol. 2000 Aug. 120(5):615-9.</ref>: | *Imaging with [[brain MRI|MRI]] if suspicion or need to rule out lesions such as<ref>Lorenzi MC, Bento RF, Daniel MM, Leite CC. Magnetic resonance imaging of the temporal bone in patients with Ménière's disease. Acta Otolaryngol. 2000 Aug. 120(5):615-9.</ref>: | ||
**[[Acoustic neuroma]] | **[[Acoustic neuroma]] | ||
**Cerebellopontine angle lesion | **Cerebellopontine angle lesion | ||
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==Management== | ==Management== | ||
*Treat vertigo symptomatically with [[scopolamine]], [[antihistamines]], or [[benzodiazepines]] | *Treat vertigo symptomatically with [[scopolamine]], [[antihistamines]], or [[benzodiazepines]] | ||
* | *Vestibulo-suppressant options<ref>Minor LB, Schessel DA, Carey JP. Ménière's disease. Curr Opin Neurol. 2004 Feb. 17(1):9-16.</ref> | ||
**[[Meclizine]] 25-50mg PO | **[[Meclizine]] 25-50mg PO | ||
**[[Diazepam]] 5-10mg PO or IV | **[[Diazepam]] 5-10mg PO or IV | ||
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*[[Diuretics]] may decrease fluid pressure in ear: | *[[Diuretics]] may decrease fluid pressure in ear: | ||
**[[Hydrochlorothiazide]] | **[[Hydrochlorothiazide]] | ||
**[[Triamterene]] | |||
**[[Acetazolamide]] | **[[Acetazolamide]] | ||
**Avoid loop diuretics due to ototoxicity | **Avoid loop [[diuretics]] due to ototoxicity | ||
*Consider IM steroid injection, followed by tapered PO [[prednisone]]<ref>Sajjadi H. Medical management of Meniere's disease. Otolaryngol Clin North Am. 2002 Jun. 35(3):581-9, vii.</ref> | *Consider IM [[steroid]] injection, followed by tapered PO [[prednisone]]<ref>Sajjadi H. Medical management of Meniere's disease. Otolaryngol Clin North Am. 2002 Jun. 35(3):581-9, vii.</ref> | ||
*Routine ENT referral for medical treatment failures (endolymphatic decompression, vestibular nerve section, labyrunthectomy, intra-TM injections)<ref>Pullens B, Giard JL, Verschuur HP, van Benthem PP. Surgery for Ménière's disease. Cochrane Database Syst Rev. 2010 Jan 20. CD005395.</ref><ref>Barrs DM. Intratympanic corticosteroids for Meniere's disease and vertigo. Otolaryngol Clin North Am. 2004 Oct. 37(5):955-72, v.</ref> | *Routine ENT referral for medical treatment failures (endolymphatic decompression, vestibular nerve section, labyrunthectomy, intra-TM injections)<ref>Pullens B, Giard JL, Verschuur HP, van Benthem PP. Surgery for Ménière's disease. Cochrane Database Syst Rev. 2010 Jan 20. CD005395.</ref><ref>Barrs DM. Intratympanic corticosteroids for Meniere's disease and vertigo. Otolaryngol Clin North Am. 2004 Oct. 37(5):955-72, v.</ref> | ||
==Disposition== | ==Disposition== | ||
*Refer to ENT | *Refer to ENT for further evaluation and management | ||
*Surgery may include vestibular nerve section (surgical or chemical), endolymph sac decompression, endolymphatic-subarachnoid shunt, or labyrinthectomy | |||
==References== | ==References== | ||
Latest revision as of 18:52, 28 October 2023
Background
- Occurs due to increased endolymph within the cochlea and labyrinth (endolymphatic hydrops)
- First attack usually occurs in patients >65yrs
- Usually is unilateral but may become bilateral with time
Clinical Features
- Episodes of sudden-onset vertigo with nausea/vomiting
- Can include "drop attacks" where the patient feels knocked to the ground
- Duration: usually 2-8hr
- Frequency: Ranges from several episodes per week to several times per month
- Roaring tinnitus
- Diminished hearing
- Fullness in affected ear
- Between attacks patient is well (although decreased hearing and constant tinnitus may persist)
Differential Diagnosis
Vertigo
- Vestibular/otologic
- Benign paroxysmal positional vertigo (BPPV)
- Traumatic (following head injury)
- Infection
- Ménière's disease
- Ear foreign body
- Otic barotrauma
- Otosclerosis
- Neurologic
- Cerebellar stroke
- Vertebrobasilar insufficiency
- Lateral Wallenberg syndrome
- Anterior inferior cerebellar artery syndrome
- Neoplastic: cerebellopontine angle tumors
- Basal ganglion diseases
- Vertebral Artery Dissection
- Multiple sclerosis
- Infections: neurosyphilis, tuberculosis
- Epilepsy
- Migraine (basilar)
- Other
- Hematologic: anemia, polycythemia, hyperviscosity syndrome
- Toxic
- Chronic renal failure
- Metabolic
Evaluation
- No workup required for classical Meniere disease in the ED
- Confirmed by ENT via glycerol testing or vestibular-evoked potentials
- Imaging with MRI if suspicion or need to rule out lesions such as[1]:
- Acoustic neuroma
- Cerebellopontine angle lesion
- Multiple sclerosis
- Arnold-Chiari malformation
Management
- Treat vertigo symptomatically with scopolamine, antihistamines, or benzodiazepines
- Vestibulo-suppressant options[2]
- Meclizine 25-50mg PO
- Diazepam 5-10mg PO or IV
- Other options: scopolamine, promethazine, prochlorperazine, metoclopramide
- Diuretics may decrease fluid pressure in ear:
- Hydrochlorothiazide
- Triamterene
- Acetazolamide
- Avoid loop diuretics due to ototoxicity
- Consider IM steroid injection, followed by tapered PO prednisone[3]
- Routine ENT referral for medical treatment failures (endolymphatic decompression, vestibular nerve section, labyrunthectomy, intra-TM injections)[4][5]
Disposition
- Refer to ENT for further evaluation and management
- Surgery may include vestibular nerve section (surgical or chemical), endolymph sac decompression, endolymphatic-subarachnoid shunt, or labyrinthectomy
References
- ↑ Lorenzi MC, Bento RF, Daniel MM, Leite CC. Magnetic resonance imaging of the temporal bone in patients with Ménière's disease. Acta Otolaryngol. 2000 Aug. 120(5):615-9.
- ↑ Minor LB, Schessel DA, Carey JP. Ménière's disease. Curr Opin Neurol. 2004 Feb. 17(1):9-16.
- ↑ Sajjadi H. Medical management of Meniere's disease. Otolaryngol Clin North Am. 2002 Jun. 35(3):581-9, vii.
- ↑ Pullens B, Giard JL, Verschuur HP, van Benthem PP. Surgery for Ménière's disease. Cochrane Database Syst Rev. 2010 Jan 20. CD005395.
- ↑ Barrs DM. Intratympanic corticosteroids for Meniere's disease and vertigo. Otolaryngol Clin North Am. 2004 Oct. 37(5):955-72, v.