A 42-year-old woman presents to the ENT clinic with a 6-month history of episodic vertigo lasting 20–30 minutes, associated with tinnitus and a sensation of fullness in the left ear. She reports progressive hearing loss in the low frequencies. Between episodes, she is completely asymptomatic. Audiometry shows sensorineural hearing loss predominantly affecting frequencies below 2 kHz. Caloric testing is normal. What is the most likely diagnosis?

## Diagnosis: Meniere Disease ### Clinical Presentation **Key Point:** Meniere disease is characterized by the classic tetrad of episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness — all present in this patient. ### Distinguishing Features in This Case | Feature | This Patient | Meniere Disease | BPPV | Acoustic Neuroma | |---------|--------------|-----------------|------|------------------| | **Vertigo duration** | 20–30 min | 20 min–several hours | Seconds to minutes | Progressive, constant | | **Hearing loss** | Low-frequency SNHL | Fluctuating, low-freq initially | Normal | High-frequency SNHL | | **Aural fullness** | Present | Yes (pathognomonic) | No | No | | **Tinnitus** | Present | Yes | Absent | Often present | | **Caloric test** | Normal | Normal (between attacks) | Normal | May show canal paresis | | **Asymptomatic intervals** | Yes | Yes | Yes | No (progressive) | ### Pathophysiology **High-Yield:** Meniere disease results from **endolymphatic hydrops** — excessive fluid accumulation in the membranous labyrinth. This causes: 1. Mechanical distortion of the cochlea → low-frequency hearing loss (early) 2. Increased pressure on the vestibular system → episodic vertigo 3. Tinnitus from cochlear dysfunction 4. Aural fullness from increased endolymphatic pressure ### Why Caloric Test Is Normal **Clinical Pearl:** Between attacks, the vestibular system recovers and caloric responses are normal. Caloric abnormalities may appear only during or immediately after an acute attack. ### Diagnostic Criteria (Modified AAO-HNS) **Key Point:** Diagnosis requires: - Episodic vertigo (2+ spontaneous episodes ≥20 min) - Audiometrically documented hearing loss (1+ episodes) - Tinnitus or aural fullness - Exclusion of other causes This patient meets all criteria. ### Mnemonic: FFTF **Mnemonic:** **F**luctuating hearing loss, **F**ullness in ear, **T**innitus, **F**luctuating vertigo (episodic) — all features of Meniere disease [cite:Dhingra ENT 8e Ch 12]