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 ¹.

• 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 ¹.
• 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 ¹. This assessment should also include otoscopy, pure tone audiometry, and tympanometry if indicated ¹.
• 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 ¹. 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) ¹.
• 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 ³. 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 ³. If trained staff are not available or if there is unstable cervical spine disease, refer in accordance with local pathways ³. 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 ³.
• 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 ¹. Do not offer manual syringing to remove earwax ¹. 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 ¹. Pre-treatment wax softeners should be used ¹. If irrigation is unsuccessful after a second attempt, refer the person to a specialist ear care service or an ENT service for earwax removal ¹. 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 ¹.