EN4.18 | Meniere's Disease — Summary & Reflection

KEY TAKEAWAYS

Meniere's disease is idiopathic endolymphatic hydrops presenting with the clinical tetrad:

• Tetrad: (1) episodic vertigo 20 min – several hours; (2) low-frequency fluctuating SNHL; (3) tinnitus; (4) aural fullness.
• Pathophysiology: endolymphatic sac dysfunction → hydrops → membranous labyrinth rupture → endolymph/perilymph mixing → uncontrolled hair cell depolarisation → attack resolves as membrane reseals.
• Investigations: PTA (low-freq SNHL, fluctuating), ECoG (elevated SP/AP ratio), caloric testing (canal paresis), glycerol test (hearing improvement = positive), MRI (exclude acoustic neuroma).
• Diagnosis: AAO-HNS criteria — ≥2 vertigo episodes ≥20 min + audiometric SNHL + tinnitus/fullness.
• Management (step-up): low-salt diet + betahistine + diuretic → intratympanic steroids (hearing serviceable) or intratympanic gentamicin (hearing poor) → surgery (ESD, neurectomy, labyrinthectomy).
• Known-trap: episode duration — Meniere's = hours; BPPV = seconds; vestibular neuritis = days. Do not confuse.

REFLECT

The patient in the opening scenario has classic Meniere's disease — all four features of the tetrad, appropriate episode duration, and a normal MRI. Reflect on what his experience is like between attacks: the anticipatory anxiety of not knowing when the next attack will strike, the gradual and irreversible decline in hearing, and the impact on professional functioning (a banker who cannot reliably be present at meetings without risk of a sudden disabling attack). Consider how you would counsel him at his first ENT visit — explaining the diagnosis, the long-term prognosis (attacks may reduce with time but hearing loss is progressive), and the step-up management plan. What information does he need to make an informed decision between starting betahistine and low-salt diet versus requesting an intratympanic injection?