A 42-year-old woman is evaluated for occasional episodes of severe vertigo with nausea, vomiting, tinnitus, and a feeling of ear fullness. Her first episode occurred 3 years ago, and since then, she has had approximately six episodes, each of which may last from a few hours to 1 or 2 days. Meclizine and diazepam taken at the onset of symptoms provide partial relief, but she often must resort to bed rest during these episodes, missing 1 to 2 days of work. She has a family history of migraine headache, although the patient does not experience headache or visual symptoms with her episodes of dizziness.
Physical examination, including vital signs, is normal. An audiogram discloses a bilateral low-frequency sensorineural hearing loss. MRI of the head is normal.
Which of the following is the most likely diagnosis in this patient?
A. Acephalgic migraine
B. Ménière's disease
C. Acoustic neuroma
D. Benign positional vertigo
E. Vestibular neuritis
Answer and critique
Ménière's disease is the most common cause of recurrent, disabling attacks of vertigo. Age of onset occurs most commonly in the fourth to sixth decade of life. Episodes typically last for several hours and are accompanied by vomiting and cochlear symptoms (for example, tinnitus, ear fullness, and/or hearing loss).
Episodes occur at irregular intervals over years, and patients may develop a progressive sensorineural hearing loss, initially unilateral and low-frequency in nature, but eventually bilateral in 30% to 50% of patients. Prior to identifying changes in an audiogram, the diagnosis of Ménière's disease is largely established clinically without the necessity of diagnostic testing. Treatment for acute episodes of this disorder is symptomatic and includes meclizine, benzodiazepines, antiemetics, and for frequent recurrences is prophylactic, requiring diuretics and a low-sodium diet because the presumptive pathophysiology involves increased endolymphatic fluid volume. Because spontaneous remission occurs frequently in long-term follow-up, endolymphatic shunting or other surgical treatments are reserved for a minority of patients.
Acephalgic migraine is a controversial diagnosis and a rare cause of vertigo in large series of dizzy patients. Migraine is a difficult diagnosis to establish in the absence of headache or classic visual or other prodromal features and would not be associated with abnormal audiometry results.
Acoustic neuroma is a very rare tumor in which the usual symptoms are a slowly progressive unilateral hearing loss with or without tinnitus. Severe vertiginous attacks are not the usual presentation for acoustic neuromas, and MRI of the internal auditory canal and adjacent structures can identify most of these tumors.
Benign positional vertigo is characterized by brief (less than 1 minute) episodes of vertigo triggered by changes of head position and not associated with vomiting or prostration.
Vestibular neuritis is typically a single episode of disabling vertigo that resolves in a few days to a week and, although it may occasionally be recurrent, is rarely manifested by the chronic, episodic course or the progressive hearing loss associated with Ménière's disease. An acute episode of dizziness resembling vestibular neuritis but associated with a unilateral hearing loss typically is referred to as labyrinthitis.
- Episodes of Ménière's disease last for several hours and involve vomiting and cochlear symptoms, and patients may develop a progressive sensorineural hearing loss.
- Prior to identifying changes in an audiogram, the diagnosis of Ménière's disease is largely established clinically without the necessity for diagnostic testing.