Meniere Disease.

A typical attack begins with a sense of fullness or pressure in the affected ear, followed within minutes by intense rotational vertigo, roaring tinnitus, and muffled hearing on that side. The spinning peaks within an hour, often forces the patient to lie still, and resolves over 20 minutes to several hours. Severe nausea and vomiting are common. Most patients feel drained and unsteady for a day or two afterward.

By the 2015 Bárány Society criteria, an attack lasts between 20 minutes and 12 hours. Episodes shorter than 20 minutes suggest BPPV, while episodes longer than 24 hours point to vestibular neuritis or a central cause. Most Meniere's attacks settle within 2-4 hours, with residual disequilibrium continuing for one to three days.

Meniere's disease cannot be cured, but it can be controlled in over 80% of patients with stepwise treatment. Lifestyle changes, diuretics, betahistine, intratympanic steroid or gentamicin, and surgical options each reduce attack frequency. Hearing loss in the affected ear progresses over years regardless of treatment and is managed with hearing aids and, in advanced bilateral cases, cochlear implants.

The proximate cause is endolymphatic hydrops, an excess of inner-ear fluid that distends the membranous labyrinth. Why hydrops develops in primary Meniere's is unclear, but suspected mechanisms include impaired endolymph absorption at the endolymphatic sac, autoimmune injury, viral involvement, genetic predisposition, and overlap with migraine pathways. Roughly 10% of cases are familial.

About 8-15% of Meniere's cases are familial, with first-degree relatives at roughly 2-8 times higher risk than the general population. Variants in genes including COCH, OTOG, TECTA, FAM136A, and DTNA have been identified in some families, but no single gene accounts for the majority. Familial cases tend to start earlier and to affect both ears.

Diagnosis is clinical, based on the 2015 Bárány Society criteria: two or more vertigo attacks of 20 minutes to 12 hours, audiometrically documented low-to-mid frequency hearing loss in the affected ear on at least one occasion, and fluctuating ear symptoms such as tinnitus or fullness. Pure-tone audiometry is the most important objective test, and MRI is required to rule out vestibular schwannoma.

Vertigo is a symptom — a sense that the world is spinning. Meniere's disease is one specific cause of vertigo, defined by episodic attacks together with hearing loss, tinnitus, and aural fullness in the same ear. Most causes of vertigo, such as BPPV or vestibular neuritis, do not involve hearing changes and have different durations and triggers.

Vestibular migraine produces episodic vertigo lasting minutes to days, frequently accompanied by headache, photophobia, or visual aura, in a patient with a migraine history. Hearing loss, if present, is mild and non-fluctuating. Meniere's vertigo lasts 20 minutes to 12 hours and is paired with progressive low-frequency hearing loss, roaring tinnitus, and ear fullness in one ear. The conditions overlap in 30-50% of patients.

BPPV produces brief vertigo of seconds, triggered specifically by head position changes such as rolling over in bed or looking upward. Hearing is normal. Meniere's attacks last 20 minutes to 12 hours, occur spontaneously, and are accompanied by hearing loss, tinnitus, and ear fullness. The Dix-Hallpike test confirms BPPV; canalith repositioning resolves most cases in one or two sessions.

Meniere's begins in one ear in 75-90% of patients. Over time, the second ear becomes involved in 25-30% by 5 years and 35-50% by 10-20 years. Bilateral disease is associated with autoimmune conditions and familial cases and complicates both hearing and balance. Regular audiograms in the unaffected ear catch second-ear involvement early.

Aim for under 1.5-2 g of sodium per day spread evenly across meals, consistent meal timing, and steady fluid intake. Limit caffeine to under 200 mg daily and minimize alcohol. Most processed and restaurant foods are high in sodium, so meals built from fresh ingredients are easier to control. Combining diet with a diuretic is more effective than either alone.

Betahistine 16-24 mg three times daily is first-line in Europe and Asia and is used off-label in the United States. Meta-analyses suggest a 30-50% reduction in monthly vertigo episodes compared with placebo. The drug is well tolerated; main adverse effects are mild gastric upset and headache. Trial duration of at least 3 months is needed before judging response.

Intratympanic gentamicin is an in-office injection of an aminoglycoside through the eardrum into the middle ear. The drug diffuses to the inner ear and selectively damages vestibular hair cells, producing a chemical labyrinthectomy. Vertigo control is achieved in 80-95% of patients, but 20-30% experience further sensorineural hearing loss. It is used when steroid injections and oral therapy fail.

Surgery is reserved for patients with disabling vertigo despite full medical therapy, including intratympanic treatment. Endolymphatic sac decompression and vestibular nerve section preserve hearing; labyrinthectomy is used when hearing in the affected ear is already non-serviceable. Roughly 5-10% of Meniere's patients ultimately need surgical intervention.

Hearing in the affected ear deteriorates progressively in most patients, even with optimal treatment. The average ear ends with moderate-to-severe sensorineural hearing loss after 10-20 years, especially at low and high frequencies. Hearing aids, contralateral routing devices, and eventually cochlear implants restore functional hearing. Early audiologic care preserves speech understanding and reduces social withdrawal.

Stress and disrupted sleep are among the most consistently reported attack triggers in patient diaries. Cortisol fluctuations and autonomic activation are thought to destabilize inner-ear fluid balance. Active stress management, sleep hygiene, and treatment of anxiety or depression reduce attack frequency. Stress does not cause the underlying disease but it does precipitate flares.

Driving is permitted between attacks for most patients, but attacks of disabling vertigo without warning are a contraindication in many jurisdictions. Avoid driving during high-attack periods and immediately after an attack until balance has returned to baseline. Tumarkin drop attacks, in particular, prohibit driving until they are controlled by intratympanic or surgical therapy. Check the regulations in your country or state.

A Tumarkin otolithic crisis is a sudden fall without loss of consciousness or warning, caused by an abrupt vestibular reflex from the affected ear. The patient feels pushed to the ground, recovers within seconds, and is fully alert afterward. Drop attacks occur in 5-10% of long-standing Meniere's patients and warrant prompt escalation to intratympanic therapy or surgery because of fracture risk.

First-line oral therapies (hydrochlorothiazide, betahistine, meclizine) are inexpensive generics. Intratympanic dexamethasone injections cost USD 100-400 per session, typically covered by insurance. Intratympanic gentamicin is similar. Endolymphatic sac surgery, vestibular nerve section, labyrinthectomy, and cochlear implantation are major surgical procedures with insurance-dependent costs in the thousands of dollars. Hearing aids range from USD 1,000 to 7,000 per pair.

Many patients qualify for disability benefits during high-attack periods because of unpredictable vertigo, hearing loss, and the inability to work safely with heights, machinery, or driving. Severity varies widely between patients. Workplace accommodations, hearing aids, and vestibular rehabilitation often allow continued employment between flares.

Pediatric Meniere's disease is uncommon, accounting for under 3% of cases. When it occurs, it is more often familial or autoimmune and warrants evaluation for genetic causes and inner-ear autoimmunity. Diagnosis and management follow the same Bárány criteria and AAO-HNS guideline as adults, with age-appropriate audiology and vestibular testing.

Vertigo attacks usually become less frequent after 5-10 years as vestibular function in the affected ear declines, but hearing loss progresses steadily through that period. Bilateral involvement develops in 25-50% over 10-20 years. Active treatment slows hearing decline only modestly but controls attacks effectively. The most predictable trajectory is gradual hearing loss with eventually reduced vertigo.