FFinalistSouthampton · 2027
ENT
AKT · ENT/Vertigo & balance

Ménière disease

Endolymphatic hydrops (raised endolymph volume)

Overview

A disorder of the inner ear from raised endolymph volume (endolymphatic hydrops), giving recurrent attacks of the TRIAD: episodic vertigo (lasting minutes–hours), fluctuating sensorineural hearing loss, and tinnitus, often with aural fullness. Hearing loss eventually becomes permanent.

Recognise

  • Recurrent spontaneous vertigo attacks lasting 20 minutes to several HOURS (not seconds, not days)
  • Fluctuating low-frequency SENSORINEURAL hearing loss + tinnitus + a sense of aural fullness/pressure
  • Usually unilateral initially; attacks cluster then remit; permanent hearing loss accrues over years

Red flags

  • Asymmetric/progressive features warrant MRI to exclude a vestibular schwannoma; drop attacks (Tumarkin) risk injury

Differentials & how to tell them apart

BPPVbrief seconds-long positional vertigo, no hearing loss
Vestibular neuritisa single prolonged (days) episode, hearing spared
Vestibular schwannomaprogressive asymmetric SNHL — MRI (neurology)
Vestibular migrainemigraine features, no progressive hearing loss

Investigations

Clinical (the triad of episodic vertigo + fluctuating SNHL + tinnitus). Audiometry (low-frequency SNHL). MRI to exclude a retrocochlear lesion. ENT referral.

Management

Acute: prochlorperazine; prevention: betahistine + low-salt diet; ENT referral

  1. 1Acute attack → buccal/IM prochlorperazine (or an antihistamine) for vertigo and vomiting. Prevention → betahistine and dietary measures (reduce salt, caffeine, alcohol). Refer to ENT.Gate: Vertigo lasting MINUTES-TO-HOURS WITH fluctuating sensorineural hearing loss + tinnitus + fullness is Ménière — the hearing/tinnitus component distinguishes it from BPPV (brief, no hearing loss) and neuritis (prolonged, single episode)
  2. 2Refractory disease → intratympanic gentamicin or steroid, grommet, or surgery (ENT); manage falls risk from drop attacks; DVLA: must inform and stop driving until controlled.
Acute attack: prochlorperazine or an antihistamine (cyclizine) — symptomatic relief of the acute vertigo/nausea
Prevention: betahistine — to reduce attack frequency
Lifestyle: low salt, reduce caffeine/alcohol — dietary measures
(Severe refractory): intratympanic gentamicin/steroid, surgery — specialist

Key points

Triad = episodic vertigo (mins–hours) + fluctuating SNHL + tinnitus/fullness. The duration and the hearing involvement place it between BPPV (seconds) and neuritis (days). Patients must inform the DVLA.

Monitor & prognosis

Attack frequency, audiometry (progressive SNHL), falls risk.

Vertigo often burns out over years but hearing loss tends to persist.

Source: NICE CKS Ménière’s disease