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Episodic vertigo with fluctuating hearing

A 47-year-old woman with recurrent attacks of vertigo, tinnitus, and aural fullness on the left.

The case

A 47-year-old social worker presents with recurrent attacks of vertigo over the past 14 months. Each attack starts with a sense of pressure or fullness in her left ear and a low-pitched roaring tinnitus on the same side, followed within an hour by severe vertigo with vomiting. Attacks last between 2 and 6 hours, after which she feels exhausted and unsteady but the vertigo resolves.

She has had perhaps a dozen attacks in 14 months, with several clusters and several weeks between clusters. Her hearing has fluctuated — worse around attacks, better in between — but her partner says her left ear is gradually getting worse overall.

Between attacks she has no symptoms apart from intermittent tinnitus on the left. There is no headache, no aura, no photophobia, no other neurological features. She has no significant family history.

Bedside examination between attacks is unremarkable. Her audiogram is shown.

Investigations

Left low-frequency rising sensorineural hearing loss-100204060801001201252505001k2k4k8kHearing level (dB HL)Frequency (Hz)normal limit (25 dB)Right air (O)Left air (X)
Fig. Right ear within normal limits across all frequencies. Left ear shows a rising low-frequency sensorineural hearing loss with no air-bone gap — the classic 'reverse-slope' configuration of Ménière's disease.

Question

Using the 2015 Bárány/AAO-HNS criteria, what is the most appropriate diagnosis?

Teaching point

The 2015 Bárány/AAO-HNS criteria for Ménière's disease require BOTH vestibular episodes AND audiometric documentation of low- or medium-frequency SNHL. The audiogram is not optional — it is the test that distinguishes definite Ménière's from probable Ménière's and from its main mimic, vestibular migraine. Get an audiogram in every patient with recurrent vertigo, ideally close to (or during) an attack if possible to capture the fluctuating component. The reverse-slope (low-frequency rising) SNHL is one of the most specific audiometric patterns in vestibular medicine.

References

  1. [1]Lopez-Escamez JA, Carey J, Chung WH, Goebel JA, Magnusson M, Mandalà M, Newman-Toker DE, Strupp M, Suzuki M, Trabalzini F, Bisdorff A. Diagnostic criteria for Menière's disease. Consensus document of the Bárány Society, the Japan Society for Equilibrium Research, the European Academy of Otology and Neurotology (EAONO), the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the Korean Balance Society. Journal of Vestibular Research 2015;25(1):1–7. doi:10.3233/VES-150549
  2. [2]Basura GJ, Adams ME, Monfared A, Schwartz SR, Antonelli PJ, Burkard R, Bush ML, Bykowski J, Colandrea M, Derebery J, et al.. Clinical practice guideline: Ménière's disease. Otolaryngology–Head and Neck Surgery 2020;162(2_suppl):S1–S55. doi:10.1177/0194599820909438
  3. [3]Nakashima T, Naganawa S, Sugiura M, Teranishi M, Sone M, Hayashi H, Nakata S, Katayama N, Ishida IM. Visualization of endolymphatic hydrops in patients with Meniere's disease. Laryngoscope 2007;117(3):415–420. doi:10.1097/MLG.0b013e31802c300c
Related moduleMénière's Disease →