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Meniere Disease

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Last Update: September 4, 2021.

Continuing Education Activity

Meniere disease is an inner ear disorder characterized by tinnitus, vertigo, and hearing loss. This is thought to occur due to the accumulation of endolymphatic fluid in the cochlea and the vestibular organ. This activity reviews the evaluation and management of Meniere disease and explains the role of the interprofessional team in improving care for patients with this condition.


  • Outline the epidemiology of Meniere disease.
  • Identify the use of the Rinne and Weber test in the history and physical of patients with Meniere disease.
  • Describe the audiometric tests used in the evaluation of Meniere disease.
  • Review the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients affected by Meniere disease.
Access free multiple choice questions on this topic.


Meniere disease is a disorder of the inner ear characterized by hearing loss, tinnitus, and vertigo. In most cases, it is slowly progressive and has a significant impact on the social functioning of the individual affected.[1]

The current diagnostic criteria defined by the Barany society by Lopez-Escamez et al. can help differentiate between a probable and a definite Meniere's disease. 

Patients with a definite Meniere disease according to the Barany Society have:

  1. Two or more spontaneous episodes of vertigo with each lasting 20 minutes to 12 hours
  2. Audiometrically documented low- to medium-frequency sensorineural hearing loss in one ear, defining and locating to the affected ear on in at least one instance prior, during, or after one of the episodes of vertigo
  3. Fluctuating aural symptoms (fullness, hearing, tinnitus) located in the affected ear
  4. Not better accounted for by any other vestibular diagnosis

Probable Meniere disease can include the following clinical findings:

  1. Two or more episodes of dizziness or vertigo, each lasting 20 minutes to 24 hours
  2. Fluctuating aural symptoms (fullness, hearing, or tinnitus) in the affected ear
  3. The condition is better explained by another vestibular diagnosis[2]


Studies of the temporal bone revealed endolymphatic accumulation in the cochlea and the vestibular organ in patients with Meniere disease. Current research links endolymphatic hydrops to a hearing loss of >40dB. Vertigo may or may not be associated.[3] Therefore endolymphatic hydrops is not entirely specific for Meniere disease and can be found in cases of idiopathic sensorineural hearing loss. 

The exact etiology of Meniere disease remains unclear. Different theories exist, but genetic and environmental factors play a role. The relation to common comorbidities remains elusive. 


The prevalence of Meniere disease varies between 3.5 per 100.000 and 513 per 100.000[4][5] and occurs more often in older, white and female patients.[4][5][6]

The identification of several comorbidities which occur in an increased fashion in patients with Meniere disease gave rise to new theories about the origins of the disease.

1) Migraine: Migraine occurs more often in patients diagnosed with Meniere disease, although there might be an overlap between basilar migraine wrongly diagnosed as Meniere disease.[7]

2) Autoimmune diseases: Several autoimmune diseases are associated with Meniere disease, namely rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis.[8]

3) Genetic component: Meniere disease is a polygenic disorder. Ten percent of cases of patients of European descendent have familial Meniere disease. MD may show autosomal dominant or autosomal recessive inheritance but may be sporadic.

History and Physical

At the emergency room or in the general practice the physician will differentiate between vertigo of central, peripheral, and cardiovascular cause. Red flags for a central origin of vertigo, according to Harcourt et al., are neurological symptoms or signs, acute deafness, new type or onset of headache, or vertical/torsional/rotatory nystagmus.[9]

If Meniere disease is suspected, the patient should be questioned about the character of vertigo, hearing loss, and earlier episodes. A full otologic history is part of the clinical investigation. 

If Meniere disease is suspected, one should perform a full otologic examination, facial nerve testing, and assessment of nystagmus with Frenzel goggles, Rinne, and Weber tests. 

Rinne and Weber: Will show sensorineural hearing loss in acute Meniere disease or advanced disease.

Frenzel goggles: May show horizontal nystagmus with a fast-beating component away from the affected vestibular organ in the acute setting.

Head impulse testing (HIT): In contrast to other peripheral vestibular disorders, this test has a low sensitivity in Meniere disease.[10]


Audiometric evaluation is mandatory in all patients with Meniere disease. Fluctuating low frequency unilateral sensorineural hearing loss is characteristic of the disease. The hearing loss can progress to all frequencies. Tinnitus is common and ipsilateral.[11]

All patients with one-sided hearing loss should undergo magnetic resonance imaging (MRI) to rule out retrocochlear pathology. In some countries a BERA (brainstem evoked response audiometry) is sufficient. There is no need to perform imaging in the acute setting but may be done within a few weeks after the onset of symptoms. High-resolution MRI imaging may directly show endolymphatic hydrops in the affected organs. More research is underway to show if this is of clinical use.[12][13]

Vestibular (caloric) function testing may show a significantly under-functioning affected organ in 42% to 74% and a full loss of function in 6% to 11%.[14]

Treatment / Management

Different treatment options for Meniere disease exist with substantial variability between countries. None of the treatment options cure the disease. As many treatments have a significant impact on the functioning of surrounding structures, one should start with non-invasive approaches with the fewest possible side effects and proceed to more invasive steps.

