Ménière's disease
Recurrent attacks of vertigo with fluctuating low-frequency hearing loss, tinnitus, and aural fullness. Peripheral HINTS pattern during the attack — but the diagnosis is by history, not by HINTS.
Clinical picture
Spontaneous attacks of vertigo lasting 20 minutes to 12 hours, with low- to medium-frequency sensorineural hearing loss documented on audiometry in the affected ear before, during, or after a vertigo episode, together with fluctuating aural symptoms — hearing change, tinnitus, or aural fullness — in the same ear7. Two or more such attacks are required for the diagnosis of definite Ménière's disease per the Bárány Society / Japan Society for Equilibrium Research / EAONO / AAO-HNS / Korean Balance Society joint consensus.
Between attacks the patient is often well, though many develop persistent imbalance, oscillopsia, or residual low-frequency hearing loss over years. Symptoms are typically unilateral at onset; a substantial proportion become bilateral with time.
HINTS during an acute attack
During an acute attack, Ménière's produces a peripheral HINTS pattern: abnormal head impulse on the affected side, unidirectional horizontal-torsional nystagmus with the fast phase beating away from the affected ear, and absent skew. The presence of tinnitus, aural fullness, and audiometrically documented fluctuating hearing loss is the distinguishing feature.
HINTS-plus is positive here — there isa new auditory change. This is the diagnostic pitfall: in a first-ever attack, Ménière's with peripheral HINTS plus new low-frequency hearing loss can resemble an AICA stroke. The discriminators are the history of stereotyped recurrence (if present), the audiometric profile (low-frequency rather than mid- or high-frequency), and the absence of vascular risk factors, brainstem signs, or persistent central oculomotor abnormalities.
Why HINTS is not the diagnostic framework here
HINTS was developed and validated for the continuous acute vestibular syndrome3. Ménière's is an episodic disorder; applying HINTS outside its validated domain can produce misleading results. The diagnostic framework is the Bárány Society 2015 consensus, which is built on the history (recurrent attacks of specific duration), the audiogram (low- to medium-frequency sensorineural loss documented during or near the time of an episode), and the associated aural symptoms7.
The distinction matters operationally. A patient with one episode of acute vertigo plus new low-frequency hearing loss does not yet meet criteria for definite Ménière's — they meet criteria for probable Ménière's if the syndrome lasts 20 minutes to 24 hours, but they also fit the AICA-with-labyrinthine-artery stroke pattern10,1. Imaging the posterior fossa during this first presentation is the standard of care.
Probable vs definite Ménière's
The 2015 consensus distinguishes two categories7. Definite Ménière's requires (1) two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours; (2) audiometrically documented low- to medium-frequency sensorineural hearing loss in the affected ear on at least one occasion before, during, or after an episode; (3) fluctuating aural symptoms in the affected ear; and (4) no better explanation by another vestibular diagnosis.
Probable Ménière's is broader: episodic vestibular symptoms — vertigo or dizziness — lasting 20 minutes to 24 hours, with fluctuating aural symptoms in the affected ear, and no better explanation. The audiogram requirement is relaxed.
Caloric and vHIT findings between attacks
Many patients show ipsilesional canal paresis on caloric testing between attacks, but vHIT gain is often relatively preserved — the so-called caloric-vHIT dissociation that has been proposed as supportive of endolymphatic hydrops physiology. cVEMP and oVEMP may be reduced on the affected side. None of these is required for the diagnosis.
Mimics
Vestibular migraine can present with episodic vertigo and migrainous headache and sometimes mild auditory symptoms — distinguishing it from Ménière's when both diagnoses are partially met is a recognised area of overlap. Autoimmune inner ear disease can produce fluctuating bilateral sensorineural loss with episodic vertigo and should be considered when the picture is bilateral from onset or progresses rapidly. Acoustic neuroma can mimic Ménière's with progressive unilateral hearing loss; MRI of the internal auditory canals is the screening test when the presentation is atypical.