The disorder
Clinical features
Four cardinal symptoms, an unmistakable attack, and an audiogram that fluctuates then fixes. Recognising the pattern — and its dangerous late variant — is the heart of the chapter.
The cardinal tetrad
Ménière’s brings four things together in one ear: spinning attacks, hearing that fluctuates, ringing, and a feeling of pressure. Tap each below to learn more.
Episodic vertigo, fluctuating sensorineural hearing loss, tinnitus and aural fullness — localised to the affected ear — make up the tetrad.1 Not all four need be present at onset; many patients begin with one or two and evolve the full picture.
The single most useful discriminator remains the duration (20 min – 12 h) paired with the documented low-frequency loss. Cochlear symptoms that localise firmly to one ear, and a roaring rather than high-pitched tinnitus, point toward Ménière’s over its mimics.2
The arc of an attack
A typical attack runs from a premonitory rise in fullness and tinnitus, through the vertigo crisis, to a long recovery and a quiescent interval. Step through it:
Sudden severe spinning vertigo with horizontal-torsional nystagmus, nausea and vomiting; the patient is prostrate and cannot function. Lasts 20 minutes to 12 hours — never just seconds, rarely beyond a day.
The fluctuating audiogram
The audiometric signature is a low-frequency sensorineural loss that worsens during attacks and recovers between them, later becoming flat, fixed and severe. Step through the stages, or press Simulate an attack to watch the low frequencies dip and recover:
The AAO-HNS staging formalises this progression by the four-tone average of the worst audiogram. Cross-reference the live ECochG and VEMP chapters for the electrophysiological correlates.
Variants and Tumarkin drop attacks
Historical variants include cochlear and vestibular Ménière’s (only the auditory or only the vestibular component) and Lermoyez syndrome (hearing improves as vertigo begins).3 The one to know and fear is the Tumarkin otolithic crisis — sudden drop attacks without warning or loss of consciousness, a late-stage feature and a trigger to escalate treatment.
Key points
- The tetrad: episodic vertigo, fluctuating SNHL, tinnitus and aural fullness in one ear.
- Attacks last 20 min – 12 h — never seconds, rarely beyond a day.
- The audiogram shows fluctuating low-frequency SNHL that later fixes and flattens.
- Tumarkin drop attacks are a dangerous late variant — escalate management.