Case 03 of 8 · Trainee · Ménière's disease

Recurrent vertigo with fluctuating hearing loss

A 52-year-old with episodic vertigo, left-sided aural fullness, and a fluctuating audiogram.

CASE VIGNETTE

A 52-year-old man reports a two-year history of episodic vertigo, with each episode lasting two to four hours. Episodes are accompanied by left-sided aural fullness, low-pitched tinnitus, and a sense that 'sounds are muffled' on the left. Between episodes he feels well, though the muffled hearing on the left has gradually persisted longer with each event.

Audiometry performed two weeks after his last episode shows the pattern below. Audiometry from one year ago (in a quiet interval) showed a normal left ear; this is a documented fluctuation.

On testing: bedside head-impulse test is normal bilaterally. There is no nystagmus in primary or eccentric gaze. Romberg is negative. DVA loss is mild on leftward thrusts only. Caloric testing (formal lab) shows a 35% unilateral weakness on the left. vHIT gain is normal bilaterally.

The audiometric signature of definite Ménière's disease per the Bárány 2015 criteria: unilateral low-to-mid frequency sensorineural hearing loss, documented during or shortly after an episode of vertigo. The rising configuration (worse at low frequencies, improving toward high) is characteristic of endolymphatic hydrops.

DVA SIGNATUREMild

Ménière's disease — left side

DVA loss: Mild — 0.15 logMAR on leftward thrusts only; within or just above normal limits
Laterality: Subtle left-sided asymmetry
Asymmetry: Mild leftward DVA asymmetry
Corroborating tests: Caloric weakness 35% left · vHIT gain normal · audiogram low-to-mid SNHL left · aural fullness and tinnitus left

Key signature: Ménière's is audiometry-led — the diagnostic core is the clinical episodes plus the documented fluctuating low-to-mid frequency SNHL. DVA is supporting evidence; the caloric-vHIT dissociation (abnormal low-frequency, preserved high-frequency response) is more useful than DVA alone.

Test-battery findings

DVA — leftward thrust	0.15 logMAR loss (mild)
DVA — rightward thrust	0.05 logMAR loss (within normal limits)
Caloric (low-frequency)	35% left unilateral weakness
vHIT gain (high-frequency)	0.9 bilaterally — normal
Audiogram	Left LF-to-MF SNHL (fluctuating, documented)
Spontaneous nystagmus	Absent (interictal)

Question

Which combination of test results is most specific for Ménière's disease as opposed to vestibular neuritis or vestibular schwannoma?

References

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Ménière's disease — left side

Test-battery findings

Question

Further reading

References