A 42-year-old woman from Delhi presents with a 6-month history of episodic vertigo lasting 4–6 hours, accompanied by tinnitus, aural fullness, and low-frequency sensorineural hearing loss. Audiometry confirms unilateral low-frequency SNHL. She denies recent head trauma or ototoxic drug exposure. Caloric testing shows reduced caloric response on the affected side. She is currently on no medications. What is the most appropriate next step in management?

Explanation

## Diagnosis and Initial Management of Menière Disease **Key Point:** The clinical triad of episodic vertigo, tinnitus, and aural fullness with unilateral low-frequency SNHL and reduced caloric response is pathognomonic for Menière disease. First-line management is conservative and medical. ### Diagnostic Criteria Met - Recurrent spontaneous vertigo (4–6 hours duration) - Unilateral low-frequency sensorineural hearing loss (confirmed on audiometry) - Tinnitus and aural fullness (endolymphatic hydrops) - Abnormal caloric testing (vestibular hypofunction) - No alternative diagnosis on history ### First-Line Management Algorithm ```mermaid flowchart TD A[Suspected Menière Disease]:::outcome --> B{Diagnosis confirmed?}:::decision B -->|Yes| C[Conservative management]:::action C --> D[Dietary sodium restriction<br/>Diuretics: HCTZ or acetazolamide<br/>Vestibular rehab]:::action D --> E{Response at 3 months?}:::decision E -->|Good| F[Continue medical therapy]:::outcome E -->|Poor| G[Consider intratympanic gentamicin<br/>or surgical options]:::action B -->|No| H[MRI to exclude<br/>retrocochlear lesion]:::action ``` **High-Yield:** The mainstay of initial therapy is: 1. **Sodium restriction** (< 2 g/day) — reduces endolymphatic fluid volume 2. **Loop or thiazide diuretics** — hydrochlorothiazide 25–50 mg daily or acetazolamide 250–500 mg BD 3. **Vestibular rehabilitation** — improves central compensation and reduces vertigo severity ### Why MRI Is Not First-Line - MRI is reserved for atypical presentations (bilateral symptoms, progressive hearing loss, absence of vertigo, sudden onset) to exclude retrocochlear pathology (vestibular schwannoma, MS, vascular lesion) - This patient has a classic unilateral presentation with typical vertigo attacks — MRI is not indicated at this stage ### Why Surgery Is Not First-Line - Endolymphatic sac decompression, labyrinthectomy, and vestibular neurectomy are reserved for **intractable cases** (> 2 years of failed medical therapy with severe functional impairment) - Medical therapy is effective in 60–80% of patients **Clinical Pearl:** Response to medical therapy typically takes 3–6 months. If no improvement by 3 months, escalate to intratympanic gentamicin (vestibulotoxic) or surgical intervention. **Mnemonic:** **SHED** = Sodium restriction, Hydrochlorothiazide, Endolymphatic decompression (if refractory), Diuretics [cite:Harrison 21e Ch 468]