Simultaneous loss of vestibular and cochlear function is most commonly due to Ménière’s disease but occasionally can have other causes. Herpes zoster causes pain, vertigo and hearing loss, with vesicles in the ear canal (and if accompanied by facial palsy is termed Ramsay Hunt syndrome). Meningitis due to bacteria or fungi, carcinoma, lymphoma or sarcoid can cause vestibular and cochlear dysfunction associated with other cranial nerve lesions. Vasculitides, including some ear- and eye-specific syndromes such as Cogan’s syndrome and Susac’s syndrome (retinocochleocerebral vasculopathy), and syphilis can mimic Ménière’s disease. Brainstem lesions involving the vestibular nerve root or nucleus, such as multiple sclerosis, rarely cause a similar syndrome.
Migraine and Meniere's disease
Over the past 25 years, awareness has increased that migraine can be associated with disturbances of balance, including dizziness, imbalance and vertigo, with or without headache, mimicking early Ménière’s disease. The overall prevalence of migraine in the general population is 13%, and a quarter of migraine patients experience dizziness or vertigo along with other more typical migraine symptoms. Because the prevalence of migraine in the general population is far greater than that of Ménière’s disease, a patient presenting with recurrent vertigo is much more likely to have migraine-associated vertigo than Ménière’s disease.
The distinction between vestibular migraine and Ménière’s disease may not be considered important in the early stages of Ménière’s disease as initial management strategies for the two disorders overlap (diet and lifestyle modification), and prescribed medications generally have few side effects. However, in the later stages of Ménière’s disease, when more invasive and irreversible treatments are being considered (e.g. gentamicin or surgical labyrinthectomy or endolymphatic sac surgery), it is crucial that the two be distinguished. If doubt exists, a trial of antimigraine management should be undertaken before considering irreversible interventions for Ménière’s disease. Vestibular migraine was discussed in detail in a previous issue of Medicine Today.8
Modern management of patients with Ménière’s disease aims to reduce the frequency and severity of symptoms and to improve the quality of life of patients and their families. A flexible management strategy needs to be formulated for each patient and for different stages of the disease. Treatments are best considered from a symptom control viewpoint, leading to a stepwise introduction of available therapies depending on their toxicities and ease of administration (Figure 5).
In general, episodic vertigo can be controlled in most patients by current interventions (70% controlled within two years of presentation), but it may take time to establish a satisfactory treatment regimen. In the advanced stages of Ménière’s disease, especially when it is bilateral, hearing loss has greater impact, often requiring powerful hearing aids or at times a cochlear implant. Tinnitus and the sensation of aural fullness are more difficult to manage. Patients often habituate to these symptoms, but they can persist and remain troublesome.
Treatment of acute vertiginous attacks
The dominant symptom during acute attacks is vertigo. This is usually associated with intense nausea, vomiting, sweating and sometimes diarrhoea. As the attacks are usually unheralded, it is wise to advise patients of strategies:
- to ensure their safety (especially while driving or working in situations of danger)
- to allow the attack to pass (which may take several hours) and recovery to ensue (often after a period of a day or two of feeling ‘washed out’).