Meniere Disease

Classify as definite Meniere disease when the patient has at least two spontaneous vertigo episodes lasting 20 minutes to 12 hours; low- to mid-frequency sensorineural hearing loss documented by audiometry in the affected ear at least once during the disease course; fluctuating ipsilateral hearing loss, tinnitus, or aural fullness; and no better explanation. The audiogram is not optional when assigning the definite diagnosis. PubMed+2PubMedThe diagnostic significance and value of vestibular function testing combined with MRI in Meniere’s diseasePubMedA bibliometric and visualization study of Meniere's diseasePubMedMeniere Disease - StatPearls - NCBI Bookshelf - NIH

Classify as probable Meniere disease when there are at least two episodes of spontaneous vertigo or dizziness lasting 20 minutes to 24 hours with fluctuating ipsilateral aural symptoms, but the required audiometric hearing-loss documentation is absent. Reassess with serial audiometry if attacks continue or cochlear symptoms fluctuate. PubMedPubMedMeniere Disease - StatPearls - NCBI Bookshelf - NIH

Do not use endolymphatic hydrops on MRI as a stand-alone diagnostic endpoint. Hydrops can occur in vestibular migraine, although it is reported more often in Meniere disease; MRI therefore modifies the differential rather than superseding the clinical syndrome and audiogram. PubMedPubMedFunctional and Molecular Markers for Hearing Loss and Vertigo Attacks in Meniere’s Disease

Vestibular migraine is the most consequential clinical mimic when recurrent vertigo coexists with migraine. Auditory symptoms and even MRI-demonstrated hydrops may occur in vestibular migraine, so a migraine-associated pattern should prevent overreliance on hydrops imaging and prompt reassessment of whether the full audiometric and temporal criteria for Meniere disease are met. PubMed+1PubMedFunctional and Molecular Markers for Hearing Loss and Vertigo Attacks in Meniere’s DiseasePubMedMeniere Disease - StatPearls - NCBI Bookshelf - NIH

Redirect patients with brief position-triggered attacks toward benign paroxysmal positional vertigo, and those with a sustained acute vestibular syndrome toward vestibular neuritis or labyrinthitis rather than Meniere disease. Sudden sensorineural hearing loss, vestibular paroxysmia, drug-induced vertigo, posterior-circulation ischemia, and intracranial mass lesions are additional alternatives explicitly requiring exclusion under diagnostic criteria. PubMedPubMedThe diagnostic significance and value of vestibular function testing combined with MRI in Meniere’s disease

Escalate beyond a peripheral-vestibular attribution when focal neurologic deficits, a central neurologic syndrome, or concern for posterior circulation ischemia is present. In patients with hearing findings or symptoms concerning for retrocochlear pathology, MRI or auditory brainstem response has been used to exclude acoustic neuroma and auditory neuropathy spectrum disorder. PubMed+1PubMedThe diagnostic significance and value of vestibular function testing combined with MRI in Meniere’s diseasePubMedCharacteristics of the Cochlear Symptoms and Functions in Meniere's Disease - PMC

Perform pure-tone audiometry to document the low- to mid-frequency sensorineural hearing loss required for definite disease and to establish a hearing baseline before potentially ototoxic treatment. Audiometric confirmation supports diagnosis, whereas imaging and laboratory studies are primarily used to exclude alternative diagnoses. PubMed+1PubMedThe diagnostic significance and value of vestibular function testing combined with MRI in Meniere’s diseasePubMedMeniere Disease - StatPearls - NCBI Bookshelf - NIH

Consider electrocochleography, cervical or ocular vestibular-evoked myogenic potentials, videonystagmography with caloric testing, video head impulse testing, or rotary-chair testing when the clinical question is vestibular phenotyping or diagnostic clarification. These tests are adjunctive: their diagnostic value remains controversial, and no individual functional test is specific for Meniere disease. PubMed+2PubMedFunctional and Molecular Markers for Hearing Loss and Vertigo Attacks in Meniere’s DiseasePubMedA bibliometric and visualization study of Meniere's diseasePubMedCharacteristics of the Cochlear Symptoms and Functions in Meniere's Disease - PMC

