A 42-year-old woman presents to the ENT clinic with a 6-month history of episodic vertigo lasting 2–4 hours, accompanied by unilateral tinnitus and progressive hearing loss in the left ear. She reports fullness in the affected ear and nausea during attacks. Audiometry shows low-frequency sensorineural hearing loss on the left. Caloric testing reveals reduced vestibular response on the left. MRI of the internal acoustic meatus is normal. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Meniere Disease ### Key Features Present in This Case **Key Point:** Meniere disease is characterized by the classic tetrad of episodic vertigo, tinnitus, hearing loss, and aural fullness, all unilateral and fluctuating in nature. This patient exhibits all four cardinal features: 1. **Episodic vertigo** — 2–4 hour duration (typical for Meniere) 2. **Unilateral tinnitus** — left ear 3. **Progressive hearing loss** — low-frequency SNHL (pathognomonic pattern) 4. **Aural fullness** — sensation of pressure in the affected ear ### Pathophysiology **High-Yield:** Meniere disease results from **endolymphatic hydrops** — abnormal accumulation of endolymph within the membranous labyrinth, causing distension and rupture of Reissner's membrane during attacks. ### Diagnostic Criteria (Modified Criteria) | Feature | Meniere Disease | |---------|------------------| | Vertigo episodes | Spontaneous, 20 min–several hours | | Hearing loss | Fluctuating, low-frequency SNHL initially | | Tinnitus | Unilateral, often roaring quality | | Aural fullness | Present, worsens before attack | | MRI | Normal (rules out retrocochlear pathology) | | Caloric test | May show reduced vestibular response | ### Why This Is Not Other Diagnoses - **BPPV:** Causes brief (seconds–minutes) vertigo with positional triggers; no hearing loss or tinnitus. - **Acoustic neuroma:** Would show retrocochlear signs on MRI and progressive, unidirectional hearing loss; MRI is normal here. - **Sudden SNHL:** Presents acutely over hours to days, not episodically; no vertigo or aural fullness. ### Clinical Pearl **Clinical Pearl:** Early Meniere disease shows **low-frequency hearing loss** (250–1000 Hz), which distinguishes it from noise-induced or age-related SNHL (high-frequency). As disease progresses, the entire audiogram becomes flat. ### Management Approach ```mermaid flowchart TD A[Suspected Meniere Disease]:::outcome --> B{Confirm Diagnosis}:::decision B -->|Audiometry + caloric test| C[Low-freq SNHL + reduced vestibular response]:::outcome C --> D{Acute Attack?}:::decision D -->|Yes| E[Bed rest, antiemetics, vestibular suppressants]:::action D -->|No| F[Prophylaxis: diuretics, salt restriction]:::action F --> G{Refractory to medical therapy?}:::decision G -->|Yes| H[Intratympanic steroid or gentamicin]:::action G -->|No| I[Continue conservative management]:::action ``` [cite:Ballenger's Otolaryngology Ch 8]