Ménière's Disease

1. 0:00Ménière's disease is the disease in which DVA is the secondary actor, not the lead. The diagnosis is anchored on episodic vertigo plus fluctuating low-frequency sensorineural hearing loss in the affected ear. The audiogram is the pivotal test here. DVA helps characterise the functional consequence of the vestibular failure between attacks and during the chronic phase.
2. 0:30The Bárány Society 2015 criteria are a joint consensus across the Bárány Society, the Japan Society for Equilibrium Research, the European Academy of Otology and Neurotology, the American Academy of Otolaryngology, and the Korean Balance Society. They define two categories: definite and probable Ménière's disease.
3. 1:00Definite Ménière's requires at least two spontaneous vertigo episodes lasting twenty minutes to twelve hours, audiometrically documented low- to mid-frequency sensorineural hearing loss in the affected ear at one moment in time around an episode, fluctuating aural symptoms — hearing, tinnitus, or fullness — and exclusion of other causes. Probable Ménière's allows a broader symptom window of twenty minutes to twenty-four hours with fluctuating aural features but without a strict audiometric requirement.
4. 1:35The DVA picture varies with disease stage. Early on, between attacks, DVA may be entirely normal. After repeated episodes the affected ear accumulates a chronic vestibular deficit; DVA then shows an asymmetric loss that resembles vestibular neuritis but without the acute vertigo and with a documented audiometric fluctuation pattern.
5. 2:10A useful diagnostic signature is the dissociation between the caloric test and the video head-impulse test. In Ménière's the caloric is commonly abnormal on the affected side while the vHIT is normal — a pattern that occurs in roughly half of patients in the published meta-analysis. McGarvie and colleagues attribute this to enlargement of the semicircular canal duct in the hydropic labyrinth, which reduces the caloric thermal gradient but leaves rotational responses intact.
6. 2:50Two practical points. First, the audiogram is the diagnostic test, not the DVA. Document the hearing fluctuation. Second, use DVA to track the chronic vestibular deficit between attacks and to monitor response to intratympanic treatment, where unilateral vestibular loss is the intended therapeutic effect.

What is Ménière's disease?

Ménière's disease is an episodic inner-ear disorder characterised by recurrent attacks of spontaneous vertigo, fluctuating sensorineural hearing loss, tinnitus, and a sense of aural fullness in the affected ear. The histopathological substrate is endolymphatic hydrops — dilatation of the endolymphatic compartment of the inner ear — though the mechanistic link from hydrops to symptoms remains incompletely understood.³²

The disease is unilateral at presentation in approximately 80–90% of cases; bilateral involvement may develop over years. Attacks last from twenty minutes to twelve hours, with prolonged unsteadiness afterwards that may take days to settle. Between attacks the patient may be entirely asymptomatic or carry a residual hearing deficit and chronic vestibular insufficiency.³²

How common is it?

Population prevalence estimates vary widely depending on case definition and ascertainment, ranging from roughly 13 to 190 per 100,000 people. The condition typically presents in the fourth to sixth decade, with a slight female predominance.³²

Bárány Society 2015 diagnostic criteria

The 2015 consensus, jointly endorsed by the Bárány Society, the Japan Society for Equilibrium Research, EAONO, AAO-HNS, and the Korean Balance Society, defines two diagnostic categories.³²

Definite Ménière's disease

1. Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours.
2. Audiometrically documented low- to mid-frequency sensorineural hearing loss in the affected ear, defining or causing the diagnosis, on at least one occasion before, during, or after one of the episodes of vertigo.
3. Fluctuating aural symptoms (hearing, tinnitus, or fullness) in the affected ear.
4. Not better accounted for by another vestibular diagnosis.

