Meniere's Disease (Dizzy Spells)

Casebank History
1

Notes about Meniere’s disease:

Symptoms:

  • Progressive episode of severe vertigo, tinnitus, hearing loss.
  • Feeling of fullness or congestion in the ear.
  • Usually, unilateral, comes on in middle age.

Stages:

  • Early-stage disease: vertigo attacks, which are sudden, unpredictable, and accompanied by nausea, vomiting, and aural fullness lasting 20 mins to 24 hrs.
  • Middle-stage disease: vertigo and fluctuating hearing loss. Tinnitus may worsen. Periods of remission are variable.
  • Late-stage disease: progressive hearing loss that is non-fluctuant. Balance issues particularly in the dark. Tinnitus may be a significant symptom.

Causes: The exact cause of Meniere’s disease is unknown, but it is associated with a
problem with pressure deep inside the ear.

Where you are:
You are an FY2 in Medicine.

Who the patient is:
Mr. Benjamin Rao, aged 30, has come to you with complaint of dizziness.

What you must do:
Talk to him, manage, and address his concerns.

  • Don’t forget (pressure or fullness in ear, lasts from half to one hour, DVT)

Doctor: How can I help?
Patient: I have been feeling dizzy. (P1)
D: Tell me more about it? Explore
P: I’ve been like this for a few days?

ODIPARA
D: Did it start suddenly or gradually?
P: Suddenly.
D: Does it come and go?
P: Yes.
D: Is it becoming worse by anything?
P: It gets worse when I stand up suddenly.
D: Does anything make it better?
P: It gets better when I lie down.
D: Anything else? Any nausea?
P: Yes.
D: Any hearing loss?
P: I had hearing loss couple of days back which lasted for few hours. (+ve finding)
D: Was it in one ear or both?
P: In my left ear.
D: Any ringing in your ears?
P: Yes (+ve finding)
D: Any earache?
P: No.
D; Any discharge from your ear?
P: No.

(P2)
D: Has anything like this happened to you before?
P: Yes, 1 week ago.
D: How did it resolve?
P: It resolved on its own.
D: Have you been diagnosed with any medical conditions in the past?
P: No.
D: Any DM or HTN?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Do you have any allergies?
P: No.
D: Any hospitalisations or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Have you travelled anywhere recently? (flight)
P: No.

DESA
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/no
D: Do you take any caffeine?
P: Yes/No
D: Tell me about your diet?
P: I eat everything, its fine.
D: Do you do physical exercise?
P: I am active sometimes, but other times lazy.
D: What do you do for a living?
P: Office job.
D: Who do you live with?
P: I live alone.
D: Do you drive?
P: Yes/No

Examination
Is OK if I check your vitals, do GPE, and examine your ear? I will be using an instrument called an otoscope to look inside the ear, and I would also like to do hearing tests and balance tests along with a specialised test called audiometry. I would also like to do blood tests.

Provisional diagnosis:
From my assessment I suspect a condition called Meniere’s disease. It is a condition of the inner ear that causes sudden attacks of vertigo, tinnitus and hearing loss.

Management
Senior

Specialist: Referral to (ENT) specialist to confirm diagnosis. He will check if you have:

  • Vertigo, with at least 2 attacks lasting 20 minutes within a short space of time.
  • Fluctuating hearing loss, which is confirmed by a hearing test
  • Tinnitus or a feeling of pressure in your ear.

Symptomatic and lifestyle:

  • There is no cure for this disease. However, symptomatic treatment will be given.
  • The 2 medicines usually recommended by GPs are; Prochlorperazine, which helps relive severe nausea and vomiting. Antihistamines, which help relieve mild nausea, vomiting and vertigo.
  • If symptoms are severe enough, people may require hospital admission for intravenous
    (IV), labyrinthine sedatives and fluids to maintain hydration and nutrition.
  • A trial of Betahistine can be considered to reduce the frequency and severity of attacks
    of hearing loss, tinnitus, and vertigo.
  • You may be offered: Counselling – including cognitive behavioural therapy (CBT); Relaxation therapy – including breathing techniques and yoga.

Lifestyle measures:
Meniere’s disease can cause you to lose balance. At the first sign of attack, you should:

  • Take your vertigo medicine if you have one.
  • Sit or lie down.
  • Close your eyes, or keep them fixed on a still object in front of you.
  • Do not turn your head quickly.
  • If you need to move, do so slowly and carefully.
    Once the attack is over, try to move around to help your eyesight and other senses compensate for the problems in your inner ear.

Things that help:

  • Diet
  • Eating a low-salt diet
  • Avoiding alcohol
  • Avoiding caffeine
  • Stopping smoking

Consider the risks before doing activities such as:

  • Driving
  • Swimming
  • Climbing ladders or scaffolding
  • Operating heavy machinery

Safety netting: You may also need to make sure someone is with you most of the time in case you need help during an attack.

Driving: You should not drive when you feel dizzy or if you feel an attack of vertigo coming on. You must inform DVLA.

Flying: Most people with Meniere’s disease have no difficulty with flying.

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