Ménière's disease
Background
- Occurs due to increased endolymph within the cochlea and labyrinth
- 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
- 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 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.