How should I manage a patient with recurrent vertigo and hearing loss suspected to have Ménière's disease?

For a patient presenting with recurrent vertigo and hearing loss suspected to be Ménière's disease, the primary step is to refer them for specialist diagnostic investigation NICE NG98.

• Referral for Diagnostic Investigation: You should consider referring adults with hearing loss that fluctuates and is not associated with an upper respiratory tract infection, or with vertigo that has not fully resolved or is recurrent, to an ear, nose and throat (ENT), audiovestibular medicine, or specialist audiology service for diagnostic investigation, following a local pathway NICE NG98.
• Audiological Assessment: As part of the audiological assessment, a full history should be taken, including relevant symptoms, comorbidities, cognitive ability, physical mobility, dexterity, and the person's hearing and communication needs NICE NG98. This assessment should also include otoscopy, pure tone audiometry, and tympanometry if indicated NICE NG98.
• Consider MRI: Consider offering MRI of the internal auditory meati to adults with hearing loss and localising symptoms or signs (such as facial nerve weakness) that might indicate a vestibular schwannoma or cerebellopontine angle (CPA) lesion NICE NG98. MRI should also be considered for adults with sensorineural hearing loss and no localising signs if there is an asymmetry on pure tone audiometry of 15 dB or more at any two adjacent test frequencies (0.5, 1, 2, 4, and 8 kHz) NICE NG98.
• Consider Other Causes of Vertigo: Be aware of other potential causes of recurrent dizziness. For transient rotational vertigo on head movement, offer the Hallpike manoeuvre to check for benign paroxysmal positional vertigo (BPPV) if a trained healthcare professional is available NICE NG127. If BPPV is diagnosed, a canalith repositioning manoeuvre (such as the Epley manoeuvre) can be offered if a trained healthcare professional is available and the person does not have unstable cervical spine disease NICE NG127. If trained staff are not available or if there is unstable cervical spine disease, refer in accordance with local pathways NICE NG127. Also, be alert to the possibility of vestibular migraine in adults who have episodes of dizziness lasting between 5 minutes and 72 hours and a history of recurrent headache NICE NG127.
• Earwax Management (if relevant): If earwax is contributing to hearing loss or other symptoms, offer to remove it in primary care or community ear care services NICE NG98. Do not offer manual syringing to remove earwax NICE NG98. Ear irrigation using an electronic irrigator, microsuction, or manual removal can be considered if the practitioner is trained, aware of contraindications, and has the correct equipment NICE NG98. Pre-treatment wax softeners should be used NICE NG98. If irrigation is unsuccessful after a second attempt, refer the person to a specialist ear care service or an ENT service for earwax removal NICE NG98. Advise adults not to remove earwax or clean their ears by inserting small objects, such as cotton buds, into the ear canal, as this could cause damage or push wax further in NICE NG98.