Recurrent vertigo with hearing loss
A 45-year-old woman has had recurrent episodes of spontaneous spinning vertigo over the past 8 months. Episodes last 2-4 hours, often preceded by a feeling of fullness and roaring tinnitus in the LEFT ear. She also notices her hearing on the left fluctuates — worse for several days after each attack, then improves but never fully recovers. No headaches.
A 45-year-old woman has had recurrent episodes of spontaneous spinning vertigo over the past 8 months. Episodes last 2-4 hours, often preceded by a feeling of fullness and roaring tinnitus in the LEFT ear. She also notices her hearing on the left fluctuates — worse for several days after each attack, then improves but never fully recovers. No headaches.
Which diagnosis fits best?
Audiogram during a symptomatic episode shows low-frequency sensorineural hearing loss in the left ear (40 dB at 250 Hz, 35 dB at 500 Hz, 20 dB at 1000 Hz, normal at higher frequencies). Right ear is normal. Speech discrimination 84% left, 100% right.
Which first-line intervention has the best evidence?
Definite Ménière's disease (left ear)
- 1.The triad: episodic vertigo + fluctuating SNHL + aural symptoms (tinnitus, fullness).
- 2.Endolymphatic hydrops is the leading pathophysiologic theory; gadolinium-enhanced MRI of the inner ear can now visualize it directly.
- 3.Stepwise treatment: diet + diuretic → betahistine (outside US) → intratympanic steroids → intratympanic gentamicin → labyrinthectomy / nerve section.
- 4.Most common mimic: vestibular migraine. Patients with episodic vertigo + fluctuating hearing + headaches need careful sorting using Bárány criteria for both conditions.