Hydrops MRI may provide supportive evidence in selected diagnostically difficult cases. A review cited vestibular hydrops MRI as having higher diagnostic value for definite disease than several audiovestibular tests, but technical pitfalls and overlap with vestibular migraine require interpretation in the clinical context. PubMed+1PubMedFunctional and Molecular Markers for Hearing Loss and Vertigo Attacks in Meniere’s DiseasePubMedA bibliometric and visualization study of Meniere's disease

Start with conservative measures for patients meeting clinical criteria who have nonemergent episodic attacks. Common first-line dietary modification includes reducing sodium, caffeine, and alcohol intake; one review describes sodium intake below 3 g/day as a proposed target, while acknowledging that dietary restriction is commonly advised rather than established by a definitive diagnostic biomarker. PubMedPubMedDietary Restriction for The Treatment of Meniere’s Disease - PMC

Use vestibular rehabilitation during the intercritical period, not as a substitute for diagnosing an active alternative vestibular syndrome. Consensus material also recommends lifestyle modification and considers psychotherapy as part of conservative care for patients with persistent disease burden. ScienceDirectScienceDirectInternational consensus (ICON) on treatment of Ménière's disease

For frequent or disabling vertigo that remains uncontrolled after conservative treatment, offer intratympanic steroid injection as a nonablative escalation strategy. Intratympanic steroids are described as a relatively safe second-line treatment with less cochleovestibular damage than gentamicin; reported long-term response is heterogeneous, so reassess vertigo frequency and hearing rather than presuming durable control. PubMed+2PubMedIntratympanic steroid versus gentamicin for treatment of ...ScienceDirectMeniere's disease: Medical management, rationale for vestibular preservation and suggested protocol in medical failure - ScienceDirectScienceDirectDifferences in responsiveness of intratympanic steroid injection for intractable vertigo in Meniere's disease - ScienceDirect

Consider intratympanic gentamicin when vertigo remains intractable and the patient accepts the hearing-preservation tradeoff. Gentamicin can provide substantial vertigo control and is often used as a less invasive alternative to surgery, but it has a potential risk of hearing loss; low-dose or titration strategies have been reported to seek selective vestibular ablation. Wolters Kluwer+2Wolters KluwerIntratympanic Gentamicin Therapy for Meniere's Disease : Otology & NeurotologyPubMedDietary Restriction for The Treatment of Meniere’s Disease - PMCScienceDirectSurgical management of Meniere’s disease in the era of gentamicin

For disease refractory to noninvasive treatment, discuss operative options with an otologist. Endolymphatic sac surgery is a nondestructive surgical option; a cited meta-analysis reported vertigo control in at least 75% of medically refractory patients and approximately 2% worsened hearing, although selection and comparative evidence should be discussed. Vestibular neurectomy and labyrinthectomy are destructive last-line procedures for intractable disease. ScienceDirect+2ScienceDirectInternational consensus (ICON) on treatment of Ménière's diseaseScienceDirectVestibular neurectomy for Meniere’s Disease - ScienceDirectScienceDirectEndolymphatic sac-vein decompression for intractable meniere’s disease: long term treatment results - ScienceDirect

At follow-up, record vertigo-attack frequency, attack duration, functional disability, interval imbalance, tinnitus or fullness, and repeat audiometry when hearing symptoms change or after hearing-risk interventions. This is especially important after intratympanic gentamicin because vertigo benefit must be weighed against potential hearing loss. Wolters Kluwer+1Wolters KluwerIntratympanic Gentamicin Therapy for Meniere's Disease : Otology & NeurotologyPubMedDietary Restriction for The Treatment of Meniere’s Disease - PMC

Counsel that the natural history can change: attacks may become less frequent while hearing loss and tinnitus become permanent. In an untreated cohort cited in a review, complete vertigo control occurred in 57% at 2 years and 71% after a mean 8.3 years; this spontaneous improvement complicates attribution of benefit in uncontrolled interventions. ScienceDirectScienceDirectMenière's disease - ScienceDirect

Escalate treatment based on ongoing disabling vertigo rather than hearing loss alone. Conversely, progressive or asymmetric auditory findings should trigger reconsideration of alternative diagnoses and selective MRI or auditory brainstem response evaluation rather than automatic progression to destructive therapy. PubMed+1PubMedCharacteristics of the Cochlear Symptoms and Functions in Meniere's Disease - PMCPubMedMeniere Disease - StatPearls - NCBI Bookshelf - NIH