A 42-year-old man presents to the clinic with a 6-month history of episodic dizziness. He describes the episodes as a sudden, intense room-spinning sensation that lasts for 2 to 3 hours, accompanied by severe nausea and vomiting. During these episodes, he also experiences a low-pitched roaring sound and a feeling of fullness in his left ear. He notes that his hearing in the left ear seems to worsen during the attacks but partially improves afterward. Past medical history is negative. On physical examination, there is no spontaneous nystagmus, and the Dix-Hallpike maneuver is negative. Audiometry reveals a low-frequency sensorineural hearing loss in the left ear. Neurological examination is unremarkable.
Which of the following is the most likely diagnosis?
The correct answer is:
D) Meniere disease
This patient’s presentation is classic for Meniere disease, an inner ear disorder characterized by the abnormal accumulation of endolymph within the labyrinth (endolymphatic hydrops). The diagnosis is clinical and defined by a specific triad of episodic vertigo lasting 20 minutes to several hours, sensorineural hearing loss (typically fluctuating and involving low frequencies), and tinnitus or aural fullness. Unlike benign paroxysmal positional vertigo (BPPV), the vertigo in Meniere disease is spontaneous and prolonged. The low-frequency hearing loss is a hallmark finding on audiometry that helps distinguish it from other causes of sensorineural hearing loss, which often affect higher frequencies first.
Answer choice A: Acoustic neuroma, is incorrect. While acoustic neuroma (vestibular schwannoma) causes sensorineural hearing loss and tinnitus, the hearing loss is typically progressive and permanent rather than fluctuating. Vertigo is usually not a prominent feature because the slow growth of the tumor allows for central vestibular compensation.
Answer choice B: Benign paroxysmal positional vertigo, is incorrect. BPPV causes brief episodes of vertigo that are strictly triggered by head movement. It is not associated with hearing loss, tinnitus, or aural fullness.
Answer choice C: Labyrinthitis, is incorrect. Labyrinthitis presents with a single, acute episode of severe, continuous vertigo and hearing loss that can last for days. It does not typically present with the recurrent, episodic pattern seen in Meniere disease.
Answer choice E: Vestibular neuritis, is incorrect. Vestibular neuritis causes a single, prolonged episode of continuous vertigo, often following a viral illness. Crucially, hearing is preserved in vestibular neuritis.
Key Learning Point
Meniere disease is caused by increased endolymphatic pressure (endolymphatic hydrops). It presents with a triad of episodic vertigo, fluctuating low-frequency sensorineural hearing loss, and tinnitus or aural fullness. Initial management focuses on a low-sodium diet and avoidance of triggers such as caffeine, alcohol, and tobacco. Diuretics (e.g., chlorthalidone) may be used for maintenance, while benzodiazepines or antiemetics are used for acute attacks.
