Return to Meniere's Disease Overview

See also: BPPV Patient Handout

Background

Dizziness is a common chief complaint seen by otolaryngologists.

One of the most common types of dizziness is vertigo, defined as:

• Feeling of motion when it is not actually present
• Room spinning

• Associated with disorders of the inner ear

   

Classification

• Peripheral
  • Inner Ear/Vestibular System
  • Benign Paroxysmal Positional Vertigo
  • Meniere's Disease
  • Vestibular Neuritis
  • Superior Canal Wall Dehiscence
  • Vestibular Migraine
• Central
  • CNS lesion
  • Tumor (vestibular schwannoma)
  • Hemorrhage
  • Brainstem/cerebellar stroke

Etiology

Benign Positional Paroxysmal Vertigo (BPPV):

• Most common cause of vertigo
• Intense vertigo for <60 seconds
• Can be triggered by head movements such asrolling over in bed
• Otoconia displaced into semicircular canals

Diagnosis: Dix-Hallpike maneuvers

• Examines posterior semicircular canal involvement
• Start supine with neck extended
• Head turned 45 degrees away from affected ear
• Examine for nystagmus, vertigo symptoms

Treatment: Repositioning maneuvers (Epley or Semont)

Meniere's Disease:

• Recurrent vertigo episodes lasting 30 minutes to several hours
  • Commonly associated with light-headedness, nausea and vomiting
• Fluctuating sensorineural hearing loss which worsens over time
• Low-frequency tinnitus
• Aural fullness
• Increase in endolymphatic fluid volume and pressure in middle ear 

Diagnosis: clinical findings as described above and audiometric data over time

Treatment:

• Non-surgical
  • Trigger reduction: Reduce salt, caffeine, alcoholol, nicotine
  • Acute episodes mangaged with antiemetics and vestibular suppressants
  • Long-Term management includes thiazide diuretics, vestibular therapy and hearing aids
  • Intratypmanic injections of gentamicin
• Surgical
  • Endolymphatic shunt
  • Labyrinthectomy
  • Vestibular neurectomy

Vestibular Neuritis:

• Acute single episode that may last several days
• Often precipitated by viral illness
• Diagnosis: Abnormal head thrust test
• Treatment: Supportive

Superior Canal Wall Dehiscence:

• Autophony, Dizziness
• Brain fog
• Tinnitus
• Due to thinning/abscence of superior semicircular canal wall of temporal bone
• Diagnosis: Thin slice temporal bone CT
• Treatment: Surgical repair

Vestibular Migraine: 

• Vertigo symptoms associated with headache or aura
• Recurrent symptoms with complete resolution between episodes 

CNS Tumor: 

• Most commonly vestibular schwannoma
  • Benign growth arising from schwann cell on vestibular portion of CN VIII
  • Hearing loss
  • Tinnitus
  • Fluctuating vertigo
  • Facial pain or numbness
  • Bilateral vestibular schwannoma is the hallmark of Neurofibromatosis Type 2

Diagnosis: MRI scanning with gadolinium contrast 

Treatment:  

• Observation
  • Since vestibular schwannomas are typically slow growing, observation with follow-up MRI scans every 6 to 12 months may be warranted in carefully selected patients.
• Surgery
  • Several approaches may be employed to gain tumor access
• Radiation 

Brainstem/cerebellar Stroke:

• Symptoms typically associated with other neurological deficits
  • Lateral medullary syndrome (PICA infarction)
    • dysphagia, slurred speech, Horner's syndrome, ataxia
    • contralateral loss of pain and temperature sensation from body
    • ipsilateral loss of pain and temperature sensation from face
• Very rarely vertigo is isolated sign of a lacunar stroke involving only the vestibular system
• Symptoms in central vertigo may not improve, or will take much longer to improve than in peripheral vertigo

Diagnosis:

• HINTS exam
  • The presence of any one of three clinical signs suggests central rather than peripheral vertigo:
    • a normal head impulse test
    • Direction-changing nystagmus
    • Skew deviation
• Imaging: CT, CT angiography, MRI

References

Dickerson, LM (2010). "Dizziness: a diagnostic approach". American Family Physician. 82 (4): 361–369. PMID 20704166.