  1. Sodium restriction diet: Low-level evidence suggests that restricting the sodium intake may help to prevent Meniere attacks.[9]
  2. Betahistine: Substantial disagreement in the medical community about the use of betahistine exists. A Cochrane review found low-level evidence to support the use of betahistine with substantial variability between studies.[15] Medical therapy in many medical centers often starts with betahistine orally.
  3. Intratympanic steroid injections may reduce the number of vertigo attacks in patients with Meniere disease.[16]
  4. Intratympanic gentamycin injections: Gentamycin has strong ablative properties towards vestibular cells. Side effects are sensorineural hearing loss because of a certain amount of toxicity towards cochlear cells.[17] 
  5. Surgery with vestibular nerve section or labyrinthectomy: Nerve section is a therapeutic option in patients who failed the conservative treatment options and labyrinthectomy when surgical options failed. Labyrinthectomy leads to a complete hearing loss in the affected side.[14]

Differential Diagnosis

  1. Basilar migraine: Associated with vertigo but without aural symptoms
  2. Vestibular neuronitis: Associated with vertigo lasting for several days, no aural symptoms
  3. Benign paroxysmal positional vertigo: Associated with vertigo related to head movements, lasting seconds to minutes, no aural symptoms
  4. Medications (e.g., aminoglycosides and loop diuretics)


According to Perrez-Garrigues et al., the number of episodes of vertigo is higher in the first years of the disease and decreases in later years regardless of whether patients receive treatment; most patients reach a "steady-state phase free of vertigo."[18]

As with vertigo, loss of hearing is highest in the early years of the disease and stabilizes in later years. Usually, there is no recovery from hearing loss.[19]


In later stages of the pathology, patients may experience sudden unexpected drops without loss of consciousness (Tumarkin attacks).[20]

One systematic review reports bilateral involvement of the vestibular organ in up to 47% of patients within 20 years.[21][22]

Patients with Meniere disease report significantly impaired quality of life compared to healthy individuals.[23]


Refer patients with signs suggestive of Meniere disease for otolaryngologic consultation.

Deterrence and Patient Education

Suspect Meniere disease if the patient experiences loss of hearing on one ear with attacks of vertigo which last from several minutes to several hours, and tinnitus.

Patients who experience the above seek consultation with their general practitioner or the emergency room.

The emergency room doctor will exclude vertigo secondary to disease of the heart or your vessels, or of neurologic origin, and refer the patient to an otolaryngologist for further testing and treatment.

Enhancing Healthcare Team Outcomes

The evaluation of patients with vertigo is complex, and patients often require medical attention from neurologists, otolaryngologists, and internal medicine. The Bárány Society published the current classification of Meniere disease. It is important to base the diagnosis of Meniere disease on the criteria published and mentioned in this article to warrant a uniform diagnosis especially in the presence of different international approaches to the diagnosis of patients with vertigo. (Level II)

