Neuroscience · Year 2 · from Neuroscience
Case 3: Meniere's Disease
Patient Presentation
Demographics: 42-year-old female
Chief Complaint: Recurrent episodes of vertigo, hearing loss, and ringing in left ear
History of Present Illness: A 42-year-old woman presents with a 2-year history of episodic attacks affecting her left ear. Attacks begin with a sensation of fullness and pressure in the left ear, followed by roaring tinnitus, decreased hearing, and severe vertigo with nausea and vomiting. Episodes last 2-4 hours before gradually subsiding. She has had approximately 10 such attacks. Between attacks, she has noticed progressive hearing loss in the left ear, particularly for low-frequency sounds. She reports that high-sodium meals may trigger attacks.
Physical Examination:
- Vital signs: Normal
- Between attacks:
- Otoscopic examination: Normal tympanic membranes bilaterally
- Weber test: Lateralizes to right ear (away from affected ear, indicating sensorineural loss on left)
- Rinne test: Positive bilaterally (air conduction > bone conduction)
- Neurological: No nystagmus at rest; cranial nerves normal; cerebellar examination normal
Workup:
- Audiometry: Left ear low-frequency sensorineural hearing loss (characteristic upsloping pattern); normal hearing right ear
- Electrocochleography (ECochG): Elevated SP/AP ratio on left (suggestive of endolymphatic hydrops)
- MRI brain with IAC protocol: Normal; no vestibular schwannoma
- Vestibular function testing (VNG): Reduced vestibular response on left during caloric testing
Diagnosis: Definite Meniere's disease (left ear)
Treatment:
- Dietary modifications: Low-sodium diet (<2g/day); limit caffeine and alcohol
- Diuretic therapy: Hydrochlorothiazide 25 mg daily
- Betahistine 24 mg twice daily (vestibular modulator)
- Vestibular suppressants (meclizine, ondansetron) for acute attacks
- Hearing evaluation with consideration for hearing aid as hearing loss progresses
- Discussion of intratympanic therapies (steroids, gentamicin) if medical management fails
- Reduction in attack frequency with dietary and medical management
Clinical Pearl: Meniere's disease results from endolymphatic hydrops - distension of the endolymphatic compartment of the inner ear, though the underlying cause remains unclear. The tetrad of symptoms (episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness) distinguishes Meniere's from other vestibular disorders. Hearing loss initially affects low frequencies (unlike presbycusis) and fluctuates but becomes progressive and permanent. Attacks typically last hours (distinguishing from BPPV's seconds and vestibular migraine's minutes to days). Salt restriction reduces endolymph volume and remains a cornerstone of treatment.
Clinical Image
Image Description: Illustration demonstrating the Dix-Hallpike test for BPPV, showing patient positioning with head turned 45 degrees and rapidly lowered to a head-hanging position, along with the anatomical representation of otolith debris in the posterior semicircular canal.
Attribution: Image from Wikimedia Commons (https://commons.wikimedia.org/), Creative Commons Attribution-ShareAlike license.