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MENIERE’S DISEASE JORDAN TROUT DIAGNOSIS • Triad of vertigo, hearing loss, and tinnitus • Definite diagnosis from AAO-HNS: • Two spontaneous episodes of vertigo lasting at least 20 minutes • Sensorineural hearing loss confirmed by audiometry • Tinnitus and/or perception of aural fullness • • • • H81.01-Meniere’s disease, right ear H81.02-Meniere’s disease, left ear H81.03-Meniere’s disease, bilateral H81.09-Meniere’s disease, unspecified ear NIH Medical Arts (Photo]. (2010, July). In National Institute on Deafness and Other Communication Disorders [NIDCD] (Author), Meniere’s disease. Retrieved from http://www.nidcd.nih.gov/health/balance/pages/meniere.aspx#5 PATHOGENESIS • Endolymphatic hydrops • Caused by the buildup of fluid in inner ear • Causes: • Idiopathic • Immune mechanism, genetic, viral, vascular, trauma Komaroff, A. (2015, July 8). What is Meniere’s disease, and what can be done to treat it [Photo]. Retrieved from http://www.askdoctork.com/what-ismenieres-disease-and-what-can-be-done-to-treat-it-201507088067 CLINICAL MANIFESTATIONS HISTORY • Presentation: • Ages 20-40 • Characterized by acute attacks lasting 20 minutes to 24 hours with associated nausea, vomiting, and nystagmus • Interval between attacks can be weeks to months • Fullness or pressure in the affected ear • Fluctuating sensorineural hearing loss of low frequencies CLINICAL MANIFESTATIONS HISTORY • ROS and Health History: • • • • • • • • • • • Allergies and Autoimmune Disorders Viral Infection Recent URI Middle ear surgery Head trauma Previous neurologic disorders Cardiovascular disease Anxiety or mental illness Use of alcohol, tobacco, caffeine, recreational drugs Medications Family History of Meniere’s Disease, TIA, CVA, migraines CLINICAL MANIFESTATIONS PHYSICAL EXAM • Vital Signs (including orthostatic blood pressure) • Otoscopic Exam • Complete Neurological Exam: • Cranial Nerve VIII: Whisper Test, Rinne and Weber Tests • Cerebellar Function with Romberg and Tandem walking • Consistent Nystagmus: Horizontal or Rotary DIX-HALLPIKE MANEUVER • Central Vertigo: • Immediate nystagmus and vertigo • Failure to resolve in 30 seconds • No fatiguing with repeated testing • Peripheral Vertigo: • Latency period of 3-40 seconds before onset of nystagmus and vertigo • Symptoms resolve in 30 seconds • Fatiguing of symptoms with repeated testing Pruitt, A.A. ( 2014) Evaluation of dizziness. In Goroll, A. H., & Mulley, A. G. (Eds.), Primary care medicine: Office evaluation and management of the adult patient (7th ed.). (p. 1203). Philadelphia: Wolters Kluwer Health. DIAGNOSTIC TESTS • • • • Audiometry Vestibular Testing (ENG) ECoG and VEMP Laboratory work • CBC, CMP, TSH, ESR, Lyme, lipid profile, RPR • CT or MRI DIFFERENTIAL DIAGNOSIS Differentials Red Flags • Benign paroxysmal positional vertigo (BPPV) • Cogan’s syndrome • Migraine • Perilymph Fistula • Labyrinthitis • Vertigo secondary to medications • Diabetes or Thyroid disease • Brainstem/Cerebellar Dysfunction • MS • TIA • Acoustic Neuroma • Syphilis: Secondary or early tertiary TREATMENT • Lifestyle: • Salt Restriction (1-2g Na/day) • Avoid stress, nicotine, alcohol, and caffeine • Acute Episodes: • Antiemetics (ondansetron 8 mg q12h; prochlorperazine 5-10 mg q6h) • Vestibular Suppressants • Antihistamines: Meclizine 25-50 mg q6h or dimenhydrinate 50 mg q4-6h • Benzodiazepines: Lorazepam 1-2 mg q8h • Anticholinergics: Scopolamine patch • Symptomatic Relief TREATMENT • Drug Therapy: • Mild Diuretics (250mg acetazolamide BID or 50 mg hydrochlorothiazide BID) • PRN Vestibular suppressants/antiemetics • Alternative medicine • Rehabilitation • Interventional Treatment by ENT: • Intratympanic injection • Surgery • Positive pressure pulse generator (Meniett) OUTCOMES • Majority of patients are able to maintain normal daily activities • Decrease in frequency after multiple attacks that can return months or years later • Progression to hearing loss of higher frequencies and may become permanent • Consider psychological impact REFERENCES • • • • • • • • • • • • • American Academy of Otolaryngology-Head and Neck Surgery (2015). Meniere’s disease: Patient health information. Retrieved from http://www.entnet.org/content/menieres-disease. Bickley, L. S., & Szilagyi, P. G. (2013). Bates' guide to physical examination and history taking (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Committee on Hearing and Equilibrium and American Academy of Otolaryngology-Head and Neck Foundation (1995). Committee on hearing and equilibrium guidelines for the diagnosis and evaluation of therapy in Menière's disease. Otolaryngol Head Neck Surg, 113(3), 181-185. Retrieved from http://oto.sagepub.com Dains, J., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care (4th ed.). St. Louis, MO: Mosby. Dinces, E. A. (2015, November 23). UpToDate. Meniere disease. Retrieved from http://www.uptodate.com/contents/meniere-disease?source=search_result&search =meniere&selectedTitle=1%7E29#H1 Furukawa, M., Kitahara, T., Horii, A., Uno, A., Imai, T., Ohta, Y., & ... Sakagami, M. (2013). Psychological condition in patients with intractable Meniere's disease. Acta Oto-Laryngologica, 133(6), 584-589. doi:10.3109/00016489.2012.759274 Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.). Philadelphia: Wolters Kluwer Health. Komaroff, A. (2015, July 8). What is Meniere’s disease, and what can be done to treat it [Photo]. Retrieved from http://www.askdoctork.com/what-is-menieres-disease-and-what-can-be-done-to-treat-it-201507088067 McCance, K. L., & Huether, S. E. (2014). Pathophysiology: the biologic basis for disease in adults and children (7th ed.). St. Louis, Missouri: Elsevier Mosby. National Institute on Deafness and Other Communication Disorders [NIDCD] (2010, July). Meniere’s disease. Retrieved from http://www.nidcd.nih.gov/health/balance/pages/meniere.aspx#5 NIH Medical Arts [Photo]. (2010, July). In National Institute on Deafness and Other Communication Disorders [NIDCD] (Author), Meniere’s disease. Retrieved from http://www.nidcd.nih.gov/health/balance/pages/meniere.aspx#5 Pruitt, A.A. ( 2014) Evaluation of dizziness. In Goroll, A. H., & Mulley, A. G. (Eds.), Primary care medicine: Office evaluation and management of the adult patient (7th ed.). (p. 1203). Philadelphia: Wolters Kluwer Health. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program (2014, May). Evaluation of vertigo in the adult patient. Retrieved from http://www.guideline.gov/content.aspx?id=48220 QUESTIONS?