Probable Ménière's disease

A broader category for the early or partial picture: episodic vestibular symptoms (vertigo or dizziness) lasting 20 minutes to 24 hours, with fluctuating aural symptoms, and not better accounted for by another diagnosis. The audiometric requirement is relaxed to allow diagnosis before objective hearing-loss documentation.³²

The caloric–vHIT dissociation

A characteristic and diagnostically useful finding in Ménière's disease is the dissociation between caloric testing and the video head impulse test. Despite both nominally probing the horizontal canal, they often disagree.^33,34

• Caloric is commonly abnormal on the affected side. A meta-analysis of 708 Ménière's patients reported altered caloric responses in approximately 64% of cases.³³
• vHIT is commonly normal in the same patients — altered in only about 28%. The dissociation pattern (abnormal caloric, normal vHIT) appears in roughly 47% of patients.³³

McGarvie and colleagues proposed an anatomical explanation: physical enlargement of the semicircular canal duct in the hydropic labyrinth reduces the thermally-induced pressure gradient across the cupula (impairing the caloric response) while leaving the rotational response (and therefore the vHIT) largely intact.³³ A 2024 confirmatory study in 2,101 patients showed the dissociation to be substantially more common in Ménière's than in vestibular migraine or other vestibular disorders — supporting its use as a differentiating feature.³⁴

The DVA picture by disease stage

DVA is unhelpful as a diagnostic test in Ménière's disease and useful as a longitudinal one. The pattern evolves predictably:

• Inter-ictal, early disease: DVA frequently normal. The patient has full vestibular function between attacks, with the caloric paresis being a low-frequency lab finding rather than a high-frequency clinical deficit. Bedside DVA is therefore insensitive at this stage.
• Per-ictal, during an attack: DVA is uninterpretable — the patient cannot tolerate head motion. Audiometry and the character of the spontaneous nystagmus (irritative pattern beating toward the affected ear early, paretic pattern beating away later) are the clinically useful tests.
• Chronic, advanced disease: Repeated attacks accumulate a chronic vestibular deficit; DVA shows an asymmetric loss greater on the affected side. The pattern resembles compensated vestibular neuritis. It is at this stage that DVA earns its keep in Ménière's — to quantify the residual deficit and to guide vestibular rehabilitation.^3,5
• Post-ablation: Intratympanic gentamicin and labyrinthectomy aim to abolish vestibular function on the affected side. DVA on the affected side falls precipitously, then partially recovers as central compensation deploys covert saccades over weeks to months — exactly the pattern seen after vestibular neuritis. DVA is the right outcome measure for this trajectory.^5,25

Treatment monitoring with DVA

Three Ménière's interventions produce predictable DVA trajectories:

• Intratympanic steroid (dexamethasone) — does not ablate vestibular function. DVA should not change. If it worsens after intratympanic steroid, investigate other causes.
• Intratympanic gentamicin — chemical labyrinthectomy. Affected-side DVA worsens within days to weeks of treatment, then partially recovers through central compensation. Pre-treatment and 6- to 12-week post-treatment DVA on the same paradigm is a useful outcome pair.
• Labyrinthectomy or vestibular nerve section — complete ablation. Affected-side DVA loss is profound and permanent. Rehabilitation focuses on developing covert catch-up saccades. The DVA recovery pattern mirrors the Herdman 2003 unilateral rehabilitation evidence.^3,5

Differential diagnosis

• Vestibular migraine — episodic vertigo with migraine features. Hearing loss is uncommon and rarely documented audiometrically. The Mavrodiev 2024 confirmatory cohort showed the caloric–vHIT dissociation strongly favoured Ménière's over vestibular migraine.³⁴
• Vestibular schwannoma — gradually progressive unilateral SNHL plus episodic vertigo can mimic Ménière's. MRI is the discriminator; consider it for any unilateral SNHL.
• Autoimmune inner-ear disease — rapidly progressive bilateral SNHL with vertigo. Considered when the disease pattern does not fit the Ménière's episodic criteria.
• Perilymph fistula — vertigo and hearing change triggered by pressure or trauma. History is the key.
• Tumarkin "otolithic crisis" / drop attacks — rare, late complication of Ménière's itself. Sudden falls without warning during the active disease phase.

Reading the report

A patient with two or more episodes of vertigo lasting 20 minutes to 12 hours, audiometrically documented low- to mid-frequency SNHL on the affected side, and fluctuating aural symptoms meets the Bárány 2015 definite Ménière's criteria.³² The vestibular test pattern — caloric paresis with normal vHIT (the dissociation) — supports the diagnosis but is not required.^33,34 DVA contributes to the chronic-phase assessment and to monitoring the response to ablative interventions, not to the initial diagnosis.