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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Meniere disease classically causes recurrent spontaneous vertigo lasting 20 minutes to 12 hours plus fluctuating low-frequency SNHL, tinnitus, or aural fullness
- Audiometry is essential to document sensorineural hearing loss and follow progression
- Differentiate from BPPV (seconds, positional, no hearing loss) and vestibular neuritis (continuous days, no hearing loss)
- Initial management: education, low-sodium diet, trigger reduction, vestibular suppressants only during acute attacks
- Persistent disabling disease may require diuretics, intratympanic steroids or gentamicin, or surgical options under ENT care
Overview
Meniere disease is an inner-ear disorder associated with endolymphatic hydrops. It produces recurrent spontaneous attacks of vertigo with fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Hearing loss often begins in low frequencies and may become progressive and permanent. It is a clinical diagnosis supported by audiometry and exclusion of alternative disorders such as vestibular migraine, vestibular schwannoma, autoimmune inner-ear disease, and central causes.
Epidemiology
Meniere disease usually presents in adults between ages 20 and 60. It may be unilateral initially but can become bilateral in a minority of patients. Migraine, autoimmune disease, family history, and prior inner-ear injury may be associated. The condition is less common than BPPV and vestibular migraine but is high-yield because vertigo plus hearing symptoms narrows the differential.
Clinical Features
Symptoms
Spontaneous episodic vertigo lasting 20 minutes to 12 hours, often with nausea/vomiting
Fluctuating hearing loss, classically low-frequency early in disease
Tinnitus, often roaring, and aural fullness or pressure
Symptoms may cluster with long symptom-free intervals
Persistent focal neurologic deficits, severe headache, or inability to ambulate suggests central cause
Sudden sustained hearing loss requires urgent sudden SNHL pathway
Signs
Horizontal or rotary nystagmus during attacks
Sensorineural pattern on tuning fork/audiometry
Normal neurologic exam between attacks supports peripheral disorder
Progressive unilateral SNHL or unilateral tinnitus warrants retrocochlear evaluation
Cerebellar signs or direction-changing gaze-evoked nystagmus are central red flags
Investigations
First-line
AudiometryDocuments SNHL, often low-frequency and fluctuating early; repeat testing follows progression
Clinical diagnostic criteriaRecurrent vertigo episodes plus auditory symptoms and exclusion of other vestibular diagnoses
Second-line
MRI internal auditory canals/brainIf asymmetric SNHL, unilateral tinnitus, atypical features, neurologic signs, or vestibular schwannoma concern
Vestibular testingNot always required but may help uncertain or pre-procedure cases
Migraine assessmentVestibular migraine can mimic Meniere but usually lacks progressive low-frequency SNHL
Specialist
ENT/neurotology referralConfirmed, disabling, progressive, or diagnostically uncertain disease
Autoimmune/infectious testingOnly if bilateral rapid progression, systemic symptoms, syphilis risk, or autoimmune features
1
Education and lifestyle
- Counsel on natural history, safety during attacks, fall risk, and driving/work precautions
- Low-sodium diet, adequate hydration, reduced caffeine/alcohol, and trigger identification are commonly recommended
- Treat comorbid migraine, anxiety, and sleep problems when present
2
Acute attacks
- Short course vestibular suppressant such as meclizine or benzodiazepine only during severe vertigo attacks
- Antiemetics for nausea/vomiting and oral/IV fluids if dehydrated
- Avoid chronic vestibular suppressants because they impair central compensation
3
Maintenance therapy
- Diuretics such as hydrochlorothiazide-triamterene may reduce attack frequency in selected patients
- Vestibular rehabilitation for chronic imbalance, not during frequent acute attacks
- Hearing aids for persistent hearing loss
4
Refractory disease
- Intratympanic corticosteroids may reduce vertigo with lower hearing risk
- Intratympanic gentamicin is vestibuloablative and can control vertigo but risks further hearing loss
- Surgical options such as endolymphatic sac surgery, vestibular nerve section, or labyrinthectomy are specialist decisions
Complications
- Progressive hearing loss: Fluctuating early SNHL can become permanent
- Falls/drop attacks: Sudden Tumarkin otolithic crises can occur
- Chronic imbalance: Persistent disequilibrium between attacks
- Psychological impact: Anxiety and avoidance from unpredictable attacks
- Bilateral disease: Less common but more disabling
USMLE Step 2 CK Exam Tips
- 1Vertigo + tinnitus + aural fullness + fluctuating hearing loss = Meniere disease
- 2Attack duration 20 minutes to 12 hours helps distinguish from BPPV seconds and vestibular neuritis days
- 3BPPV has no hearing loss; Meniere does
- 4Audiometry is the key diagnostic/supportive test
- 5Meclizine is for acute attacks only, not chronic prevention
- 6Vestibular migraine is the major mimic; progressive low-frequency SNHL favors Meniere
- 7Unilateral progressive SNHL/tinnitus still needs MRI to exclude vestibular schwannoma
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