Review Questions


Magnan J, Özgirgin ON, Trabalzini F, Lacour M, Escamez AL, Magnusson M, Güneri EA, Guyot JP, Nuti D, Mandalà M. European Position Statement on Diagnosis, and Treatment of Meniere's Disease. J Int Adv Otol. 2018 Aug;14(2):317-321. [PMC free article: PMC6354459] [PubMed: 30256205]
Lopez-Escamez JA, Carey J, Chung WH, Goebel JA, Magnusson M, Mandalà M, Newman-Toker DE, Strupp M, Suzuki M, Trabalzini F, Bisdorff A., Classification Committee of the Barany Society. Japan Society for Equilibrium Research. European Academy of Otology and Neurotology (EAONO). Equilibrium Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). Korean Balance Society. Diagnostic criteria for Menière's disease. J Vestib Res. 2015;25(1):1-7. [PubMed: 25882471]
Attyé A, Eliezer M, Medici M, Tropres I, Dumas G, Krainik A, Schmerber S. In vivo imaging of saccular hydrops in humans reflects sensorineural hearing loss rather than Meniere's disease symptoms. Eur Radiol. 2018 Jul;28(7):2916-2922. [PubMed: 29564597]
Alexander TH, Harris JP. Current epidemiology of Meniere's syndrome. Otolaryngol Clin North Am. 2010 Oct;43(5):965-70. [PubMed: 20713236]
Wladislavosky-Waserman P, Facer GW, Mokri B, Kurland LT. Meniere's disease: a 30-year epidemiologic and clinical study in Rochester, Mn, 1951-1980. Laryngoscope. 1984 Aug;94(8):1098-102. [PubMed: 6611471]
Tyrrell JS, Whinney DJ, Ukoumunne OC, Fleming LE, Osborne NJ. Prevalence, associated factors, and comorbid conditions for Ménière's disease. Ear Hear. 2014 Jul-Aug;35(4):e162-9. [PubMed: 24732693]
Ray J, Carr SD, Popli G, Gibson WP. An epidemiological study to investigate the relationship between Meniere's disease and migraine. Clin Otolaryngol. 2016 Dec;41(6):707-710. [PubMed: 26666684]
Gazquez I, Soto-Varela A, Aran I, Santos S, Batuecas A, Trinidad G, Perez-Garrigues H, Gonzalez-Oller C, Acosta L, Lopez-Escamez JA. High prevalence of systemic autoimmune diseases in patients with Menière's disease. PLoS One. 2011;6(10):e26759. [PMC free article: PMC3203881] [PubMed: 22053211]
Harcourt J, Barraclough K, Bronstein AM. Meniere's disease. BMJ. 2014 Nov 12;349:g6544. [PubMed: 25391837]
Fukushima M, Oya R, Nozaki K, Eguchi H, Akahani S, Inohara H, Takeda N. Vertical head impulse and caloric are complementary but react opposite to Meniere's disease hydrops. Laryngoscope. 2019 Jul;129(7):1660-1666. [PubMed: 30515842]
Stölzel K, Droste J, Voß LJ, Olze H, Szczepek AJ. Comorbid Symptoms Occurring During Acute Low-Tone Hearing Loss (AHLH) as Potential Predictors of Menière's Disease. Front Neurol. 2018;9:884. [PMC free article: PMC6215849] [PubMed: 30420828]
Shi S, Guo P, Wang W. Magnetic Resonance Imaging of Ménière's Disease After Intravenous Administration of Gadolinium. Ann Otol Rhinol Laryngol. 2018 Nov;127(11):777-782. [PubMed: 30156867]
Patel VA, Oberman BS, Zacharia TT, Isildak H. Magnetic resonance imaging findings in Ménière's disease. J Laryngol Otol. 2017 Jul;131(7):602-607. [PubMed: 28583226]
Syed I, Aldren C. Meniere's disease: an evidence based approach to assessment and management. Int J Clin Pract. 2012 Feb;66(2):166-70. [PubMed: 22257041]
Murdin L, Hussain K, Schilder AG. Betahistine for symptoms of vertigo. Cochrane Database Syst Rev. 2016 Jun 21;(6):CD010696. [PMC free article: PMC7388750] [PubMed: 27327415]
Phillips JS, Westerberg B. Intratympanic steroids for Ménière's disease or syndrome. Cochrane Database Syst Rev. 2011 Jul 06;(7):CD008514. [PubMed: 21735432]
Postema RJ, Kingma CM, Wit HP, Albers FW, Van Der Laan BF. Intratympanic gentamicin therapy for control of vertigo in unilateral Menire's disease: a prospective, double-blind, randomized, placebo-controlled trial. Acta Otolaryngol. 2008 Aug;128(8):876-80. [PubMed: 18607963]
Perez-Garrigues H, Lopez-Escamez JA, Perez P, Sanz R, Orts M, Marco J, Barona R, Tapia MC, Aran I, Cenjor C, Perez N, Morera C, Ramirez R. Time course of episodes of definitive vertigo in Meniere's disease. Arch Otolaryngol Head Neck Surg. 2008 Nov;134(11):1149-54. [PubMed: 19015442]
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Pyykkö I, Manchaiah V, Zou J, Levo H, Kentala E. Do patients with Ménière's disease have attacks of syncope? J Neurol. 2017 Oct;264(Suppl 1):48-54. [PubMed: 28321563]
Huppert D, Strupp M, Brandt T. Long-term course of Menière's disease revisited. Acta Otolaryngol. 2010 Jun;130(6):644-51. [PubMed: 20001444]
Green JD, Blum DJ, Harner SG. Longitudinal followup of patients with Menière's disease. Otolaryngol Head Neck Surg. 1991 Jun;104(6):783-8. [PubMed: 1908968]
Söderman AC, Bagger-Sjöbäck D, Bergenius J, Langius A. Factors influencing quality of life in patients with Ménière's disease, identified by a multidimensional approach. Otol Neurotol. 2002 Nov;23(6):941-8. [PubMed: 12438860]
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